The current nursing shortage is a double-edged sword. It means staff shortages and exhausting shifts for nurses, compromising patient outcomes.[i] It also means that salaries are at an all-time high and that employers are offering new incentives and benefits, flexible scheduling, and chances for nurses to participate meaningfully in decisions that affect their work environments as well as patient care. There are also unprecedented opportunities for advanced practice nurses (APNs) and specialty nurses.
This article describes current and projected numbers of nurses in the workforce, the demand for registered nurses, the effect nursing shortages have on patient care, and anticipated employment opportunities for RNs in 2004.
NURSING THE NUMBERS
Every four years since the mid 1970s, the Bureau of Health Professions of the U.S. Department of Health and Human Services has provided the most extensive and comprehensive statistics available on registered nurses currently licensed to practice in the United States. The following data are from the most recent survey, conducted in 2000, available online at http://www.bhpr.hrsa.gov/nursing/sampsurvpre.htm.[ii]
How many are we? According to the survey, the estimated number of licensed RNs in the United States is 2,696,540. Although this figure represents a 5.4% increase from 1996, it is the lowest increase reported since the beginning of the quadrennial surveys. (Between 1992 and 1996, the total number of RNs increased by about 14.2%.) Of the total number of licensed RNs, 58.5% work full time, compared with 52.0% in 1980; 23.2% work part time, down from 24.6% in 1980; and 18.3% are not employed as RNs, down from 23.4% in 1980. The total number of RNs employed in nursing is 2,201,813.
How old are we? As a workforce, we are aging. The average age of an RN is 45.2; the average age in 1996 was 44.5 years. In 1980, 52.9% of RNs were under 40. According to the 2000 data, 31.7% are under 40. A recent exhaustive study by Buerhaus and colleagues in the Journal of the American Medical Association predicted that the total number of equivalent RNs per capita working full time would peak around the year 2007 and decline steadily thereafter as the largest cohorts of RNs retire.[iii] By 2020, according to the study, the RN workforce will be roughly the same size as it is now, which will be 20% below projected demand. The study found that the main reason for the older workforce is a decline in the number of young women choosing nursing as a career since 1980.
How have we been prepared? During the past 20 years, entry-level nursing education has shifted away from diploma to associate-degree or bachelor’s degree programs. In 1980, 63% of licensed RNs had received their basic nursing education through diploma programs, compared with 29.6% now. In 1980, 19% of nurses graduated from associate-degree programs, compared with 40.3% now; 17.3% had baccalaureate degrees in 1980, compared with 29.3% now. The net effect of these changes is that nurses are spending less time on their entry-level education. Even though the number of bachelor’s and master’s programs is increasing, a far greater increase is seen in the number of nurses in associate-degree programs than in the number of nurses in hospital programs. Associate-degree programs are two years long; hospital programs are three.
The number of two-year community colleges with RN programs exploded in the 1960s and has steadily increased since then. At the same time, three-year hospital diploma programs have been closing. Not only was the demand greater for the two-year programs, but hospitals were forced through harsh economic forces — brought about by the managed care system — to close unprofitable programs.
One result of these shifting trends in basic nursing education is that, according to Donley and Flaherty, practicing nurses are undereducated when compared with other members of the health care team. This is a real problem, as they view it, because “undereducated members of the health care team rarely sit at policy tables or are invited to participate as members of governing boards. Consequently, there is little opportunity for the majority of practicing nurses to engage in clinical or health care policy.”[iv]
On the bright side, more nurses than ever are pursuing postgraduate education. In 1980, 5% of the 1,662,382 RNs had a master’s or doctoral degree. According to the last survey, 10.2% of nearly 2.7 million RNs have such degrees. These statistics also reflect the dramatic increase in the number of master’s degree programs in nursing available to people who have bachelor’s degrees in areas other than nursing. The influx of baccalaureate-prepared people from other fields into nursing increases our diversity and broadens our perspective.
Where do we work? Of today’s employed RNs, 59.1% work in hospitals, 18.3% in public and community health (including occupational and school health settings), 9.5% in ambulatory care, 6.9% in nursing homes and extended care facilities, 2.1% in nursing education, and 3.6% in other settings (such as prisons, jails, and insurance companies). The settings that saw the largest increase in number of RNs were the public and community health sectors, including state health departments, community health centers, and visiting nursing services.
