Academic Examples

PROFESSIONAL ISSUES IN NURSING

In this paper, I will focus on three issues that I believe are among the most important faced by the nursing profession today. While different, each issue bears heavily on the nature of nursing as a profession as it moves forward into the future. The issues, while distinct, are not entirely unrelated; each overlaps with the others in important ways. The first issue I will address is one that has been plaguing the health care sector for roughly two decades — the nursing shortage. The second issue is 80 in 20 and related proposals that aim to increase levels of educational attainment among nurses. The third issue is the practice of mandatory overtime. All three issues can influence the working situations of nurses as well as patient care outcomes.

Without question, one of the most serious issues that nursing continues to face in the United States is the long-running nursing shortage. While the U.S. has the largest nursing workforce in the world, some three million nurses (USDHHS, 2006), the size of that workforce is not nearly enough. According to a 2006 estimate by the Health Resources and Services Administration, the country faces a growing shortage that will reach one million nurses by 2020 (Sharp & Clancy, 2008). Professors Chandra and Willis from Marshall University project a slightly smaller nurse deficit of some 800,000 in 2020 (Chandra & Willis, 2005), but regardless of the exact size of the nursing deficit, few disagree that it exists, and most believe it is huge and will continue to be so into the next decade.

There are many factors that have contributed to this growing shortage. One is demand. The aging of the American population is accelerating rapidly as the baby boomer generation continues to move into retirement. Since 2000, according to the U.S. Department of Health and Human Services, the population of Americans aged 65 and over has increased by over 15 percent, and the population of Americans who will reach 65 over the next two decades had increased by over 30% (USDHHS, 2011).  This older population will continue to require ever-greater health care services, and a growing number of nurses. Alongside demand is the issue of supply. The existing nurse force is aging along with population at large. The average age of nurses is 43, and one third of the nursing workforce is fifty years old or greater and will retire over the next two decades (Chandra & Willis, 2005). Replacing these nurses as they retire isn’t easy. The pool of applicants is limited. Many Americans don’t see nursing as a rewarding career choice, because of working conditions, salaries, or a lack of professional respect and development. Among those who chose a career in health care, other options may be more appealing. Even if there were a greater number of applicants, the educational capacity of American institutions is limited. There are an insufficient number of educational facilities and faculty to train a greater number of nurses. This teaching shortage is expected to get worse; the average age of nursing faculty is 51.5 years old (Allen, 2008). Finally, many nurses leave the field long before retirement age. They are unhappy with their jobs because of unsatisfactory working conditions, excessive patient-nurse ration, long hours, and care issues that they perceive are unsafe for patients.  According to one study, one in five nurses plan to leave the profession within five years, and 30% of one group of respondents left within their very first year (Bowles & Candela, 2005).

The nursing shortage has numerous consequences. Most obvious are its ramifications on patient care quality when an insufficient supply of nurses is available to service the quantity of patients. Institutions are forced to use many different methods of filling the labor shortage. One is the importation of foreign nurses. In 2007, nearly 10% of the nursing work force was foreign educated (Aiken, 2007). Though the use of foreign-trained nurses can alleviate the shortage here, it impacts their countries of departure, draining professionals who might otherwise serve the health care needs of their own countries. The nursing shortage also leads to understaffing and overwork of the existing workforce with negative consequences for both nurses and their patients. Many nurses, unhappy with their working situations, leave the profession, and their departures reinforce the shortage.

There are numerous proposals to alleviate the crisis. These include investment in the educational system to increase nursing school capacity, a focus on better working conditions to increase nurse retention, and increasing the productivity of the existing workforce. In my opinion, a solution will probably require many different pathways. One aspect of the nursing shortage that I feel is important is how it manifests itself in different locations. In some areas of the country, nurses can easily find jobs. In other areas, however, nursing jobs are not so easy to find despite the national shortage. Part of the solution will be probably involve increasing incentives for nurses to move to areas of greater need and easing licensing barriers that make nursing mobility difficult.

80 in 20 is one of a number of proposals that were made in 2010 to increase the educational level of the nursing work force by a committee of the Robert Wood Johnson Foundation and the Institute of Medicine. The 80 in 20 recommendation calls on academic nurse leaders, educational institutions, funders and employers to work in concert to increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020 (Institute of Medicine [IOM], 2010), a doubling of the current number. The reasons for the committee’s call are many: to make nurses equal partners with other, more educated health care professionals; to provide better patient care; and to prepare nurses to handle their ever more complex responsibilities in the 21^st century’s ever-evolving health care system, and to allow them to take a leadership role in this evolution.

The proposal certainly would produce some positive outcomes. It has been shown that better educated nurses can produces better outcomes for patients. On the other hand, depending on the methods used to achieve “80,” there might be negative consequences as well and some have questioned its need. After all, there are certainly hundreds of thousands of very skilled nurses currently performing their duties perfectly with just an associate degree. The need for many of them to gain an additional degree may increase financial or scheduling stress on already overworked nurses unless they are provided with the proper support by the institutions they work for. And somewhat paradoxically, for new nurses, 80 in 20 may increase barriers to entry in a profession, which is already facing a shortage of practitioners. On the other hand, it may create new interest in applicants if it helps make nursing more respected as a career.

While I am in favor of the committee’s call for leaders to find ways to better educate the future nursing force, I am unsure if 80 in 20 is the best of the committee’s proposals. Other of its recommendations, such as increased transition-to-practice nurse residency programs and support for life long learning seem perhaps more beneficial than the call for a set percentage of nurses with a particular degree.

