THE NATION WIDE NURSING SHORTAGE
JOSHUA KANAABI MULIIRA
There is no very precise way of defining the concept of nursing shortage, but an explanation of this concept can give a clear understanding of the problem. Health care organizations in USA are experiencing increased demand for nurses while the supply is very low. Health care organizations encounter nursing shortages when their demand for nurses to fill job openings in the organization is higher than the available supply of qualified nurses. Usually such vacancies remain unfilled for a prolonged period of time and thus causing shortage. Both the demand and supply factors cause the apparent shortage. For instance experienced nurses in key specialties such as intensive care, midwifery and others are in short supply and the demand for these skills is so high in most health care organizations.
In USA today, 56% of hospitals report that they are using agency or travelling nurses-at expenses because they can not fill vacancies (American Hospital Association 2001). On average, nurses work an extra 8weeks and a half of over time per year as a result of nursing shortage (Service Employers Interest Union 2003). It is also estimated that by the year 2020 there will be at least 400,000 fewer nurses available to provide care than will be needed. The American Association of Colleges of Nursing reports that there are roughly 21,000 fewer nursing students today than in the year 1995. Despite the shortage now, indications are that the demand for health care and public health in general will continue to grow through this first decade of the millenium. This is attributed to demographic transitions (a growing population with a greater number of elderly people), advances in medical practice and technology, the impact of new diseases and infections [e.g. Human Immunodeficeincy virus (HIV) Acquired immune deficiency syndrome (AIDS)], and changes in public (consumer) expectations of the public health system.
Health care being a 24 hour, 365 day industry, its resources have to be deployed to match continuous, but changing demands. The most important resource in this labor intensive industry is its personnel: they account for up to two thirds of total expenditure, and even then remuneration is often inadequate because of budget limitations. The health care industry is so unique in that the manufacture of the commodity that is purchased and the consumption of that commodity take place at the same time . The interaction between patients/consumers and nurses is an integral part of the provision of health services. This intensive use of labor for service delivery, and the possibility of variability in professional practice, requires that the attention of public health managers be directed towards managing the performance of critical services such as nursing services. Trends in worker force for public health are even much important now than ever before because of the pressure and efforts towards managed care and cost reduction. The already complicated puzzle of nursing shortage in a managed care health care system is further complicated by the requirements of quality assurance. The requirements of quality assurance have shifted the discussion further, from the focus of quality control designed to reduce errors in existing patterns of care, to continuous quality improvement designed to achieve higher levels of, and increased uniformity in standards of care and performance. These changes in the health care system require even more well qualified nurses and health professionals in general. Therefore individuals who are already involved in public health management or studying to develop careers that may require public health management skills, should be well versed with the ever shifting trends in the public health work force.
To develop a good analysis of this important concept of trends in public health work force, it is necessary to break down the different health disciplines into manageable categories for separate analysis. However, it is again also not feasible to analyze such trends in each discipline with precision in one chapter. Therefore for this chapter to sustain a reasonable analysis and commentary it will focus on the Nursing discipline and later inclusion of the other disciplines will be considered.
TRENDS IN THE NURSING WORK FORCE
Many professions are involved in the provision of public health or health care in general, but the largest cohort is made up of nursing personnel. In most of the health care systems in most countries, Nurses form the majority of the health care providers and the backbone of health care systems. They are the frontline implementers of the important basic health care and public health interventions. The changing scope of Nursing practice (i.e. from Licensed Practical Nurses through Registered Nurses to Nurse Practitioners), lack of equitable access to health care, emergence of new disease patterns and managed care have all synchronously enhanced the importance of Nursing to public health. The trends in Nursing work force that have resulted therefore pose a formidable challenge to public health today and in the future.
A recent survey examining the status of nursing and midwifery identified that many developed and developing countries are experiencing serious shortages in adequately prepared individuals to meet the nursing needs of their populations . In a case study of Nursing health human resources in Canada (O’Brien-palls e tal 2000), also highlighted that the key concerns related to the current trends in Nursing work force are; inadequate numbers of trained personnel to meet health system needs, limited opportunities for improved nursing and midwifery in relation to primary health care, lack of legislation to guide nursing resource development, limited influence of nursing on health policy, unacceptable working conditions and poor career opportunities.
