Xtreme Nursing and the Nursing Shortage

Johnson JE, Billingsley MC, Costa LL
Nursing Outlook.  2008;54(4)

This article examines the stark reality of today's nursing shortage and its certain impact on the future. There is major concern about nursling's continuing ability to provide quality care for patients given the escalating nursing shortage. These authors suggest that society is entering a period of "Xtreme nursing," a "state of serious imbalance between the demand for and the supply of nurses."

Nursing organizations, governmental agencies, advisory groups, blue-ribbon panels, and articles in the professional nursing literature and the popular press have all had their opinions on the nursing shortage. Projections are becoming dire as the dimensions of the nursing shortage become more precise. The authors argue that 4 conclusions have emerged:

  • The nursing shortage is the result of a complex amalgam of societal forces for which there is no simple, immediate solution.
  • The shortage is a long-term concern, which is national and global in scope.
  • Corrective measures to increase the diminishing supply of nurses are urgently needed.
  • If current trends continue, the shortage will have devastating effects within the American healthcare system.

By 2010, the situation will get steadily worse. At the time when the population is increasingly aged, there will be a "staggering decline" and shortage of registered nurses specifically and other healthcare assistive personnel in general. The authors point out that "Technology is not the answer. It cannot change beds, dispense medication, or bathe or dress people. There simply will not be enough people to provide the touch, the smile and the skill to care for the elderly." In fact, if the root causes of the nursing shortage are not addressed, the "profession will continue toward a shortage of unmatched proportions -- one in which nurses will simply not be available to support the patient care needs of the nation."

Congress has been involved in addressing the nursing shortage issue since 2002 when both the US House and Senate passed the US Nurse Reinvestment Act on the same day. Congress hoped to enhance nursing's attractiveness as a career, provide financial incentives for educating both new nurses and graduate nurses, and help hospitals develop improved career paths for nurses that would give them incentive to remain at the bedside.

When the legislation was passed, the fanfare ended. Momentum was lost and the goals of the new bill have not been realized. Controversies about implementation of programs have been subsumed in other governmental and societal priorities, such as the war in Iraq. Congressional appropriations have remained flat. Efforts to increase the supply of nurses, boost the retention of nurses, and develop strategies to make the practice of nursing more effective and rewarding have been instituted but have shown limited effect on the total problem.

The situation slowly worsens; the current prediction is that by 2020 the demand for nurses will exceed the supply by 20% (400,000-nurse shortage). New types of healthcare "extenders" or assistive personnel are being created. Over time, family members or friends may be expected to become part of the formal caregiving process, and nurses with advanced education, such as nurse practitioners and clinical nurse specialists, may lead patient care teams.

These authors advocate for the use of "scenario planning" to replace strategic planning. They point to this process as a way for the nursing profession to think and plan differently about how nursing care might be implemented in the future. This process would help develop potential scenarios -- descriptive narratives of plausible alternative projects of a specific part of the future -- and then integrate these scenarios into decision-making. Scenarios include analysis of driving forces, logics, plots, and end states. The article explores in some depth how this process might be helpful for hospitals in particular.

"The magnitude of the nursing shortage, the aging RN population, and the substantial dissatisfaction in the RN workforce coupled with the lack of perceived opportunities for career advancement, as well as empirical links among RN care, patient safety, and quality, suggest that policy implementation that recognizes the central role of nursing in patient care is not only necessary, but also an ethical imperative." Changes must be made, not to save our current conceptualization of nursing as profession, but to deal with the reality of today -- where nursing has evolved to "a stage never contemplated in the past....'Xtreme nursing,' a contemporary phenomenon for which the solutions from the past simply will no longer work."