Nursing Labour Force in the United States Health Care System

Abstract

The well-anticipated demographic change attributed to the ageing of the baby boomer population in the USA will led to a significant demand on the healthcare industry in the long run. Important resources such as the nurse work force will be required to provide quality health care services to the population. This research paper will provide a brief description and statistics of the nurse labor force in the USA, the educational requirement needed to be a nurse, the challenges face by the nurses in the healthcare system. The last part of the paper identifies the nursing shortage and the solutions for the short and long run, the recommendations and finally, the conclusion.

LABOR FORCE IN THE U.S. HEALTHCARE SYSTEM

The healthcare system in America is a complex and unique setting comparing to the other 34 countries in the Organization for Economic Co-Operation and Development (OECD). In 2016, The United States spent $3.3 trillion on health care benefits, or 10,348 per person annually, which represents17.9 % of the total GDP and remained at top of all OECD countries for the healthcare expenditures. About 30% of the cost was spent on hospital care, 20% on physician and clinical services, 10% on prescription drugs and 5% on nursing care. However, the life expectancy is 78.6 years which ranked 22^nd of the OECD countries (Medicare & Services, 2015). Meanwhile, problems such as growing population, aging and shortage of physicians and nurses are causing the increasing demand for healthcare benefits (Levit & Patlak, 2009). In 2016, there were 5,534 registered hospitals including 4,840 community hospitals in the U.S, most of the healthcare facilities are owned by private companies and 60% of the community hospitals are non-for-profit organizations, 20% are for-profit and 20% are owned by government. In U.S, the most value of healthcare system in America is the health professional, also considered as health providers (AHA, 2018).

THE NURSING WORKFORCE

According to U.S Bureau of Labor (2018), the total labor force was around 160 million. Nurses are playing an important role in the healthcare system. Nursing demographic consists of:

• 1.5 million certified nursing assistant (CNA), which represents about 1% of the U.S labor force who are responsible supporting patients’ daily activities such as taking vital signs, dispensing prescribed medications, bathing and transporting patients. Certified nursing assistant is concerned as nursing assistant as general or patient care assistant. CNA is like medical assistants that both assist physicians, nurses and such healthcare providers. Usually, CNAs are assigned in an inpatient hospital and residential facilities such as nursing home and day care centers. Till 2016, the average salary for CNA was $26,590 while VA hospitals might offer better salary, around $37,450. Alaska pays the highest average salary which was $17.81/hour while it was $11.6/ hour in West Virginia. In fact, the market expected the demand for CNAs would increase about 11% during 2014 to 2024.
• 738,000 licensed practical nurse (LPN), which represents about 0.5% of U.S labor force, who are responsible for administering injections, surgical preparation and communication between patients and physicians. LPNs also do assistant works such as recording and maintaining communication with patients, registered nurses and physicians. LPNs are directly assigned to take care of patients that keep patients comfortable. Sometime, LPNs are assigned to take blood pressure, insert catheters and such activities. LPNs usually work in hospitals, nursing homes, doctor’s offices and any healthcare facilities. In fact, LPNs are the direct contact between patients and physician that they are responsible for keep patients’ knowledge about treatment and procedures. The average salary for an LPN was $44,000 and the number is expected to increase. Connecticut state pays the highest average salary which was 24.30/ hour, comparing to the lowest paying state West Virginia with $14.25/ hour or $29,640 per year.
• 3 million registered nurse (RN), which represents the largest group of all types of nurse and 1.9% of U.S labor force, who are qualified with license to make nursing diagnoses and work as a supervisor of CNAs and LPNs. RNs work with physician and healthcare teams to improve healthcare quality and treatment quality. RNs also educate patients for their health conditions and support patients and their family members on further living. Since it is the largest group, the competition is fierce. Depending on the specialty, education and experience, the average salary was around $70,000 in 2015. Some hospitals might offer better payment to $100,000. California owns the largest number of RNs, which was around 300,000 and it pays the highest salary in America, which was $98,400 on average. The market expected a 16% increase of RNs from 2014 to 2024.
• 151,000 advanced registered nurse practitioner (ARNP), who received additional education with master’s degree or post graduate degree and additional medical experience. ARNPs work as clinical nurse specialist and nurse anesthetists that they are certified to diagnose, prescribe medication and therapy, provide treatment and counsel to patients. ARNPs are specify into multiple types such as acute care, nursing information, nurse administrator, travel nursing, family nursing, psychiatric nurse, neonatal nurse and pediatric nurse. The average wages for ARNPs was $95,000 or $46.40/ hour.

