Working
in the future

by Barbara Bronson Gray, MN, RN
August 27, 1998

Photo by Margie Paschke
Illustration by Malcolm Garris

When it comes to tough questions about workforce shortages in health care, the Center for the Health Professions at UCSF is often the first place policy experts turn. Janet Coffman, MPP, associate director of workforce policy, coordinates the center’s work on supply and demand for health professionals and education policy. She recently co-edited Strategies for the Future of Nursing, an assessment of the implications of healthcare trends for nursing education and practice (Jossey-Bass Publishers, 1998).

Coffman received a bachelor’s in history from Haverford College in Pennsylvania, a master’s in U.S. history from the State University of New York at Binghamton, and a master’s in public policy from the University of California, Berkeley. She has served on the legislative staff of the U.S. Senate Committee on Veterans Affairs.

Q: There is a lot of data predicting shortages in nursing and allied health in the next few years and well into the coming century. What are the most significant facts and how do you see workforce availability and demand problems in the next five years, especially?

A: Trying to forecast the adequacy of the future supply of nurses and allied health professionals is like forecasting the weather. It’s hard to be terribly precise, but there are some general patterns that emerge. I think it’s not at all clear that what we have is a shortage of people, but rather some institutions are having difficulty recruiting and retraining the RNs that are out there at the present time.

Q: What is the difference between having difficulty recruiting and a shortage?

A: I would define a shortage as simply a lack of RNs out there. It’s not as if nurses are widgets and every nurse is going to go out there and work 40 hours a week; it’s just not that simple. I think there are some critical intervening variables, and the three most important are wages, working conditions, and family circumstances. So when you hear reports of individual facilities having difficulty with recruitment and retention, I think the first question is, Has there been any effort to adjust wages, to perhaps entice the folks to work or have working conditions changed substantially, to attract folks? We’ve been enjoying some very robust economic growth, and we know that the majority of our nurses are married, so there is a second income in the family. I think it’s quite reasonable that some nurses may well say, "At least for the time being, I’m not going to work, or I’m not going to work full time."

Q: I’m hearing from nurses in their 40s who are finding that their work has recently gotten much harder than it ever has been and are tossing in the towel, regretfully.

A: I think there is often a tendency when we hear shortage to say, "Oh, we need to train more people." Well, that may be—and I think that is actually true over the long term. But I think folks can jump to that conclusion too quickly without looking at some of the intervening variables. With the change in working conditions and the greater complexity in acute care, producing more RNs does nothing to change that.

Q: Don’t all the demographics point to a growing risk of shortage?

A: We have an alarming number of nurses poised to retire within the next 10 years; about 35 percent are age 50 or older. In that cohort, already, you see a higher fraction who are not working in nursing. The other thing important to note is that the age of entry to practice has risen to the early 30s, so that the people who enter nursing are simply going to have fewer years of work in the field.

So, in the short term, we may well have some shortages in certain specialty areas, but not in the aggregate. But we need to get the folks in the pipeline now so that they are out there and able to practice five to 10 years from now, when those needs become more evident.

In California there is a prediction for higher population growth, so there is heightened concern.

Q: In your book, you talk about how to adjust the way we are educating the nursing work force as a shortage builds.

A: It’s a critical time. What we’ve seen in past nursing shortages, at least in the last 30 years or so, has been a tendency to ramp up the ADN programs. That could well be the response this time. That may not be the best way to go, or perhaps we ought to be ramping up both associate-degree and bachelor’s programs. I think this is really going to take leadership. Legislators want results, and they want them quickly. Increasing the supply of associate-degree nurses will bring more people into the profession, but I’m not sure that will bring in people at the level that’s needed.

Q: What do you think about differentiated practice?

A: What we need is differentiation of education and practice together, differentiated education for roles. Right now, there are some differences in education, but roles are not necessarily differentiated. For the most part, we don’t see a lot of differentiation in roles among employers, and I don’t know that we see the differentiation in education that would be most appropriate to prepare folks. The advantages of differentiation are building on what we’ve got and the flexibility for people to enter nursing with more than one type of training at more than one level.

Q: I guess that’s both a pro and a con if you’re looking at creating a profession.

A: I think that’s a pro in terms of casting your net widely to bring people into the profession. I think it can be a negative in the sense of, how do you define the profession? We have these three streams coming in—associate degree, diploma, and bachelor’sit does make it a little more challenging in terms of defining what the nursing profession is and what nurses do.

Q: How is allied health being affected by shortage situations?

A: It’s such a diverse group it’s hard to give an answer for the whole group. I think pharmacy and physical therapy are carving out niches for themselves. In pharmacy, they’re working very hard to move away from primarily the dispensing function to a medication management function. I think there are more challenges when you ask how much work will be done by, say, respiratory therapists, because it’s my understanding that a lot of the work of the respiratory therapist was originally work that nurses did.

Q: Do you think the trend is more toward specialization in the long run or toward the growth of the generalist role?

A: I’m not sure. How care is delivered in the hospital and who is delivering what and what the role of the RN is, that is fundamentally changing. We are already moving away from some of the more basic care delivery to a coordination or managerial role.

Q: What is going to happen to salaries?

A: I don’t know that you’re going to see big growth in salaries the way you did in the late 80s, but we’ve gone through a period where nursing wages have been pretty stagnant, and we may be at a point where employers choose to make a change in order to recruit and retain staff. But in a more cost-conscious system, you may see rates of growth that are less dramatic than in the past.

Q: What about the lack of compensation difference between those with AA or diploma degrees and those with bachelor’s degrees?

A: I think nursing has, at the associate level, one of the higher salaries in comparison to other jobs you can get with that degree. At the bachelor’s level, nursing does not offer one of the highest salaries that folks can get for that degree.

Nurses do feel a sense of mission, more so than lots of professions. But communicating that to attract people who are thinking about career choices—that’s going to be important.

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