Facilities must devise short- and long-term solutions to narrow the widening gap between persons needing care and those able to provide it.

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any research studies, government reports, and surveys of nurses, nurse executives, and nursing associations conclude that, compared to previous shortages, the current nursing shortage is more complex and likely to be more severe—and that it will intensify over the next 2 decades. Women, who traditionally composed the majority of the nursing field, continue to have more career options outside of nursing. Females in the 1990s were 35% less likely to choose nursing as a career than those who graduated in the 1970s.¹
       A combination of factors is contributing to this situation. The overall aging of the nursing workforce, the inadequate supply of new nurse graduates, the global nature of the nursing shortage, and the simultaneous shortages of allied health professionals and support personnel are all contributing to this growing problem. According to the Health Resources and Services Administration (HRSA)’s National Sample Survey of Registered Nurses, in 2004 the average age of a bedside nurse was reported to be 46.8 years of age, up from 45.2 in 2000.
       Additionally, the shortage of nursing instructors is resulting in a large percentage of qualified nursing student candidates—nearly 42,000 in 2005, according to the American Association of Critical Care Nurses (AACCN)—being turned away. These factors combined with the fact that the population of persons 65 years of age and above will double between the year 2000 and 2030 result in a severe nursing shortage crisis. By 2020, the total number of full-time registered nurses (RNs) is projected to fall 20% below the HRSA’s projections of the number that will be required to meet demand. Demographic changes are widening the gap between the number of persons needing care and those available to provide it.

Figure 1

National Council of State Boards of Nursing (NCSBN) Pass Rates for its NCLEX Nursing Licensure Examination

       In addition, AACCN reported a 9.6% enrollment increase in entry-level baccalaureate programs in nursing in 2005 over the previous year. However, due to the number of young RNs decreasing so dramatically over the past 2 decades, enrollments of young persons in nursing programs would have to increase at least 40% annually to replace those expected to leave the workforce via retirement.¹ According to the National Council of State Boards of Nursing (NCSBN), pass rates for its nursing licensure examination, NCLEX, increased steadily since 2002 (see Figure 1). But even a continued increase in NCLEX pass rates is unlikely to meet the projected need for more than 2 million new nurses by 2020.
       Steven Colarusso, Executive Director of Sachem Skilled Nursing and Rehabilitation Center (East Bridgewater, Mass), discusses the challenges in staffing his modest facility:
       “As the workforce grows older in healthcare and more of the long-term nurses go into retirement, the challenges are increasing to provide quality care for our patients in the skilled nursing facility (SNF) environment. The environment has become very competitive to attract nursing staff. Companies are offering a wide variety of incentives to seasoned nurses as well as new graduates. Sign-on bonuses, tenure bonuses, shift differentials for overnight and weekend shifts, and pay in lieu of benefits are just a few of the programs being offered to attract employees. Most companies are offering education assistance as well for the future growth of their employees. The labor wages necessary to run a facility continue to rise and are among the most expensive costs on a yearly basis.”

Increasing Vacancy Rates and Turnover

       In addition to the inadequate supply of new nurses entering the profession, of increasing concern is the rising number of nursing vacancies within healthcare institutions and the growing turnover rate. According to a 2005 survey by the American College of Healthcare Executives (ACHE), 85% of healthcare administrators reported having a shortage of RNs. Additionally, 82% of healthcare facilities reported having more difficulty in recruiting nurses, 60% reported an increase in RN vacancies since 1999, and 32% reported that the average years of tenure for RNs decreased since 1999. In a 2000 national sample survey of RNs, approximately 18.3% of nurses with current licenses were not employed in nursing. This represents an increase of about 28% since 1992. Half of currently employed RNs have considered leaving the patient-care field over the past 2 years for reasons other than retirement.²

Figure 2

Average Vacancy and Turnover Rates in Skilled Nursing Facilities (SNFs) Source: The American Health Care Association (AHCA)

       High nursing turnover rates and decreasing tenure are a result of growing job dissatisfaction among direct care nurses. According to the 2002 study by the American Health Care Association (AHCA), turnover rates in SNFs averaged close to 50% for RNs and licensed practical nurses (LPNs) and over 70% for certified nursing assistants (CNAs) (see Figure 2). Approximately 75% of RNs believe the nursing shortage presents a major problem for the quality of their work/life balance, the quality of patient care, and the amount of time nurses can spend with patients. Almost all nurses surveyed see the shortage as a catalyst for increasing stress on nurses, lowering patient-care quality and causing nurses to leave the profession.³ Approximately 40% of nurses surveyed reported being dissatisfied with their jobs, with 1 in 3 under the age of 30 reporting plans to leave the profession in the next year.² This high level of job dissatisfaction will likely impact the extent of the current and future nursing shortage. Efforts undertaken to improve workplace environments may serve to improve both retention and recruitment abilities.

