Trends in Nursing

Trends in nursing are closely tied to what is happening to healthcare in general. Trends are fascinating phenomena, but they do not exist in vacuums. Most are interrelated; one trend often spawns another. Although trends are more than fads, they are far from money-back guarantees. We watch to anticipate the direction that a particular trend will take us, to remove the element of surprise. When we look back on trends, however, some will have heralded permanent changes, but others might have been no more than blips on the radar screen. Trend #1: Where Art Thou, Nurse? There are nearly 2.7 million nurses in the United States, comprising the largest division of the healthcare workforce. Yet in 2004, we continue to face a slowly growing shortfall of nurses. Although this is not the first nursing shortage our nation has faced, there are some worrisome differences this time. This shortage is not caused by any single factor in isolation, such as the voluntary cutbacks in the nursing labor force of the 1990s, which could be solved by ramping up recruitment efforts. This shortage is caused by a convergence of many pressures, including financial constraints, a dissipating workforce, and an increasingly complicated and stressful work environment. Furthermore, the global nature of this shortage makes it impractical to recruit nurses from other countries to fill vacancies in the United States. Many registered nurses (RNs) have left nursing for better opportunities and higher paying jobs. In 2002, there were nearly half a million licensed nurses not employed in nursing.[1] When experienced nurses leave their positions after only a few years in the profession, they are often replaced with recently graduated and inexperienced staff members. This is the revolving door syndrome, the worst possible model of workforce replacement for a profession such as nursing. Notwithstanding the tragic loss of nursing expertise that occurs when a nurse leaves the profession, new nurses who are usually mentored by the older, experienced nurses after graduation must then learn to cope without such guidance. Job dissatisfaction and wages have both been cited as factors contributing to the nursing exodus. A 2000 survey of nurses found lower levels of job satisfaction, particularly among staff nurses, than in surveys of previous years.[1] Nurses are in the best position to evaluate the quality of care, and they believe that it is declining. In addition, wage growth of RNs in the United States is, on average, relatively flat. After adjusting for inflation, RNs have seen no real increase in purchasing power of their salaries over the last 9 years.[2] Another important factor relating to the nursing shortage is the "aging RN factor" -- the demographic that paints the gloomiest picture of our healthcare future:

The average age of the RN population in 2000 was 45.2 years (in 1983 it was 37.7 years)[1] Only 9% of RNs are under the age of 30 years[1] Only 18.3% of RNs are under the age of 35 years[1] Only 37.7% of RNs are under the age of 40 years.[1]

Retirement is looming for baby-boomer nurses (those born between 1946 and 1964). More than a million new and replacement nurses will be needed in the United States by the year 2010.[3] It is estimated that we will lack 29%, or more than 434,000 nurses by 2020.[2] The situation is just as dire in Canada. The Canadian Nurses Association predicts that by 2011, they will be short 78,000 RNs and by 2016, they will be short 113,000 nurses.[4] Fewer college students are choosing nursing as a profession now compared with several decades ago. New graduate RNs declined by 26% from 1995 to 2000.[5] Nursing's negative image and low status, relatively low pay, and a wealth of alternative opportunities for women are among the reasons for the decline. Right now, there are not enough students in the educational pipeline to replace the number of nurses leaving the workforce.[6] This year will bring more efforts to improve the image of nursing to encourage more young people to choose nursing as a career. Are we already too late to avert a crisis in patient care? Will demographics be our downfall? Much depends on whether employers and policymakers pay as much attention to retaining the current experienced workforce as they do to increasing enrollments. Everyone has to care about the nursing shortage, both now and in the future, because everyone will be affected by it at some point in time.