During the first decade of 21^st century, the job opportunities in the healthcare segment of United States grew with a pace of 20% while, in all other segments of the industries nationwide, the same growth was merely 3%. The growth rate has boomed in the US healthcare market, demanding for more and more registered nurses and nursing professionals in the current decade as well. These opportunities have created various job profiles so far in the evolving hospital settings. New hospitals and home care-based jobs are also emerging rapidly. “It is anticipated that the rate of employment in the health care sector will grow faster than the rate of employment in all other sectors between 2014 and 2024, with projected increases of nearly 22% and 5%, respectively. Other service sectors are projected to grow by about 8% during the same time period .” (Martiniano, Chorost, & Moore, 2017).

Currently there are more than six million of the staff available across states in the healthcare settings for RNs and NPs working in various administrative positions in United States. The growth rate is also having positive rays of hopes in terms of having future job employments because of the fact that between 2014 to 2024, it is estimated that the home care based jobs are expected to increase by 60% while jobs in the offices of the healthcare practitioners are also said to have the increase of 25% because as of now, there are more than 4 million of jobs that are available in the same position—the job positions are subjected to be vacant and filled at the same time, depending on the conditions of the nurses who are employed and leave their jobs due to unforeseen conditions (Martiniano et al., 2017).

Researches showed that there would be a 1 million shortage of RN in 2020 because of the dropping economic situation in America. In fact, the shortage has been ongoing since 1998 that it has been always a lack of supply. The supply was higher than the increase of demand. There were several reasons behind the shortage. Ageing of nurses might be the most concerned issue in recent that many nursing practitioners are getting older. Since 2012, the 50-60 year-age group represented the largest group on RNs and these group is expected to retire before 2025 but they are the ones who are the most experienced for taking care of patients (Levit & Patlak, 2009). 

The U.S government also supports foreign-born nurses in order to fill the gap between supply and demand. In 2008, international nurses represented 15% of the nursing workforce. One concern was the communication that international nurses might have problems on communicating with patients and doctors even thought they had passed the English language test such as TOEFL and IELTS. In fact, foreign-born nurses on average cost less than American born nurses and they contribute extra value on international patients (Levit & Patlak, 2009).

NURSING PROFESSION’S QUALIFICATION

With the expansion of the ACA, allowing more people access to health care and insurance coverage, and the aging of the population, which increases the nationwide rate of terminal illnesses such as heart failure and cancer, the demand for care is higher than ever and there prompts the big question of whether the current health care workforce can adequately meet that demand. To fill the obvious gap that will occur, non-physician providers will be needed. Potential candidates for the positions are no other than advanced trained nurse. In the1990s, funding for nursing education drew the attention of policymakers as people realized there would be substantial shortfalls of nurses in the next decades. Efforts to increase funding for nursing education have been intermingled with advocacy for increased emphasis on baccalaureate entry-level education. In the past, many RNS were educated in hospital-based diploma programs, but most of these programs has been converted to associate or bachelor’s degree programs. The shift in nursing education from hospitals to universities marked the importance of the body of knowledge that the nursing profession should possesses. More essentially, it defined nursing as something much more than assistant to the physician. As an effort to alleviate a looming cycle of nursing shortage, community colleges and technical schools started offering nursing program in the 1970s. Since then, the nursing education has greatly evolved to better prepare their students for the ever-changing and challenging world of health care system.

