Workforce Trends among U.S. Registered Nurses

A Report for the International Council of Nurses ICN Workforce Forum
Stockholm, Sweden
September 21-October 1, 1997

by Beverly L. Malone, PhD, RN, FAAN
President, American Nurses Association

and

Geri Marullo, MSN, RN
Executive Director, American Nurses Association

Introduction

The culture of health care in the United States continues to undergo deep and rapid transformation. Restructuring and corporatization of the health care industry are changing, among other things, how health services are financed and delivered. While the system that is emerging is not yet fully evolved, aspects of the new paradigm are starting to become clear. Chief among these is the growing dominance of a market-driven health system whose defining characteristics are cost cutting, reduced utilization of services, and maximization of revenues and return on investment. The impact of cost containment pressures, in turn, is raising fears that the quality and safety of the nation's health care is eroding even as nurse staffing levels and skill mix are shortchanged for short-term profits and workplace health and safety problems mount. In this context registered nurses continue to advocate for their patients as well as for fair and equitable compensation.

Trends in Remuneration Strategies

Two previous reports by the American Nurses Association (ANA) for Remuneration Network meetings provided a broad outline of the key elements of RN compensation in the United States, namely, wages, differentials, health insurance, pension benefits, work schedules, paid and unpaid time off, and tuition reimbursement. Other economic benefits commonly sought for the 17.9 per cent of U.S. registered nurses represented for purposes of collective bargaining include life and long-term disability insurance, layoff and recall protections, successorship language, promotion criteria and limits on the use of casual or "agency" RNs. Additional negotiated reward strategies include limitations on involuntary shift rotation, provision of voluntary permanent shifts of choice, and limitations on both the number of weekends and holidays worked and on involuntary temporary assignment to other patient units.1

The union "premium" for registered nurses as measured in mean weekly earnings and mean hourly earnings remains substantial. In 1996 unionized registered nurses had mean weekly earnings of $742 and mean hourly earnings of $20.85 compared to $637 and $18.11 for non-unionized RNs. The union "premium" for 1996 was 16.5%. By comparison, over the past decade the difference between union and non-union mean weekly and mean hourly earnings, i.e., the union "premium," was 10.2% in 1986 and 15.3% in 1991.2

Two recent developments affecting RN remuneration are the focus of this report: (1) RN compensation systems that threaten to diminish standards of nursing practice, and (2) the impact on employee rights of privatization of public health facilities and the conversion of not-for-profit health care facilities and insurers to for-profit tax status.

As previously reported to the Remuneration Network, the 1996 ANA House of Delegates (HOD) adopted a resolution calling for the investigation of RN compensation schemes that may encourage the misuse or misappropriation of nursing services which could undermine nurses' professional responsibilities to their patients. In response to the HOD action ANA surveyed its fifty-three constituent state nurses associations (SNAs) to determine the prevalence of these types of compensation systems and developed a preliminary framework of questions to evaluate the ethical, legal, labor and practice implications of such systems.

The survey of SNA executive directors and Economic & General Welfare program directors revealed some limited activity with "gain-sharing," "at risk" or other similarly named incentive or performance-based pay systems. Generally, the SNAs reported that employers were proposing "gain-sharing" arrangements which focused on controlling or reducing costs, improving patient satisfaction, and improving quality and enhancing teamwork. Under these arrangements, RN compensation was linked to company-set targets such as decreased cost per adjusted discharge, decreased length of stay, decreased nosocomial infections and increased patient satisfaction. Some of the "gain-sharing" arrangements were limited to registered nurses; others included all company employees. Some of the proposals did not entail loss of wages if employer-set targets were not met. In another instance the incentive arrangement, which focused primarily on advanced practice registered nurses (APRNs), called for APRNs to put 10% of salary "at risk" and share in the positive or negative results of the corporation. On the whole, the proposed incentive systems did not specify precise targets or spell out either the standards of measuring economic gain and patient satisfaction or the criteria by which "gain" would be shared.

The SNAs reported caution and skepticism toward these systems and have made it clear to employers that they intend to be vigilant in monitoring the impact of "gain-sharing" programs on nurses and patients.

Besides the practical questions related to implementing such schemes, there is a more fundamental question at issue: where is the dividing line between professionally acceptable and unacceptable compensation systems? Such a determination calls for an understanding of the ethical, legal, labor and practice implications of various RN compensation systems. To assist registered nurses understand and evaluate "gain-sharing" or other incentive or performance-based programs, ANA developed a framework of questions to provide context and guide analysis. The following list is meant to be supplemented and modified as necessary.

Ethical

  • Are all financial incentives related to nursing compensation inherently unethical? If not, what are the circumstances under which they might be unethical?
  • Do particular compensation systems, e.g., those involving salary withholds, create greater conflict between the interests of patients and the interests of registered nurses? Are compensation systems which tie an RN's base salary to employer-set targets more ethically suspect than those with bonus options related to patient care? What about arrangements where reduced wages can be won back if production and/or quality targets are met?
  • How might compensation systems affect the longstanding ethical values of the nursing profession including benefiting patients, preventing harm, patient advocacy, loyalty, a trusting patient-nurse relationship and independent professional judgment?
  • Is there an obligation to disclose the nature of the compensation arrangement to the recipients of care? If so, how and by whom should the patient be informed of the financial situation?
  • What can registered nurses do, individually and collectively, to maintain professional integrity when dealing with conflicts of interests in financial incentive systems?

