One year ago, NurseWeek produced an attention-grabbing cover story under the headline "Critical Condition" that heralded an emerging worldwide shortage of registered nurses. The article reported that some nurses and their employers already were wrestling with the shortage and beginning an urgent search for solutions in the hopes of averting a potential catastrophe in health care.

The ink on those editions was barely dry when NurseWeek announced it was joining the American Organization of Nurse Executives to conduct a landmark national research study of registered nurses in the United States to learn their career intentions and perceptions of their work environment. The goal was to produce a research study that would provide objective data about workforce trends and identify possible steps that might be taken to address the shortage in the years ahead.

The results of the scientific survey, conducted for NurseWeek and the AONE Institute for Patient Care Research and Education by Harris Interactive, are now in. And what nurses told us is a mixture of good and bad news. In a nutshell, here's what more than 4,100 registered nurses across the country who participated in the research study had to say:

America's nursing shortage has worsened during the past year and is eroding the quality of patient care.

Despite their concerns about the shortage, most nurses remain satisfied with their jobs and would recommend their profession as a career choice.

Most nurses believe their employers share their commitment to quality patient care, a finding that provides renewed hope that together they can find and work toward solutions, thereby safeguarding and improving patient care.

The most distressing findings, according to members of the NurseWeek/AONE research advisory group that helped shape the survey and analyze the responses, involve the apparently widening scope of the nursing shortage and the resulting effect on the delivery of patient care. Seven of 10 nurses working in hospital settings said that during the past year they had witnessed a negative impact on the quality of patient care as a result of staffing problems.

"The results of this survey show that nurses truly love their profession, but are finding it increasingly difficult to provide the patient care they feel is needed," said advisory team member Mary A. Blegen, Ph.D., RN, FAAN, professor and interim associate dean for research at the University of Colorado Health Sciences Center School of Nursing.

Advisory team member Karen Donelan, Sc.D., an international expert on health survey research and a former faculty member at the Harvard School of Public Health, said the survey's ultimate importance may rest on its ability to serve as a catalyst for more candid >> discussion about what is really happening in nursing.

"The public, policy-makers and nurses all are well aware there is a nursing shortage," Donelan said. "We have conveniently avoided talking about the impact of that shortage on patients. We have avoided airing some rather difficult realities of how hard this job really is. We want to lure new people into the field, but we are afraid to be honest about what they will face there."

"Nurses are worried about the impact the shortage is having on the delivery of patient care," said advisory team leader Deloras Jones, MS, RN, a renowned nursing and health care consultant and former Kaiser Permanente executive. "We need to listen to them."

The numbers suggest that the nursing shortage has become more pervasive than it was a year ago, when most available evidence indicated that, for the most part, its effects were confined to certain geographic areas-mostly inner cities and isolated rural areas-and to some nursing practice specialties such as critical care.

Peter Risher of Harris Interactive, the project's senior research director, said the survey indicates that virtually all registered nurses in the United States believe there is a nursing shortage and that the vast majority have witnessed its effects firsthand.

"Most RNs also report that staffing problems at the place where they work have gotten worse in the past year and that these problems are having a negative impact on the quality of patient care," Risher wrote in an executive summary of the research report. "Barring a reversal of current trends, the nursing shortage that now exists can be expected to worsen as RNs reduce their active participation in the nursing workforce."

In the survey, 95 percent of working RNs agreed that a nursing shortage exists and 88 percent said that in their communities, the supply of registered nurses working in patient care settings is less than the demand.

A large majority of RNs who work in hospitals believe that the nursing shortage-and staffing problems that are a direct consequence of the shortage-are having a negative effect on the quality of patient care, Risher said.

Nearly three-fourths of the hospital nurses said that, in the past year, they have witnessed a negative impact on the quality of patient care as a result of a greater number of patients per nurse and higher turnover among experienced RNs.

Peter Buerhaus, Ph.D., RN, FAAN, a member of the NurseWeek/AONE research advisory board and one of the nation's foremost authorities on nursing workforce trends, finds a silver lining in what nurses have to say about how the shortage is damaging patient care.

"The public understands there are shortages, is concerned that they will hurt the performance of the overall health system and worried that shortages will harm the quality of care they personally receive," said Buerhaus, the Valere Potter professor of nursing and senior associate dean for research at Vanderbilt University School of Nursing.

"In this survey, RNs tell us that they believe harmful effects have resulted. Thus, this information should be helpful to stimulate both public and private sector policy-makers that it is time to make addressing the causes and consequences of the current nursing shortage a high priority on the domestic policy agenda."

