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To make matters worse, the mean age of nurses is increasing rapidly. In 1980, 53% of RNs in the United States were less than 40 years old, and 26% were less than 30 years old. By 2000, 32% were younger than 40, and just 10% were younger than 30.1 Today, the mean age of nurses in the Unites States is 45 years, and that mean is increasing every year, with nursing school enrollments decreasing to less than the number needed to replace the nurses who retire or leave the practice.3
According to the American Association of Critical-Care Nurses, the largest nursing specialty organization in the world, the nursing shortage continues to threaten the long-term well-being of every person in the United States and puts substantial strains on the US healthcare system.4 The nursing shortage is real, a situation that is exacerbated by an increasingly older population, and with the ever-increasing acuity level of hospitalized patients, the demand for experienced, highly skilled nurses to care for these patients is greater. However, attracting and keeping the best and the brightest to staff critical care units are tremendous challenges because so many other employment options are available to these nurses.
The shortage of nurses does not have an easy solution, particularly, the shortage that affects the staffing issues of critical care units in the United States. Raising nurses’ salaries might assist in ameliorating the problem, but increased compensation alone most likely will not affect the limited popularity of nursing as a career choice among the wide expansion of options now available to women.5
Robert G. Johnson,3 president of the American College of Chest Physicians, called for greater accountability and support of nurses on the part of the entire healthcare delivery system when he stated,
From our colleges and nursing schools to the hospital itself, we need to address a true cultural change in the way we value the contributions of nurses in America.3
As critical care nurses, we need to heed Johnson’s recommendation and look at how we present critical care nursing to the general public and to the nursing profession. Do we value our contributions to nursing practice? Can we promote critical care nursing to the general public and to the nursing profession?
In this article, I present suggestions that might be used with the general public, prospective students, and schools of nursing to help reduce the vacancy rate so that orientation classes for critical care positions might one day be filled to capacity with new graduates.
General Public
As concerned critical care nurses, what can we do to counteract the distressing trends related to the shortage of nurses? Perhaps we should first look at our own attitudes about nursing practice. Do we encourage and support persons who express an interest in a nursing career? Nothing is so negative as a practicing nurse who says something like, "I would never advise my children to become nurses." Yet, nothing is so positive as a practicing nurse who says something like, "Nursing has offered me so many opportunities, and I am happy I chose this career path." Make a proactive decision today to speak to at least 1 group of potential nurses and tell them about the rewards that nursing has provided for you. This step could possibly be arranged though a local school, or perhaps through a scout troop or a faith-based organization.
Image campaigns, such as the one launched by Nurses for a Healthier Tomorrow,6 a coalition of 32 professional nursing and health-care organizations, have increased public awareness of the shortage of nurses. However, awareness of the problem alone is not enough; action is required. Johnson & Johnson, a long-standing supporter of the nursing profession, is taking such action. They are developing projects designed to promote the critical role and value of nursing. Working with key nursing organizations in The Campaign for Nursing’s Future, Johnson & Johnson is funding prime-time advertising, educational scholarships, recruitment initiatives, and a Web site (www.discovernursing.com) that provides information on careers in nursing. The best place to learn more about critical care nursing is the Web site of the American Association of Critical-Care Nurses (www.aacn.org).
Nursing Students
Clinical preceptors, who teach in capstone critical care nursing courses, need to be aware of and take responsibility for helping nursing students prepare for graduation and for practice. In the final semester or quarter of a nursing program, students are concerned about fulfilling graduation requirements and passing the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Schools of nursing have the same concerns, and in an effort to assist students in being successful on the NCLEX-RN the first time the students take the examination, many schools have implemented policies that require students to make certain scores on standardized examinations in order to progress toward graduation or to take the NCLEX-RN.
Increasingly more schools of nursing use the Exit Exam (E2) of Health Education Systems, Inc, as a benchmark for progression.7 A series of 4 studies,7–10 conducted over 4 consecutive years with a total sample size of 17342 students, indicated that E2 scores are a highly accurate (96.36%–98.30%) predictor of success or failure on the NCLEX-RN examination. Analysis of 14787 of the students’ scores indicated that students who had low E2 scores were significantly more likely (P=.001) to fail the licensure examination than were students with high scores.7,8 Morrison et al11 investigated the NCLEX-RN outcomes of students at schools of nursing that used the E2 as a benchmark for progression and remediation. The authors interviewed administrators in 7 nursing programs where faculties had implemented policies that made graduation or permission to take the licensing examination contingent on obtaining a satisfactory E2 score. Within 2 years after the policies were initiated, NCLEX-RN pass rates had improved in all 7 programs by 9% to 41%.