The two most common paths for people pursuing a nursing degree is either obtaining a 2-year associate degree (AND) or a 4-year baccalaureate program (BSN). Many community and technical colleges offer ADN programs and they are more attractive to prospective nurses because of their affordability and a shorter time period to finish. Graduates from the programs are qualified to sit for the National Council Licensure Examination for Registered Nurse (NCLEX-RN). This type of program provides a solid foundation for entry-level nursing positions at a wide array of health-related establishments, including hospitals, primary care clinics, and nursing homes. In addition, nurses can later register for the RN-to-BSN bridge programs to obtain their BSN. The 4-year BSN, while more time consuming, opens up more opportunities for nursing students upon their graduation. BSN candidates receive intensive training not only in the clinical field, but also in leadership and communication skill. The goal is to provide more professional development to their students through a comprehensive curriculum that covers some of the most pressing issues within the profession, such as public health, social sciences, nursing research, and management and leadership. Most of nursing programs are not recommended to be taken online as they are hands-on profession. Averagely, nursing program costs $15,000 per academic year (Registered Nursing Degrees, 2018).

In the 1990s, nurses once passed their board licensing received the same licenses and often hired to perform the same jobs. Their background education, whether they had an associate degree (ADN) or a baccalaureate degree in nursing (BSN), did not differentiate the task they performed in any health care facility. While the practices and educational differences between ADN and BSN were proven to exist, there was a general but often weak correlation in patient outcomes based on the initial education preparation of the RN providing the care (Kovner & Schore, 1998). A meta-analysis done in 1988 by Joyce Johnson pointed out that BSN RNs attained higher scores in the field of communication, problem solving, and professional role when compared with AND RNs. Contrariwise, these associations decreased when experience was taken into account, and no distinguishing result existed in measuring level of leadership and autonomy between BSN and ADN RNs. Time has changed and so as the complexity of the health care system. The role expectations and educational outcome differences for ADN and BSN has been more clarified. Although the health care system required nurses prepared at both levels of education, the graduates of these programs hold different competencies and should be valued for those differences (N/A, 1995). A study done in 2003 further proved this notion by showing the connection between higher levels of nursing human capital and improvement in patient outcomes – a 10 percent increase in nurses with baccalaureate degree yielded a 5 percent decrease in patient mortality and complications (Kutney-Lee, Sloane, & Aiken, 2013). This clarification in the roles of ADN and BSN nurses are vital to the delivery of high quality care and require the restructure of their education curriculum as well as validation in the systems in which these graduates are employed.   

ISSUES IN THE NURSING LABOR FORCE

Like many other health care professional, the nursing workforce has many problematic areas that need to be resolved. One of the most pressing one is the shortage in labor force. The Patient Protection and Affordable Care Act (ACA) since its enactment in March, 2010, has successfully provided insurance coverage for around 19.2 million people and dropped the number of uninsured population from 20.5 percent to 12.2 percent in 2016 (Garrett & Gangopadhyaya, 2016). This influx of new patients has driven up the demand for nurses with the U.S. Department of health and Human Services projected a shortfall of over one million nurses by 2020 (DHHR, Resources, Workforce, & Analysis, 2017). However, the current state of the workforce is gradually depreciated due to several factors. The aging baby boomer nurses reaching their retirement ages contributes as the first factor in this shortage crisis. This aging workforce has been dealing with increasing pressure due to higher work demand resulted from nursing shortages, and their health suffers tremendously with a significant higher number of senior nurses experiencing chronic pain, tiredness, and exhaustion among the group (Gabrielle, Mannix, & Jackson, 2008). An obvious fix to this problem is to increase the number of qualified nurses in the labor market through nursing school recruitment campaign. Unfortunately, the majority of nursing schools nationwide do not have the capacity to accept new candidates due to a lack of faculty, budget constraints and limited clinical sites for students to practice. While all schools reported reaching their full capacity and even going over their students limit each year, many applicants got rejected, with 78 percent of ADN applicants and 62 percent of BSN candidates, all of them had qualified credentials, were turned away from nursing school in 2016 (Nursing, 2016). This would directly reduce the chance to generate enough nursing graduates to meet the upcoming demands facing the health care industry. Beside the restricted nursing enrollment rate, health care providers only preferred nurses who already had several years of experience and turned down many potential applicants only because they newly graduated. Another realistic alternative to fill the gap in nursing staff is by hiring foreign-educated nurses. However this solution is poorly received since it stirs up concerns regarding the level of competency of nurses trained outside the U.S. and immigration issues (Williams, 2014).