Trend #2: The Patient Safety Imperative

A vigorous demand for increased patient safety is being heard from all sectors. Patient safety will be paramount in 2004. Although a greater focus on patient safety has been a trend since the Institute of Medicine's landmark report in 1999 estimating that 44,000-98,000 people die yearly as a result of medical errors,[7] several recent studies have turned the spotlight on nursing as a safety net. Reflect upon these sentiments expressed by the authors of a major new report about nurses and patient safety: "how well we are cared for by nurses affects our health, and sometimes can be a matter of life or death...in caring for us all, nurses are indispensable to our safety".[8] When nurses' workloads are too heavy, safety can too easily become compromised. Can we expect nurses caring for too many patients or working too many hours to continue to intercept 86% of the medication errors made by physicians and pharmacists that they usually intercept before such errors reach the patient?[9] Can we expect the same outcomes of care that are achieved with more reasonable workloads? To no one's surprise, heavier patient loads are associated with higher rates of infection, gastrointestinal bleeding, pneumonia, cardiac arrest, and death from these and other causes.[10] The typical work environment of nurses harbors many latent conditions that are sources of threats to patient safety.[8] Sicker patients, inadequate orientation for new nurses, communication failures, interruptions, and distractions were among the environmental factors found to contribute to errors. A new report from the Institute of Medicine finds that "the work environment of nurses needs to be substantially transformed to better protect patients from healthcare errors."[8] The report calls for changes in how nurse staffing levels are established and mandatory limits on nurses' work hours as part of a comprehensive plan to reduce problems that threaten patient safety by strengthening the work environment in 4 areas: management, workforce deployment, work design, and organizational culture.[8]

Trend #3: Skyrocketing Healthcare Costs

Healthcare is rapidly becoming unaffordable. The United States spends more on healthcare than any other industrialized country. In 2001, total national healthcare spending reached $1.4 trillion (an increase of 8.7% in a single year!) or 14.1% of the nation's gross domestic product.[11] Increasing at a rate that is 5 times the inflation rate, healthcare spending in 2003 continued to rise at the fastest rate in our history.[12] Unless spending slows significantly, health insurance premiums will continue to rise rapidly and the number of uninsured Americans will increase.[13] Healthcare spending is projected to reach $2.6 trillion in 2010. A big contributor to escalating healthcare costs in the United Stated is the medical litigation system. The runaway litigation system raises the costs of healthcare for everyone, costs that are paid for through higher premiums for health insurance, higher out-of-pocket payments to obtain care, and higher taxes.[14]

Trend #4: Born Earlier and Living Longer

Neonatal nurses have witnessed a flood of premature babies in the past several years, a trend that is likely to continue in 2004. The increase in prematurity is partly a consequence of the popularity of assisted reproductive technology (ART). In 2000, 53% of infants born through ART were twins, triplets, or higher-order multiples compared with 3% of the general population.[15] Twins and other multiples are more often premature and/or of low birth weight, and often require neonatal intensive care. As a group, the number of premature infants may be getting larger, but individually, it seems that premature infants are getting smaller all the time -- the phenomenon of "the incredible shrinking preemie." Though it is extremely difficult and heart-wrenching at times, neonatal nurses and physicians cannot shrink from the question of how small is too small. It is a question that has been asked for decades now, and still has no easy answer. Decades of research and experience in perinatology and neonatology have convinced us that the best approach is to prevent preterm labor if at all possible. The focus in 2004 will be on the prevention of prematurity in a broad sense, instead of focusing on more high-tech ways to save the lives of increasingly immature newborns. Look for a high-profile media campaign from the March of Dimes aimed at both professionals and the general public so that everyone gets the message -- babies are better off born at term.[16] On the other end of the life spectrum, people are expected to live longer (77.2 years, in 2001).[17] The "over 85s" are the fastest growing segment of the older population.[17] In fact, the whole population is getting older. The percentage of people over the age of 65 years in the United States is now 12%, compared with 8% just 50 years ago.[17] We can expect this to rise further as the first of the baby boomers enter their sixties just 2 years from now.

Trend #5: Shorter Lengths of Hospital Stay

The latest data on national trends in hospitalization show that hospital stays are declining. According to the National Hospital Discharge Survey, the average length of stay (LOS) for hospital inpatients in the United States was 4.9 days in 2001 (the latest year for which data are available), down from 7.3 days in 1980.[18] In 2001, most patients stayed in the hospital for 3 days or less, 27% stayed for 4 to 7 days, and only 16% stayed longer than a week.[18] Forces that have exerted pressure on the hospital LOS include:[18]

A shift from a Medicare cost-based to a prospective payment system for hospitals, beginning in the 1980s Greater development and coverage of postacute care alternatives to hospitalization The growth in utilization review programs Increased enrollment in managed care plans Advances in technology and drug therapies that allow earlier diagnosis and treatment of acute conditions and safer and less invasive surgeries.

