By now, almost every aspect of the health care system has felt the impact of the emerging nursing shortage. If this trend is not reversed, it will soon have serious ramifications for the profession of midwifery.
According to a survey published in the May/June 2001 issue of Health Affairs (1), large numbers of registered nurses (RNs) are experiencing “burnout,” and many are ready to leave the nursing profession. In fact, enrollment in RN education programs has declined by 50,000 or 22% since 1993; since 1996, the number of nursing school graduates has dropped by 20% (2). While the total supply of nurses is currently adequate for some states, in others, nurses are already in short supply. The American Hospital Association surveyed 715 hospitals in 2001 and concluded that there were 126,000 unfilled positions for registered nurses in our nation's hospitals (2). In the past, hospitals recruited foreign-trained nurses to meet the market demand for RNs in this country. However, this “solution” to the impending nursing shortage is no longer viable because there is also a concurrent global nursing shortage. The International Council of Nurses, which includes 125 nursing organizations worldwide, reported in 2001 that many countries had fewer nurses entering the profession than are needed to fill vacancies in hospitals around the globe (3).
Ironically, this impending nursing crisis is happening at a time when the absolute number of nurses is actually increasing. According to the 2001 National Sample Survey of Registered Nurses, there are 2.6 million registered professional nurses in the United States—an increase of 5.4% since 1996 (4); however, only about 80% of this number are actually employed in nursing positions (5). Moreover, it is projected that 2.6 million full-time practicing RNs will be needed by the year 2005 (4). Even now, some emergency rooms are being forced to close while some ambulatory surgeries are being forcibly postponed because of inadequate nursing staff. This raises the question: was the critical shortage in nursing anticipated?
Hospital administrators, federal and state policymakers, legislators, regulators, and nursing professionals have all predicted the emerging nursing shortage. Nevertheless, there are many factors fueling this shortage.
First, there is an aging workforce. In 2000, the average age of working registered nurses was 43.3 years; at the same time, the proportion of RNs under the age of 30 declined from 30.3 to 12.1% between 1983 and 1998, representing a 41% decline (2).
Second, women of today have more career options; indeed, the increasingly attractive employment alternatives for women have expanded at an unparalleled pace over the past two decades, especially for younger women. Thanks in large part to the feminist movement as well as changes in social and cultural attitudes, women are now empowered to enter almost any field. Today, schools of business, law, and medicine have as many women enrollees as men. Recognizing the potential and opportunity to choose from a broader range of careers, women are no longer reluctant to enter into occupations for which they are qualified. For example, there are as many, if not more, female obstetric/gynecologic residents in our academic health science centers today than their male counterparts in residency teaching programs. Today's women no longer have to choose the traditional “female occupations” such as teaching, nursing, and secretarial jobs that were popular for women years ago.
The popular image of the nursing profession is the third problem. Over the years, physicians have occupied the dominant position in the health care arena; thus, in the eyes of many consumers, the work of all other health care professionals—including nurses—is perceived as revolving around that of physicians. This mystique of the supportive role nurses have assumed and their lack of independence makes the nursing profession seem less desirable.
The fourth issue is the effect of managed care/cost containment on the nursing workforce. Cost cutting, increased workload, and stressful working conditions have accelerated the pace of burnout, especially for nurses who are the front-line personnel staffing hospitals on a 24/7 schedule. It has also been reported that nurses have more nursing responsibilities and sicker patients to care for than they had previously.
Finally, the fifth contributing factor is a shortage of nursing faculty. With fewer candidates applying to nursing programs as well as funding cut backs, fewer faculty are being hired. Moreover, like the nursing workforce in general, the nation's nursing faculty are aging, with fewer qualified nurses who have the requisite teaching credentials and experience to replace them (6).
What, then, are the implications of the nursing shortage for the midwifery profession? First, midwifery has its roots in nursing and most of the 45 currently ACNM accredited nurse-midwifery education programs are located in schools of nursing. Second, midwifery education programs have always drawn the vast majority of their applicants from pools of registered nurses. The question is whether the decline in nursing enrollment and subsequent decline in graduation rates will negatively affect the number of applicants to midwifery education programs. Will the nursing shortage pose a threat to the midwifery profession or will it simply pose a new set of challenges?
