Ruth P. Shumaker, RN, BSN, CNOR

As a perioperative nurse, and one who remains clinically connected, my interest in the impending nursing shortage is focused towards solutions. The nursing shortage impacts all practice areas and so all of nursing must work together for solutions. The word shortage suggests that too few nurses are available to fill the positions hospitals require. In fact, today's nursing shortage is often the reverse; it is actually a shortage of positions for trained nurses. One symptom was borne of hospitals cutting back. Hospitals contend the pressure of managed care left them no choice but to explore alternate staffing practices that resulted in too few nursing positions an in turn, too few nurses to provide care. Others counter that managed care companies were not the reason hospitals cut back but rather that the cutbacks were engineered to achieve increased profits. Whichever is more accurate keep in mind the country's current scarcity of trained and experienced nurses is not a temporary one.

Some experts feel the nursing shortage of the 1980's never ended but was masked by the changes in the healthcare setting, namely managed care. Many healthcare professionals feel managed care in the mid 1980s is to blame for the hospital cost cutting measures, which led to downsizing the professional nurse's position. The first people to lose jobs were the experienced skilled nurses who served as educators and mentors. It was a time when words such as re-organization, re-engineering, and right sizing were frequently used. In the mid 80's I watched many nurses lose their jobs. It was a painful time for nursing and one from which we have not fully recovered. Approximately one-third of a hospital's budget is spent on nursing salaries. In an attempt to decrease cost and yet enhance nursing care, hospitals countrywide increased the use of unlicensed assistive personnel. This led to an encroachment of nursing practice.

The number of students entering into a nursing program has steadily decreased in US nursing schools. Women make up the vast majority of the profession and now have many career options. Nursing is a wonderful career, but young woman and men have countless career opportunities. An intensive campaign, in schools is needed which features nursing as a rewarding and financially secure career.

The aging nursing workforce is also a problem. The average age of the practicing nurse is between 44 and 45 years old. There is a definite increase in the average age of all nurses and perioperative nurses are often one to two years older than that. When the baby boom generation starts to reach retirement age, there will be an unprecedented need for all kinds of medical services.

In a recent survey prepared by the Federation of Nurses and Health Professionals, 700 current nurses and 207 former nurses were interviewed. FNHP reported one in five nurses plans to leave the profession within five years because of unsatisfactory working conditions. The survey suggest nurses are leaving because of severe understaffing, larger patient loads, stressful and physically demanding jobs, mandatory overtime, irregular hours, low pay and morale.
Hospitals report it takes an average of 90 days to fill vacancies for clinical care, operating room and nurse managers. One only has to look in the nursing journals to see advertisements for positions in all parts of the country seeking staff and nurse managers. Traveling and registry nurses are filling many vacancies. Recruiting nurses from other countries is also a measure hospitals have used. The nursing shortage is worldwide, and every nation is focusing on it, so the trend to recruit foreign nurses may not hold up. The nurses most in demand are, clinical nurse specialist i.e. perioperative and emergency room nurses, nurse practitioners, nurse anesthetists and certified nurse midwives. These are the nurses who provide home care for patients or attend to seriously ill patients in the operating room, intensive care units, neonatal acute care units, and emergency rooms, where a complex array of technology and medical advancements require highly skilled staff. Perioperative nurses work in many settings. They often provide post-anesthetic care in rural hospitals or specialized units where nurses provide total patient care.

Experts are finding the nursing shortage uniquely serious. It is considered both a supply and a demand shortage, combining a broad range of issues. Constant change in the health care system challenges the notion that one nurse can be all things to all people. Nurses with varied education and practice competencies bring different skills to patient care, and they must be able to practice to the fullest potential of these capabilities. The environment in which nurses practice is another significant contributing factor to the difficulty in recruiting and retaining nurses. Increased demands and dissatisfaction with the job have exacerbated the underlying issues. Although low pay rates continue to be cited by nurses as a professional drawback, surveys indicate the leading factors given for turnover are workload and staffing.

Strategies to reverse the nursing shortages are multi-faceted. Nursing must be repositioned as a highly versatile profession where young people can learn science and technology, customer service, critical thinking and decision-making. Practice settings must build on relationships between nurses, physicians, other health care professionals, patients and communities. Employers must develop career enhancement incentives and promote more equitable compensation. The work environment should offer greater flexibility and scheduling programs. Nurses should be given autonomy over their practice in all settings. Employers should redesign work to enable the aging workforce to remain active in direct care roles. Staff development programs and lifelong learning for continued competencies must be created. Legislatively, nursing education must receive better funding. Marketing strategies should be developed to address the image of nursing and the recruitment of qualified students into nursing as a career. Steps to reverse the nursing shortage must be implemented now instead of later

It has especially been a challenge for nurses to get OR experience. Nursing schools use to include a rotation in the operating room but that hasn't been the case for a long time. Over, the past several decades, OR nurses have recognized the need to develop perioperative educational programs and restore an OR rotation back in schools of nursing. These programs have taken many forms. To cope with the current shortage of OR nurses, many hospitals have created their own OR training programs to grow their own resource of nurses. While many of these programs are successful, many do not have adequate resources to devote to such a program. Six to twelve months of clinical training is needed to become adequately trained for OR nursing. It requires both high-tech and high-touch needs of patients. How can all the problems that have been created and threaten to worsen the perioperative nursing shortage be remedied?

One solution is implementing an effective preceptor program. Experienced staff members provide novice nurses entering the OR the ability to enter with confidence and the necessary skills needed to provide quality patent care. A perioperative course must offer academic development with a clear progression of perioperative clinical practice. Perioperative nurses are responsible for identifying, interpreting and implementing professional standards. I taught Perioperative Nursing 101 for AORN and will continue to do so in my present position at ISH. I know the course requires core competencies to prepare the Registered Nurse for an entry-level position as a perioperative nurse. I have drawn from the experience and wisdom of many nurses. Working in the OR is an ongoing learning experience and challenge. I have witnessed nurses who have a deep understanding and passion for what they do. This passion needs to be conveyed to the new generation of nurses.

With the nursing shortage and the graying of nurses in the work force it is increasingly importance to recruit and grow a new generation of perioperative nurses.

Just as new surgical technologies and better-computerized systems lead to a more effective surgical intervention, our approach to recruitment, retention and perioperative education must be creative. Education is a cornerstone in the delivery of quality patient care. Organizations must support and provide adequate staffing in order to provide the care required. Finally and of vital importance, nurses must support, educate and mentor those who will follow in their steps.

1. J. Cannily, "The Nursing Shortage Affects You," Globe Syndicate, The Health Care Advocate, December 1999

2. http://www.cnn.com/Health, "New survey says nursing shortage will get worse", April 2001(accessed December 2001)

3. http://www.Bostonglobeonline, "Where the need is greatest; nursing shortage is most acute", September 1999(accessed December 2001)