The problem of Nursing shortage in the USA is not happening for the first time. During and after the Second World War, hospitals struggled with a nursing shortage . For nurses returning from the military, job in industry or in doctors offices, advanced education under the G.I bill (Government Issues) or marriage were all more attractive than the low paying, long hours of hospital nursing. In 1950, the American Hospital Association reported 22,486 vacancies for graduate nurses. As of March 2000, the total number of licensed RNs in the USA was estimated to be 2,696,540, an increase of 137,666 over the 2,558,874 licensed RNs reported in 1996 . Although this was a 5.4 percent increase in the total RN population, it was the lowest increase reported in the previous national surveys. By comparison, the highest increase in the RN population was experienced between 1992 and 1996 when the total number of RNs increased by an estimated 14.2 percent or 319,058 (from 2,239,819 to 2,558,874). Today in USA the American Hospital Association (2002) has recently estimated 126,000 vacancies or a rate of 11%, as the unified position of the current nursing shortage. This is expected to worsen if concerted strategies are not employed to improve the situation. The shortage is widespread and articles are appearing in local, national and international media about the impact of nursing shortage on public health. However the question to ask in this chapter is, How does a public health manager know with certainty that there is a shortage of nurses in the labor market?
INDICATORS OF NURSING SHORTAGE
There are four main process indicators that can be used to follow and highlight trends and variations in nurse staffing shortages or over supply . These are;
· Vacancy Rates;
The state of California only has nurse vacancy rates that hover around 20% . According to the American Hospital Association (June 2001), 126,000 nurses are currently needed to fill vacancies in USA hospitals and it further quotes that 75% of all hospital personnel vacancies are for nurses. The most common proxy measure of vacancy rates, at both the state and national level, is the index of newspapers help/ vacancy adverts produced by the conference board, or other bodies of professional nursing organization. Vacancy rates generally represent the extent to which an organization is unable to recruit staff to fill vacant posts and this is often used as an indicator of shortages. Trend information of vacancies is helpful in monitoring the impact of shortages or other imbalances between supply and demand. A look in any of the major local Newspapers and national papers show that nursing Jobs are the most advertised posts. In fact the shortage may be under estimated if one goes by vacancy rates because of “suppressed vacancies”  i.e. posts not advertised because of no expectation of successful recruitment, hidden vacancies or posts filled with less qualified or less skilled individuals.
§ Nurse Staff turnover rates;
This is based on transfer with in an organization and wastage i.e. controlled wastage e.g. retirement, redundancy and redeployment, and uncontrolled or voluntary wastage owing to employ leaving for their own reasons mainly career progression, better paying new jobs and dissatisfaction in nursing.
§ The Extent of Use of Temporary Staff;
Temporary nursing staff usage such as bank nurses, agency nurses, travel nurses or internal float pool nurse, is an indicator of shortage or difficulties in recruiting staff. The use of temporary staff represents an increased trend towards a casualized work force, and “just in time” staff replacement . This tendency also is very common in situations where qualified work force is difficult to find. This approach is vulnerable to laxity in quality of nursing care.
§ The Number of Overtime/ Excess Hours that are worked;
The extent to which permanent staff nurses regularly and consistently have to work additional hours is also an important proxy indicator of shortage.
Other potential shortage indicators may include; Pre-registration nursing and midwifery education (gives an indication of trends in the attractiveness of nursing as a career), the number of acceptable applicants per advertised vacancy (if low, this is an indicator of a tightening labor market), patients’ mortality rates, adverse events after surgery, increased cross infection, increased accidents and work related injuries among existing nurses .
§ Number of new graduates Registered for nursing practice
The most direct ways of measuring the nursing shortage is through use of registers from state licensing boards. For instance, according to the National Council of state boards of nursing, the number of first-time US-educated Nursing graduates who sat for the NCLEX-RN- the national licensure examination for all entry level RN; decreased by 26% from 1995-2001. This is a very objective measurement that can not be manipulated by employers.