LOS for children did not change significantly in 2001.[19] Neonatal intensive care unit LOS for preterm infants is closely tied to gestational age at birth and birthweight.[20] A recent analysis of 147,224 premature infants confirmed that mean hospital LOS decreases with increasing gestational age and birth weight. For example, for an infant born at 25 weeks gestation, mean LOS was 92 days, and for an infant of 30 weeks gestation, mean LOS was 30.4 days.[18] One group for whom LOS has actually increased is postpartum women. After LOS following uncomplicated vaginal delivery fell to an average low of 1.4 days during the "drive-through delivery" days of the late 1980s to mid 1990s,[20] it has now rebounded and stabilized at around 2.5 days.[19]

Trend #6: Healthcare Consumerism and "E-Health"

"Americans want the best healthcare someone else will pay for."[21] Consumerism is an intriguing trend that bears close watching in 2004. "Consumerism" is a buzzword that means different things to different people with different interests. In its truest sense, consumerism is "a movement seeking to protect the rights of consumers by requiring such practices as honest packaging, labeling, and advertising, fair pricing, and improved safety standards."[22] No argument there! In healthcare, a consumer has come to mean a more informed participant, perhaps one who uses the Internet to obtain information about health, disease, and quality ratings of providers and hospitals. Defined as such, consumerism is a positive development in healthcare. However, in industry, consumerism also refers to a type of health insurance plan called a consumer-directed health plan that gives the consumer (the employee) more choices about how his or her insurance dollars will be spent. And, in practice, this means, plainly stated, that the consumer is paying for more of the healthcare costs.

The big push behind the consumerism movement is the hope that it will ultimately drive down healthcare costs. However, employers have been shifting more of the costs of health insurance premiums to employees for years now, yet the cost of health insurance keeps soaring. Are the majority of Americans suddenly going to adopt healthier lifestyles to save money on out-ofpocket medical expenses? We are taking the risk that many Americans are simply going to forego spending money on healthcare whenever possible. And since we are already in the midst of epidemics of obesity and diabetes in this country, we could end up paying with our health. Further, it is believed that information technology will help consumers make better choices about healthcare, getting more "value for money." Indeed, use of healthcare Web sites by consumers tripled in 2002 as individuals spent more time exploring their options before making healthcare decisions.[23] The problem is, even with a boatload of information about disease, diagnostic tests, and treatment options, someone with a healthcare background can have difficulty making decisions about what is necessary and what is fluff, particularly when faced with the crisis of a serious illness. How is the average lay consumer to accomplish this? Hospital and physician "report cards" and other forms of quality ratings will become more prevalent, purportedly to help consumers make choices about where to spend their healthcare dollars. It remains to be seen if people will shop for healthcare services the way they do for a car or a television set, or if they will continue to rely on word of mouth, convenience, and what they are comfortable with, just as they have done in the past.

Trend #7: Complementary and Alternative Medicine

Hand-in-hand with the healthcare consumerism movement is a trend known as complementary and alternative medicine, or CAM. CAM is a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.[24] In 1999, the National Center for Complementary and Alternative Medicine became 1 of 27 institutes and centers of the US National Institutes of Health.[24] In attempts to improve their health and/or combat illness, approximately 4 in 10 Americans will use CAM therapy this year,[25] and many parents will also provide CAM for their children.[26] Most healthcare consumers will use the Internet to find information about alternative therapies. While some scientific evidence exists regarding some CAM therapies, for most there are key questions still unanswered.[24] Nurses will not only be questioned about complementary and alternative therapies, but they will need to be proactive and open dialogues with patients about their use of CAM in order to address safety issues. In the very near future, nurses might have a greater role in providing CAM in some healthcare settings, including hospitals. The flurry of interest in CAM has stimulated a movement to integrate CAM into the conventional healthcare system,[25] and has led to funding for clinical trials to determine safety and efficacy of CAM therapies.[24]

