The Americans for Nursing Shortage Relief (ANSR) Alliance represents a diverse cross-section of health care and professional organizations, health care providers, and supporters of nursing issues that have united to address the national nursing shortage. Our country continues to be challenged by a chronic nursing shortage of registered nurses (RNs) that was first noted in 1998 and is currently showing no signs of abating. It will have a negative impact on health care delivery in the foreseeable future.

Nursing is one of the largest health care professions with an estimated 2.9 million licensed RNs in the United States. Nurses work in a variety of settings, including public health, long-term care, and hospitals. Advanced practice nurses (nurse practitioners, nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists) practice in numerous settings, including primary care, hospitals and surgical care facilities. Approximately three out of five jobs are in hospitals. A federal report published in 2004 estimates that by 2020 the national nurse shortage will increase to more than 1 million full-time nurse positions. According to these projections, which are based on the current rate of nurses entering the profession, only 64 percent of projected demand will be met. A recent study that uses different assumptions published in Health Affairs has adjusted the demand projection to 340,000 nurses by 2020. In either scenario, the shortage presents an extremely serious challenge to health care access and quality patient care. Even considering only the smaller projection of vacancies, this shortage still results in a frightening gap in nursing service, essentially three times the 2001 nursing shortage.

The ANSR Alliance believes Congress must enact and fund a comprehensive set of initiatives to address these challenges and ensure that the nation has an adequate infrastructure of well-qualified nurses. This Consensus Document outlines programs and evidence-based, cost-effective best practices across the federal agencies that the ANSR Alliance believes hold the most promise for the federal government to adequately address and mitigate the complex factors contributing to the current and expected nurse and nursing faculty shortages. These best practices will help establish a foundation of available nurses to respond to public health emergencies and provide quality acute and long-term care to patients in need.

To meet the basic nurse workforce demands, the ANSR Alliance recommends that Congress:

• Build capacity of nursing education programs and enhance nursing research;
• Strengthen the capacity of the national nursing public health infrastructure;
• Help retain nurses, with special emphasis on the older nurse; and
• Expand recruitment of new nurses with emphasis on those with diverse backgrounds.

The remainder of this document will discuss in greater depth each of these four policy areas and proposed strategies. In addition, ANSR identifies the one critical action needed to mitigate the immediate effect of the nursing shortage and to address all of these policy areas. ANSR requests at least $200 million in funding for Nursing Workforce Development Programs under Title VIII of the Public Health Service Act at the Health Resources and Services Administration (HRSA) in FY 2008. As part of this funding, the Advanced Education Nursing training program (Sec. 811) should be funded at an increased level on par with the other Title VIII programs.

Nursing vacancies exist throughout the entire health care system, including long-term care, home care and public health. Even the Department of Veterans Affairs, the largest sole employer of RNs in the U.S., has a nursing vacancy rate of 10 percent. In 2005, the American Hospital Association reported that hospitals needed 118,000 more RNs to fill immediate vacancies, and that this 8.5 percent vacancy rate is hampering the hospitals’ ability to provide emergency care. Government estimates indicate that this situation only promises to worsen due to an insufficient supply of individuals matriculating in nursing schools, an aging existing workforce, and the inadequate availability of nursing faculty to educate and train the next generation of nurses. At the exact same time that the nursing shortage is expected to worsen, the baby boom generation is aging and the number of individuals with serious, life-threatening, and chronic conditions requiring nursing care will increase. Consequently, more must be done today by the government to help ensure an adequate nursing workforce for the patients of today and tomorrow.

A particular focus on securing and retaining adequate numbers of faculty is essential to ensure that all individuals interested in-–and qualified for--nursing school can matriculate in the year they are accepted. In 2005, research reported by the National League for Nursing found that schools of nursing rejected more than 147,000 qualified applications because of shortages of faculty, classroom space, and clinical placement for students. Aside from having a limited number of faculty, nursing programs struggle to provide space for clinical laboratories and to secure a sufficient number of clinical training sites at health care facilities.

ANSR supports the need for sustained attention on the efficacy and performance of existing and proposed programs to improve nursing practices and strengthen the nursing workforce. The support of research and evaluation studies that test models of nursing practice and workforce development is integral to advancing health care for all in America. Investments in research and evaluation studies have a direct effect on the caliber of nursing care. Our collective goal of improving the quality of patient care, reducing costs, and efficiently delivering appropriate health care to those in need is served best by aggressive nursing research and performance and impact evaluation at the program level.