Legal

  • What are the legal ramifications of various compensation systems? Can registered nurses be required to comply with such systems?
  • Are there legal protections for RNs who refuse to participate in a particular compensation system because of concern over the quality and safety of patient care?
  • Are there safeguards in place within compensation systems including prospective and retrospective review and monitoring mechanisms? Does the health plan/institution promulgating a particular compensation system have a routine procedure to scrutinize the impact? Are there grievance processes available?

Labor

  • Are gain-sharing/incentive pay adequate substitutes for base pay and cost of living increases?
  • Does the collective bargaining agreement protect the needs of the patient as well as the financial interests of the RN?
  • How are "performance targets" defined and measured? By whom? How much influence or control do registered staff nurses have over measures such as length of stay?
  • Does the collective bargaining agreement stipulate limits to the percent of income that can be involved and that financial remuneration be calculated for group rather than individual achievements?
  • Does the collective bargaining agreement under which "gain-sharing" is negotiated provide an option to discontinue the program if it is determined to be professionally compromising?

Practice

  • How can compensation arrangements that promote patient welfare (or at least have no detrimental affect) be distinguished from those that jeopardize patient well-being?
  • Does changing the financial risk of the registered nurse precipitate and/or force changes in practice?
  • Do financial incentives foster inappropriate limits in care and decision-making to benefit the nurse's financial self-interest rather than patient welfare?
  • Is the compensation arrangement tied to the withholding of necessary nursing care? Who decides what is necessary care?
  • How is the quality of care affected by "gain-sharing" or incentive pay? Are there aspects of nursing care that might be lost to the patient because they are not rewarded by the incentive system?
  • Are the financial incentives related to the quality of patient care (e.g., using quality indicators as a measure) or to the quantity of services rendered?
  • Can the standards of nursing practice be promoted and protected under the compensation system?

ANA is closely monitoring these emerging compensation systems and is encouraging its SNAs to raise the visibility of this issue with their councils and cabinets. At the same time ANA continues to further clarify ethical, legal, labor and practice implications related to incentive proposals, in particular, how they may affect both the RN-patient and RN-employer relationship.3

Another dramatic trend underway in the U.S. health care system is the change in ownership status of hospitals, health systems and health plans. This includes the privatization of public (i.e., government-owned) facilities and the conversion of not-for-profit hospitals, health systems and health plans to for-profit (i.e., investor-owned) status through sale, merger or various other means. Both privatization and for-profit conversions raise serious questions about the rights of the affected registered nurse employees. For example, privatization of public facilities might lead not only to the shredding of the health care "safety net" for the poor, the uninsured and other underserved groups but also may deprive registered nurse employees of civil service standing and benefits and other rights related to public employment. Similarly, for-profit conversions must not be used as occasions to slash wages, cut pensions, benefits and seniority, reduce RN utilization, jeopardize the quality of patient care, and/or undermine or eliminate collective bargaining. Registered nurses are understandably wary that investor-owned, profit-driven health care gives priority to stockholders over stakeholders which, in turn, erodes commitment to quality health services and produces a more adversarial workplace environment.4

ANA supports careful public oversight of privatization and conversions of nonprofit entities to for-profit status in order to ensure continued access to affordable, quality health care, including the maintenance of uncompensated care; a fair accounting of the assets of the entity being privatized or converted; and an assurance that converted assets are used to maintain and improve access to affordable, safe and quality health services. The rights and benefits of employees must also be carefully safeguarded in any privatization or conversion move. In addition, ANA urges that all hospitals, regardless of ownership or tax status, must be held accountable for the delivery of safe, quality services and should be required to disclose data regarding staffing, patient outcomes, cost and delivery of uncompensated care. Continued data collection will be necessary to guide further development of public policy to address privatization and for-profit conversion.5

Trends in Supply and Demand

Statistical Profile

Registered nurses are the largest group of health care providers in the United States. According to the most recent National Sample Survey of Registered Nurses (NSSRN, March 1996) an estimated 2.55 million individuals hold current licenses to practice as RNs. Of these, some 2.11 million (82.7%) are employed in nursing. This represents are increase in the total RN population of more than 300,000 since 1992 (the year of the last national sample survey) and an increase of more than 260,000 registered nurses employed in nursing. While the proportion of the total registered nurse population that was working in nursing positions remained the same in 1996 as in 1992 (i.e., 82.7%), a larger percentage of RNs employed in nursing were working full-time: 71.4% in 1996 compared to 68.9% in 1992.6 The data listed below indicate the total RN population, the number and percentage employed in nursing, and the percent working full-time and part-time for the past sixteen years.7

Year Total Nurse Population Number and Percent Employed in Nursing Percent F/T and P/T Employed in Nursing
1980 1,662,382 1,272,851 76.56% 68.2% 31.8%
1984 1,887,697 1,485,725 78.70% 66.3% 33.7%
1988 2,033,032 1,627,035 80.02% 67.6% 32.4%
1992 2,239,816 1,853,024 82.73% 68.9% 31.1%
1996 2,558,874 2,115,815 82.68% 71.4% 28.6%