Trend #8: Technological Wonders and Woes

Imagine a wireless, disposable endoscopy camera in a capsule that provides real-color images of the gastrointestinal tract after being swallowed and moved along by peristalsis. Or picture an antibody-coated stent that prevents restenosis of coronary arteries. And envision in the works -an artificial pancreas and a robot that performs delicate surgery inside of an MRI chamber. Consider the possibility of delivering a baby by Cesarean section -- halfway -- so that the baby can be intubated and resuscitated before clamping the umbilical cord, all because there is a large tumor growing on the baby's trachea.[27] These miracles of modern medicine are the feel-good side of high-tech, the side we cannot get enough of. In sharp contrast to the way healthcare embraces new technology for diagnostic and treatment purposes, hospitals have lagged far behind other industries when it comes to the adoption of information technology. We are still wallowing in paper, while the paperless, or electronic, medical record that has been talked about for years is still mostly just talked about. It looks as though this will soon be changing, though. The US Department of Health and Human Services is in the process of developing a standardized model of an electronic health record, expected to be ready sometime this year. More nurses can look forward to experiencing the challenges of working with new information technology systems in 2004. Computerized provider (or physician) order entry and barcodeenabled point-of-care medication management systems are new applications designed to improve efficiency and reduce medication and other errors in the clinical setting.[28] Computerized provider (or physician) order entry systems were highly anticipated to replace handwritten prescribing by the end of 2003.[29] Barcode medication management systems are designed to prevent medication administration errors.[28] Both are slowly making their way into more of the nation's hospitals.

Trend #9: Web-Based Nursing Degrees

Online advanced degree programs in nursing have multiplied rapidly in the past few years. Today, it is possible to get an RN to BSN degree, an RN (bridge) to MSN degree, or an MSN in an array of clinical or nonclinical advanced practice majors. Do you already have your master's? There are even online post-master's certificate programs for nurses who want to become nurse practitioners. Some online programs are entirely Web-based, using online lectures, libraries, discussion groups, conferencing, and email for communication between instructor and student. Others conduct coursework online but require site visits one or more times per semester for laboratory or clinical practice. Some are self-paced (asynchronous), while others follow a typical college schedule with all students participating simultaneously (synchronous). To date, there is little uniformity in online nursing degree programs -- many different combinations of online coursework and campus attendance requirements exist. When nursing degree programs first went online in the late 1990s, some concerns were voiced over whether Internet education was appropriate for a practice-oriented discipline like nursing and whether the same high standards of traditional classroom learning could be maintained.[30]

Since then, the growth of such programs has been impressive, and students and faculty alike express satisfaction with distance learning programs in nursing.[31] Despite unresolved questions about quality of the curriculum, clinical standards, accreditation, and jurisdiction issues,[31] it appears that online degree programs in nursing are here to stay.

Trend #10: Disparities in Healthcare

The year 2004 will witness the emergence of an even more diverse nation, and thus a more diverse patient population, largely due to the rapid growth of the Latino population. On the 2000 US census, 71% of the population identified themselves as white, 12.1% as black, 12.5% Latino, 2.8% Asian, and 1% Native American/Alaskan Native.[32] These and countless other individuals from countries all over the world reside in the United States and are consumers of US healthcare. Why is this important to the healthcare professional? Over and above the need to understand and incorporate cultural differences into the provision of care, there are some basic, alarming facts about the health of racial and ethnic minorities that all healthcare clinicians need to be aware of. In 2004, despite the tremendous strides we have made in modern medicine and technology, minority Americans face serious disparities in disease incidence, morbidity, mortality, and in the healthcare they receive.[33] People in racial and ethnic minorities tend to receive lower-quality healthcare than whites do, even when insurance status, income, age, and severity of conditions are comparable, according to a 2002 report from the Institute of Medicine.[34] Infant mortality is approximately 2.5 times higher in black infants as it is in white infants. Differences in the way heart disease, cancer, and HIV infection were treated contributed in part to higher mortality rates for minorities. Also responsible are bias, prejudice, and stereotyping on the part of healthcare professionals.[33] Because healthcare disparities are so serious and pervasive, this issue deserves immediate attention from nurses and all healthcare clinicians. Possible interventions to combat inequities include increasing public and professional awareness of disparities, the promotion of consistent care through evidence-based practice, better patient education, and empowerment and the integration of cross-cultural education into the training of all health professionals.[33]