How much do we make? The Bureau of Health Professions survey measures average RN earnings through two indices: the actual average earnings of RNs employed full time and the “real” average earnings of those RNs, based on the consumer price index for 1982 to 1984. The actual average annual salary of a full-time RN is at an all-time high of $46,782—it was $17,398 in 1980.[v] However, real compensation amounts to only $23,369 when changes in the purchasing power of the dollar are taken into account through the consumer price index. Real salaries have been about the same since 1992.
How many of us work in advanced practice? The number of nurses prepared to be nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists rose to 196,279 by 2000, or 7.3% of RNs—up from 6.3% in 1996. Of nurses working in advanced practice, most are nurse practitioners; the next largest group is clinical nurse specialists. These two together, including people who are trained to do both jobs, make up approximately 80% of all APNs. Nurse midwives account for 4.7% of APNs (up from 1996), and nurse anesthetists comprise 15.2% (up from 1996).
NURSING THE DEMAND
Today there are more than 126,000 unfilled nursing positions—around 7% below the workforce requirement.1 The nursing shortage is expected to continue at this rate so that the number of nurses is 12% below what’s needed by the year 2010, 20% below by 2015, and a staggering 29% below the workforce need in 2020.3
Advances in medical technology and pharmaceuticals as well as healthy lifestyle choices have resulted in “the graying of America” as life expectancy increases and quality of life improves. The current number of unfilled nursing positions pales when compared with the number of nurses needed when 78 million baby boomers begin placing unprecedented demands on the system when they hit 65 in a few years.
WHY THE SHORTAGE?
Why, if there’s job security and decent pay, is there such a profound shortage of nurses? The reasons are numerous and complex. A 20-year buildup of conditions created the “perfect storm”—our current protracted, calamitous nursing shortage. The economic pressures that started with the introduction of the managed care system in the 1980s and continued with hospital mergers in the 1990s necessitated a rethinking of how care was delivered.
This transformed healthcare system transferred much of inpatient care to the outpatient setting and to the home. This shift is reflected in the dramatic decrease in hospital average lengths of stay in the last two decades. In 1980, the average length of stay was 7.3 days.[vi] In 2000, the average length had fallen to 4.9 days.[vii] What this means for the nearly 60% of RNs who work in hospitals is that today’s patients are sicker than in the past, requiring more intense nursing care.
Another factor that has influenced today’s shortage was a 1995 report by a blue-ribbon commission funded by the Pew Charitable Trusts. The report warned that hospital mergers would close the doors of almost 50% of our nation’s hospitals by 2000, which would mean a loss of 60% of hospital beds and a surplus of 200,000 to 300,000 nurses.[viii] The Pew prediction was wrong, and far fewer hospitals closed than anticipated, but the report left its mark on history by discouraging young people from entering the nursing field.
The reshaping of health care by market forces has meant fewer hospital resources for nursing. Dealing with intense assignments and extra shifts (including mandatory overtime), nurses are overworked and have become stressed, burned out, and left with little job satisfaction; all these contribute to the nursing shortage. Furthermore, as nurses get older and retire, more people are leaving than entering the profession, even with increased enrollments in schools of nursing. Women account for 95% of nurses, and young women are not choosing to become nurses as frequently as they once did. This is leading to a further reduction in the number of nurses. But at the same time that nursing enrollment is down, the number of women entering medicine is up. Medical schools now boast a 50:50 female to male enrollment ratio (see www.aamc.org/data/facts/famg52002a.htm for information.) We don’t have the capacity to educate as many nurses as we used to, as evidenced by a far higher number of applicants than enrollees.
Gail Collins wrote about the shortage in a 2001 New York Times article: “[Nurses are] unhappy, and they’re spreading the word. . . . Management has a right to be efficient and demand results, as long as everybody remembers that the nurses of the future have a right to sign up for dentistry or accounting.”[ix]
NURSING THE EFFECTS
According to a white paper by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nursing shortage is “a prescription for danger.”1 The JCAHO report shows that the shortage contributed to a staggering 24% of the unanticipated problems in hospitals that result in patient death or injury, citing insufficient numbers of nurses as a reason for those cases. The JCAHO used its “sentinel event” reporting system (a computer database that includes 1,609 reports of patient deaths and injuries between 1996 and the report date), as well as detailed explanations from hospitals to generate these results.1
The paucity of nurses affects more than patient injuries and deaths. It contributes to some of the thorniest problems in health care today. It’s a major factor in ED overcrowding and “diversions,” cancellation of elective surgeries, discontinuation of clinical services, and limitations in the health care system’s ability to respond to mass casualties. Ninety percent of nursing homes report that they do not have enough nurses to provide even the most basic level of care, and some home health agencies are being forced to refuse new admissions.1
WHO CAN FIX THE SHORTAGE?