Mandatory overtime is another important issue in the nursing profession today. As in other industries, mandatory overtime is a way for employers to deal with a temporary shortage of labor. Also called compulsory overtime, this practice means that nurses have to work extra shifts in addition to their regular hours (Huston, 2010). There are a variety of reasons that health care institutions demand mandatory overtime from their nurses, from urgent patient needs to natural disasters, and there are obvious times where it makes sense to require a nurse to continue care beyond his or her regularly scheduled shifts — as in the case of an ongoing surgical procedure when no replacement, for whatever reason, is immediately available. Due to the aforementioned nursing shortage, mandatory overtime may be especially prevalent in the nursing profession. It’s one way hospitals make up for chronic understaffing (Bae, Brewer & Kovner, 2012). , but there can be serious negative implications from its use as a regular practice, both for nurses and the patients whom they care for.

For one, extended work hours for nurses have been repeatedly associated with adverse outcomes for patients including increased mortality. According to a 2004 study of some 400 nurses , those who worked more than 12.5 consecutively were three times more like to make an error than those nurses who did not (Rogers, Hwang, Scott, Aiken & Dinges, 2004). Overtime doesn’t just lead to greater fatigue during a shift, but also to less time between shifts. Nurses forced to work overtime may get less sleep between shifts and this work schedule component was found to be the one most closely associated with patient mortality (Trinkoff et al, 2011) This factor can be seen in a story cited by Sharp and Clancy of 16-year old patient who died after being mistakenly administered an anesthetic intravenously by a nurse who had worked two 8-hour shifts the day before with just seven hours in between (Sharp & Clancy, 2008).

Another negative implication of mandatory overtime is that nurses who perform it  are more likely to feel overworked and overstressed. More than anything else, these feelings are those that drive nurses out of their profession. Burnout, 45%, and too many hours, 41%, were the top two reasons for departure cited by nurses who had left their profession (Trinkoff et al., 2011).

These are among the reasons that Rodgers argues that overtime for nurses should be eliminated, and in fact, many states are placing limits or prohibitions on the practice, 16 states as of 2010. These restrictions have two major goals, “to protect patients from harm related to nurse fatigue” and “to protect the nurse from long work hours” (Bae at al., 2012). In New York State, for example, hospitals, with certain exceptions, have been banned from having nurses work more than their regularly scheduled hours since 2009 (NYSNA, 2009). It is not completely clear how well these restrictions work in practice. In some cases, mandatory overtime may be replace by voluntary overtime which may not fully protect either nurses or patients from the negative consequences of extended work hours (Bae et al., 2012).

In conclusion, I feel that all three of these issues, the nursing shortage, the 80 in 20 education initiative, and mandatory overtime are very important to the profession and related in significant ways. Mandatory overtime, for example, can lead to stressed, overworked nurses who are more likely to leave the profession. And this exodus, in turn, can make the nursing shortage worse. Fewer nurses serving a greater population can become a vicious cycle with negative consequences both for nurses and the patients they serve. 80 in 20 is a proposal that has the potential to help alleviate some consequences of these issues. By making nursing more respected and desirable, more people may decide to enter the profession, helping to alleviate the chronic nursing shortage and producing the outcome of better patient care. If enacted poorly, however, without support for continued education and concern for the financial needs and workloads of existing nurses, 80 in 20 also has the potential to drive talented, qualified nurses out of the profession, worsening the shortage, and perhaps increasing demands for overtime work.

 

References

Aiken, L. (2007). US nurse labor market dynamics are key to global nurse sufficiency. Health Services Research, 42(3 Part 2), 1299-1320.

Allen, L. (2008). The nursing shortage continues as faculty shortage grows. Nursing Economic$, 26(1), 35-40.

Bae, S., Brewer, C. S., & Kovner, C. T. (2012). State mandatory overtime regulations and newly licensed nurses’ mandatory and voluntary overtime and total work hours. Nursing Outlook, 60(2), 60-71. doi:http://dx.doi.org.citytech.ezproxy.cuny.edu:2048/10.1016/j.outlook.2011.06.006

Bowles, C., & Candela, L. (2005). First job experiences of recent RN graduates: improving the work environment. Nevada Rnformation, 14(2), 16-19.

Chandra, A., & Willis, W.K. (2005). Importing nurses: Combating the nursing shortage. Hospital Topics, 83(2), 33- 37.

Huston, Carol. (2010). Professional Issues in Nursing: Challenges and opportunities (2nd       edition). Philadelphia, PA: Lippincott, Williams and Wilkins

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved March 11, 2013 from http://www.thefutureofnursing.org/IOM-Report

Mandatory Overtime Law. New York State Nurses Association. Retrieved March 27, 2013 from http://www.nysna.org/practice/mot/intro.htm

Rogers, A., Hwang, W., Scott, L., Aiken, L., & Dinges, D. (2004). The working hours of hospital staff nurses and patient safety: both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours at a stretch. Health Affairs, 23(4), 202-212.

Sharp, B., & Clancy, C. (2008). Limiting nurse overtime, and promoting other good working conditions, influences patient safety. Journal Of Nursing Care Quality, 23(2), 97-100.

Trinkoff, A., Johantgen, M., Storr, C., Gurses, A., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), 1-8. doi:http://dx.doi.org.citytech.ezproxy.cuny.edu:2048/10.1097/NNR.0b013e3181fff15d

U.S. Department of Health and Human Services (2006) Preliminary Findings the Registered Nurse Population: National Sample Survey of Registered Nurses March 2004.

U.S. Department of Health and Human Services. Administration on Aging. (2011) A Profile of Older Americans: 2011. Retrieved March 27, 2013 from http://www.aoa.gov/Aging_Statistics/Profile/2011/docs/2011profile.pdf