Workforce Advocacy and the Nursing Shortage

Workforce Advocacy and the Nursing Shortage

Debra D. Hatmaker, PhD, RN-BC, SANE-A


Additional resources are available online at:


As a new graduate, 26-year-old Elena Gonzalez is searching for her first position as a registered nurse (RN) in a large metropolitan city. As part of her education, she learns about the importance of a nurse’s role in advocating for a workplace conducive to delivering safe and effective quality health care. She also understands that the workplace is filled with complex issues—nursing shortages, staffing issues, potential exposure to bloodborne diseases—affecting the nurse, the patient, the organization, and the profession. Elena receives offers from various organizations. However, she wisely chooses not to accept a job on its “face value” and decides to investigate her opportunities more thoroughly. Using the Internet, she searches the websites of hospitals in her target area. She is looking for the answers to questions, such as:

Answers to these questions can be found on health care organizations’ websites or from their nurse recruiters or nurse educators. Armed with answers to these and other questions, Elena decides to accept a position with a large tertiary care center that she believes has created an environment most supportive of ensuring the delivery of quality patient care. However, she knows that with the acceptance of this position, her role as a workforce and patient advocate has not ended; rather it has only just begun.

Promoting Workforce Advocacy and a Professional Practice Environment

Professional nurses are experiencing involvement and control in the work environment that was unheard of 20 years ago. Important research is validating the contribution and value of RNs in the following areas:

Within this context of the important contributions that nurses make to patients, hospitals, and health care in general, we find nurses challenged to deliver care against all kinds of barriers and with dwindling resources. Nurses’ strong concern and commitment to patient care and their role as patient advocates often place them in direct conflict with those who have more control, such as physicians and health care administrators. How a nurse reacts to such conflicts within the workplace and continues to advocate to improve patient care is a necessary focus for the profession—a focus called workforce advocacy.

As we visit Elena Gonzalez 6 months after she assumed her new position, we find that she has become involved in advocating for a safe work environment. Elena and the other nurses working on the medical unit are concerned because there is a limited amount of safe patient handling equipment available on their unit. The patients on the medical unit often have mobility issues, and the nurses are worried about suffering musculoskeletal injuries when transferring and repositioning patients. Where will they find information about ergonomic safety and other workplace safety issues? Are there regulations that require hospitals to implement safety measures to protect their staff against debilitating musculoskeletal injuries? What legal rights do nurses have to demand safe patient handling equipment? Is there an avenue to work with hospital administrators to decrease the costs associated with unsafe practices and to move toward a user-friendly work environment? All of these questions are related to workforce advocacy. Examples of workforce advocacy are included in Box 12-1.

For over a century, the American Nurses Association (ANA) and its state affiliates have advocated for the professional nurse and quality patient care. Through research, continuing education, and knowledge sharing among today’s nursing community, the ANA offers powerful resources to nurses seeking to overcome workforce challenges and realize opportunities. In 2003, the ANA’s commitment to workforce advocacy was advanced with the creation of services and tools designated to help individual nurses self-advocate in their professional and personal development. This focus is on the individual nurse rather than the nurse’s workplace and addresses key elements of the nursing workforce: staffing, workflow design, personal and social factors, physical environment, and organizational factors (Box 12-2). Five opportunities and challenges for workforce advocacy programs are highlighted in Box 12-3. Other examples of workforce advocacy and specific workplace issues are discussed in the following sections.


1. Identify mechanisms within health care systems that provide opportunities for RNs to affect institutional policies.

2. Develop conflict resolution models for use within organizations that address RNs’ concerns about patient care and delivery issues.

3. Seek legislative solutions for workplace problems by reviewing issues of concern to nurses in employment settings and introducing appropriate legislation, such as the following:

4. Develop legal centers for nurses that could provide legal support and decision-making advice as a last recourse to resolve workplace issues.

5. Provide RNs with self-advocacy and patient advocacy information, such as the following:

American Nurses Association: Five opportunities/challenges for workforce advocacy programs. Adapted from the Texas Nurses Association: Workplace advocacy program (website).

The Nursing Shortage

The nursing profession has a long history of cyclic shortages, which have been documented since World War II (Minnick, 2000). The shortage affecting the nation during the late 1990s and the early 2000s was a direct result of the struggle to implement managed care as a means of controlling the escalating cost of health care. What now appears to be a chronic nursing shortage has attracted significant attention from key groups including state and federal policymakers and leaders in education, health care, and manufacturing. Interventions by these groups have positively affected the shortage, resulting in growth in RN employment and nursing school enrollment.

The downturn in the U.S. economy in 2009 led to an easing of the nursing shortage in some parts of the country (Thrall, 2009). This was largely due to many retired nurses re-entering the workforce due to economic pressures, nurses who had planned to retire who are holding on to their positions, some nurses working part-time who have taken full-time positions, and hospitals treating fewer patients because many people are delaying procedures or not seeking care due to loss of insurance (American Hospital Association, 2008; Buerhaus, 2008).