A shortage of nurse will ultimately lead to a change of nurse staffing pattern in care centers, with one nurse tending for more patients. A study by Cummings and Estabrooks (2003) pointed out the negative effects the change in nurse staffing patterns had brought upon the remaining nursing staffs’ health and their competency to provide quality care. Other research literature also reported imbalance nurse staffing pattern can drive up the rate of preventable medical errors and adverse events (e.g. hospital-acquired pressure ulcers, wrong blood transfusion) (Cho, Ketefian, Barkauskas, & Smith, 2003). The predominant effects of hospital restructuring on nurses are mostly negative with a decrease in efficacy and ability to provide quality care, reduction in job satisfaction, and disparity in teamwork among care providers, which resulted in an increase in turnover rate.

Cost containment initiatives in many health care establishment can also further deplete the nursing workforce. The U.S. health care expenditure has skyrocketed over the past decade and accounted for 17.9 percent in the overall share of gross domestic product (GDP) and more than $10,000 per capita in 2016 (Llanos & Rothstein, 2007) (CMS, 2016). Regardless, the U.S. index for health care outcomes such as life expectancy, maternal mortality, child and infant mortality are far behind other OECD nations (Institute of Medicine, 2007). As a result, several health reform programs were introduced in an attempt to increase access-to-care for the population, reduce the health care cost, and improve the quality of health care. The implementation of these pilot programs put tremendous pressure on health care providers and organizations to contain their cost while maintaining optimum treatment to their patients. Many care facilities decided to restructure their workforce by decreasing the overall labor pool. As one of the largest personnel group in the health care workforce and oftentimes claimed for the largest piece of the hospital budget pie, approximately 33 percent of hospital operation cost (Walston, Burns, & Kimberly, 2000), nursing positions were the primary target for cost-containment strategies in many organization. The result was an increase in substitution for lower credential nursing position, such as Licensed Practical Nurse which only required two years of associate degrees, or even unlicensed personnel like patient-care technicians. This shift in work force in the 1990s, however, had driven up the rate of medication errors, patient injuries and infection (Kunen, 2001).

To better adapt to the ever changing environment of health care bureaucracy and population health priorities with finite capital and human resources, all health-related establishments should develop strategies with emphasis in organization and culture restructure that has positive impact on the outcomes of patients and nurses. Beside financial incentives, political advocacy from both the federal and state government, as well as professional opinion and standard setting can further make changes to the recruitment and retention of qualified nurse workforce.

THE GOVERNMENT’S EFFORT IN SOLVING THE ISSUE OF NURSE SUPPLY

One of the problems the healthcare system in the U.S. is facing is that of shortage of nurses. Some factors which contribute to this shortage is the fact that women have more options in choosing their career path in society today when compared to the past. From an economic point of view, this problem of shortage is cause more by the supply side rather than the demand side thus, making it a more complex shortage (B. & J.I., 2001). This shortage of nurses might worsen in the long run if the government do not develop and implement solutions to solve this problem. Some economic solutions where developed in the past to help solve this problem such as relocation coverage, new premium packages and sign on bonuses; however, they were all short-term solutions which helped in redistributing the supply of nurses instead of increasing it (B. & J.I., 2001). Due to the shortage of nurses in the healthcare system, the government has developed and implemented solutions which will be examined below.