Reversing the nursing shortage will not be simple, but the shortage is fixable, and it’s up to us. It will take a community—nurse executives, hospital leadership, policymakers, schools of nursing, physicians, accreditors, private industry, and nurses ourselves. The cited 20002 JCAHO report also called for reforms to the nursing education system and for the federal government to tie Medicaid and Medicare payments to a hospital’s improvement in nursing care and nurses’ work environments.
The nursing profession. Perhaps the greatest hope for alleviating the nursing shortage is the Magnet Recognition Program, the brainchild of the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association. Magnet hospitals are desirable settings for RNs and better patient outcomes than do other hospitals; this gives them an edge in recruiting and retaining nurses in a tough market.
The Magnet program came about in response to the severe nursing shortage of the early 1980s. The American Academy of Nursing, the ANA, and a group of nurse executives were looking to combat that shortage and decided to conduct a national study to identify those hospitals that attracted and retained nurses. That study led to 41 hospitals receiving the designation “Magnet hospital.”[x] There are now two groups of Magnet hospitals — one from the early 1980s, the other certified since the early 1990s.
In the early 1990s the ANA, through the ANCC, formalized the (Magnet) program to acknowledge excellence in nursing. It’s a form of external peer review available to all hospitals and healthcare organizations. The Magnet designation is awarded according to 14 standards of nursing: high-quality care, strong nursing leadership (including a nursing staff that makes decisions about clinical care and its own practice), dynamic performance improvement, large number of APNs, heavy involvement on the part of nurses with the community, and high degree of interdisciplinary collaboration. Organizations are evaluated in a process that consists of several stages, including documentation of attainment of the 14 standards and on-site review. Currently 85 organizations in the United States and Britain have been awarded this nursing seal of approval. Magnet status is elite: Fewer than 2% of hospitals have achieved this rigorously determined certification.[xi] Magnet recertification is required every four years. Studies by Linda H. Aiken, PhD, RN, FRCN, FAAN, and others have demonstrated the value of the Magnet program in terms of fostering both positive patient outcomes and satisfactory work environments for nurses.10, [xii]
Policymakers. The nursing shortage has certainly gotten the attention of the U.S. media. Policymakers at the state and national levels have watched the news, read their newspapers, listened to their constituents, and begun to pass legislation to alleviate the shortage.
In mid 2002 Congress passed, and President Bush signed, the Nurse Reinvestment Act. This law modified funding for existing nursing programs—including ones for advanced practice nursing, basic nursing (nurse education, practice, and retention), nursing workforce diversity, and loan repayment and scholarship—and created geriatric care training and faculty loan programs. For fiscal year 2003, Congress appropriated a total of $113 million for all nursing programs—an overall increase of $20 million over levels from fiscal year 2002 but still less than the recommended $250 million.{Public Law No. 108-007. Omnibus appropriations bill for FY03, passed February 20, 2003.}
Most states have begun to address the shortage through legislation and funding to expand nursing. Some states have passed laws to improve the workplace. Texas, for example, addressed nurse staffing ratios administratively: The Texas Hospital Association and the Texas Nurses Association worked with the state’s department of health, which has rule-making authority, to change nurse staffing plans in March 2002. Texas hospitals are now also required to form advisory committees with mandated input from front-line nurses. The implementation of California’s safe-staffing law, signed in October 1999, proved difficult; all hospitals in California must comply by January 1, 2004. In 2003, states’ hands were tied when all but a handful of states experienced huge budget shortfalls.