There is more recent evidence that the focus on the nursing shortage is generating positive results: an unexpected number of young women entered the nursing workforce from 2002 to 2009 causing faster growth in the supply than anticipated. The number of full-time registered nurses 23 to 26 years of age increased steadily, by 62%, during that time—a rate of growth that has not been seen since the 1970s (Auerbach et al, 2011). Despite this positive sign of stabilization, workforce analysts caution nurse educators, policymakers, employers, and other stakeholders that considerably more progress is needed if the country is to meet the fast-growing needs for professional nurses at a time when the population is aging, more people are living with chronic conditions, and health care reform is poised to dramatically increase the number of people accessing care.

The analysts (Auerbach et al, 2011) indicate that instead of declining in absolute and per capita terms as had been previously projected, the nursing workforce is now projected to grow at nearly the same rate as the population through 2030. This good news could cause some policymakers to believe that the shortage has been solved; however, analysts predict that the replacement of the retiring “Baby Boom” nurses is not going to happen over the next few years and may not be realized until the next decade. Continuing attention to the issue is necessary in order to encourage young people to remain interested in nursing.

Future RN Employment Opportunities

Professional nursing is the largest U.S. health care occupation according to the Bureau of Labor Statistics (U.S. Department of Labor, 2011). Employment of registered nurses is expected to grow by 22% from 2008 to 2018, much faster than the average for all occupations. Thousands of job openings will result from the following:

Employment will not grow at the same rate in every setting—hospital employment will grow more slowly because many procedures and care are shifting to outpatient and home health settings, more sophisticated procedures can safely be done outside the hospital, and home health and long-term care facilities will see employment growth due to the aging population. Planning for an adequate workforce will remain one of the most critical challenges of the new century. Although the current nursing shortage is related to supply-and-demand issues, a closer look at several confounding variables provides an insight into the complexity of the shortage and the need for an array of actions.

Health Care As a Challenging Work Environment

In examining the shortage of nurses, it is important to consider the nurses work environment as a contributing factor. In a comparison of three national random sample surveys of RNs, areas identified as negatively affecting nursing satisfaction were: 1) opportunities to influence decisions about workplace organization; 2) recognition of accomplishments and work well done; 3) opportunities for professional development and advancement; and 4) opportunities to influence decisions about patient care (Buerhaus et al, 2009). In a 2011 job satisfaction and career plans survey of RNs, results showed that job satisfaction is declining with 24% surveyed indicating that they will seek a new place of employment as the economy improves (AMN Healthcare, 2011). Close to half said that in the next 1 to 3 years they would consider career changes such as switching to a less demanding nursing position, working as a travel nurse, switching to part-time, or retiring. The identification and recognition of these workplace challenges charge health care systems with the unavoidable requirement to redesign work and workplace environments so that they are able to attract, retain, and develop the best RN workforce.

Nursing School Enrollments and Recruitment

Numerous efforts were undertaken over the past decade to recruit more students into nursing—efforts that have been largely successful. Professional nursing associations and health care companies educated the public regarding the shortage and the benefits of a nursing career. The Johnson & Johnson Campaign for Nursing’s Future, a multiyear $30-million national initiative, was designed to enhance the image of the nursing profession, recruit new nurses and nurse faculty, and help retain nurses currently in the profession (Johnson & Johnson, 2009). Unfortunately, even when attempts to recruit more people into nursing have been successful, most schools and universities find themselves unable to expand their nursing programs to accept the qualified applicants because they are faced with a serious shortage of nursing faculty. National and statewide efforts have resulted in increases in nursing school enrollments for 11 consecutive years (2001 to 2011), yet these increases will not balance out the impending wave of RN retirements or employment changes as the economy recovers (American Association of Colleges of Nursing [AACN], 2011a).

Along with the need to recruit into the profession, nursing must continue to examine the ways in which new nurses are introduced into the nursing work culture. Adequate orientation, mentoring, and preceptor programs are essential to introduce and retain new nurses.

Educational Preparation

During past shortages, employers have hired RNs regardless of their degree preparation. The current and projected demands for RNs require not simply more RNs, but more RNs of the right type and right educational and skill mix to handle increasingly complex care demands. Demand has intensified for more baccalaureate-prepared nurses with critical thinking, leadership, quality improvement, case management, and health promotion skills who are capable of delivering care across a variety of health care settings. Demand has also increased for experienced RNs; for nurses in key clinical specialties, such as critical care, emergency department (ED), operating room, and neonatal intensive care; and for master’s- and doctoral-prepared RNs in advanced clinical specialties, teaching, and research.