The RN population continues to age. The average age of all registered nurses in 1996 was 44.3 years, up from 43.1 in 1992. Among those employed in nursing the average age was 42.3 years. The profession is still predominately female and white. Among the 2.11 million employed RNs in 1996 an estimated 113,683 or 5.4% were men, an increase of 1.1% since 1992. About 90% of the total nurse population is white (nonhispanic); 4.2% African-American (nonHispanic); 3.4% Asian/Pacific Islanders; 1.6% Hispanic and 0.5% American Indian/Alaskan Native. In 1992 about 9% of the total RN population came from racial/ethnic minority backgrounds.8

According to NSSRN data, the average annual salary of an RN employed in nursing on a full-time basis in 1996 was slightly more than $42,000, an eleven percent increase over the average salary of $37,738 in 1992. RNs in staff nurse positions averaged an annual salary of $38,567 in 1996, an increase of 9.5% since 1992.9

In regard to educational preparation, of the 2.11 million registered nurses employed in nursing: 58.4% had less than a baccalaureate degree as their highest nursing-related educational preparation; 502,959 had diplomas and 731,613 an associate degree. An estimated 672,914 or 31.8% had a baccalaureate degree as their highest preparation. Those with a master's degree totaled 193,159 (9.1%), and those with doctorates accounted for 14,300 (0.6%) of the total. These data show a slight movement since 1992 when 31% of employed registered nurses had a baccalaureate degree, 31% had an associate degree and 30.1% were graduates of diploma programs. Nurses who had earned masters degrees accounted for 7.4%, doctorate-prepared, 0.5%.10 Of the total RN population in 1996, approximately 161,711 or 6.3% had formal preparation to practice in advanced nursing positions, with the following breakdown among types: 7,802 were prepared to practice as either a clinical nurse specialist or nurse practitioner; 53,799 as clinical nurse specialists; 63,191 as nurse practitioners; 30,386 as nurse anesthetists; and 6,534 as nurse-midwives.11

Enrollment of nursing students in entry-level bachelor's degree programs dropped by 6.2% in the 1996-1997 academic year compared to a year ago. This follows a decline of 2.6% for the 1995-1996 academic year compared to the previous year. Master's degree enrollments, which had risen steadily in recent years, also declined for the first time since 1988, down 3.4% in fall 1996 from a year ago.12

Supply, Demand and Need

Although another RN shortage cannot be ruled out, especially in light of the aging of the RN workforce, at present the U.S. appears to have an adequate aggregate supply of registered nurses to meet the nation's current and near-term demands.13 The average annual increase in the estimated active supply of registered nurses between 1980 and 1994 exceeded 55,000, and the total number of RNs per 100,000 population also grew from 560 to 793 during that same time.14 Between 1991 and 1995 more than 433,000 students graduated from nursing programs.15 The continued enlargement of the RN labor pool in the face of an already tight RN labor market accounts in part for the recent decline in nursing enrollment.16

During the past few years health researchers and policy makers have refocused their attention on the balance between RN "supply" and "demand" and on the tug of war between "demand" and "need" for health services. Questions about an adequate supply of registered nurses, economic demand for their services and the concept of "need" of health care are not new. What is new is the spotlighting of these issues by the tremendous cost containment pressures roiling the health care industry, and the promise of managed care to stanch and even reverse rising health care expenditures. Since the debate over RN supply centers more on educational background than on aggregate numbers, this report now looks at two recently published studies dealing with RN demand and then contrasts them with the "needs" approach to health care proposed by ANA.

In November, 1995, the Bureau of Labor Statistics (BLS), U.S. Department of Labor, released its latest employment projections by industry and occupation for the period 1994 to 2005. "Health Services" is among the ten industries with the fastest projected job growth, and "Registered Nurses" ranks fifth in the top ten occupations with the largest projected job growth. According to the BLS, under a moderate growth pattern some 473,000 RN jobs (a 25% increase overall) will be added to the economy during this eleven year period, even accounting for the restructuring currently transforming the health care industry.17

A closer look at the data reveals a rise in RN hospital positions of 12.5% or an average annual increase of 1.14%. Of particular note is the fact that the number of RN hospital jobs as a percentage of the total number of RN jobs in all employment settings is projected to decline -- from 63.8% in 1994 to 57.4% by 2005. This projection is consistent with the 1996 NSSRN data which show a 6% decline since 1992 in the proportion of employed RNs working in a hospital setting 18 and with anecdotal reports that RN hospital in-patient employment is shrinking as hospitals reduce their utilization of RNs and replace them with ancillary personnel.