The ACNM membership data collected annually shows that in 1999, the typical certified nurse-midwife (CNM)/certified midwife (CM) was 46 years old, white, held a master's degree in nursing, and has been certified for 12 years. This is slightly older than the mean ages of CNMs surveyed in previous years, which were reported as 42.3 years of age in 1991, 43 years of age in 1993, and 42.9 years or age in 1994 (7), and as might be expected, slightly older than the mean age of RNs. Currently, there is little information regarding the average age of retirement for midwives. It is, therefore, a challenge to project how many midwives will be needed in the next decade to maintain and/or replace our own aging workforce currently serving the nation's women.
Although ACNM has doubled its membership in the last two decades, historically, the growth of nurse-midwifery/midwifery has been slow because of the many political, economic, social, and legal barriers that had to be addressed and overcome at the local, state, and regional level. Responding to consumer demand, and the membership at large for increased numbers of graduate midwives, the National Commission on Nurse-Midwifery Education was established in 1992 to develop a strategy to reach the goal of 10,000 CNMs by the year 2001. A decade has passed, and our goal of 10,000 CNMs/CMs will likely be reached by the end of the year 2002. What is our next goal for the profession? This is an opportune time to reflect and take the action necessary to augment the survival and growth of our profession.
Other variables affect the midwifery workforce and the number of people who leave the profession for reasons other than retirement. How satisfied or dissatisfied do today's CNMs/CMs feel about their employment, their ability to practice full-scope midwifery, and the adequacy of reimbursement for services rendered? With the advent of managed care, many midwives—especially those in private practice and in freestanding birthing centers—see their livelihoods being jeopardized by inadequate reimbursement levels.
The nursing shortage will not be a transient phenomenon due, in part, to fundamental demographic changes occurring in America as well as globally. Declining enrollment in health care education programs and the competition from other professions will pose significant threats to some health care professions, especially nursing and midwifery. Unless there are drastic changes in the way nursing and midwifery practice is facilitated, working environments are improved, obstacles to practice are addressed and lessened, and payment schedules are more fairly adjusted, there will be more and more practitioners leaving the professions at an earlier age with fewer people to replace them.
There will be many challenges and opportunities confronting the profession of midwifery in the next decade. Education programs will have to be flexible and innovative in considering who might be qualified midwifery applicants. Currently, most schools limit the applicant pool to baccalaureate prepared nursing graduates who constitute 31% of the total RNs in the United States (8). However, some education programs do accept students whose prior education was not in nursing; these candidates already have their BS or BA degrees and can be fast-tracked to earn their nursing, midwifery, and graduate credentials. The post-baccalaureate direct-entry pathway for nonnurses is another option for education programs located in states that permit the legal practice of midwifery by ACNM certified midwives (ie, CMs). In addition, community-based distance education programs do exist, but they are too few to accommodate the many potential candidates who do not live near an ACNM-accredited program and would like the opportunity to be educated as midwives.
Perhaps an ACNM national task force on the future of midwifery education should be established to successfully address the problem of decreased enrollment, which is facing many education programs and which may require different strategies and solutions than yesteryear. Education programs will need the assistance and active collaboration of midwifery practices to prepare the type of graduates who can carry the ACNM philosophy forward and serve our nation's women with safe and competent care.
This is a wake-up call for midwifery educators and for all midwives in practice today: with fewer baccalaureate-nursing graduates to draw from, we must develop a new paradigm with innovative strategies and bold initiatives to attract motivated and committed midwifery applicants. The current issues and barriers are, perhaps, more complex than the ones we have faced in previous decades, but we must address them thoughtfully and forthrightly if we are to flourish as a profession and fulfill our mission of providing this nation's women and families with safe, competent, and comprehensive care. The society that neglects its own basic health care resources without effectively replenishing and regenerating them will only become more vulnerable and diminish its own future.
Students at Frontier School of Midwifery and Family Nursing. Photo courtesy of Frontier Nursing Service, Wendover, Kentucky.