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The nursing shortage: Its impact on the care of children

Article  in  Newborn and Infant Nursing Reviews · March 2003

DOI: 10.1016/S1527-3369(03)80007-7

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Abstract
The nursing shortage is likely to have
a serious impact on the various roles
of pediatric nursing and the care of
children. An earlier perception that
there were too many “specialty”
nurses is simply untrue. The future
demand for pediatric nurses is
expected to increase dramatically as
the gap between the number of elderly
people needing care and those
available to provide services shifts
resources away from children.
Vulnerable pediatric populations at
risk for poor outcomes will be
adversely affected first. Short-term
solutions to the nursing shortage will
not directly impact pediatric nursing.
Many of the roles pediatric nurses fill,
such as the pediatric intensive care
unit, require up to 2 years of
experience. Pediatric nurses who work
in the community in expanded roles
require advanced practice training
beyond the BSN. Given these
particular workforce issues, recovery
of pediatric nursing is expected to lag
behind other nursing specialties.
Copyright 2003, Elsevier Science
(USA). All rights reserved.
From the Catholic University of America,
School of Nursing, Washington, DC.
Address reprint requests to Deborah Shelton,
PhD, RN, CNA, The Catholic University of
America, School of Nursing, 620 Michigan Ave
NE, Washington, DC 20064.
Copyright 2003, Elsevier Science (USA).
All rights reserved.
1527-3369/03/0301-0002$35.00/0
doi: 10.1053/nbin.2003.36084
The Nursing
Shortage: Its
Impact on the
Care of Children
By Deborah Shelton, PhD, RN, CNA
T
oday’s nursing shortage is very real and different from any experienced
in the past. This shortage is exacerbated by fewer nurses entering the
workforce, acute nursing shortages in certain geographic areas, and a
shortage of nurses adequately prepared to meet certain areas of patient need in
a changing health care environment.1 As a result, there is a growing realization
that the supply of appropriately prepared nurses is inadequate to meet the needs
of clients and that this shortfall will grow more serious over the next 20 years.
A model constructed by Buerhaus et al2 projects that the number of full-time
registered nurses (RNs) per capita will peak in 2007 and then begin to decline
in 2012. By 2020, the nurse workforce supply will be 20% below the Health
Resources and Services Agency (HRSA) projected need.3 This article describes
the characteristics of the current shortage, pending legislation, and health policy
implications for pediatric and neonatal nursing.
The shortage of RNs has reached critical levels across the United States. This
trend is caused primarily by the aging of the nurse workforce and the declining
enrollment in schools of nursing to counterbalance the number of nurses that are
retiring or leaving the profession.4 Faculty shortages fuel the overall decline in
new enrollments, as some schools of nursing are turning away qualified stu-
dents because of insufficient number of faculty, clinical sites, classroom space,
clinical preceptors, and budget constraints.5 Declining enrollments are also
caused by the wider range of career options for women that offer better pay for
less demanding work. Stress and job dissatisfaction have been identified as
major factors contributing to the current crisis.6 Inadequate staffing, heavy
workloads, increased use of overtime, a lack of adequate support staff, and the
inadequacy of wages are contributing factors.
Job dissatisfaction and the demand for nurses have been directly influenced
by changes in the structure, organization, and delivery of health care service.7
Hospitals, the major employer of nurses, were once the traditional provider of
acute care services. Advances in technology and a greater emphasis on cost-
effectiveness combined with a decline in the number of hospital admissions and
lengths of stay, shifted care from inpatient to ambulatory or community-based
settings. Those patients remaining in the hospital had higher acuity levels while
the medical complexity of patients in the community increased. The result was
to double the demand for nurses that now work within hospital settings and in
the newer community settings. This change contributed further to the inade-
quate staffing, heavy workloads, and increased use of overtime.