Trend #11: Living With Chronic Disease

A total of 72% of all deaths in the United States are attributable to 4 major diseases: heart disease, cancer, chronic obstructive pulmonary disease, and diabetes.[35] These and innumerable other preventable and nonpreventable conditions such as asthma, arthritis, stroke, kidney disease -- the list goes on and on -- represent a way of life for millions of Americans living with a chronic disease. When chronic disease is complicated by comorbidities such as obesity and hypertension, management becomes that much more difficult. Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. As the elderly proportion of the population grows, chronic disease could very well overtake acute illness as our primary healthcare concern. Prevention of chronic disease, its complications, and optimal disease management require a different approach to healthcare than we have been

used to, and we will have to adapt accordingly. In order to turn the tide on chronic disease for future generations, we need to redouble our efforts to help young and old clients avoid the known risk factors such as tobacco use, and encourage them to adopt healthy diets, exercise, and stress management.

Trend #12: Return of the Plagues

It started with AIDS. Before 1981, incurable infections were ancient history, or so it was believed. But when HIV started its worldwide spread, it became clear that, as a society, we were not as safe from twentieth century plagues as we thought we were. Our complacency, which stemmed from our success with antibiotics and vaccine programs, has been shaken further by the recent appearance of antibiotic-resistant infections, caused by pathogens that have flourished in the era of antibiotic overuse. We have witnessed lethal strains of influenza, West Nile virus, SARS, and multiple-drug-resistant tuberculosis. Mad-cow disease has become a domestic menace. The AIDS virus continues to mutate and spread throughout the world.[35] The threat of bioterrorism, carrying the risk of infecting millions with smallpox or anthrax, is all too real. Government agencies are keenly aware of these problems, but the solutions, such as newer antibiotics, antivirals, and vaccine programs, are unlikely to be ready in time to combat pathogens as fast as they appear on the scene.[36] Nurses and other healthcare professionals must be prepared to contain and prevent the spread of infectious diseases. They must increase their awareness of the threat of communicable diseases and their role in preventing and managing the bona fide public health crises they represent. And the time to do this is before an outbreak or attack occurs.

The Top Trends that will Impact Nurses in 2010

No matter what you think of healthcare reform and whether you back President Obama's plan, one thing is for certain: The introduction of a new healthcare bill has brought the entire US medical system to the forefront of the media in a way that it has never been before. In light of such a drastic change, the medical profession has found their voices and has stepped up to be heard. No one is more willing to accept change than US nurses, and there are many issues on the radar for RN's in the next year.

Until recently, there has never been change in Washington that so directly affected a profession as the new healthcare reform bill will affect nurses. Politics and the nursing profession will go hand and hand in 2010, as many realize that they can affect change for citizens in their communities. Nurses will begin speaking out to their members of Congress and participating in debates as the voice of experience. In addition, the health care reform has brought to light the need for nurses to be ready to deal with the thousands of individuals who never previously had health care. Nurses will no longer be on the sidelines; they will play a broad leadership role in developing new types of health care and promoting prevention within local communities. Even with the success of accredited online nursing programs to train nurses, staffing will be a major issue in 2010. As the economy continues to recover, the need for nurses will grow but the amount of actual registered nurses will decrease as many leave the profession once their own economic situation stabilizes. The US has been looming on the cusp of a nursing shortage for many years, and with the baby boomers preparing to retire, the focus will continue to remain on massive hiring. It will be difficult to keep up with the demand for new recruits. The entire model of how nurses perform their job must change, and the focus will be on organizing specific tasks and attempting to reprioritize so that nurses are not torn between many different tasks at once. New students who have recently taken the RN career path will be the leaders in new and innovative change to both quality and safety in the profession. For those entering educational institutions to pursue nursing, the current employment situation is one of good prospects. Most students are able to secure employment immediately, although some have predicted that the application process will drop slightly as finding a job becomes more difficult. The desire for more academic faculty in Universities is a growing concern, as an influx of students requiring teachers will become a prominent concern. The economic crisis and health care reform has caused true concern and the desire for change within the nursing profession in 2010. As more nurses stand up and make their voices heard with regard to the politics of health care, they are positioning the profession and the country on the path to a strong future.

