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What Caused the Nursing Shortage?
The current nursing shortage is a direct result of hospital management policies during the 1990s, including significant nurse layoffs in many hospitals. While some commentators point to a change in the cultural status of nursing as a profession or the increased career options for women workers, no evidence supports these dynamics as primary factors creating the nursing shortage. Furthermore, no evidence suggests that public relations campaigns promoting the image of nursing can make a significant dent in the problem. Instead, the roots of the shortage, and the source of any potential solution, clearly lie in management practice. As JCAHO President Dennis O'Leary explains,
This problem is a direct product of the public policy directions of the past decade that have deliberately sought to shrink the installed capacity of health care organizations. ... Some of the earliest and most graphic impacts of this public policy orientation were the widespread layoffs of nurses and support personnel that were accomplished under the heading of organization restructuring and similar euphemisms.62
The nursing profession is now facing a crisis on multiple fronts: shortages of hospital nurses, too few students enrolled in nursing schools, a shortage of nursing faculty and school infrastructure limiting enrollments, and continuing high numbers of RNs who are choosing not to work in the profession. The American Organization of Nurse Executives has given one of the best concise histories of the crisis, locating the origins of each of these problems in management strategies adopted in the 1990s:
In the early 1990s, managed care penetration increased dramatically across the country. Capitated payment systems drove decreases in the length of inpatient stays. ... One manifestation of this change was a 15 percent decrease in bed utilization between 1985 and 1994 in community hospitals. Many of the decisions made at that time, including those which responded to decreasing patient days, resulted in nurse layoffs or unusually low rates of nurse hires. New graduates had difficulty finding employment in hospitals and schools of nursing subsequently experienced declining enrollments. In an additional strategy to slow health care cost growth, many hospitals instituted restructuring and redesign of their care delivery systems, reintroducing non-RN caregivers to their skill mixes, including unlicensed assistive personnel. This had the effect of reducing the percentage of RN staff even though the number of nurses employed in hospitals continued to rise. As recruitment needs declined, the commitment of resources by facilities and educational institutions to the infrastructure that supported the nursing workforce, such as specialty training programs and investments in mentoring new graduates, declined proportionately.63
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