Although most nursing shortage reports focus on the nursing shortage in the
hospital environment, the decreased number of individuals entering the nursing
Newborn and Infant Nursing Reviews, Vol 3, No 1 (March), 2003: pp 27–31 27
28 Deborah Shelton
workforce also has a significant impact on the number of
nurses who choose to advance their education and pursue
advanced practice roles.8 A review of the Bureau of Health
Professions’ Division of Nursing’s National Sample Sur-
vey of Registered Nurses (NSSRN)9 reveals that nurses
who work outside hospitals have a baccalaureate in nurs-
ing or higher. Thus, the shortage of nurses impacts the
primary care arena, especially in the medically under-
served areas, federally underserved areas, and rural and
urban health professional shortage areas. As an example of
this phenomenon, rural geographic areas that historically
lack pediatric services will have an even tougher time
competing.10 Dr. Mueller, Director for the Center for
Rural Health Policy Analysis, predicts that rural hospitals
are likely to be hard hit.
For hospitals and agencies that provide specialty care to
children and adolescents, the competition for nurses is
even fiercer. Specialty practice requires specialty training
and seasoned professionals. The workforce data noted in
the NSSRN report has limited published data on nursing
specialties such as the estimated number of pediatric
nurses in the United States. Of all nurses graduated, it is
estimated that 6.6% work in pediatrics.11 Of these, approx-
imately 38% work in community settings, such as school
health, ambulatory care, physician’s offices, and health
departments. The data fail to present detail on other pedi-
atric nursing roles, such as child and adolescent behavioral
health nursing. The importance of these roles has gained
importance since the terrorist attack on September 11,
2001. Attention to stress reactions and anxiety are neces-
sary to avoid future physical illness and to reduce the
influence of stress on the learning and future of children
across the nation.
Impact on Specific Newborn, Infant, and
Pediatric Nursing Roles
H igh-stress areas, such as pediatric and neonatal in-
tensive care units, require multifaceted skills in a
highly technical environment. Children’s hospitals tradi-
tionally recruit nurses with at least 1 to 2 years of training
in these critical areas.12 To address this need, skilled,
experienced nurses are mixed with inexperienced recruits,
which at times causes undue stress for both sides. Men-
toring programs and internships are mechanisms popular
for pairing expert nurses with new or inexperienced nurses
or to recruit new nursing graduates. There is much to be
learned about the technology of these sophisticated envi-
ronments, but there is much to be learned as well regarding
the skill of caring and the power of therapeutic touch. It is
the experienced nurse who can assist the new nurse to see
the value of such mundane tasks as changing beds, dis-
pensing medicine, or bathing a small child.
Legislative Watch
T he importance of this issue to the health care of the
nation is reflected in the unprecedented number of
bills in the current legislature addressing the aspects of the
nursing shortage. Currently there are 40 bills addressing
the nursing shortage, 16 of which focus specifically on
nursing workforce issues. The most important bills to
watch are as follows: Nursing Shortage Response Act of
2001 (H.R.2594); NEED Act (S.721 and H.R.3020);
Nurse Reinvestment Act (S.1864 and H.R.436); and Nurse
Retention and Quality of Care Act of 2001 (S.1594 and
H.R.4654).13
The Nursing Shortage Response Act of 2001
(H.R.2594) seeks to amend the Public Health Service
Act’s criteria for the designation of health professional
shortage areas to (1) include tertiary-care nurses in deter-
mining the number of health professionals and (2) accept
such nurses as National Health Service Corps members
and provide for their participation in the Scholarship and
Loan Repayment Programs. This bill was referred to the
Subcommittee on Health with little action.