ANSR Recommendations:

• Expand the funding of the Nurse Faculty Loan Program Grants (Title VIII of the Public Health Service Act, Sec. 846A) and Nurse Loan Repayment and Scholarship Programs (Title VIII of the Public Health Service Act, Sec. 846).
• Boost appropriations for the advanced practice nurse education programs (Title VIII of the Public Health Service Act, Sec. 811) to have an available pool of nurses who can serve as faculty for schools of nursing.
• Raise budget allocations to expand the Veteran’s Administration faculty/clinical service model.
• Fund and modify the Nurse Faculty Loan Program (NFLP) (Title VIII of the Public Health Service Act, Sec. 846A) to eliminate the matching fund requirements from the schools of nursing.
• Increase funding of the Department of Labor's High Growth Job Training Initiative to enhance capacity of nursing education programs.
• Grow the investments across federal departments (e.g., Departments of Defense, Education, Health and Human Services, Labor, Veteran's Affairs) to enhance nursing research and evaluation studies that test models of nursing practice and of nursing workforce development.

Strengthen the Capacity of the National Nursing Public Health Infrastructure

The National Center for Health Workforce Analysis at the Bureau of Health Professions housed within HRSA reports that the nursing shortage makes it challenging for the health care sector to meet current service needs. The distinct possibility that our nation may soon face a pandemic or other natural or man-made disaster of significant proportions highlights the nursing shortage as a major concern and an essential part of national preparedness dialogue and action. This threat is exacerbated by the reality of today’s health care facilities capacity problems. Given that current health care staff levels are insufficient on a day-to-day basis, this problem would be compounded during a regional or national emergency that results in an influx of patients to hospitals. The current public health infrastructure will be further stretched by the health issues of the aging baby boom generation. Conditions such as obesity, heart disease, Alzheimer’s and cancer will further stretch the nation’s limited health care resources. A December 2006 report published by the Trust for America’s Health called "Ready or Not?" contains state-by-state health preparedness scores based on ten key indicators to assess health emergency preparedness capabilities. One of the key indicators in this assessment was state nurse workforce capacity. Forty states were found to have a shortage. These nurse workforce shortages have a significant adverse impact on the ability of a state or locality to respond to a regional disaster. It clearly indicates that in the event of a national health emergency such as pandemic flu, the shortage of nursing services will pose a serious threat to public health in some areas of the country.

The Robert Wood Johnson Foundation recently noted that the President’s FY 2008 budget proposes $185 million in cuts to programs that would support upgrading state and local capabilities and hospital readiness. This represents a more than 25 percent cut from FY 2005 levels of public health preparedness funding. This decrease in funding for public health agencies has a significant impact on their ability to respond to daily public health issues, let alone respond effectively and efficiently in a crisis. Nurses are an important aspect of the public health system, and are among the first responders in public health emergencies.

ANSR Recommendations:

• Provide adequate funding for federal programs to increase the size of the public health nursing workforce capable of responding to bioterrorism and other public health emergencies.
• Increase funding for recruitment and retention efforts to increase the U.S. Public Health Service and Armed Services nursing workforce.
• Support efforts to expand scope of practice and expand the utilization of advanced practice registered nurse providers to contribute to the public health and primary health care infrastructure.
• Expand the use of Nurse-Managed Health Centers (NMHC). Fund federal demonstration projects through the Centers for Medicaid & Medicare Services and Department of Health and Human Services to increase the use of these safety net providers for the provision of care to the under and uninsured.

Some of the recent forecasts of the nursing shortage indicate that nursing workforce will continue to grow older. Interest in nursing among individuals in their early to mid-twenties is at its lowest point in forty years. One study reports that the average age of RNs in the workforce would increase from 42.0 years in 2000 to 44.7 years in 2012. It is important to note that RNs in their 50s may comprise a large part of this workforce and a number of nurses may work into their 60s. Retaining these experienced, older nurses in the workforce will make a critical contribution to curbing the effect of the nursing shortage. Nursing is a physically demanding career. Strategies will be needed to encourage and accommodate these nurses to stay in the workforce.

ANSR Recommendations:

• The Occupational Safety and Health Administration (OSHA) should establish appropriate patient handling approaches and develop criteria for healthier work environments for nursing professionals.
• HRSA should fund demonstration projects with facilities to identify and encourage best strategies for retention and recruitment of older nurses.

RNs, advanced practice nurses, and nursing faculty are all critically necessary to sustain an adequate supply of nurses available to deliver quality health care. The U.S. nursing shortage is part of a larger world-wide nursing shortage. The international scope of this problem makes it critical that our nation develop additional strategies to appeal to men and women to pursue nursing and teaching nursing as a profession. Congress specifies the mission of Title VIII is to ensure a sufficient national supply of nurses; Title VIII programs must be adequately funded to fulfill that important mission.

At a March 2007 Senate hearing, officials discussed a serious shortage of military nurses. It was reported that the Army, Navy and Air Force have a 10 percent shortage of nurses overall; the shortages rises as high as 40 percent for some areas of nursing specialty practice. This growing shortage poses a threat to the health and well-being of American military members at home and abroad.

Between 1994 and 2002, the total percentage of minority nursing students grew to more than 20 percent of the overall nursing student population. This period of growth appears to have ended. In 2004-2005, the overall percentage of minority nursing students declined by almost two percent. The percentage of blacks, Hispanics, and American Indians all have slipped downward each year since 2002. While the distribution of black, Asian, and American Indian students enrolled in pre-licensure nursing programs closely mirrors that of the student bodies of U.S. colleges and universities, there is one glaring exception: Hispanic students represent only 5.3 percent of nursing students compared with more than 10 percent of the undergraduate population at large i.e., one in 10 U.S. college students is of Hispanic origin, compared with one in 20 pre-licensure nursing students.