Private industry. It’s in the best interest of private industry for our nation to have a full and sustainable nursing workforce. One example of private industry aggressively addressing the shortage is Johnson & Johnson’s 2002 advertising campaign, featuring the “dare to care” television spots which portrayed nurses very positively and appealingly. In February 2002, the company launched a two-year, $20 million campaign to attract more people to the nursing profession. The campaign includes scholarships for undergraduate nursing students and nurse educators; television ads celebrating nurses and their contributions; national fundraising events to honor excellence in nursing (and to support the student and faculty scholarships); and recruitment brochures, posters, and videos for distribution in 20,000 high schools, 1,500 nursing schools, and nursing organizations. In addition, the company launched a Web site, www.discovernursing.com, that offers information on careers in nursing, profiles of 105 nurses across the nation in different jobs, a database of nursing schools, and more than 300 nursing scholarship programs.
Nurses ourselves. It used to be said that nurses “eat their young,” holding recent graduates to very high standards, sometimes resulting in their departure from the profession. Today, established nurses embrace new nurses and traveling nurses. Nurses everywhere feel the strain of the shortage every day, and they’re happy to get what help they can; they show their appreciation.
When I see new graduates I thank them for going into nursing. When I see promising young people, I ask them if they’re happy with their jobs, and if not, I ask them to think about becoming nurses. Nurses ourselves are surely our profession’s best recruiters.
One of the most basic ways individual nurses can contribute is by joining the ANA, state and national professional nursing organizations, as well as specialty organizations. Organized nursing plays a critical role in informing the public and policymakers about the needs of the profession. The people in these organizations are the voice of nursing in the halls of state houses and in Congress (sometimes with the help of the media). Nurses must prompt elected officials when nursing bills come up for vote.
NURSING THE OPPORTUNITIES
Both the complexity of health care and the shortage have brought about unprecedented opportunities for nurses. The following are only a few areas of nursing that are innovative and promising.
Staff nursing. The need for hospital staff nurses has continued to rise, and the good news in nursing is that nurses can continue to work at the bedside while finding fulfillment. With the move toward Magnet nursing, the bar has been raised for staff-nurse contributions in hospitals. Staff nurses have opportunities that did not exist before.
I am a staff nurse at a Magnet hospital. Staff nurses are encouraged to participate meaningfully in making decisions that affect patient care and the work environment. I participate in a refined shared governance structure and culture consisting of a strong chief nursing officer, a nursing executive council, a nursing congress, and eight specialty councils (acute and postacute care, ambulatory care, behavioral health, critical care, emergency care, pediatrics, perinatal, and surgery). This hospital, like other Magnet hospitals, has a high degree of interdisciplinary collaboration, which I find very rewarding. We have a clinical ladder program that rewards nurses for participating in shared governance and for promoting health on a volunteer basis in the community.
Teaching. There is also a shortage of nurse faculty members.{Hinshaw AS. A continuing challenge: the shortage of educationally prepared nursing faculty. Online Journal of Issues in Nursing. January 31, 2001. http://www.nursingworld.org/ojin/topic14/tpc14_3.htm.} New money from government to increase the supply of nurses will have little effect if there aren’t enough teachers. Furthermore, the faculty shortage is a major factor limiting enrollment in schools of nursing.
The average age of a nursing teacher is 50.2, and with the retirement of this “graying professoriate,” the shortage is expected to escalate.{Hinshaw 2001 (above).} (This phenomenon is unique to nursing because nurses are encouraged to gain clinical experience before earning higher degrees and teaching.) A nurse with five years’ solid experience can teach. With opportunities to guide future nurses as well as chances to do important research, teaching can be very rewarding. Nurses wanting to teach may do well to consider pursuing that goal earlier in their careers than the last generation did.
Genetics nursing. The remarkable work of the U.S. Human Genome Project is a catalyst for growth in the number of opportunities available to nurses. Coordinated by the Department of Energy and the National Institutes of Health, the project, which began in 1990, has mapped the human genome—the collection of about 35,000 genes and the sequences of the 3 billion base pairs that make up human DNA.{Human Genome Project Information found at http://www.ornl.gov/TechResources/Human_Genome/home.html} The implications for health care are profound. Most health conditions are believed to result from a combination of genetics and environmental influences; the new knowledge will improve the prediction, diagnosis, and treatment of many illnesses.
Physicians, nurses, and other health care workers, regardless of specialty, will need to integrate new information on genetics into routine practice, especially when explaining responsiveness to treatment and options for care.{Jenkins JF. An historical perspective on genetic care. Online Journal of Issues in Nursing. Sept. 30, 2002. http://nursingworld.org/ojin/topic13/tpc13_2.htm.} In response, medicine has developed a specialty, offering services, resources, and education in genetics. For example, where I work in the NICU, when a neonatologist suspects a patient has a particular syndrome but is unsure of which one, another medical specialist—a geneticist—is called in to help identify the syndrome. The geneticist identifies the syndrome, gives a prognosis and the probability that the syndrome will occur in other children of the same parents. Staff nurses assist in reducing complex information into practical, understandable terms for families.
