Fresh signs of a growing nursing shortage—more ads, some sign-on bonuses, even new grad programs here and there—are suddenly drawing attention from newspapers, television, and radio news. Is it just the annual rise in demand from the flu, or is it a more real and lasting shift?

It’s an unsurprising but spotty shortage, according to Ed O’Neil, PhD, director of the Center for the Health Professions at the University of California, San Francisco, and executive director of the Pew Health Professions Commission. O’Neil says the increased demand for nurses is a natural part of the merger-and-acquisition-based realignment of health systems. It’s also partly caused by the confusion within the industry about just how to deliver good care with less money, he said.

Think local
The shortage isn’t occurring everywhere, because health systems are in different stages of adaptation to managed care, O’Neil said. "Is there a shortage in California? You can’t ask the question for the whole state. You have to say, ‘Where and in what kind of specialties and services is the shortage hitting?’ "

Experts say the nation isn’t facing the specter of a big nursing shortage, but certain regions—especially those in the middle or late stages of managed care—are. "Nursing labor markets are local and regional phenomena," said Patricia Prescott, PhD, RN, workforce consultant to the Robert Wood Johnson Foundation’s Colleagues in Caring project in Washington, D.C. The first clues of regional shortages appear in the ads in leading trade magazines and metropolitan newspapers, but the real sign of significant shortage is when salaries start rising, she said. "Usually, if you want something bad enough, you’ll pay more for it," Prescott said. Karen Ringl, MSN, RN, vice president for patient care services at San Gabriel Valley Medical Center, reports some nursing executives in Southern California are starting to discuss raising salaries.

Katie Bray, MBA, RN, nurse recruitment manager for Kaiser Permanente in Northern California, says there is a significant and growing shortage. She thinks it’s due to a host of factors, including the downsizing of the last few years, which often induced experienced nurses to take early retirement. She also points to four to five years of not offering new nursing graduates jobs or internships and an increased demand for health care as the improving economy provides more workers with health insurance.

Demolished recruitment
"The recruitment infrastructure was demolished during downsizing," said Bray, adding that most hospitals aren’t set up to effectively recruit now. "And we had several years of not providing opportunities to new grads. It’s kind of like nature, you can’t reproduce during a drought."

For about six years, the California Strategic Planning Committee for Nursing has been developing a model to better plan for the nursing needs of the state, and Ellen Lewis, MSN, RN, project director, says she has been expecting the shortage. "With the changes in the financing of health care and the economy, particularly in California, there was a long time when people didn’t have health insurance," she said. Pent-up demand, particularly for elective surgeries and preventive care, is contributing to the shortage, she said.

It’s the economy
The troubled California economy also contributed to an exodus of residents, including nurses, from the state, according to Lewis. As the economy has improved, more people are returning, unexpectedly increasing demand. The Department of Finance released a study last month showing that 21,270 more people moved into California last year than left. The study also showed that the state’s population rose to 32.96 million as of July 1997, an increase of 1.8 percent from 1996.

Lewis said California is entering a booming economic era with a relatively low supply of nurses, with the state ranking 48th in the nation in the number of nurses per 1,000 residents. "We just don’t have the base of nurses to draw from," she said.

Complicating the picture is the fact that experienced nurses and those in advanced practice are finding new opportunities for jobs in home health, consultation, and case management, according to Lewis and nurse recruiters familiar with the emerging market. Clinical nurse specialists, whose positions were often the first to be axed during downsizing, are now in great demand, Bray said.

Spotty shortages
Ringl is seeing a shortage particularly in the specialty areas, like labor and delivery and critical care. "I think, however, that we can meet that need by educating our current work force," she said. Ringl reported that UniHealth America, the parent company of San Gabriel, is creating a plan to prepare nurses with one year of med/surg
experience for high-demand specialty areas.

Sign-on bonuses are starting to creep back into recruitment ads for some of the tough-to-hire positions. Ringl is offering such an incentive for an OR charge nurse on the evening shift at her facility. "I think there are enough OR charge nurses out there, but not ones willing to work evenings," she said.

Barbara Bucher, RN, PHN, Southern California recruitment and staff development specialist for Olsten Health Services, says the home care industry is in flux and the job opportunities are typically for experienced field nurses only. "I keep hearing about this nursing shortage, but so many of our competitors are closing down or consolidating," she said. Olsten recently closed down its Long Beach and Los Angeles offices, but adjacent offices will likely absorb some of the staff. "We’re at the crossroads. Good home health nurses are thinking, If I get laid off by one more company, I’m going back to the ER or to the real estate industry."

On the whole, Bucher—who has worked in home care for 18 years—is finding recruitment a little bit easier than in previous years, although sub-specialty nurses are still hard to find and keep. Some home health agencies succeed in hiring nurses with specialties in pediatrics, for example, but lose them when the facility doesn’t have enough pediatric patients. And some regions, such as San Diego, are having particular difficulties attracting home care nurses, Bucher said.

Is it really a shortage?
Lori Brault, MS, RN, vice president of the Healthcare Association of Southern California in Los Angeles, doesn’t think there’s a full-fledged nursing shortage now, but rather a narrow shortage only in the specialty areas of operating room, critical care, and neonatal care. But Brault says that there is data suggesting a shortage is on the way. Hospital census is rising a bit, as longer minimum obstetrical stays have been legislated and some health plans have modified their length-of-stay rules for some diagnoses and surgeries, she said. And 88 percent of the nurses in the state are employed, suggesting there isn’t a pool of eager-to-work nurses who could pick up the slack as demand increases, Brault added.

There is also data showing that, as of the end of 1997, more nurses were hired at the Healthcare Association’s 110 reporting hospitals than left those institutions, with the number of part-time nurses remaining fairly constant. What isn’t known, however, is the number of hours part-time nurses are spending on the job.

Prescott said that nurses are actually beginning to have shorter careers because many graduate from nursing programs in their late 30s. "Today, the work life of a nurse is very short. You’re looking at a 20-year career now instead of a 40-year career," she said. This will reduce the number of nurses in the work force just when baby boomers hit their decades of peak healthcare need, she said.

"We have shot ourselves in the foot historically by running our demand model by shouting shortage," Prescott said. "We constantly cried shortage because that was the mechanism by which our education system was supported. But a large supply of nurses guarantees holding down wages, and that ultimately is not good for the profession."

While the debate continues about the seriousness of the current shortage, most nurses and workforce experts agree that a pronounced shortage is just around the corner. "We’re in for a significant shortage," Bray said. "I see us having some very big-time challenges, and I think we’re in for very difficult times."