Nursing Leaders Reveal Top Trends Impacting Nurses in 2010

Jan. 15, 2010 - What are and will be the critical issues facing nurses this year and in the coming decade? NurseZone spoke with several of the country's top nursing leaders--including association executives, distinguished educators, chief nursing officers and consultants--to get their opinions on the most important issues of the day. Their insights reveal a number of trends and hot topics that nurses will want to watch in the months ahead. Health reform and revamped roles for nurses

Cheryl Peterson, RN, MSN, reports that health care reform has energized nurses and hopes their interest in governmental processes continues.

Health care reform and how it may affect nursing remains the big unknown as the profession enters 2010, yet regardless of the outcome, the debate has elevated the topic to the forefront of issues facing the country and galvanized many nurses to speak up. "The health care reform debate has really energized nurses," said Cheryl Peterson, MSN, RN, director of the American Nurses Association's department of nursing practice and policy. "They are contacting their members of Congress, have been engaged in that debate and attended the town hall meetings at the local level." Peterson hopes the profession can retain that enthusiasm as the legislation moves into a regulatory phase, where the details are worked out. "We should have health care reform on our radar," added Beverly Malone, Ph.D., RN, FAAN, chief executive officer of the National League for Nursing. "Nurses need to be prepared to deal with the complex, comprehensive patient in the home and in the community. That is a huge issue we will be dealing with. The nation is gearing up for that, and nurses need to be leaders in that." Malone expects preparing nurses to the level they need to provide that complex care will become a "hot issue."

Fay Raines, RN, PhD, said the nursing profession should anticipate an increased demand for nurses and nurse practitioners due to health care reform.

American Association of Colleges of Nursing President Fay Raines agreed, saying that the profession must ensure it educates sufficient entry-level and advanced practice nurses. Raines and most nursing leaders expect health reform will create opportunities for nurses, as millions of formerly uninsured people obtain coverage and seek care. "Nurses are going to have an expanded role," said Rosemary E. Mortimer, MSEd, RN, CCBE, instructor at Johns Hopkins School of Nursing in Baltimore and immediate past president of the Maryland Nurses Association. She expects registered nurses will find new positions as hospitals expand, home care embraces telehealth, and prevention and lifestyle change come to the forefront, while nurse practitioners will see greater demand for them to become front-line providers. "We don't have the primary care providers to care for those people, so I think the demand for nurse practitioners will grow astronomically," said Karen Haller, RN, PhD, FAAN, vice president of nursing at Johns Hopkins Hospital. "This will be as a real opportunity for advanced practice nurses, as primary-care providers and leaders of medical homes, and with enhanced reimbursement opportunities," said Judith Haber, Ph.D., APRN-BC, FAAN, the Ursula Springer Leadership Professor in Nursing and associate dean of graduate programs at New York University College of Nursing. Nurse advocacy What nurses have seen in the past year is that what happens in Washington can and will affect their lives. Many also have found that they can influence those decisions. "We are going to have to get nursing educators and nurses involved in the Congress of this United States and get the nurse at the bedside up to snuff on terms of what it means to be political while you are a clinician and taking care of patients," said Malone, suggesting it can be as easy as email, Twitter and Facebook. "There are so many ways to touch Congress and decision makers. It's about getting the passion for politics into nursing. 2010 will be the beginning of a new decade for that."

