US healthcare

Published: 27/06/2002, Volume II2, No. 5811 Page 32

The US should concentrate on making its nursing workforce more representative of its own population rather than relying on nurses from other parts of the world. Howard Berliner reports

Nursing shortages are relatively common in the US, occurring on a periodic basis - in the late 1950s, early 1970s, late 1980s and re-emerging at the beginning of this decade. By all accounts, the US is in the midst of a serious shortage that will culminate in the largest shortage of hospital nurses at a time when the demand for their services will be the greatest - after 2010.

It has become commonplace to note that hospital-based nurses 'love' their work and 'hate' their jobs. This seems to be true for the UK, Canada and other countries, as well as the US. To the extent that this is an accurate reflection of the dominant view of hospital nurses, it seems that structural features of clinical nursing are serious barriers to job satisfaction.

Therefore, attempts to deal with the current shortage through increasing the supply of nurses alone are not likely to succeed.

The past few years have seen a declining number of new nurses entering the field, increasing problems getting new nurses to stay in hospitals, and nurses retiring or leaving the field early. The combination of these factors forms the crux of the nursing shortage in the US today.

Almost 2.7 million people had nursing licences in the US in 2000, an increase of 1 million from 1980, yet the rate of growth between 1996-2000 was less than half that of the rest of the period. Almost 500,000 people with nursing licences were not working in the field in 2000, an indication that they are making alternative career choices, such as education and insurance.

The average age of the current nurse workforce is 45.2, and only 9.1 per cent were aged under 30 in 2000, compared with 25.1 per cent in 1980.

Prior shortages have been resolved by importing nurses from abroad. As a result we have large numbers from Canada, the Caribbean, the Philippines, the UK, India, Pakistan, and English-speaking African countries.

They come to the US on work visas that are quite restrictive. They come because of the higher wages and the chance to send large amounts of capital back to relatives.This staffing strategy is short-term because these nurses eventually return home and their presence has deflected from new approaches to building a domestic nurse supply.

As the Wall Street Journal noted in January this year: 'Many other poor nations [besides Ghana] are losing nurses, too, mainly to rich nations.

Thousands of nurses have left South Africa - one of the nations hardest hit by AIDS - for the UK, Australia and the US.Half of Trinidad and Tobago's nurses have left the country. So many nurses have left Jamaica that the government forced the UK to put a moratorium on hiring them.Many nurses leave Canada each year for the US, forcing Canada to raid the UK, which in turn poaches nurses from Ghana.'

More than 86 per cent of US nurses are white, with only 4.9 per cent African-American and 2 per cent Hispanic.This contrasts with an overall US population that is 69 per cent white, 12 per cent African-American and 12.5 per cent Hispanic.Clearly there is a need to bring more ethnic minorities into the nursing pool. Since minority women are well represented in the caring occupations, it is likely that their absence in nursing is due to educational deficits which could be corrected with directed attention.

This would require enriched maths and science teaching at junior high-school and high-school levels, along with mentoring and hospital internships, so young people from ethnic minorities could gain the educational skills necessary to pursue a career in nursing and an appreciation for the work.

Recent data from New York City indicates that half the new nurses working in hospitals leave before the end of their second year.To the extent that this is not atypical of the rest of the country, the implication is that we would need twice as many nurses to enter the field to remain with the current low supply. Stated bluntly, as long as hospitals understaff their nursing units, require nurses to float from unit to unit and require mandatory overtime, the constant turnover will continue.

The numbers and types of people going into nursing must be increased, working conditions must be improved, and mechanisms found to keep nurses working longer than they have traditionally done.

These are not insoluble problems, but they do require hospital administrators and state and national policy-makers to expand their vision.They cannot hope the issue will resolve itself - it will not.

Howard Berliner is professor of health policy and management, Milano Graduate School, New School University, New York.