More attention seems to be focused on S.721 and
H.R.3020---Nursing Employment and Education Develop-
ment Act (the NEED Act)---which amends the Public
Health Service Act. The NEED Act seeks to provide for a
Nurse Corps Scholarship program to provide scholarships
to individuals seeking nursing education in exchange for
service from such individuals in a critical nursing shortage
area on completion of such education. A more expansive
bill than H.R.2594, these bills address more of the issues
thought to contribute to the nursing shortage. Included are
a public awareness and education campaign encouraging
pursuit of the nursing profession; an area health education
centers program to develop models of excellence for
nurses; community nurse outreach grants; educational as-
sistance for nurses from diverse or disadvantaged back-
grounds; career ladder program grants for nurses; nurse
training grants, nurse internship and residency grants; a
fast-track nursing faculty loan program; a stipend and
scholarship program to encourage individuals to seek ad-
vanced nursing degrees; and a National Commission on
the Nursing Crisis. This bill is receiving favorable review
in the House Subcommittee on Health as well as by the
Senate Committee on Health, Education, Labor, and Pen-
sions.
The Nurse Reinvestment Act (H.R.3487) varies from
the bills noted above by amending the Public Health
Service Act and requesting appropriations through 2007 to

award grants to schools of nursing and/or health care
facilities to develop and support educational outreach pro-
grams that will encourage entry into the profession, tar-
geting primary, secondary, and other schools; the disad-
vantaged, underrepresented minorities; and underserved
rural and urban communities. This bill addressed the de-
mographic trends toward an aging society by focusing on
efforts to encourage long-term care nursing services for
the elderly as a career choice. Also included is the estab-
lishment of a National Commission on the Recruitment
and Retention of Nurses to make innovative and creative
recommendations concerning recruitment, retention, and
advancement including expanding existing school mentor-
ing programs. This bill, 1 of 4 on the floor, was passed by
both the House and the Senate and has now been passed
through the Appropriations Committees.
The Nurse Retention and Quality of Care Act of 2001
(S.594 and H.R.4654) amends the Public Health Service
Act to award grants to eligible health care facilities that
will demonstrate models and best practices in nursing care
to develop strategies for nurse retention. Such strategies
will promote nurse satisfaction, communication, collabo-
ration in decision-making, professional advancement, and
high-quality patient care. This bill was read twice and
referred to the Senate Committee on Health, Education,
Labor, and Pensions. On the House side, H.R.4654 was
referred to the House Committee on Energy and Com-
merce, Subcommittee on Health.
Since the initial introduction of the bills mentioned,
Secretary Tommy Thompson announced a series of grants
totaling more than $33 million that are designed to ease
the nation’s nursing shortage and improve the “quality of
nursing services” nationwide.14 While these efforts are to
be applauded, the impact will not adequately address the
immediate need for nurses, nor does it begin to address the
more systemic problems that have a historical pattern of
cyclical reoccurrence.
Future Trends
F our areas of opportunity have been identified. These
areas include workforce development, data, training,
and working conditions. Highlights of these trends follow.
● As the number of advanced practice nurses increases, an in-
crease in nurse-managed health care services will be seen.
Nurses capitalizing on the public’s perception of nurses and
dissatisfied by work environments that pressure them to pro-
vide care that does not meet the standards to which they have
been formally educated will move out into the community
where less traditional services are more accepted.
● Restructuring job roles to move nursing expertise back to
patient care. Use of other providers should focus on supportive
The Nursing Shortage 29
roles that free nurses to do the thing that they are educated for,
rather than substitute for nursing care that has been demon-
strated to produce positive patient outcomes.
● Career ladders, particularly for gerontology, will gain support.
Evidence of state and local efforts to assure a workforce to
meet the growing demands of the aging population are already
evidenced in a number of states. The approach is to establish
career ladders, training, and support systems for entry-level
workers with an aim to address the nursing shortage by “grow-
ing the profession from within.”15
● Capitalizing on the trends toward “welfare to work” program-
ming, health systems have tapped welfare recipients and
former welfare recipients as a pool of labor by developing
customized programs for recruitment, training, and retention.