The government is trying to recruit more students and educators in the nursing field to combat with the increasing demand in the workforce. For some years now, recruitment of students in the school of nursing has been declining. According to the American Association of College of Nursing, the number of nursing students who enrolled in the bachelor’s degree program had been declining in the past five years (Larson, 2016). In 1999, the number of nursing students felt by 4.6% nationwide. Nursing master program also suffered the same fate with a decline of 1.9% in some states (Larson, 2016). To better utilize the current aging workforce, healthcare circles decided to recruit the old and retired practicing nurses who can no longer administer treatment to the growing population and appointed teaching positions to them in nursing schools. They came to a conclusion that this ageing nurse’s will better teach the students as they are teaching out of experienced and it is said experienced is the best teacher (Johnson et al., 2006). Practice and experience are two important factors that teachers most acquired in order to teach students effectively.

Also, in San Diego, six hospitals donated $ 1.3 million to support a program known as “Nurses Now”, which will be an opportunity to add faculty members and additional nursing students in the San Diego University (Costantini, 2016). Moreover, in order to support students to do nursing, the Texas hospital donated $ 425,000 in scholarships to local students to do their bachelor’s degree program in nursing. Moreover, in New Jersey the Board of Free holders donated scholarships to local students who accepted to work in the long term care facility in the USA (Costantini, 2016). These are examples of some successful collaborative efforts between healthcare organizations, nursing schools and the USA government to help solved the problem of nursing shortage in the USA.

Moreover, in order to solve to problem of shortage, hospitals are re-implementing intensive training programs for nurses in various specialities. This has gone a long way to retain nurses who are seeking for a transfer and has also help build a vocation development path for nursing staff. A research that has been done on Magnet hospitals indicate that some of the organizational characteristics that create a centre of attention and retain nurses are professional practice models for delivery of healthcare with independence and responsibility to make decisions (B. & J.I., 2001). Moreover, effective managerial structure, quality patient services and investment in nurses’ professional development in the healthcare system are very necessary and important. Nurses must be involved in developing and implementing the practice of care in hospitals since they are very close to patients. Some of this practise includes; participating in the financial management of the hospital and developing new strategies in hospitals. If healthcare leaders developed intensive programs for nurses in each specialities, it will motivate them to realize that they are very important in the healthcare system thus, encouraging them to remain in their various specialities in nursing.

Furthermore, healthcare leaders need to developed models of care in order to solve the problem of nurses shortage in the USA, the government need to implement regulatory and policy issues (Johnson et al., 2006). Some regulatory and policy problems could also cause the nursing shortage such as federal and state laws, licensure and nursing practice act, and requirements from reimbursement organizations, private organization and the government (Johnson et al., 2006). Inside an organization, insistent process developments initiatives can assist standardize and simplify documentation. Healthcare leaders should drive this problem with some consultation from some internal experts in reimbursement, patient documentation and risk management.

Furthermore, nursing trainers should use technology as one of the training tool. Although most of the section in nursing learning is clinical experience, most of the classroom teaching can be done through the new technology we have today such as internet teaching, distance education, and accelerated educational programs. As the healthcare of patients become more associated to technological improvement, routine nursing performance can drilled by utilizing the same technology. Technology improvement could also be use to test and certified nursing educators (Larson, 2016). All these new methods of teaching nurses through technology advancement will motivate younger adults who like using the internet and other forms of technology to learn to join the nursing field thus, helping to solve the problem of nursing shortage.

In addition, to help solve the problem of nurse shortage in the USA, healthcare leaders should concentrate on training our own nursing and retaining them from traveling to other countries such as Canada. One good approach to solve this problem is to employ bachelors and masters students who are already in the faculty programs and provide them with qualified training and prepared them as well-trained nurses to be employ in the nursing field (Buchan & Aiken, 2008). Guidance into the clinical faculty is one of the best in this context, and this will improve nursing student’s capacity to do their work in the nursing field efficiently. The main idea is to guide them to grow into the nursing profession and eventually make nursing their profession of choice. This strategy will work well to the nursing field advantage because, it will encourage students to choose nursing as a career thus, increasing the number of nurses for the future.