BLS makes similar projections for RN home health and nursing home positions. In home health BLS projects a 127% increase over the eleven year period for an average annual increase of 11.55%. RN home health positions as a percentage of the total number of RN jobs in all employment settings are expected to rise from 5.95% in 1994 to 10.8% by 2005. The numbers are similar if less dramatic for nursing homes. BLS projects an increase in RN positions of 77% between 1994 and 2005 (an average annual increase of 7.0%) and a rise of RN nursing home jobs as a percentage of total RN jobs from 5.8% in 1994 to 8.2% by 2005. (These data exclude self-employed registered nurses.) Again, the 1996 NSSRN findings are consistent with the BLS data.19

The BLS projections are widely used for studying long-range economic and employment trends, and thus can serve as an important benchmark for addressing long-term trends. However, they do not clearly indicate RN demand or employment shifts in the short-term. The utility of the data, therefore, is limited. Furthermore, given the speed and scope of change in health care that have occurred just in the past few years, it is reasonable to question the overall accuracy of projections that span more than a decade. In sum, while the BLS projections offer a useful standard for examining long-range trends, they are much less helpful for looking at RN demand in the next few years, nor are they sufficiently sensitive to record the rapid and deep changes affecting today's nursing workforce.

In November 1995, the Pew Health Professions Commission released a report entitled "Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century." Among its various recommendations the Commission called for the closing of 10-25% of nursing schools based on its projection of a surplus of 200,000 to 300,000 nurses. The latter projection itself is based on a prior Commission projection that by the end of the century "as many as half of the nation's hospitals" will close with a resultant "loss of perhaps 60% of hospital beds."20

While there is much in the Pew report that ANA credits and supports, ANA takes issue with the Commission's failure to explain the basis of its nursing workforce projections. For example, what assumptions did the Commission use to project an RN surplus (read unemployment) of 200,000 to 300,000? If, as it appears, this projection is based largely on the Commission's prediction of hospital closings, one might properly inquire about the Commission's projection of a near 50% drop in the number of U.S. hospitals by the year 2000. In 1994, the year when America publicly debated national health care reform, the number of hospital closings hit a 14-year low -- just seventeen (17) hospitals, down from thirty-four (34) in 1993, stopped providing acute care services. This marked the sixth consecutive year that the number of acute care closings dropped since 1988, when 85 shut their doors.21 (Perhaps one reason for the continuing decline in closures is the fact that aggregate profits earned by acute care hospitals in 1994 hit a record high of $13.8 billion.22) According to statistics of the American Hospital Association, there were 5,256 nonfederal short-term general and other special hospitals in the United States in 1994. Assuming no hospital openings between 1994 and 2000, more than 2,600 hospitals (or some 433 hospitals a year) would have to close to approximate the Pew Commission's projection. This seems highly unlikely. While no one can claim to predict accurately the precise pace of hospital closings, at the very least, the Commission's lack of specificity about the source of its data and the assumptions behind its projections raise serious questions about its validity.

ANA supports a balance between RN supply and demand, but it also believes that any assessment of the nation's health care future or projections about the RN workforce must begin with an analysis of the health care needs of the American people.

ANA's assessment of the nation's health care system and the role of the registered nurse in that system stands in sharp contrast to the market's demand approach which is failing to provide safe, affordable, quality health services to millions, especially to aging Americans, the mounting numbers of uninsured and underinsured, and to disease-specific populations. Rather than demand, ANA proposes to examine nursing workforce requirements as determined by the actual and emerging health needs of the American people and articulate how an adequate number of appropriately prepared and properly utilized registered nurses can meet these needs.

ANA's needs-based approach, reflected and articulated previously in Nursing's Agenda for Health Care Reform (visit here for current agenda,)23 runs counter to the current direction of health care restructuring. It allows organized nursing to argue for policies and measures to meet the immediate and anticipated health needs of the American people with an adequate number of appropriately prepared RNs distributed across all care settings. In this way ANA and the nursing profession can continue to meet their responsibility to focus on the reality of the American people's health needs while at the same time assist registered nurses in managing the employment challenges posed by the rapidly changing health care environment.

Negotiating Tools

Registered nurses and the associations representing them have long understood the link between quality RN care and positive patient outcomes. There is a growing body of nursing research that ties higher RN staffing levels with positive patient outcomes such as lower mortality rates, fewer complications, reduced lengths of stay and lower costs.24 While much evidence has already been published indicating that outcomes of care delivered by RNs include fewer incidents of mortality for persons over age 65 when those individuals are hospitalized in RN-rich acute care settings,25 there is need to document the full range of outcomes resulting from RN-delivered care. Substantiating this connection and assuring that it become the guidepost for reengineering and redesigning the health care workplace remain ANA priorities.

Articulating the value of nursing with "hard" data is difficult because nursing-sensitive quality measures, i.e., yardsticks that measure the influence of nursing interventions on a given patient outcome, are generally not included in the quality and outcome data usually reported by the nation's hospitals and health care facilities, even though most acute care hospitals collect such data because of government mandate or other requirements. Typically, these data are treated as proprietary information which makes it difficult for the public to understand how changes in health care delivery affect cost of health services and possibly compromise patient safety.26