FACTORS CONTRIBUTING TO NURSING SHORTAGE
One of the key determinants of the labor market behavior is age. Nursing in USA as in most first world countries in the North has an aging population. This has a number of employment policy implications. Older nurses may be more likely to wish to reduce the number of hours they work, and can have differing needs for life long learning than young or more recently experienced nurses’ . The average age of registered nurses has risen from 44.3 to 45.2 years, therefore leaving only 20 years period to retirement. Many nurses will be ready to retire and deciding on how to replace these lost skills will represent a growing challenge for the public health system.
The population of USA is aging i.e. the older population (65+ years) numbered 35 million people in 2000, an increase of 3.7 million or 12% since 1990. The number of Americans aged 45-64- the “baby boomers” who will reach 65 over the next two decades increased by 34% during this decade (A profile of older American 2002). This implies that more health care and testing are increasingly required for this vulnerable population in addition to the already existing large population needs. It is therefore reasonable to conclude that as the graying population increases the shortage of the nursing work force will also increase or even worsen. This implies that the problem of baby boomers is going to hit the nursing work force with a double effect i.e. increased demand on the limited nursing resources by the aging population and reduction of available skilled nurses for recruitment due to retirement. USA like all other countries faced with the shortage, will most likely carry on this trend of nursing shortage in the future as attrition and retirement rates among nurses continue to parallel out put of trained nurses. The result will be a cumulative loss of experienced personnel and the impact to public health will be disastrous.
The most reliable out put for nursing human resources like any other profession, are the nursing schools. Fewer students are enrolling in nursing schools. According to Richard Penell 2002, nursing school enrollment has dropped in each of the last three years. The in-take of new nursing students today is less by 21,000 than it was in the year 1995. The number of nursing educators is also declining as budget cuts have limited funding for nursing education. The few nurses who get trained and the most talented with postgraduate degrees, have found opportunities for better pay and more rapid advancement in fields outside nursing, medicine or public health.
Today unlike in the past, health professionals and nurses in particular work in a variety of health’s related settings, not just hospital. These settings may include health insurance companies, research companies, pharmaceutical companies and many others. The number of new nurses needed for health care and related fields is not keeping pace with demand given the new wide array of job opportunities available today. Most of the new non-traditional settings where nurses are working provide competitive salaries, good work environment, and nursing professional autonomy. This trend forces the traditional public health employers of nurses to compete for the few nurses in an increasingly competitive market place that demand bigger salaries. The ramification of this tendency is in part the nursing shortage, high costs of health care, and subsequently inaccessibility to public health care services.
The reduction in the pool of available nurses over many years combined with rising demand for nurses in both acute care and community settings has also contributed to this catharsis of nursing shortage. The shortage experienced today represents a build up of smaller shortages that have gone unattended to over the years. The factors responsible for the reduction in pool can be summarized under the following category .
¨ Failure by health systems to improve nurse remuneration as a strategy of cost containment in managed care systems. This has made the nursing profession unattractive to new students in colleges and has also discouraged those already in nursing to early retirement, or complete change of career
¨ The unavailability of nurses due to sickness, annual leaves, study and training days, retirement etc.
¨ The pattern of turn over rates by age cohorts and life events. An example of this is pregnancy, which is a fact of life in a profession where women account for, nearly 90 percent of the work force.
Why nurses have to leave the profession and why no new people join nursing? The answer to this question also provides another important factor that silently and continuously contributes to the nursing shortage. The answer is more inclined to conditions of employment and wages. Studies have indicated that poor career advancement, poor wages, increased work load and poor work place relations are the most important factors in determining quitting intentions among nurses . In addition, if you take into account that one of the most important characteristics of the nursing profession is the large amount of shift work- for most individuals shift work is more stressful than working normal hours (Costa C.1996).