In October 2010, the Institute of Medicine (IOM, 2011) released its landmark report on “The Future of Nursing: Leading Change, Advancing Health” initiated by the Robert Wood Johnson Foundation, which called for increasing the number of baccalaureate-prepared nurses in the workforce to 80% by 2020 (the 2008 HRSA Sample Survey listed 50% of the RN workforce as having a baccalaureate degree or higher). This and other evidence-based recommendations contained in the report state that to respond “to the demands of an evolving health care system and meet the changing needs of patients, nurses must achieve higher levels of education” (IOM, 2011).

Faculty Shortage

One of the most critical problems facing nursing and nursing workforce planning is the aging of nursing faculty (AACN, 2011b). The mean age of nursing faculty has steadily increased to 60.5, 57.1, and 51.5 years for doctoral faculty at the ranks of professor, associate professor, and assistant professor, respectively. For master’s-prepared faculty, the average ages for professors, associate professors, and assistant professors were 57.7, 56.4, and 50.9 years, respectively. Unfortunately, the shortage of faculty is contributing to the current nursing shortage by limiting the number of students admitted to nursing programs. In 2011, the AACN reported that 67,563 qualified applications to nursing baccalaureate and graduate programs were not accepted, and an insufficient number of faculty were cited by schools as a reason for not accepting all qualified baccalaureate applicants (AACN, 2011b). The National League for Nursing (NLN) reported that 99,000 qualified applicants were turned away from their member schools, which are primarily associate degree programs (NLN, 2009). Faculty salaries continue to be a major contributor to the faculty shortage. According to the AACN, academic institutions, especially those faced with budget cuts, generally cannot compete with nonacademic employers when it comes to salary benefits.

Nurse Retention

Past nursing shortages have proven that the retention of professional nurses is a key to any organization’s success. The ability of an organization to retain nurses primarily depends on the creation of an environment conducive to professional autonomy. Nurses want to work in an environment that supports decision making and effective nurse-physician relationships, which are critically important to patient safety. Although some progress has been achieved, RNs’ perceptions of the hospital workplace environment, as measured across three national surveys, demonstrate much need for improvement (Buerhaus et al, 2009).

In the national surveys, many areas of work-related quality of life were rated poorly by RNs employed in hospitals, with fewer than one in four RNs rating them “excellent” or “very good” (Buerhaus et al, 2009). When asked to rate the quality of their relationships with others in the workplace, RNs assigned their highest overall ratings to their relationships with other RNs, followed next by their relationships with physicians and nurse practitioners, and then frontline nurse managers. RNs ranked their relationships with administration and management the lowest. In contrast to these perceptions, RNs in the surveys were generally satisfied with their jobs, and satisfaction had increased over time. The increase in job satisfaction was predicted by several factors: organizations that emphasized quality of patient care, management that recognized the importance of their personal and family lives; satisfaction with salary and benefits, high job security, and positive relationships with other nurses and with management. Decreases in job satisfaction were predicted by feeling stressed to the point of burnout, feeling burdened by too many non-nursing tasks, experiencing an increase in the number of patients assigned, and having a general negative overall view of the health care system.

Magnet® Hospitals

One of the most successful nurse retention models focuses on promoting standards for professional nursing practice and recognizing quality, excellence, and service. In 1980, recognizing a critical and widespread national shortage of nurses, the American Academy of Nurses, an affiliate of the American Nurses Association (ANA), undertook a study to identify a national sample of what were referred to as “magnet hospitals” (i.e., those that attract and retain professional nurses in their employment) and to identify the factors that seem to be associated with their success in doing so (McClure et al, 1983). This landmark study, titled “Magnet Hospitals: Attraction and Retention of Professional Nurses,” identified workplace factors, such as management style, nursing autonomy, quality of leadership, organizational structure, professional practice, career development, and quality of patient care as influencing nurse job satisfaction and low turnover rates in the acute care setting. Out of 163 hospitals initially participating, only 41 were deemed Magnet hospitals for their ability to support nurse autonomy and decision making in the workplace.

As a result, the ANA’s credentialing arm, the American Nurses Credentialing Center (ANCC), began a program recognizing hospitals with excellent nursing recruitment and high retention rates. As the Magnet Recognition Program® evolved, it sought to combine the strengths of the original study with quality indicators identified by the ANA and the standards of nursing practice as defined in the ANA’s Scope and Standards for Nurse Administrators so that both quantitative and qualitative factors of nursing services were measured. The qualitative factors in nursing, referred to as the 14 Forces of Magnetism®, provided the conceptual framework for the appraisal process. In 2007, the ANCC commissioned a statistical analysis of Magnet appraisal team scores from evaluations conducted using the 2005 Magnet Recognition Program® Application Manual. This analysis clustered the sources of evidence into more than 30 groups, yielding an empirical model for the Magnet Recognition Program. The new, simpler model reflects a greater focus on measuring outcomes and allows for more streamlined documentation (Figure 12-1).