In 1994 ANA and its constituent members began a major initiative to identify a set of nursing-sensitive quality indicators focused on acute care. The indicators include nosocomial infection rate, patient injury rate, patient satisfaction, maintenance of skin integrity, nurse staff satisfaction, mix of RNs, LPNs, and unlicensed staff caring for patients in acute care settings, and total nursing care hours provided per patient day. (Work on a set of similar indicators for community-based nursing is underway.) Along with various pilot studies of these indicators, ANA commissioned an additional study to measure the relationships between RN staffing and RN skill mix and selected adverse patient outcomes such as pressure ulcers, hospital-acquired pneumonia, urinary tract and post-operative infections. Length of stay was also analyzed in relation to staffing variables. The study concentrated on three states (New York, California and Massachusetts) for two years (1992, a year following the most recent nursing shortage and 1994, the most recent year for which data were available.)27

Two principal findings emerged from the study. First, shorter lengths of stay were found to be strongly related to higher nurse staffing per acuity-adjusted day, and second, patient morbidity indicators for preventable conditions, e.g., urinary tract infections, were found to be inversely related to RN skill mix and, to a lesser extent, nurse staffing per acuity-adjusted day.28 In sum, the study supports ANA's long-standing contention that registered nurses contribute significantly to achieving positive patients outcomes leading to both the discharge of healthier patients and lower costs for the health care system.

Much more research needs to be done, but the ANA study offers an example of how to articulate nursing's value. At the same time, it provides a guide to health system restructuring that would assure patient safety and achieve quality health care.

As a negotiating tool, the collection and reporting of standardized data across indicator sets would go a long way toward "proving" the value of nursing at the collective bargaining table: in financial terms (cost containment and reduction), in economic terms (the benefit of employing registered nurses over less expensive but less qualified licensed and unlicensed personnel), and in patient outcomes.

Data Collection and Analysis of Workforce Statistics

During the 1996 Network meeting, the National Nurses Associations (NNAs) recognized the need to gather and share statistical information about nursing personnel and, more broadly, health economics, in order to better understand emerging workforce issues. The NNAs agreed that collecting and analyzing such data were essential to influence public opinion toward nursing's agenda. As noted above, ANA's quality indicators initiative represents an important step in that direction.

ANA is also marshaling support for its legislative proposal entitled the "Patient Safety Act of 1997" which was recently introduced in the United States Congress. The bill focuses on safety, quality and workforce issues for registered nurses who are employed by health care institutions and their patients who receive care in those institutions. Specifically, the legislation requires health care institutions which participate in the Medicare program (a nationwide, federally administered health insurance program for those 65 years of age and older and for other eligible persons) to release statistical information on staffing levels, skill mix and patient outcomes. At a minimum, health care institutions must make public the number of registered nurses providing direct patient care; the number of unlicensed personnel utilized to provide direct patient care; the average number of patients per registered nurse providing direct patient care; the patient mortality rate; incidence of adverse patient events; the methods used for determining and adjusting staffing levels and patient care needs; data regarding complaints filed with an appropriate agency and the results of any investigations or findings related to the complaint. "Whistleblower" language in the act protects registered nurses from termination and other acts of retaliation for reporting or voicing concern about poor staffing.29

The legislation also addresses the impact of mergers and acquisitions of health care facilities on the local community. It requires an institution seeking to merge or acquire another institution to report the impact of the merger on the availability and accessibility of primary, acute care and emergency services; services for mothers and children; and services for other specific populations including the poor, the elderly, minority populations, the uninsured and the disabled. In addition, the legislation mandates an assessment of the impact of such a transaction on overall employment in the community and on the institutions' workforce. Employers are required to provide information on the status of any collective bargaining agreements as well as plans for retraining and redeploying employees who are displaced by the merger or acquisition.30 ANA believes that enactment of the legislation will lift the veil of secrecy that keeps hospitals' staffing and outcomes a mystery to patients, give consumers access to information they need to make informed decisions, and protect nurses who speak out on behalf of safe patient care.

In a related development, ANA is pleased to report that President Bill Clinton has appointed ANA President Beverly Malone, PhD, RN, FAAN, to his Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Created in part as a result of ANA's strong public lobbying to preserve the safety and quality of health care, the Commission's top priority is to prepare a "Consumer Bill of Rights" to ensure that patients have adequate appeals and grievances processes in their contacts with the health care system. The "Consumer Bill of Rights" will emphasize (1) the importance of providing the best available care; (2) safeguards against the limiting of patient care due to inappropriate financial incentives to providers; (3) access to care by the most vulnerable populations; and (4) access to information about the rights and responsibilities of health plans, including benefits and the quality of health care providers. The Commission will hold a series of public meetings and hearings to collect and evaluate information and develop policy recommendations on improving quality in the health care system.31

At the state nurses association level, one of the most innovative responses to the challenge of collecting and analyzing nursing workforce data is occurring in Mississippi. In 1996 the Mississippi Nurses Association (MNA) successfully lobbied the state legislature to establish the Office of Nursing Workforce Redevelopment (ONWR). The ONWR is charged with assessing the impact of changes in health care financing and delivery on the state's registered nurses. It will create a statewide infrastructure to meet the continuing education needs of the nursing workforce and, among other things, design and conduct a systematic annual survey of nursing workforce needs through a state-wide nursing manpower prediction model. The project's overall mission of building an education and workforce "safety net" for nurses is seen as a significant first step toward securing a strong future for nurses and the nursing profession.32

