Federal figures project that if current trends continue, rising demand will outstrip the supply of RNs beginning approximately 2010. By 2015, 114,000 jobs for full-time-equivalent RNs are expected to go unfilled nationwide, according to the Division of Nursing of the U.S. Department of Health and Human Services. But already, in an expanding number of markets, hospitals and other employers are struggling to meet the rising demand for RN care and have stepped up recruitment. Today's intensified hiring of RNs is being spurred by:

• The mounting health care needs of increasing numbers of elderly;
• a growing population of hospitalized patients who are older, more acutely ill, and in need of more skilled RNs per patient;
• the rapid expansion of front-line primary care to many sites throughout the community;
• technological advances requiring more highly skilled nursing care; and ;
• an aging RN workforce. The average age of RNs in 1996 was 44, up from 40 in 1980. Moreover, only 9 percent of RNs were under age 30 in 1996, with high levels of retirements projected in the next 10 to 15 years.

As nursing and health care delivery expand, opportunities abound outside the hospital.

Between 1992-1996, the number of registered nurses in community health settings, including home health care, rose by 42 percent, nearly triple the growth in the previous four years, and climbed by 32 percent in long-term care facilities. Almost 9 percent of RNs were practicing in outpatient settings in 1996, including health maintenance organizations and physician- and nurse-based practices. Median annual earnings of registered nurses employed in hospitals and home care were $39,700 in 1997, according to the federal Bureau of Labor Statistics. Nurse practitioners, advanced clinical nurses prepared at the master's-degree level, earned an average of $52,532 in 1997, ranging from averages of $43,386 in college health clinics to $59,285 in their own practices and $60,208 in surgical facilities. Nursing professors with a doctoral degree earned an average $66,132 in 1998.

With patient care now more complex, and with associate degree- and hospital diploma-prepared nurses already in oversupply, ensuring a sufficient RN workforce isn't merely a matter of how many nurses are needed, but what types, and providing them in the right educational mix. The National Advisory Council on Nurse Education and Practice has urged that at least two-thirds of the basic nurse workforce hold baccalaureate or higher degrees in nursing by 2010. Currently, only about 40 percent do. Moreover, a 1995 report by the Pew Health Professions Commission recommended the closing of up to 20 percent of the nation's associate-degree and hospital diploma nursing programs in favor of accelerated production of nurses from bachelor's- and graduate-degree programs. Today's rising need for registered nurses does not appear to be a repeat of the widespread nursing shortage of a decade ago, when employers hired qualified entry-level RNs virtually regardless of their nursing degree preparation. 
Rather, today's demand is different because:

• Employers are seeking nurses prepared at the bachelor's and graduate-degree levels who can deliver the higher complexity of care required across a variety of acute-care, primary-care, and community health settings, and to provide other needed services such as case management, health promotion, and disease prevention.
• Demand is particularly acute for nurses in key specialties, such as critical care; neonatal nursing; emergency, operating room, and labor and delivery units; and for advanced practice RNs such as nurse practitioners and clinical specialists.
• Though hiring of RNs is accelerating in more cities, today's demand varies region by region, market by market, contrary to the pervasive nationwide shortfall of RNs in the late 1980s. 

Job commitments for new graduates show the climbing demand for RNs with advanced clinical skills. While nursing schools estimate that an average of 77 percent of entry-level BSN graduates had jobs waiting upon graduation between August 1997 and July 1998, that number was 93 percent for master's-degree nursing graduates and 82 percent for graduates of master's-level nurse practitioner programs. 
However, in the same period, graduates of RN-to-BSN tracks saw the largest pool of placements, a sign of employers' especially acute demand for experienced RNs. Nearly all -- an estimated 98.6 percent -- of RN-to-BSN graduates between August 1997 and July 1998 had jobs waiting, according to nursing schools responding to AACN's latest annual survey. Flexibility is the key. All projections forecast accelerating demand for nursing care and for nurses with expanded education and skills. 
Still, the accelerating demand for RNs varies by region and market. As a result, flexibility will be key both for entering and moving within the profession. Some graduates may need to pursue employment in different parts of their home states, in another state, or even in another region where hiring in certain clinical settings or specialties may be more plentiful.