Addressing the Nursing Shortage

       Legislation at both the federal and state level has been proposed or implemented to address the nursing shortage and includes both short- and long-term solutions. In most cases, legislation addresses education, staffing, and working conditions for nurses. The American Nurses Association (ANA) has identified 5 major legislative priorities: no mandatory overtime, whistleblower protection, collection and reporting of nursing-sensitive quality data (requiring valid and reliable staffing systems), and collection of nursing supply and demand data.
       It is important to understand all of the underlying causes of the nursing shortage, as solutions may vary to address the root cause. Expanding educational opportunities is an important aspect in addressing the long-term supply and demand issues. This includes providing for educational opportunities to a wider range of potential students, including support for lower-income students and those who may need additional remedial education to prepare for nursing education.
       It is cheaper and faster to bring a trained nurse back to the profession than to train new nurses. High job dissatisfaction rates have contributed to an overall negative image of the nursing profession. Measures to address working conditions have the potential to attract nurses back to direct patient care. Therefore, to address short-term supply and distributional problems, working conditions need to be addressed in a systematic way, with national support and visibility.
       Additionally, because acuity in hospitals has been rising rapidly over the last 5 years, hospitals are increasingly viewed as large intensive care units, a perception that has had a direct effect on the rise of the visibility of SNFs. Thus, the demand for more skilled and specialized nurses is even greater. Most healthcare employers are reporting more difficulty in attracting nurses to fill vacancies. In the absence of a strong retention plan, the traditional tricks of attracting new recruits (eg, sign-on or hiring bonuses) are ineffective and short-lived.

Understanding the Cost of Turnover

       Using data from numerous studies that examine the cost of staff turnover in long-term care facilities, a report issued by The Institute for the Future of Aging Services (through its “Better Jobs Better Care” program) combines direct and indirect costs of replacing direct care employees, who provide the majority of hands-on personal care to older disabled adults. Direct costs, which can total about $2,500 per loss for each worker, include: hiring temporary staff or paying overtime wages to current staff until replacements come on board; advertising, interviewing, and background checks; and orientation and training of new employees. Indirect costs, which can add another $1,000 to the cost of replacing an employee, include lower productivity of temporary and new staff and reduced service quality due to staff shortages and low staff morale. Some studies reviewed in the report found that direct costs can run as high as $5,200 when human resource staff time is taken into account.
       Considering the current average turnover rate of nearly 50% for a facility employing 50 direct care workers, this would amount to $130,000 annually. Even a modest goal of reducing the turnover rate by 10% would result in savings of over $25,000 per year. This is certainly a goal worth striving for; with some additional investment, it would accomplish significant overall savings for the institution.
Another tactic that employers should consider revising is how they approach the hiring process. Because recruiting is absolutely critical to a company’s bottom line, employers should ensure that the processes they have implemented bring in only the top talent, which, in turn, would reduce the turnover rate.
The Importance of Effective Hiring Practices
       One significant way to decrease turnover rates and improve retention is to hire the right persons. Statistics show that behavioral interviewing is 5 times more accurate than the traditional interview style for choosing the right candidates that fit in with the organization’s goals and culture. By simply implementing proper interviewing and selection techniques, organizations can save thousands of dollars per year.
       Using behavioral-based interviewing techniques, the hiring manager can reasonably project the future performance of a candidate based upon the responses garnered during the interview. Behavioral interviews are based on the premise that past behavior predicts future behavior. This comprehensive process uses carefully structured, in-depth questions to gather and evaluate information on a candidate’s experience and skills. Therefore, developing appropriate questions to encourage a candidate to provide direct experiences describing prior performance is the most effective method of truly evaluating an employee’s performance.

Developing a Behavioral Interview

       To follow are 6 steps for preparing a behavioral interview:
1. Analyze the job. Break each position down into the competencies and behaviors needed to be successful at that job.
2. Identify skills within each competency category. Once the competencies are determined, identify the necessary skills within each category.
3. Develop questions related to each skill, competency, and behavior. The next step is to prepare 2 or 3 appropriate questions for each of the skills, competencies, and behaviors identified.
4. Conduct the interview. Ask the questions you have developed, in sequence, to each candidate. Make sure that you keep good notes on each candidate’s responses to the question.
5. Rank the response. For each question, rank the candidate’s response. Candidates could be ranked using a scale from “not demonstrated” to “partially demonstrated” to “strongly demonstrated” for each skill.
6. Evaluate the results. Compare each candidate’s responses to your company’s needs. If you are interviewing several people, compare your results.

Basic Recruiting Techniques

       Effective interviews of candidates will only be useful if employers are reaching the most qualified candidates in the market. Organizations cannot just place a help-wanted ad in the newspaper and expect to be flooded with top-notch candidates. Although advertising has its place in the hiring process, it is not enough. In today’s global economy, good persons will not just come to you. You have to aggressively look for them. Some additional recruiting techniques include:
• Networking: Establish relationships with professional associations, nursing organizations, church groups and other interest groups.
• Referrals: Develop an internal referral program and promote it. Encourage your current employees to recommend your company to persons they know, and offer cash bonuses for referrals that result in hiring.
• Re-activation: Maintain a database on all prior employees; keep them updated on all your job openings and any new benefits you are offering.
• Schools and College Career Fairs: Partner with nursing schools to use your facility as a clinical rotation site.
• Nurse Intern Training Programs, Employment Agencies, and Online Job Boards.