To continue, to solve the problem of nursing shortage in the USA, the government should augment the supply of nurses by using tax credit. For example, three bills where pass to permit the creation of refundable tax credit for all register nurses (Johnson, Posner, Biermann & Cordero, 2006). This is a positive impact that would have help retain nurses in the profession and it will also help to increase their salaries. Moreover, it will motivate them to maintain their various positions in hospitals thus, working positively in reducing the problem of nurse shortage in the USA.

More so, in order to solve the problem of nursing shortage in the USA, hospital managers should offer bonuses to nurses who accept and sign up to work in that hospital for a long period of time. For example, in St. Paul hospital in Minnesota, the hospital leaders are giving out bonuses of about $8,000-$10,000 to nurses with essential care experience who have sign up to work in the hospital for a long period (Larson, 2016). This strategy has help St. Paul hospital to keep most of it nurses. If more hospitals could adopt this method, it will help solve the problem of nurse’s shortage in the USA.

Moreover, in order to solve the problem of nurse shortage in the USA, the government need to increase the salaries of nurses. The work load of nurse’s especially register nurses is much as they are the ones who spend most of the time taking care of patients (B. & J.I., 2001). Most of them leave the nursing field because they are not well pay for the work they do and most of the time, some are not pay for the extra work they do. In order to solve this problem, the USA government has increased the salary of nurses for example in California; the salary of register nurses went up to $94, 120 per year (B. & J.I., 2001). This has motivated many people to join the nursing field. According to experts’ projections from the Bureau of Labour Statistics, by 2022, the nursing field will experience an increase in the number of register nurses of about 526,800 (B. & J.I., 2001). This is a good sign for the healthcare field for the future – absolutely a field with good prospects.

ALTERNATIVES FOR THE SHORTAGE IN NURSING SUPPLY

Nurses form an essential part of the working force in the healthcare system in the USA and the great role they play cannot be ignored. This explain why the USA government, over the years have been trying to solve the problems nurses are facing in the healthcare system in order to motivate more people to join the nursing field. Due to all this, some recommendations are made to help improve the nursing working force.

One of the recommendations is that, healthcare leaders should change consumers’ knowledge of healthcare services. Most patients like meeting register nurse for them to take care of them whereas; they are other nurses in the hospital who can take care of them better. Healthcare leaders’ need to change this perception some patients have concerning the choice of nurses.

More so, some patients believe that nurses who are well paid do the work better than nurses who are less pay. That is why patients keep traveling from one state to another in order to seek for hospitals where nurses are been well pay. For example, most Americans travel to big states such as California in order to receive treatment from physicians and nurses. This believes is not good because it creates nurses shortage in big states compare to small states (Costantini, 2016).

The USA government should develop and implement public health programs that will help educate the population on how to prevent certain illnesses. This will help reduced the number of people who get sick, thus reducing the number of patients, nurses have to take care of. People should do more of physical activities and eat healthy in order to avoid unnecessary illnesses which could be avoided by doing this. Also, the population should be sensitize about the problem of nursing shortage in the country. This will motivate them to take good care of themselves in order to avoid falling sick.

Based on the execution of these recommendations, it will assist to achieve healthy people 2020 objectives. These recommendations are strategic plans that can be utilize by the government, people, private and public health providers and communities to improve the health of the population thus making the USA government to achieve its goal of healthy people 2020.

CONCLUSION

Nurses play a very significant role in providing medical treatment to patients and they also help to re-enforce the physician’s shortage labour force in the USA. Many health care organizations can not do with out nurses as they play a significant role. If the shortage of nurses worsens, many patients will no longer have access to care thus, creating a huge problem in the country. The USA government need to take the problem of nursing shortage in the country very serious as the baby boomer nurses retirement will cause a serious shortage. With the fast growing population of America, as many immigrants are coming in, it is necessary for the USA government to attract more nurses into the health care system. It there is surplus of nurses in the country, it will help the government, Medicare & Medicaid and other health organizations contain healthcare cost which is very expensive. It will also increase quality and access to medical care.

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