Program outcomes met or exceeded welfare to work efforts of
other industries.16
● Closer collaborations between the Department of Labor and
HRSA can be expected to enhance health care workforce
planning. Regional Centers for Health Workforce Studies will
support and enhance state and local efforts in analyzing labor
market supply and demand, as well as providing consistency in
data across the nation.17
● Financial incentives and support for broadening access to
nursing as a career trajectory is expected. Expansion of
prenursing preparatory programming will enhance options for
nontraditional and other labor pools, including welfare recip-
ients, low-income students, displaced workers, and youth. Job
Corp Centers already offer health-related training, and as such,
offer a model for enabling individuals who have difficulty
accessing or succeeding in the traditional education system.18
● Appropriate changes in legislation or in existing standards that
address working conditions such as mandatory overtime,
whistleblower protections, and worker safety are already oc-
curring. The significance of job satisfaction on retention of
nurses makes these issues cost-efficient enough to be heard and
addressed.
Conclusion
B ased on this review of recent research and employ-
ment projections, it is clear that the nation will face a
nursing shortage in the next decade and that some locali-
ties are already facing shortages. As reflected by the mul-
titude of approaches to the nursing shortage as outlined in
the legislative actions outlined above, there is no single
solution. The National Association of Pediatric Nurse
Practitioner’s19 supports a multifaceted approach to solv-
ing the nursing workforce crisis by calling for a systemic
examination of educational programs, health care delivery
systems, reimbursement issues, minority recruitment and
retention, state and federal regulations, and health policy
implications.
The shortage of pediatric nursing subspecialists during
the next decade may become the strategic and operational
issue facing children’s hospitals and other child service
30 Deborah Shelton
agencies. These trends have become noticeable only re-
cently as the demand for services has increased, dispelling
reports that assert there are too many specialists.20 The
future demand for pediatric nurses is expected to increase
dramatically if the core issues that have impacted the
recruitment and retention of nurses are not addressed. As
the number of elderly increase, the gap between the num-
ber of people needing care and those available to provide
it will widen, shifting resources away from pediatric nurs-
ing. Care available to the children identified as “vulnera-
ble” will be further stressed. Those subgroups at particular
risk to poor outcomes will be adversely affected first.
Trends toward care provided by those other than nurses
will increase. During such a crisis, there is a predictable
trend to deregulate and substitute lesser-prepared per-
sons.21 Lowering educational standards is inappropriate
and a potentially dangerous response to a shortage of
health care professionals. Such a short-term response will
only interfere with quality patient care and contradict the
nursing belief system and development of nursing as a
profession.
Expanding education is best suited for addressing the
long-term expected increases in demand, but is less effec-
tive at addressing the short-term problems. To keep up
with demographic changes, educational opportunities must
be expanded to a broader population of potential students.
Nursing academicians need to be more flexible in the
delivery of nursing education and not reduce the quality of
the content. Few advanced practice child and adolescent
specialty nursing programs currently exist in the nation.
Yet they provide the most targeted solution for matching
nursing knowledge and skill to patient needs in these
rapidly changing health systems.
How successfully nurses, employers, educators, and
policymakers handle the coming challenges in the nurse
labor market will be critical not only to maintaining the
public’s trust in the nursing profession but to preserving
the public’s confidence in the health care system as a
whole.4 Recent national polls show that more than 80% of
Americans believe that nurses are doing a “good job” of
serving health care consumers,22 a rating that has held over
time and has exceeded the rating attributed to other pro-
viders.
Even with the projected shortages, the opportunities for
newborn, infant, and pediatric nurses to impact care lie in
leadership through legislation and advocacy. Being a nurs-
ing leader is within the capability of each nurse. Each day,
whether large or small, nurses do amazing things. Sharing
these challenges and accomplishments are critical for sus-
taining and enhancing the profession. To address recruit-
ment and retention of nurses already in newborn, infant,
and pediatric nursing, nurses need to take leadership roles
in assisting the health care industry to achieve these goals.
Who better than the nurses in these roles to contribute
unique and innovative ideas that would appeal to a variety
of individuals? As noted by Ferguson,23 a nurse leader and
champion for children, “Pediatric nurses [and indeed all
nurses] hold the key to successfully recruiting, retaining,
and encouraging others to consider being a pediatric
nurse.”
References
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The Nursing Shortage 31
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