Another ray of hope can be found from the substantial majority of nurses who said they are satisfied with their jobs and would recommend the nursing profession to young people as a career choice. The results stand in stark contrast to some widely publicized, often unscientific polls during the past year that have portrayed nurses as so profoundly unhappy with their profession that they wouldn't recommend it to anyone.

"I am excited and thrilled by the finding that, in the face of trends cited in the results, most nurses would recommend nursing to others," said research advisory board member Karen Haase-Herrick, MN, RN, executive director of the Seattle-based Northwest Organization of Nurse Executives.

"And that younger nurses and those with more education are more likely to recommend nursing. This finding thrills and excites me because I am passionate about the wonders of nursing as a profession personally and the findings in this survey convey a 'hopefulness' about nursing as a profession."

Risher agreed it's especially significant that younger RNs and those with higher levels of education are even more likely to recommend nursing. So, too, he said, is the finding that, despite some signs of strain in the working relationships between nurses and management, RNs overwhelmingly agree that patient care remains a priority at the organizations where they work.

"Along with these positive views toward nursing," Risher wrote in his executive summary, "opportunities clearly exist to attract and retain more RNs as working nurses. Many RNs who plan to leave their present jobs in the next few years say they would consider staying-and many others who have left nursing altogether say they would consider returning-if certain conditions were met.

"Among these conditions are better compensation, an improved work environment, better hours and more respect from management. Nurses with no immediate plans to leave echo many of these same sentiments."

Not surprisingly, based on dozens of letters, e-mails and phone calls about the nursing shortage to NurseWeek during the past year, money ranks at or near the top list of concerns.

The response to our open invitation for readers to share their thoughts about the shortage generally falls into two categories. One group says it's all about money and there's no need for scientific surveys to find out anything more. The other group says the reasons for the shortage are more complicated. While acknowledging that money is important, this group says other factors, including job stress and professional status, may be even more critical.

In our scientific sampling, 79 percent said improved wages and benefits would help a great deal to solve the shortage. But even more, 83 percent, said improved working environments would be helpful. Seventy percent said higher status of nurses in the hospital environment would help.

Among nurses who say they plan to leave their present nursing position within the next three years, 58 percent say improved compensation or benefits would be "very likely" to cause them to reconsider. Fifty percent say better staffing and 48 percent say more respect from management would very likely cause them to reconsider.

But among survey participants who are not working as paid nurses, less than one-third, or 29 percent, said more money would "very likely" cause them to consider returning to work as a nurse. Almost half, or 45 percent, said a less stressful work environment would likely cause them to consider returning.

The results suggest that nursing recruitment and retention promise to be challenging in the years ahead.

Survey advisory team member Karen R. Sechrist, Ph.D., RN, FAAN, said one of the most significant findings is that 14 percent of the nurses now employed intend to leave the profession within three years, with more leaving for other professions than those leaving for retirement.

Sechrist, project investigator for the California Strategic Planning Committee for Nursing, said the survey helps debunk a common perception in the health care industry that the shortage might be significantly reduced if nurses were to increase the number of hours they work.

"The point that is obvious in the survey and corroborates other findings is that more nurses intend to decrease hours rather than increase them," she said. "This finding is consistent with the aging workforce and the stress of additional hours."

So what are employers to do if more overtime isn't a practical or attractive option?

"The only area in which the shortage might be impacted with the current workforce is to make the working environment as positive as is possible to retain nurses planning to leave the profession to work in another field," Sechrist said. "There will always be some loss to the profession for this reason, but it is one of the few areas where employers can make a positive difference."

But Risher said even that will not be easy.

"Reducing stress in the work environment-a leading cause of nurses leaving the profession prior to retirement-will be particularly difficult because this stress is a result as well as a cause of the shortage," Risher concluded in his executive summary. "Still, even as the shortage continues, steps could be taken to reduce stress by giving RNs more say in workplace decisions, more opportunities for professional development, more recognition and a physically safer and more accommodating workplace."

Carol Bradley, regional vice president and editor of NurseWeek's California edition, said she would like to see survey serve as an important tool for health care planners and policy-makers. "Nurses have now told us what their world is really like, what can be done to improve it and what they plan to do in their careers in the future," Bradley said. "For both nursing and health care to succeed, we must listen to what they have said and act on it."

"Nurses believe that nursing is a good profession," said Pamela Thompson, MSN, RN, executive director of AONE. "We must all work to secure that opinion for the future as well."

Contact Tim Graham at timg@nurseweek.com