Due to the space limitations of this paper, examples of other forecasting models used to calculate near-term and long-term demand for nursing personnel are not included to this report.33

Safety and Health

Workplace violence is a major problem in the United States. On average, twenty workers are murdered each week while on duty or at work, and an estimated one million more are assaulted annually. Government data indicate that the majority (some 64%) of nonfatal assaults occur in the service industries which include health care. Of assaults in the service sector, 27% occurred in nursing homes, 13% in social services and 11% in hospitals. In almost half the cases of nonfatal assaults (45%) the source of injury was a health care patient, with another 31% described as "other person" and 6% as "coworker or former coworker."34 The U.S. Occupational Safety and Health Administration's (OSHA) "Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers" cites two studies which indicated that weapon-carrying patients in both general emergency and psychiatric services were not uncommon: some 25% of major trauma patients treated in a large urban hospital emergency center were carrying lethal weapons (Wasserberger et al, 1989), and 17.3% of psychiatric patients searched by security officers in a university emergency department were also found to be carrying weapons (Goetz et al, 1991).35 Other researchers studying stressors among nursing home workers found that violent or aggressive verbal and physical behavior by patients is part and parcel of the nursing home work environment.36

Besides violence, injuries and illnesses suffered by health workers also make health care a risky occupation. According to the latest U.S. government statistics, in 1995 hospital-employed health care providers experienced an injury and illness incidence rate of 10.1 cases for every 100 full-time workers, higher than the 1995 national rate of 8.1. Within the industry code of "Nursing and personal care facilities," the rate of injury and illness -- 18.2 -- was more than twice the national rate. This builds on an injury and illness rate among hospital and nursing home workers that jumped dramatically between 1980 and 1992 during which time the rate for hospital and nursing home health care providers surpassed the rate for workers in private industry.37 One measure of the hazards of health care is the fact that RNs have a higher rate of injury and illness than do U.S. construction workers.38

Among the leading causes of injury and illness for registered nurses are health care restructuring, latex allergy and poor indoor air quality. In 1995, the Minnesota Nurses Association (MNA), a constituent member of ANA, collected and analyzed injury and illness data from 12 hospitals in the Minneapolis-St. Paul area. The data showed that between 1990 and 1994, when RN positions in the hospitals under study were downsized by 9.2%, the number of work-related injuries or illnesses among RNs increased by 65.2%. Although causality could not be inferred from the data, the MNA used the study's findings during 1995 collective bargaining negotiations to improve health and safety conditions for the 7,000 RNs covered by the agreement. Just as important, the MNA study provided a model which, with support from ANA, other state nurses associations are using to conduct similar studies. Should these on-going studies produce similar results, they would further validate the MNA study and strengthen the argument that hospital restructuring may be hazardous to RNs' health.39

Another growing health problem with potentially disabling occupational consequences afflicting registered nurses is latex allergy. Latex allergy is defined as "a Type 1 lgE-mediated hypersensitivity reaction that involves systemic antibody formation to proteins in products made from natural rubber latex."40 Allergic reactions to latex range from skin disease, most commonly, hand dermatitis, to asthma and anaphylaxis and can result in chronic illnesses, disability, career loss, and in rare instances, death. To date, there is no known treatment for latex allergy except complete latex avoidance.41 Experts estimate that between 8-12% of workers in all health disciplines are affected by latex allergy. One study at a major U.S. medical facility found that 8.9% of registered nurses were sensitized to latex.42 A conservative estimate of the lifetime cost of occupational latex sensitization for American health care workers is placed at $64 billion.43

ANA is educating registered nurses and the public about the dangers associated with latex allergy and is taking steps to protect RNs and patients. For example, ANA is working with OSHA and the National Institute for Occupational Safety and Health (NIOSH) to inform health care providers, employers and government compliance officials about latex allergy. ANA also monitors OSHA enforcement of regulations that compel employers to provide appropriate gloves if their health care employees are sensitive or allergic to latex. Besides developing educational materials and strategies to reduce risk at the work site, ANA successfully lobbied NIOSH to include latex allergy as an occupational research priority and urged another federal agency, the Food and Drug Administration, to require labeling of all medical supplies for latex. ANA is collaborating with state nurses associations to include language in collective bargaining agreements that assists RNs to identify latex allergy, ensure a safe workplace for sensitized nurses, and provide appropriate accommodation under the Americans with Disabilities Act and through workers' compensation.

In 1995, the ANA House of Delegates (HOD) authorized ANA to take a leadership role in the work to eliminate hazardous workplace air quality threatening the health and safety of registered nurses and other health care workers. At the 1996 HOD meeting, ANA sponsored continuing education on indoor air environment and disseminated resource information to the SNAs. At the national level, ANA continues to work with OSHA, NIOSH and the Environmental Protection Agency (EPA) on research and regulatory issues. ANA is working to secure EPA funding of educational initiatives for registered nurses on indoor air environment. In addition, at the request of ANA and the Massachusetts Nurses Association NIOSH conducted a health hazard evaluation of a major medical facility in Boston in the spring of 1996 to evaluate the indoor air environment as a hazard. The results of the NIOSH investigation have not yet been released.