Of the total licensed RN population in March 2000, an estimated 58.5 percent of RNs reported working full-time, 23.2 percent reported working part-time, and 18.3 percent reported not being employed in Nursing . These findings indicate that a considerable number (18.3%) of trained nurses are not available for employment in nursing jobs. It also shows that increasingly a good number of nurses (23.2%) are available for less time to provide nursing care, this as indicated by the number of nurses working part time. In a situation of already raging shortage the country can not afford the luxury of having any number of nurses working out of the nursing jobs nor being available for less than normal working time. This shows the intertwined nature of the factors that are contributing to nursing shortage in USA today.
THE CONSEQUENCES OF NURSING SHORTAGES
The effects of the shortage of nurses on public health are significant in terms of the impact on organizational costs and in relation to quality and continuity of care provided. Shortage of nurses deprives the health care setting of necessary tools for advancing quality and cost-effective care .
The current nursing shortage has opened up hospitals to lapses in patient care that happens when staffing levels are low. The first things to go are less critical tasks such as bathing patients and changing bandages. As these interactions fall away nurses spend less time in each room and start to miss subtle changes in the patient’s condition. At first the icing-on-the cake stuff doesn’t get done, like baths, and at first nurses may cope well, but then it can get so busy. Commonly shortage in nursing staffing can lead to increased mistakes, lab tests mislabeled, medications may come late or patient calls may go unanswered . Literature has also for long indicated that hospital acquired infections, bedsores, patient falls, wrong drug dozes and other preventable complications can increase in a situation of decreased nurse staffing levels.
The nursing shortage has also consistently come to the forefront of recent health news. The New England Journal of Medicine (May 2002), published the results of a study by the Harvard school of Public Health and Vanderbilt University school of Nursing stating that a direct link exists between the number of registered nurses and the hours they spend with patients. The researchers, utilizing 1997 data from more than 5 million patient discharges from 799 hospitals in 11 states, found that there were consistent relationship between nurse staffing variables and five adverse patient outcome. The five adverse out comes are urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, and increased length of hospital stay in medical and major surgery patients . The same study also showed that higher RN staffing was associated with a 2 percent to 25 percent reduction in adverse outcomes. Clearly this creates a threat to quality of health care. The cost associated with patients’ complications can be substantial, and patient complications arising from nursing shortage propagate a cycle of increased demand on the already meager nursing resources.
Failure to address nursing shortage therefore results into failure to reduce the rates of adverse outcomes or complications, failure to reduce hospital costs as well as significant financial and psychological costs to patients and their families. James Buchan and Ian Seccombe (1995) noted that the main issues for management arising from nurse shortage and absence are;
· Impact on quality of care
· Impact on continuity of care
· Impact on productivity
· Impact on organizational costs
· Effect on remaining staff-overwork
· Time spent organizing cover
· Time spent by remaining staff monitoring temporary staff
· Attendance control policies and practice
· Measuring and monitoring absence and,
· Building in absence rate in staffing levels.
The options available to managers faced with the above problems that accrue from nurse shortage, range from doing nothing so that workloads of remaining staff are increased and hence burning out, through juggling with available staff by transferring employees, to recruiting temporary cover staff from an internal bank or external agency. Other options that are used in practice include re-allocation/ delay/ or postpone work, available staff working long hours and employment of temporary additional staff or less qualified staff . These options can not help the situation, but only serve to propagate the problem and may be the cause of other concerns related to quality and standard of care.
The problems of nursing shortage need concrete strategies if quality care, continuity of care and cost containment is to be addressed. The options of internal reallocation, delay and postponement of work only work to decrease the quality of care, to erode staff nurses’ morale and curtail continuity of care.
STRATEGIES FOR ADDRESSING NURSING SHORTAGE
The current and future workforce shortage has and will continue to affect the health care system and health of the American public. Timely action to address the problem of nursing shortage will save the health care system a lot of time and other resources which may be needed in future to overcome the cyclic problems that may result. Some organizations i.e. government agencies and health policy makers have started devising strategies that will increase the supply of registered nurses.
This section reviews the potential interventions that can be employed and are being employed to address nurse recruitment and retention difficulties in order to overcome the shortage. All the strategies highlighted, though explained independently, in actual practice of public health management an integrated framework using the different strategies is the best approach to improving nurse recruitment, retention and utilization.