ADVANCED PRACTICE NURSING: EXTENDING PRIMARY CARE'S REACH 

The health system's increasing demand for front-line primary care, and the accelerating drive toward managed care, prevention, and cost-efficiency, are driving the nation's need for nurse practitioners, certified nurse-midwives, and other RNs with advanced practice skills. 
Prepared typically in master's-degree programs, advanced practice nurses (APNs) include the following four categories of clinicians: 
Among their clinical roles, nurse practitioners (NPs) conduct physical exams; diagnose and treat common acute illnesses and injuries; provide immunizations; manage high blood pressure, diabetes, and other chronic problems; order and interpret X-rays and other lab tests; and counsel patients on adopting healthy lifestyles and health care options. 

In addition to practicing in clinics and hospitals in metropolitan areas, the nation's estimated 71,000 nurse practitioners also deliver care in rural sites, inner cities, and other locations not adequately served by physicians, as well as to other populations, such as children in schools and the elderly. Many NPs work in pediatrics, family health, women's health, and other specialties, and some have private practices. Nurse practitioners can prescribe medications in all states and the District of Columbia, while 18 states have given NPs authority to practice independently without physician collaboration or supervision. 

Clinical nurse specialists (CNSs) provide care in a range of specialty areas, such as cardiac, oncology, neonatal, and obstetric/gynecological nursing, as well as pediatrics, neurological nursing, and psychiatric/mental health. Working in hospitals and other clinical sites, CNSs provide acute care and mental health services, develop quality assurance procedures, and serve as educators and consultants. An estimated 54,000 clinical nurse specialists are currently in practice nationwide. The nation's approximately 6,500 certified nurse-midwives (CNMs) provide prenatal and gynecological care to normal healthy women; deliver babies in hospitals, private homes, and birthing centers; and continue with follow-up postpartum care. In 1996, CNM deliveries accounted for 6.5 percent of all births in the U.S., up from 3.6 percent in 1989, according to the National Center for Health Statistics.

More than 30,000 certified registered nurse anesthetists (CRNAs) administer more than 65 percent of all anesthetics given to patients each year, and are the sole anesthesia providers in approximately one-third of U.S. hospitals, according to the American Association of Nurse Anesthetists (AANA). Of the 24 million anesthetics given annually, about 20 percent are administered by CRNAs practicing independently and 50 percent by CRNAs in collaboration with physician anesthesiologists, says AANA. Working in the oldest of the advanced nursing specialties, CRNAs administer anesthesia for all types of surgery in settings ranging from operating rooms and dental offices to outpatient surgical centers. 

Mounting studies show that the quality of APN care is equal to, and at times better than, comparable services by physicians, and often at lower cost. For example, Even after acknowledging flaws in some of the studies it reviewed in 1986, the congressional Office of Technology Assessment (OTA) concluded that nurse practitioners can deliver as much as 80 percent of the health services, and up to 90 percent of the pediatric care, provided by primary care physicians, at equal or better quality and at less cost. In 12 studies it reviewed, OTA found that the quality of care by nurse practitioners -- including communication with patients, preventive actions, and reductions in the number of patient symptoms -- was higher than comparable care by physicians.At the University of Rochester, researchers reported that intensive-care babies cared for by neonatal nurse practitioners averaged 2.4 fewer hospital days and more than $3,400 less in charges than those cared for by medical residents, despite the fact that the NPs' infants were younger and had significantly lower birthweight. Unlike residents, nurse practitioners don't rotate, are "more consistent caregivers" who can follow infants through their entire stay, and need to rely less on support services to stay apprised of a patient's progress, the authors suggest in the 1994 study. 

FOR MORE INFORMATION:

Nursing School Enrollments Decline as Demand for RNs Climbs
(AACN news release - February 2000)

With Demand for RNs Climbing, What's Ahead Isn't Typical "Shortage Cycle" (AACN Issue Bulletin - February 1998)