Cultural competent health care providers are essential to the provision of high quality health care in this nation. Ideally, the health care workforce should reflect the cultural diversity of the general population. Studies have shown that people are most comfortable receiving care from someone of their own cultural and ethnic background. Studies provide evidence that minority practitioners are more likely than their Caucasian counterparts to serve in minority and medically underserved communities. It is critical that we invest in strategies to encourage this diversity in nursing, and work to enhance cultural competence among nurses of all ethnic backgrounds.

Recommendations:

• Provide at least $200 million in FY 2008 to the Public Health Service Act (42 U.S.C. 296 et seq.) Title VIII Nursing Workforce Development Programs. In addition, the Advanced Education Nursing training program (Sec. 811) should be funded at an increased level on par with the other Title VIII programs.
• Fund the Nursing Education Loan Repayment Program (NELRP) (Sec. 846) and the Nursing Scholarship Program (NSL) Program (Sec. 846[d]) to increase the number of students who can complete their nursing education and enter clinical practice.
• Fund demonstration programs that would allow HRSA to coordinate with the U.S. Public Health Service to offer NELRP and NSL recipients incentives to join the U.S. Public Health Service nurse corps.
• Focus on recruitment and retention of nursing candidates from a variety of racial and ethnic backgrounds. Fund Nursing Workforce Diversity grants (Sec. 821) to prepare disadvantaged students to become nurses.Provide adequate funding for evidence-based, capacity-building intervention strategies used across the federal departments and agencies (e.g., Department of Education, Department of Health and Human Services, and the National Science Foundation) that expand pre-college science and math curricula in order to better prepare and encourage more students to select nursing as a career.

The undersigned organizations endorse this Consensus Document. If you have any questions, please contact:

Academy of Medical-Surgical Nurses (AMSN)

American Academy of Ambulatory Care Nursing (AAACN)

American Academy of Nurse Practitioners (AANP)

American Academy of Nursing (AAN)

American Association of Critical-Care Nurses (AACN)

American Association of Nurse Anesthetists (AANA)

American Association of Nurse Assessment Coordinators (AANAC)

American Association of Nurse Executives (AANE)

American Association of Occupational Health Nurses, Inc. (AAOHN)

American College of Nurse-Midwives (ACNM)

American College of Nurse Practitioners (ACNP)

American Organization of Nurse Executives (AONE)

American Radiological Nurses Association (ARNA)

American Society for Pain Management Nursing (ASPMN)

American Society of PeriAnesthesia Nurses (ASPAN)

American Society of Plastic Surgical Nurses (ASPSN)

Association of Pediatric Hematology/Oncology Nurses (APHON)

Association of periOperative Registered Nurses (AORN)

Association of Rehabilitation Nurses (ARN)

Association of State and Territorial Directors of Nursing (ASTDN)

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

Dermatology Nurses’ Association (DNA)

Developmental Disabilities Nurses Association (DDNA)

Emergency Nurses Association (ENA)

Infusion Nurses Society (INS)

International Society of Nurses in Genetics, Inc. (ISONG)

National Association of Clinical Nurse Specialists (NACNS)

National Association of Neonatal Nurses (NANN)

National Association of Neonatal Nurse Practitioners (NANNP)

National Association of Nurse Massage Therapists (NANMT)

National Association of Nurse Practitioners in Women's Health (NPWH)

National Association of Orthopaedic Nurses (NAON)

National Association of Pediatric Nurse Practitioners (NAPNAP)

National Association of Registered Nurse First Assistants (NARNFA)

National Association of School Nurses (NASN)

National Black Nurses Association, Inc. (NBNA)

National Conference of Gerontological Nurse Practitioners (NCGNP)

National Council of State Boards of Nursing (NCSBN)

National Gerontological Nursing Association (NGNA)

National League for Nursing (NLN)

National Nursing Centers Consortium (NNCC)

National Nursing Staff Development Organization (NNSDO)

National Organization for Associate Degree Nursing (NOADN)

National Organization of Nurse Practitioner Faculties (NONPF)

National Student Nurses' Association, Inc. (NSNA)

Nurses Organization of Veterans Affairs (NOVA)

Oncology Nursing Society (ONS)

Pediatric Endocrinology Nursing Society (PENS)

RN First Assistants Policy & Advocacy Coalition (RNFA PAC)

Society for Vascular Nursing (SVN)

Society of Gastroenterology Nurses and Associates, Inc. (SGNA)

Society of Otorhinolaryngology and Head-Neck Nurses (SOHN)

Society of Trauma Nurses (STN)

Society of Urologic Nurses and Associates (SUNA)

Wound, Ostomy and Continence Nurses Society (WOCNS)