Because E2 scores are a reliable predictor of NCLEX-RN outcomes and are being used increasingly by more schools of nursing as a benchmark for progression and remediation, critical care preceptors should become familiar with the E2 so that they can help students succeed on the E2 and ultimately on the licensing examination. Some may think that this problem is a problem for nursing education, not nursing service. No doubt poor E2 scores place a burden on nursing faculties because students must be given remedial instruction, and poor NCLEX-RN pass rates hurt schools of nursing in terms of the schools’ accreditation and public image. Nursing service and nursing education both suffer from the consequences of students who obtain unsatisfactory E2 scores, or worse yet, fail the NCLEX-RN. These students are eager to play a part in helping to decrease the shortage of nurses and solve critical care staffing problems, yet they risk losing everything they have worked for in nursing school if they are unsuccessful on these examinations. The profession, and the patients we serve, simply cannot endure the loss of even one of these precious resources, namely, our new nursing graduates.
Critical care nursing preceptors can play a role in helping these students achieve success on these examinations. Students who do not achieve the desired E2 scores, as identified by their schools, are allowed to take remedial instruction and then take a different version of the E2.
Preceptors should ask to see the printouts of students’ E2 scores, which indicate the students’ specific remediation needs. An experienced critical care nurse can use this information to enhance a student’s knowledge and decision-making skills, through practice in the critical care clinical setting, in areas in which the student is weak. For example, critical care preceptors can use a Socratic reasoning technique when working with students by asking them open-ended questions designed to reveal the students’ problem-solving and decision-making abilities. Such an approach will compel students to think critically when solving clinical problems and implementing nursing interventions. These exercises can help students be successful in answering the critical thinking test items on the E2 and on the NCLEX-RN. Thinking critically also prepares students to function as safe, competent, entry-level staff nurses.
Success on the NCLEX-RN is important to hospital staff and administrators as well as to schools of nursing, not to mention individual students whose careers must be put on hold until licensure as an RN is achieved. New graduates who are unsuccessful on their first attempt at taking the NCLEX-RN pose a tremendous financial burden to the employing agency. The cost of orientation to a critical care unit increases each year, and new graduates who do not pass the licensing examination cannot fill the critical care positions for which they were oriented, thereby further increasing the costs. In states in which new graduates are permitted to work for a certain period without a nursing license, it might be wise for employing agencies to review new graduates’ E2 scores before hiring the graduates. That practice would allow employers to objectively estimate the risk for failing the NCLEX-RN and identify specific remediation needs. Such information might be useful in helping new graduates obtain learning experiences that might ultimately help them pass the NCLEX-RN the first time they take the examination.
Nursing Education
Nursing education has been greatly affected by the shortage of nurses. With the aging of nurse educators, large numbers of nursing faculty are reaching retirement age. Without nursing faculty, programs are severely limited in the number of students that can be admitted.12 However, schools of nursing are acutely aware of their responsibility in helping reduce the shortage of nurses, and many have initiated creative curricula that are more "user friendly" to students, produce graduate nurses in less time, and require fewer faculty hours for teaching.
For example, many schools of nursing are now offering evening classes and are hiring adjunct faculty from their affiliate hospitals to handle clinical teaching responsibilities. Such programs are helpful to students with jobs and family responsibilities and allow nurses with advanced degrees to experience a faculty role without relinquishing seniority within the hospital system. Other programs are providing accelerated baccalaureate programs in nursing for persons who have a bachelor’s degree in another field. Still others are offering innovative RN-to-BSN or RN-to-MSN programs that provide students with credit for courses taken during the students’ associate degree or diploma programs, thus decreasing the amount of time required to complete the degrees.13
A positive by-product of the shortage of nurses is the increasing trend to develop creative partnerships between schools of nursing and the schools’ clinical affiliates. For example, some hospitals have provided release time for nurses who have master’s degrees to serve as clinical instructors for nursing students. The school pays the hospital the equivalent of an adjunct instructor’s salary for the release time required for each nurse with a master’s degree to teach for a semester, and the hospital continues to pay the nurses their usual salaries for service within the hospital, which generally exceeds the compensation most schools offer adjunct faculty. In this manner, the hospital is essentially funding part of the faculty salary. This funding is a generous gift from the hospital and is a win-win situation all the way around. The schools can admit more students because more instructors from the clinical affiliates are available to teach. This increase in the number of admissions potentially provides a greater number of new graduates who are likely to become employees of the hospitals within their communities. Nurses with a master’s degree have the opportunity to teach, which can provide an enriched teaching/learning experience for both instructors and students. Finally, students’ interactions with the hospital-based faculty members create a recruitment mechanism for the hospital. Critical care nurses are in high demand as instructors, and they should investigate the possibility of initiating or increasing involvement partnerships between nursing education and nursing service.
Summary
The shortage of nurses is here, and the complexity of the issues involved will take time to resolve. Undoubtedly, this process will be slow and frustrating. Critically ill patients who require intensive, highly skilled nursing care are among those most affected by the shortage of nurses. Nursing service, in partnership with nursing education, should create innovative strategies that will ultimately alleviate the shortage of nurses. What we have to gain is more precious resources, our new graduates filling all the chairs in future summer critical care orientation classes.
References
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