§ New Technologies to Automate Non-Valued Tasks
Analysis of registered nurses work still shows that a significant portion involves non-direct care activities. This figure may go as high as 40% in some cases (American Academy of Nursing 2002). This situation leads to ineffective use of nursing resources and could be a significant contributor to the growing workforce shortage. Therefore automation of non-valued work tasks in order to make more time devoted to direct patient care is still a potential strategy that can help in alleviating the shortage. An example of such a strategy that has shown to be effective is computer based charting of patient’s progress, and requisition of drugs from the pharmacy on the computer instead of a nurse walking to the pharmacy. The pneumatic tube system used now in most hospitals to forward laboratory samples taken from patients to the central hospital laboratories is another vivid example. These strategies help by reducing workload, preventing burning out and thus increasing the number of nurses available for full time work schedules. Automation has been implemented in some health care settings, but more innovations can still be implemented. This strategy can also be viewed as a revolution to redesign public health care delivery by finding new ways of delivering public health care with fewer health professionals. However the challenges and problems of applying new and emerging technologies in health systems should not be under estimated. Initial capital investment, education, training and errors may increase the costs of health if the strategy is not well thought through before implementation.
§ International Recruitment
In an era of globalization with free mobility of labor, no country can anticipate being totally self-sufficient in its nursing resources. This is more important and relevant to the first world countries because of their big population and aging section of the population. In 2001/2002, about 4% of the new nurses on the UK nursing register came from non-UK sources . The strategy of importing ready-made nurses from other countries is apparently a cheap quick fix for countries facing political pressure to solve the shortage. Though traditionally international recruitment has taken place in countries such as Philippines, China and Caribbean, a potential source exists among developing countries of Africa, which share Official language, common educational and post-colonial ties with USA. The UK is actively using countries that are members of the Common Wealth Association as sources of nursing resources. However, to achieve better results from the international recruitment strategy there is need for cooperation at organizational and government level to identify a scope for a win – win situation. The current agreement between Spain and England for Spanish nurses to work in the National Health Service in England for a defined period of time provides a good template . Such cooperation helps to avoid the political and ethical dilemmas in international recruitment and in preventing a situation of exporting the problem of nursing shortage to already burdened developing countries. The introduction of special immigration legislation to facilitate nurses and other profession access to work permit is one step taken by the USA government in using this strategy .
§ Legislation and Policy to promote Re-entry nursing practice, Recruitment and Retention
The national registered nurses (RN) turn over rate for USA was 18 percent in the year 2000, representing the highest in decades . Staff vacancies are indications of staff shortages and are the reflection of the extra work and strain imposed on the existing staff . Legislation and policies that require specific hospital wide Nurse-to-patient ratio, just as there are minimum ratios for airlines, daycare centers and other areas of public safety are vital in enforcing organizations that choose not to recruit as away of cost containment. Improvement in this regard can potentially attract re-entry nurses, part time to full time employment and enrollment in nursing schools. For instance in California if all the part-time RN increased their employment to full-time, the overall RN labor supply would increase by approximately 11 percent .
The top most reasons nurses have cited for discontent, early retirement and changing from nursing to other jobs are, increased work road, inadequate staffing, poor patient ratios, harmful changes in health care delivery systems as away of cost containment and decreased quality of care. These factors have a direct effect, and response is the alarming erosion of care standards and hemorrhaging of nurses away from the bedside or other public health positions. A comparable turn around to overcome nursing shortage due to factors such as early retirement, change of professions and poor work conditions, can be achieved if strong policies and legislation on nurse-patient ratio and remuneration are adopted by state and federal efforts without crippling delay.
Staffing levels and workplace satisfaction affects patient care and nurse retention rates. Patient care suffers as fewer nurses are left to care for older and sicker patients. Therefore public health managers need to actively participate in policy and legislation such as the Nurse Reinvestment Act 2002, which is going to give scholarships and grants to help hospitals retain the nursing staffs and encourage individuals to enter the nursing professionals. Similar to this, following the Second World War the nursing shortage that resulted was in part eased by the liberal use of licensed practical nurses and the Nurse training Act of 1964 which funded nursing schools expansion and student loans . In addition individual hospitals responded to the shortage with various innovations such as offering on-site childcare to enable nurses with families to rejoin the work force, and expanding the duties of licensed practical nurse. Other legislation aimed at improving nurse-patient ratio, remuneration and workplace environment should also attract the same attention.