ANA, through its occupational safety and health programs, is working with health care providers, policy makers, government agencies and other professional and advocacy organizations to remain in the forefront of the fight to protect the health and safety of registered nurses at the workplace.

Conclusion

Market forces increasingly drive health care transformation in the United States. As macro-economic pressures exert greater influence over RN remuneration and supply and demand, nursing must respond to the challenge to "prove its worth" in the marketplace. Through the quality indicators initiative and legislative campaign for data collection and mandatory public disclosure, ANA is taking steps to articulate nursing's value even as it works to provide the American people with safe, quality health care and support registered nurses in their workplace. Exchanging ideas and strategies to advance this dual commitment is the thrust of this report and ANA's hope for this conference.

Endnotes

  • 1. For a discussion of these and related issues, see "Remuneration of Registered Nurses in the United States," A Report for the International Council of Nurses, Royal College of Nursing, London, England, June 1-3, 1995; "Registered Nurse Reward Strategies, Staff Appraisal and Skill Mix in the United States," A Report for the International Council of Nurses, American Nurses Association, Washington, D.C., September 9-11, 1996.
  • 2. Union Membership and Earnings Data Book: Compilations from the Current Population Survey (1997 Edition). Washington, D.C.: The Bureau of National Affairs, Inc., 1997, 107, 119, 131.
  • 3. 1997 ANA House of Delegates Status Report, "Compensation Systems That Threaten to Diminish Standards of Nursing Practice."
  • 4. For a discussion of these and related issues, see "Hospitals and Health Plan Conversion," Health Affairs (March/April 1997):9-242.
  • 5. Position Statement on "Privatization and For-profit Conversion," American Nurses Association, forthcoming.
  • 6. Calculations from data provided in: Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services. Advance Notes I and II from the National Sample Survey of Registered Nurses. March 1996; telephone conversation with Evelyn Moses, Chief, Nursing Data and Analysis Staff, Division of Nursing, May 16, 1997.
  • 7. See The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses. 1980-1992 and Advance Notes I and II from the National Sample Survey of Registered Nurses. March 1996.
  • 8. Advance Notes I and II.
  • 9. Advance Notes II.
  • 10. Advance Notes I; The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses. March 1992. Table 19.
  • 11. Advance Notes II.
  • 12. "Data Bank," Nursing Economic$ 15 (2), 72; Daily Labor Report. Washington, D.C.: The Bureau of National Affairs, Inc., January 5, 1996, A-2.
  • 13. Aiken, L. and Salmon, M. "Health Care Workforce Priorities: What Nursing Should Do Now," Inquiry, 31: Fall 1994, 321. Although aggregate numbers appear sufficient, the educational preparation of the RN workforce might not be adequate to meet the demand of nursing in the near future with its increasing emphasis on clinical autonomy, increased professional judgment, demand for capability to practice in expanded spheres with less supervision and more independence. There is also the question of proper geographical distribution of the RN workforce.
  • 14. Calculations by author from "Estimated Active Supply of Registered Nurses by Educational Preparation as of December 31, 1980 to 1994," prepared by the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, November 1995.
  • 15. "Graduations from Basic RN Programs and Percentage Change from Previous Year, by Type of Program: 1975-76 to 1994-95," Nursing Data Review, New York, New York: National League for Nursing, 1996.
  • 16. "Data Bank," Nursing Economic$, 15 (2), 72.
  • 17. "National Industry-Occupational Matrix: Employment by Industry and Occupation, 1994 and Projected 2005 Alternatives: Registered Nurses," Bureau of Labor Statistics. Washington, D.C.: U.S. Department of Labor, 1994.
  • 18. Advance Notes I.
  • 19. "National Industry-Occupational Matrix;" Advance Notes I.
  • 20. "Critical Challenges: Revitalizing the Health Care Professions for the Twenty-First Century," Pew Health Professions Commission. San Francisco, CA: University of California at San Francisco Center for the Health Professions, 1995, I, 48-51.
  • 21. "AHA Data:Hospital Closures Drop to Record Low in 1994," Modern Healthcare, 26 (17), 2.
  • 22. "Lower '94 Spending on Poor Fuels Record Bottom Line," Modern Healthcare, 26 (17), 2.
  • 23. American Nurses Association. Washington, D.C.: ANA, August 1991.
  • 24. Prescott, P. "Nursing: An Important Component of Hospital Survival under a Reformed Health care System," Nursing Economic$, 11 (4), 192-199.
  • 25. See, for example, Linda Aiken et al. "Lower Medicare Mortality among a Set of Hospitals Known for Good Nursing Care." Medical Care, 32 (8), 771-787.
  • 26. H. 1697. An Act Relative to Public Access to Comparative Nursing Care Data. Testimony from the American Nurses Association to the Committee on Health Care, State of Massachusetts, May 15, 1997.
  • 27. "Implementing Nursing's Report Card: A Study of RN Staffing, Length of Stay and Patient Outcomes," American Nurses Association. Washington, D.C.: ANA, 1997, 1-4.
  • 28. Ibid.
  • 29. "Patient Safety Act Introduced," Capitol Update. Washington, D.C.: American Nurses Association, 15 (4), 1-2.
  • 30. Ibid; "Daily Labor Report," April 2, 1997. Washington, D.C.: Bureau of National Affairs, Inc., 332.
  • 31. "Malone Appointed to President's Health Quality Commission," Capitol Update. Washington, D.C.: American Nurses Association, 15 (5), 1-2.
  • 32. "Executive Summary: Mississippi Nursing Workforce 2000 Grant -- The Robert Wood Johnson Foundation 'Colleagues in Caring: Regional Collaboratives for Nursing Workforce Development,'" Nursing Organization Liaison Committee, 1995.
  • 33. For models specific to nursing, see "Future Supply of and Requirements for Registered Nurses," in National Advisory Council on Nurse Education and Practice: Report to the Secretary of the Department of Health and Human Services on the Basic Registered Nurse Workforce. Washington D.C.: Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services. 1996, 37-42; Sechrist, K., Lewis, E., and the California Strategic Planning Committee for Nursing. "Planning for California's Nursing Work Force: Final Report of the Nursing Work Force and Education Forecasting Initiative." Sacramento, CA: ONE-California, 1996. For models dealing with, more broadly, industrial and occupational employment, see BLS Office of Employment Projections, "Projection Methodology." Washington, D.C.: U.S. Department of Labor, December 1, 1995.
  • 34. Division of Safety Research, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Public Health Services, U.S. Department of Health and Human Services, "Violence in the Workplace: Risk Factors and Prevention Strategies." Washington, D.C.: U.S. Government Printing Office, 1996, 1, 11.
  • 35. Washington, D.C.: U.S. Department of Labor, 1996, p.11. See also Lipscomb, Jane. "Violence in the Health Care Industry," in Violence: A Plague of Our Land. Washington, D.C.: American Academy of Nursing, 1995, 49-58.
  • 36. Lusk, S.L. "Violence Experienced by Nurses'Aides in Nursing Homes," The Journal of the American Association of Occupational Health Nurses, 40 (5), 237-241.
  • 37. BLS Office of Safety , Health and Working Conditions, "Nonfatal Occupational Injury and Illness Incidence Rates per 100 Full-time Workers, by Industry, 1973-1995." Washington, D.C.: U.S. Department of Labor, 1997.
  • 38. Shogren, E., Calkins, A. And Wilburn, S. "Restructuring May Be Hazardous to Your Health," American Journal of Nursing, 96 (11), 64.
  • 39. Shogren et al, 64-66.
  • 40. Position Statement on Latex Allergy. American Nurses Association, 1997, 1.
  • 41. Ibid.
  • 42. Martellotto, Joan. "Stop Latex Sensitization." Chart, 94 (4), 6.
  • 43. Position Statement on Latex Allergy, 1.

