chapter 10 | Quality and Safety 1456.Single-Payer/National Health Coverage.
A single-payer system aims to decrease the cost
of care by eliminating third-party insurers,
costly overhead, and bureaucracy while provid-
ing coverage for all. Plans may offer choices to
consumers regarding providers, hospitals, and
specialty services, and physicians and hospitals
are paid through negotiates, fee-for-service, or
salary. Costs are controlled through budgeting,
bulk purchasing, and negotiation (Physicians
for a National Health Plan, 2008).
Proponents of a single-payer system cite lower costs
per capita while ensuring access to care for all
Americans. Opponents cite that the possible trade-
off for decreased cost and improved access leads to
increased mortality, poorer outcomes of care, limited
to no-cost savings, and loss of control by consumers
(National Center for Policy Analysis, 2008).
The intended effects of regulation and competi-
tion are to decrease cost. Despite the variety of
attempts over the years to drive down costs, they
continue to go up, imposing a heavy burden on
consumers or employers (Center for Studying
Health System Change, 2008). However, improved
quality and safety prevent unnecessary deaths and
errors that contribute to the high cost of care
(IOM, 2000; IOM 2003a). The U.S. government,
consumers, providers, and organizations have a
vested interest in controlling health-care expendi-
tures and in preventing waste while maintaining
quality care.
Nursing Labor Market
RNs comprise 77% of the nurse workforce, and
almost 60% of RNs are employed by hospitals. The
nationwide unemployment rate for RNs is only 1%.
Vacancy rates nationwide are reported at anywhere
from 13% to 20% and are rising. A serious nursing
shortage is here, and it will continue until at least
- The demand for nurses is expected to
increase even more dramatically as the baby
boomers reach their 60s, 70s, and beyond. From
now until 2030, the population age 65 years and
older will double.
Def ining and Identifying the Nursing Shortage
The nursing shortage is defined simply as a supply-
demand issue. Unfortunately, the current nursing
shortage is more complex and severe than previous
shortages in terms of the available supply, the
demand from employers, and the new graduate
pipeline for RNs.■Supply of existing RNs.The total supply of
U.S. RNs is estimated at 2.9 million and is pro-
jected to remain the same though 2020. The
supply of active RNs, including those who are
licensed, working, or seeking employment as an
RN, is projected be 2.1–2.3 million from 2000
to 2020 (U.S. Department of Health and
Human Services [HRSA], 2006).
■New graduate supply pipeline.Nursing program
graduation and NCLEX-RN pass rates affect
supply. The American Association of Colleges of
Nursing (AACN) reported an increase in bac-
calaureate level–entry enrollments, up by 5.4% in
2006 (AACN, 2008). According to the National
Council of State Boards of Nursing (2008), first-
time candidates for nursing licensure in 2007
numbered 200,209, with a pass rate of 69.4%.
However, HRSA (2006) projected that U.S.
nursing programs must graduate 90% more nurs-
es to meet the U.S. demands for nurses (p. 2).
■Demand from employers.The Bureau of Labor
Statistics predicts the RN job to be among the
top 10 in growth rate (U.S. Department of
Labor, 2008). Total job openings for RNs will
exceed 1.1.million, including new job growth
and replacement of retiring nurses.In a survey of over 5000 community hospitals, the
American Hospital Association (2007) reported
116,000 RN vacancies as of December 2006. The
effects of these vacancies contribute to decreased
employee and patient satisfaction and increased hiring
of foreign-educated nurses. The majority of urban
hospital emergency departments reported capacity
issues and spend time on by-pass or diversion due to
a lack of properly staffed critical care beds.
In 2002 more than 100,000 new RNs were
hired; the majority were foreign-born nurses and
nurses over age 50 returning to the workforce in
tough economic times. Although the new hires and
a sharp increase in RN salaries are positive, the cur-
rent nursing shortage is far from over.Factors Contributing to the Nursing Shortage
Many complex factors have led to and continue to
contribute to the current critical nursing shortage:
■High acuity, increasing age of patients in
hospitals.Medically complex patients require