To achieve the goal of increasing the number of nurses available for public health requires a concerted effort by all stakeholders to spawn initiatives such as pay increase, family friendly policies, improved working conditions and role enhancement opportunities. The efforts to achieve the goal of eliminating nursing shortage should avoid the fragmented approach of policy makers and instead focus on an integrated approach . The problem of nursing shortage is a chain of problems that includes issues such as nurse recruitment, retention, high quality care, managed care, patient satisfaction and more specifically low pay, poor job prospects, low morale, stress, increased work load and poor staffing levels. For unless all constituents of the chain are tackled and the linkages recognized, the chain which is only as strong as its weakest link will break.
§ Establishment of Bank Nurses to provide service in shortage/Crisis
To address the problem of nursing shortage and to provide a buffer during work-shifts experiencing shortage several ways can be used. Staffs may stay on at the end of their normal shift, taking time off in lieu or receiving payment for their extra hours, or they may be part of a nursing pool deployed to work wherever there is a shortfall. This pool is what is referred to as bank nurses. Permanent staff may also work additional shifts by registering with an in-house trust bank, also called local organization or hospital nurse bank.
The buffer of bank nurses is very good option in some specialties e.g. theatre nursing and intensive care where staff transferred from other care environments would not have the relevant skills to operate effectively. The use of bank nurses is one of those strategies that are regarded to affect the quality of care provided as is overtime working . Therefore use of bank nurse as a cover option is more effective where there is local control over the nurse bank. This is more likely to lead to employment of bank nurses who are acquainted with the work and care environment. Large general banks are less accessible-to by individual organizations, and organizations have little control over choice of nurse, quality of the nurse and cost of hiring them.
§ Marketing and Continuos Recruitment
The health care industry should adapt the latest methods to compete and survive, such as use of more marketing tools to attract nurses who may be practicing in other industries and promote diversity . The health care industry and public health in general has lagged behind other industries in securing high performance marketing personnel to help them in the marketing strategy for attracting personnel. The result is that newly qualified young nurses end-up being employed in the non-traditional organizations that now employ nurses e.g. pharmaceutical industries, marketing health products and others. However, with the development of health maintenance organizations, this trend may be changing.
Public health organizations must have a continuous influx of nurse-candidates for potential employment. New employee positions are required as a marketing strategy and as service areas expand or new-services are initiated. Recruitment should occur even when there is a limited growth or even decline in service capacity, because individuals with specialized skills or training who leave the organization must be replaced and services or technologies that have been revised or modified must be staffed . The strategy of continuous recruitment of nursing personnel may play an important role in helping the organization to adapt and remain competitive. Employees who have recently finished professional nursing training are an important source of information on new methods and techniques in service delivery that allow the organization to remain competitive in its traditional services.
§ Training and Development
Investment in the existing nursing human capital of a health service organization through a well managed training and development activity pays long term dividends for public health organizations. Improvement of the skill and abilities of LPNs to RNs and Nursing Aides to LPNs can contribute to sustained reduction in the shortage of well trained nursing work force. The changing environment of health services industry and public health in general, ensures that the training and development of current nursing staff members contribute to organizational performance in one part, and attracting other young people to the nursing profession on the other hand. Public health institution should develop innovative ways of responding to the nursing shortage to ensure constant flow of the nursing resources.
§ Contracting out Labor Intensive Nursing services
As a way of immediate response to the problem of Nursing shortage the strategy of contracting out labor intensive Nursing services to specialized organizations can be employed. Such services may include care of bedsores, nutrition care for patients and others. Though this has a potential of fragmenting patients care may help a lot in providing quality care in times of crisis. This strategy does not solve the problem of Nursing shortage as such but helps those setting hit by the shortage to survive while providing quality care in the short run. In USA, Canada and Australia there are increasing example of staff support services such as payroll, planning, marketing and human resources being contracted out . The net result has been a decrease in staff costs, and access to more specialized expertise via subcontracting with outside firms. In public health this has the potential of increasing the time available for the few nurse to provide quality care to the patients, and may provide the patients access to specialized nursing care for some conditions from out side firms.