As part of genetics teams, nurses provide care in regional genetics networks, private office settings, and specialty genetics clinics, offering assessment, education, counseling, testing, and interpreting of test results. The International Society for Nurses in Genetics (ISONG) (www.globalreferrals.com) is recognized as the main organization in offering annual conferences, developing nursing standards of practice, and promoting communication and research on genetics.
Nurses with a master’s in nursing may qualify for the credential of APN in genetics. Those with a bachelor’s may qualify for the genetics-nurse credential. The Genetic Nursing Credentialing Commission (www.geneticnurse.org), a subsidiary of ISONG, recognizes clinical nursing practice with a genetics component by granting credentials based on a portfolio of evidence indicating professional experience.
Advanced practice nursing. This collective term refers to four specialties: nurse practitioner, clinical nurse specialist, certified nurse midwife, and certified registered nurse anesthetist. The number of APNs has increased with a rise in opportunities for employment: In 2000, there were nearly 200,000 APNs, or 7.3% of the total RN population, up from 6.3 in 1996.{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).}
APNs are trained by nurses, credentialed by nurses, regulated by nurses, and most have their own medical malpractice insurance. These highly qualified providers are legally allowed to practice in all 50 states. Certain requirements, such as that they be supervised by physicians, vary from state to state and are specified through the states’ nursing practice acts and medical practice acts, the rules of their nursing and medical boards, and hospital licensing laws. {Inglis T. Nurse anesthetists: one step forward, one step back: physician supervision requirements for CRNAs jeopardize access to care. AJN 2003;103 (1):91-4.}
I’ve worked in the same NICU for the past 24 years. In the 1990s, our medical coverage evolved from 100% neonatologists to around 50% neonatologists and 50% neonatal nurse practitioners (NNPs), all employed by a national physician management group. Most of the NNPs here are former NICU staff nurses who completed advanced NNP training and stayed at our hospital. Their work involves nursing and medicine: They write orders (cosigned by a neonatologist) and expertly perform most of the procedures neonatologists perform, such as intubation, insertion of arterial lines, and lumbar punctures. The NNPs have improved the scope of medical care because of their holistic approach to practice and by providing relief to overworked physicians burdened by a neonatologist shortage.
In the hospital where I work, APNs work in other positions. Certified registered nurse anesthetists work alongside anesthesiologists to deliver anesthesia care. Certified nurse midwives deliver infants in a highly sought-after method of childbirth. Nurse practitioners and clinical nurse specialists make up roughly 80% of APNs,{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).} and their subspecialties are as varied and numerous as nurses’ interests: community health, gerontology, family practice, medical–surgical, neonatology, pediatrics, perinatal care, psychiatry and mental health, and women’s health, to name just a few.
Infusion nursing. Happily for patients and nurses, medicine is no longer dependent on peripherally inserted short-term catheters for venous access. Implanted, tunneled, and peripherally inserted central catheters (PICCs) are used for long-term venous access, ideal for patients receiving chemotherapy with irritant or vesicant drugs, long-term antibiotic therapy, and total parenteral nutrition. The insertion procedure, which is a sterile technique, with placement confirmed by X-ray, requires a medical order.
Where I work in the NICU, nurse clinicians take an eight-hour class from nurses hired by the makers of the neonatal PICCs. After three successful supervised insertions, participants are deemed by our institution competent to insert them. For the rest of the adult and children patient population in our hospital network, a cadre of “venous-access” nurses are on call to insert them. National certification as an infusion nurse is available through the Infusion Nurses Society (see www.ins1.org for information).
End-of-life nursing. The aging population has increased the demand for gerontology nurses. At the same time, a national movement toward dignifying the death experience has been taking place, giving renewed life to hospice and palliative care.