References

  • "AHA Data: Hospital Closures Drop to Record Low in 1994." 1996. Modern Healthcare 26: 2-3.
  • Aiken, L., and Salmon, M. 1994. Health care workforce priorities: What nursing should do now. Inquiry 31: 318-329.
  • Aiken, L., Smith, H.L., and Lake, E.T. 1994. Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care 32: 771-787.
  • American Nurses Association. 1997. Implementing nursing's report card: A study of rn staffing, length of stay and patient outcomes. Washington, D.C.: the Author.
  • Bureau of Labor Statistics (BLS). U.S. Department of Labor. 1994. National industry-occupational matrix: employment by industry and occupation, 1994 and projected 2005 alternatives: Registered nurses. Washington, D.C.: U.S. Government Printing Office.
  • _____. Office of Safety, Health and Working Conditions. U.S. Department of Labor. 1997. Nonfatal Occupational Injury and Illness Incidence Rates per 100 Full-time Workers, by Industry, 1973-1995. Washington, D.C.: U.S. Government Printing Office.
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  • "Hospitals and Health Plan Conversions." (1997). Health Affairs, March/April, 9-242.
  • Lipscomb, Jane. 1995. "Violence in the Health Care Industry." In Violence: A Plague of Our Land, 49-58. Washington, D.C.: American Academy of Nursing.
  • "Lower '94 Spending on Poor Fuels Record Bottom Line." 1996. Modern Healthcare 26: 2-3.
  • Lusk, S.L. 1996. Violence experienced by nurses' aides in nursing homes. The Journal of the American Association of Occupational Health Nurses 40: 237-241.
  • Martellotto, Joan. 1997. Stop latex sensitization. Chart 94: 6.
  • National Institute for Occupational Safety and Health, Division of Safety Research, Centers for Disease Control and Prevention. 1996. Violence in the workplace: risk factors and prevention strategies, 1-20. Washington, D.C.: U.S. Department of Health and Human Services.
  • Pew Health Professions Commission. 1995. Critical challenges: Revitalizing the health care professions for the twenty-first century, 1-83. San Francisco, CA: University of California at San Francisco Center for the Health Professions.
  • Prescott. P. 1993. Nursing: an important component of hospital survival under a reformed health care system. Nursing Economic$ 11: 192-199.
  • Shogren, E., Calkins, A., and Wilburn, S. 1996. Restructuring may be hazardous to your health. American Journal of Nursing 96: 64-66.