Malone added that nurses must realize that elected officials are interested in funding programs that make a difference for the citizens of the country, not because they are good for the nursing profession, so nurses must tailor the message accordingly. "That's the real learning for 2010," Malone said. Many nurse leaders expect the trend toward nurses' greater involvement in shaping the health care debate to continue this year and in the years ahead. "We will see more interest in legislation," Mortimer said. "Health care reform has gotten people interested in legislation and lobbying." Nursing organizations are starting to speak with one voice to law- and policymakers about broad issues affecting nursing. "Nursing has finally come together," said Brenda Nevidjon, MSN, RN, FAAN, president of the Oncology Nursing Society and a clinical professor and specialty director of nursing and healthcare leadership at Duke University School of Nursing in Durham, N.C. "We have figured out a way to come together and not be fractured, and that is making a difference on The Hill. I hope and expect that trend will continue." Workplace and workforce issues "The biggest challenges we're going to face, from a nursing standpoint, are preparing for the staffing challenges," said Eileen Gillespie, RN, ND, vice president and chief nurse executive at Advocate South Suburban Hospital in Hazel Crest, Ill. "As we go through 2010 and the economy recovers, more nurses will exit the job market." Recent data supports that concern. The U.S. Bureau of Labor Statistics announced in November its expectation that registered nurses will experience greater job growth than any other occupation by 2018, with 581,500 jobs or a 22.2 percent increase. Not only will the country need more nurses, "the intensity of the work is not going to diminish," Nevidjon added. Holy Cross Hospital Executive Director of Nursing Services Taren Ruggiero, MSN, RN, also expects high acuity of inpatients will continue. "We will need to find nurses who have critical thinking and are getting away from being task oriented," Ruggiero said. "We are over-hiring to prepare for retirements and such." Holy Cross has a nurse residency program, which has helped with retention of new hires. Increasingly, hospitals are turning to such programs when bringing in recent graduates. Many leaders believe the economy is improving and will affect nurses' employment opportunities and decisions.

"New graduates will have an easier time getting jobs, and we may see some experienced nurses who came back into the workforce go back home, which would be too bad," said Julie StanikHutt, Ph.D., ACNP, CCNS, FAAN, director of the mater's program at the Johns Hopkins University School of Nursing. Haller reported steady staffing at Hopkins, with almost no vacancies, which she expects will continue as long as the economy remains level. "New graduates will have to start looking earlier and broaden their search geographically and clinically," Haller said. "Eventually, we will see what I call a silver tsunami of retirement, because boomers cannot hang on forever. But right now they are deferring retirement." If, as many expect, the nursing shortage returns, "the light will shine again on nurse retention," said Kristin Baird, RN, president of Baird Consulting of Fort Atkinson, Wis. "We'll have to pay close attention to nurse engagement, so they stay longer."

Beth Hammer, RN, MSN, APN-BC, anticipates improving the work environment will be important in 2010, and the American Association of Critical-Care Nurses offers tools to help nurses achieve that goal.

Beth Hammer, RN, MSN, APN-BC, president of the American Association of Critical-Care Nurses, predicts improving the work environment, including resolving staffing, leadership and communication concerns, will become even more important in 2010 as the need for nurses increases. "This is coming to the forefront with retention and where new nurses want to work," Hammer said. Lillee Gelinas, RN, MSN, vice president and chief nursing officer of VHA Inc., a network of not-for-profit hospitals, encourages hospitals to look at capital spending before cutting personnel, which will destroy trust and fuel the fire of unionization. "Employees are our most important asset," Gelinas says. "Yet that's where we go first for cost reduction. Nonlabor expense reduction is the priority for 2010, and we need to make sure we have creative solutions everywhere."

Provider perspectives and initiatives

Lillee Gelinas, RN, MSN, encourages hospitals to look for innovative ways to become more efficient without cutting staff.