Retention Programs

       Industry experts estimate it takes 1–3 times the dollars spent on a position’s annual salary to recruit and train a replacement. According to the US Department of Labor, the top reason why persons leave their jobs has nothing to do with pay or promotions; they leave because they “don’t feel appreciated.” Savvy employers are developing retention programs that invest in their employees’ happiness and satisfaction and help them achieve a work/life balance. How well do you value your employees? How many times this week did you reprimand, correct performance, or address a negative behavior issue? Now, how many times did you positively recognize an employee, compliment performance, or acknowledge someone for staying late or doing a little something extra? If the positive does not exceed the negative by twice the amount, then you need to work harder at recognizing more of your employees’ positive performances.

Table 3

       The three rules of employee retention are respect, recognition, and rewards (see Table 3). Respect is the foundation of keeping your employees. Rewards and recognition will have little or no meaning if your employees do not feel respected.

Using a Staffing Agency

       While plans are being developed to help curtail the staffing dilemma for the long run, healthcare organizations need immediate solutions to address theses shortages. This is where the true value of an agency or travel staff can be seen. While the use of agency staff is not the ultimate desire for hospitals and other healthcare providers, it is the current reality. The American Hospital Association (AHA) reported that 56% of hospitals use agency staff in order to fill vacancies.
       Hiring temporary staff through an agency can be a good business decision when patient volumes and procedures fluctuate. Temporaries can be used as full-time staff “extenders” by covering permanent employees’ vacations and medical and family leaves as well as open positions. Filling your positions with temporary staff can also improve employee morale by reducing the patient-care load of full-time employees. This is especially true of cases in which management faces the danger of hiring permanent employees only to lay them off in the future.
       Just like any other service or product that is purchased, the quality of the staffing service depends on the company from which it is purchased. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed a certification program for healthcare staffing companies. Using an independent quality measurement like JCAHO certification provides a facility with the confidence that certain quality standards are met. (For more information on the quality standards, visit www.jcaho.org.) One can also assess other characteristics of a staffing company to determine quality, including its:
• Credentialing process
• Knowledge level of the office staff
• Orientation and training programs
• Elements of the contractual agreement
• Ability to handle and resolve problems
• Quality of candidates
• Availability of staff during off hours.
       Depending on your particular needs, companies offer a variety of staffing options. For example:
• A travel division can provide coverage for chronic shortages of both nursing and allied health professionals and fills census-related staffing gaps with 8–26 week contracts nationally
• A per diem division can fill flexible day-to-day shifts 24/7 in select geographical areas
• A specialty staffing division can provide short-term contracts and permanent placement in targeted areas, such as case management, allied health, and social work, as well as other non-clinical healthcare professions
• A permanent placement division can provide customized searches for direct hires nationwide for one flat fee
• A managed services division can centralize all of your staffing to a single point of contact, alleviating valuable corporate resources so that you can focus on your core business.

A Nurse Manager’s Perspective

       Melissa Weinand, Director of Nursing Services at Overlook Masonic Health Center (Charlton, Mass), provides her insight on the nursing shortage and the benefits of using a staffing firm to recruit qualified healthcare professionals:
       “The obvious risk is open shifts that cannot go uncovered. Facilities need a backup plan to ensure continuity of care. The nursing shortage and resultant open shifts reduce continuity of care, thereby increasing risks to patients. Such risks include medication errors and omissions in treatments or services. Having regular supplemental staff can help in reducing some of these shortage and agency-induced errors. This can be accomplished by partnering with an agency to block-book the same nurses repeatedly so that they become as familiar with your clients as your regular staff.
       Nearly all long-term care facilities rely to some extent on supplemental staffing agencies to help fill these holes. While many facilities view this as a “necessary evil,” the relationship established between a facility and an agency can be a mutually beneficial and positive one. However, not all agencies are created equally.
       Facilities need to focus on the qualitative differences in agencies. It is critical for the management of a facility to carefully consider what it needs from an agency and clearly lay out its expectations before entering into agreements. Some major areas to consider include: What experience level does the agency require of prospective staff? How does it measure staff competence? What avenues of communication and follow-up are available if issues arise? What orientation is expected and needed to ensure agency staff comfort? Is the agency JCAHO-accredited?

Conclusion

       Short- and long-term solutions are necessary elements to address the current nursing shortage. However, every organization has the ability to address some of these issues that are contributing to the shortage, and we all bear responsibility for being part of the multidimensional solution. Job dissatisfaction, working conditions, hiring practices, and employee retention are primary qualities of which an organization has control. One of best resources that any organization has is its own internal staff. The most successful ideas can come from the people within the organization who have the most to lose or gain from the solutions that are implemented.