Salary and Remuneration
One of the most important determinants of job or career choice is the salary or remuneration that it provides. Nursing is consistently known to provide remuneration inconsistent with education or work experience. The actual average annual earnings of RNs employed full-time in 2000 were $46,782 . However, when changes in the purchasing power of the dollar were taken into account utilizing the consumer price index, the “real” salaries of RNs employed full time in 2000 was $23,369 (National Survey of RN nurse 2000). Real salaries for nurses are actually very low compared to the amount and type of work they do. This has left the nursing professional in limbo in terms of attracting new students. Many nurses have left to seek for employment in better paying work settings other than nursing or have gone back to school to change professions. A reasonable revision of the remuneration for nurses based on qualification has the potential of alleviating the situation. Remuneration is one the most powerful motivating factor to any worker, and it increases job satisfaction, and important in attracting new people to the profession.
1. Elizabeth Temkin 2002, “Rooming-In: Redesigning Hospitals and Motherhood In cold war America” Bulletin Of History in Medicine, 76: 271-298
2. James Buchan 2002, “Nursing Shortage and evidence-based interventions: a Case study from Scotland” International Council of Nurses, International Nursing Review, 49, 209-218.
3. Yi M. and Jezewski M. A 2000, “Korean nurses adjustment to Hospitals in The USA” Journal of Advanced Nursing, 32 (3), 721-729
4. Mia Defever 1995, “Health care reforms: the unfinished Agenda” Health Policy 34 (1995) 1-7.
5. Graham Martin 1994, “Characteristics of successful health organizations- the human resource Dimension” Health Manpower Management 20(1) 35-40.
6. Junaid Siddiqui and Brian H. Kleiner 1998. “Human resource management in health care industry” Health Manpower Management 24 (4) 143-147
7. Tor Helge Holmas 2002, “Keeping Nurses at Work: A duration Analysis” Health Economics 11: 493-503
8. James Buchan and Ian Seccombe 1995. “Managing Nurse absence” Health Manpower Management 21 (2) 3-12.
9. Linda O’Brien-Pallas and Andrea Baumann 2000, “Toward evidence-based policy decisions: A case study of nursing health human resources in Ontario Canada”. Nursing Inquiry 2000; 7: 248-257
10. James Buchan 2001, “Nurse Migration and International Recruitment”. Nursing Inquiry-Blackwell Science LTD 8 (4), 203-204
11. Karin Newman etal 2001, “The nurse retention, quality of care and patient satisfaction chain” International Journal of Health Care Quality Assurance 14 (2001) 57-68.
12. Mereille Kingma 2001, “Nursing migration: Global treasure hunt or disaster-in-the-making?” Blackwell Science LTD, Nursing Inquiry 8 (4) 205-212.
13. James Buchan 1999, “The Graying of the United Kingdom Nursing Workforce: Implications for employment policy and practice” Journal of Advanced Nursing. 30 (4), 818-826.
14. Richard C. Pennell 2002, “Lets give nurses a fair shake” Editorial opinion, The American Journal Of Surgery 184 (2002) 87-88.
16. Peter Buerhaus 2002, “USA nursing shortage continues to affect patients” New England Journal of Medicine 2002.
17. Kovner C. and Gergen J. 1998, “Nurse Staffing Levels and Adverse events following Surgery In USA Hospitals. Image: Journal of Nursing Scholarship 30, 315-321.
18. Lisa Rapaport 2001, “Need for Nurses Gets more acute: Some worry about Lapses in care at area hospital” Published in Bees Newspaper September 2, 2001.
19. Nursing shortage- A Demand for action Nurse-to-patient Ratios are needed now.
20. National sample survey of registered Nurses 2000. U.S Department of health and human services bureau of health professions, Division of Nursing.
USEFUL WEB SITES ABOUT THE SUBJECT OF NURSING SHORTAGE