"The nursing care model today is FRED--frantically running every day, that we cannot decide between one task and another," Gelinas says. "To be an effective leader in 2010, we need a clear picture, we need to maintain perspective, focus on the right things and rise above the distractions. For nurses, that means our core skills of assessment, intervention and evaluation have to take precedence, and we need to stay focused on delivering outstanding nursing care, no matter the odds." That will require creativity on the part of nurses, she said, and for hospital executives to provide them with a greater understanding of the big picture. Nurses also will need to remain more vigilant in protecting patient privacy, Gelinas indicated, and not give in to the temptation to share confidential information on social media Web sites. Haller reported a shortage of applicants for nursing leadership positions--nurse managers, clinical nurse specialists and educators. "This is a good time to be in school," said Haller, who reported the creation of patient safety officer positions at Hopkins, filled by master's-prepared nurses. "Quality and safety improvements are by and large led by nurses." Quality and safety will remain top concerns. Leaders are paying attention to nurse-sensitive indicators and communication lapses and taking action where they see a need for improvement, said Anne Jadwin, RN, MSN, AOCN, NE-BC, assistant vice president of nursing services at Fox Chase Cancer Center in Philadelphia. "It's become a blueprint for how we conduct day-to-day business, and that movement has been driven by consumers and insurance companies," added Jadwin, who expects hospitals will also continue to focus on improved productivity, throughput and cost containment. "We will try to maintain quality but do so under more constrained resources," Jadwin said. "With all of the stresses the environment is under, this is often a time when you will see the most innovation and creativity, when people are forced to start thinking about how we can do things differently and better."

The federal government has allocated funds to support implementation of health information technology. "There's a push to use information technology to enable clinical practice, to make us more efficient and more effective, so there is a demand for nurses to work in informatics and redesign workflow," Haller said. Gillespie added that patient-safety goals require acute-care nurses also prepare patients for taking care of themselves at home. Home-health nurses also will ensure patients and families have the knowledge and skills they need to manage safely at home, added Meg Doherty, MSN, ANP, MBA, executive director of the Norwell Visiting Nurses Association and Hospice in Boston. She expects a growth in homehealth nursing. "I see more nurses transitioning out of acute care hospitals to work in community settings and in particular what is now acute and sub-acute care at home," said Doherty, who predicted that will include specialty nurses and nurses with degrees in management and education. Nevidjon expected more technology will be placed in patients' home, enabling nurses to monitor, educate and manage care from afar. Education expectations While some in academia have seen greater interest in nursing, including Haber at NYU and Mortimer at Hopkins, Patrick R. Coonan, EdD, RN, NEA-BC, dean and professor of the Adelphi University School of Nursing, in Garden City, N.Y., anticipated a drop off as candidates watch fewer new graduates able to secure jobs. "We're seeing some decline in applications," Coonan said. Only half of Adelphi's new graduates secured jobs this year compared to 100 percent three years ago. On the other hand, Mortimer reported that all of Hopkins 2009 graduates who wanted a job found one. "We were used to hiring 300 or 400 people a year, but now it's much reduced, but compared to other fields, it's still a good field to be in," Haller said. The American Association of Colleges of Nursing will introduce a central application service this year, making it easier for potential students to apply to multiple nursing programs. If as most experts and data suggest the country needs more nurses, nursing leaders from the provider side and academia agree that the profession needs more faculty. "We're going to have to look at issues of how nurse educators are recruited and retained, and compensation is going to be a part of that issue," Malone said.

Gillespie added nurse employers will need to continue working with educators to ensure they have enough faculty. "From a nurse executive perspective, the challenge continues to be strengthening partnerships between academia and practice, so we can help support the ongoing education and development of our future nursing staff," Gillespie said. Haber reports significant investments are being made in simulators to aid in training nurses and advanced practice nurses to provide measurable, standardized clinical experiences and ensure they possess needed competencies. At NYU, students spend half of their clinical time in the simulation lab and half with real patients. Preparation also includes the use of actors to allow nurses to hone history-taking and communication skills. Educators also anticipate the growth of specialties, such as forensic nursing, reported by Vida Lock, PhD, RN-BC, director of the school of nursing at Cleveland State University in Ohio, and genetics, according to Nevidjon. Overall, the nursing profession remains strong but with some uncertainty that mirrors the nation and the health care industry as a whole. "We're looking at a time with lots of challenges and also opportunities," Raines said. "If the number of people who have access to care is expanded with health care reform, the need for nurses will increase to provide care to these people. We need to make sure we are preparing sufficient numbers of nurses and nurse practitioners to meet the demand."