In the 1990s, numerous studies revealed disturbing data about people dying in U.S. hospitals being subjected to unwanted extraordinary measures. Family members were not happy with how patients were treated at the end of their lives. Then, in 2000, Bill Moyers’s public-television series, On Our Own Terms: Moyers on Dying, opened a dialogue about death and dying. (The show was partially funded by the Robert Wood Johnson Foundation, which exerted more cultural influence on health care by providing grants for programs that improved end-of-life care. )
Nurses comprise and manage end-of-life, palliative, and hospice care teams in many settings—at patients’ houses and in hospitals, and elsewhere in the community. Staff nurses whose patients are dying (in NICUs, EDs, ICUs, and long-term care facilities, for example) are finding more enlightened collaboration possible with physicians and other healthcare workers.
Public health nursing. The largest increase in RN employment from 1996 to 2000 was in the public and community health settings (state health departments, for example).{Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000 (above).} Because of the events of September 11, 2001, it is likely that more RNs will be employed in this setting. The Centers for Disease Control and Prevention is working with universities, the Department of Homeland Security, and state and local health departments to prepare for and respond to acts of terrorism. Last year, nurses were asked to voluntarily immunize themselves against smallpox — a vaccination not without potentially lethal side effects.
ALWAYS IN DEMAND
The areas discussed here represent only a tiny fraction of the boundless opportunities available to nurses. One thing is clear: Nurses can now choose alternatives, and because of the changes brought about by the Magnet program, they can work in settings where they are valued and can positively affect patient care and their own work environments.
The high demand has increased the number of choices for nurses. Travel nursing is in full bloom to fill seasonal needs at hospitals and elsewhere, and this kind of work is a wonderful opportunity for young nurses looking for the right community. As nurse consultants, meanwhile, nurses can work in offices, home care, health care licensing and regulating agencies, schools, legal practices, jails, and insurance and pharmaceutical companies—the list is long.
Qualified nurses are always in demand, as “the primary source of care and support for patients at the most vulnerable points in their lives,” as the JCAHO recently stated.{from JCAHO report August 7, 2002.} “Nearly every person’s health care experience involves a registered nurse. Birth and death, and all the various forms of care in between, are attended by the knowledge, support, and comfort of nurses.”
[i] Joint Commission on Accreditation of Healthcare Organization, “Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis,” August 7, 2002. http://www.jcaho.org/news+room/news+release+archives/nursing+shortage.htm
[ii][ii] Bureau of Health Professions. Division of Nursing. The registered nurse population: findings from the National Sample Survey of Registered Nurses, March 2000. Rockville, MD: U.S. Department of Health and Human Services; 2002. http://www.bhpr.hrsa.gov/nursing/sampsurvpre.htm.
[iii] Buerhaus PI, Staiger DO, and Auerbach DI. Implications of an aging registered nurse workforce. JAMA 2000;283(22):2948-54.
[iv] Donley R, Flaherty MJ. Revisiting the American Nurses Association’s first position on education for nurses. Online Journal of Issues in Nursing. May 31, 2002. 7:2, manuscript 1. http://www.nursingworld.org/ojin/topic18/tpc18_1.htm.
[v] http://www.bhpr.hrsa.gov/nursing/images/avgsalary.jpg.
[vi] National Center for Health Statistics, Vital and Health Statistics, series 13, as cited by the Statistical Abstract of the United States, 1997, published by the U.S. Department of Commerce.
[vii] National Center for Health Statistics, Fast Stats AtoZ, Hospital Utilization, Advance Data from Vital and Health Statistics, No. 329, June 19, 2002. http://www.cdc.gov/nchs/fastats/hospital.htm.
[viii] Pew Health Professions Commission. Critical challenges: revitalizing the health professions for the 21st century. December 1995. http://www.futurehealth.ucsf.edu/summaries/challenges.html.}
[ix] Collins G. Nursing a shortage. New York Times, August 13, 2001.
[x] Aiken LH, Havens DS, and Sloane DM. The magnet nursing services recognition program: a comparison of two groups of magnet hospitals. AJN 2000;100(3):26-35.
[xi] American Nurses Credentialing Center, Magnet Recognition. http://www.nursingworld.org/ancc/magnet/magnet2.htm.
[xii] Aiken, Havens, and Sloane. 2000 (above). and Aiken LH. Superior outcomes for magnet hospitals: the evidence base. In: McClure ML and Hinshaw AS (eds.), Magnet hospitals revisited: attraction and retention of professional nurses. Washington, DC: American Nurses Publishing, 2002: p. 61-81.
Austin, Texas