With its link between quality patient care and nursing excellence, the Magnet Recognition Program has reached a coveted level of prestige within the nursing community and among acute care facilities. Research has consistently shown that Magnet hospital nurses have higher levels of autonomy, more control over the practice setting, and better relationships with physicians (Aiken et al, 2000; Aiken et al, 2008; Aiken et al, 2009; Armstrong et al, 2009; Wade et al, 2008). Magnet status is now seen as the single most effective mechanism for providing consumers and nurses with comparative information, the gold standard for quality nursing care. Nurses advocating for a strong workplace should advocate for their hospital to achieve Magnet status.

Pathway to Excellence® Hospitals

In 2003, the Texas Nurses Association (TNA) began work to positively affect nurse retention by improving the workplace for nurses and established the Texas Nurse-Friendly Program for Small/Rural Hospitals. The program was partially funded with a 5-year grant from the HRSA. The goal of this program was to improve both the quality of patient care and professional satisfaction of nurses working in small and rural hospitals in Texas. To be responsive to a national market for this program, the TNA sold the rights to the Nurse-Friendly Program to the ANCC in 2006, and it has undergone revision to meet national criteria. The renamed Pathway to Excellence® recognition is earned by acute-care and long-term care organizations that create work environments where nurses can flourish. The award substantiates the professional satisfaction of nurses and identifies best places to work. As this program matures, research focused on nursing and patient outcomes will demonstrate the value of an improved work environment.

Aging Workforce and Retention

As the nation works to increase the supply of professional nurses through education, strategies must be developed to retain the older, expert professional nurse within the nursing workforce. The following statistics detail the extent of the aging workforce issue (HRSA, 2010):

There has been little research to test the effectiveness of recruitment and retention strategies with older nurses. In a qualitative study on influences on the older nurse to continue bedside practice, the authors found that the most pervasive and difficult experiences in the sample of older nurses involved dealing with stress, frustration, constant change, physical and mental declines, and dealing with intergenerational conflict (Spiva et al, 2011). Despite the challenges, the nurses in this study found positive aspects of and meaning in being a nurse—through the recollection of earlier and happier memories, making a connection with patients, and cherishing the preciousness of caring for patients and families. This and other studies on ways to keep older nurses practicing cite the following suggestions for employers in creating positive environments:

Although many organizations have added on-site daycare and sick care for children of younger nurses, organizations may need to consider adding adult daycare to assist older nurses who are caring for aging parents. Creative staffing plans with shorter shifts and identified respite periods may help extend the work life of aging nurses. Technology has provided many workplace accessories that reduce the physical demands on nurses that can result in injury or stress, especially to aging nurses. The ANA’s Handle with Care® campaign aims to eliminate lifting in the hospital environment by using technology and assistive devices to do the heavy work (ANA, 2011a). Ergonomic issues are important for staff of any age, but additional attention is needed as the workforce ages. Organizations that strategically plan for an aging workforce will be best positioned to deliver quality health care to their customers.

Emerging Workforce Recruitment and Retention

In addition to planning for retention of an aging workforce, health care is challenged to become the employer of choice for the younger emerging workforce. A number of studies have focused on the work and management expectations of today’s young worker who expects balance and perspective in the workplace. In a study focused on Generation Y (those born after 1980) nurses, recognition was reported as a key motivator. The younger nurses identified their needs as stability, flexible work schedules, recognition, opportunities for professional development, and adequate supervision (Lavoie-Tremblay et al, 2010). Elena, the young nurse described at the beginning of the chapter, will be searching for opportunities to gain advanced training, education, and certification as she seeks to make herself more marketable in her professional nursing role. She expects feedback on her performance to help refine her skills and build her confidence. She also expects her manager to take a personal interest in her, to know her name, and to help her build a competitive portfolio. Many managers are unaware of these expectations in emerging workforce employees and contribute to their hastened exit from the workplace by not attending to their personal and career needs.

International Nurse Recruitment

For several decades, the United States has regularly imported nurses to ease its nurse shortages. Internationally educated nurses represent a larger percentage of the U.S. nursing workforce in recent years with 5.1% of RNs licensed before 2004 and 8.1% of RNs licensed since that time. The Philippines has dominated the nurse migration pipeline to the U.S. and to other recruiting countries (HRSA, 2010). International nurses coming to work in the U.S. find supportive resources through the Commission on Graduates of Foreign Nursing Schools (CGFNSs) including verification of the foreign nurse’s knowledge-based practice competency. The economic recession and visa retrogression have slowed down the entry of internationally educated nurses to about 50% of 2007 levels, although it is believed that numbers will again increase in the near future.

Nov 6, 2016 | Posted by in NURSING | Comments Off on Workforce Advocacy and the Nursing Shortage
Premium Wordpress Themes by UFO Themes