American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Statement in Support of a Sustainable, Competent, and Diverse Nursing Workforce

This statement addresses the importance of ensuring that the nation has an adequate supply of well-trained nurses to ensure the quality and safety of surgical patient care. It also outlines policies supported by the American College of Surgeons to achieve that goal. The statement was approved by the Board of Regents at its October 2003 meeting.

Nursing supply and demand

Registered nurses form the largest segment of the U.S. health care professional workforce. Nonetheless, the number of nurses is shrinking steadily and has not kept pace with the demands of a growing and aging American population. In 2000, the number of full-time equivalent registered nurses was estimated at 1.89 million, while demand was estimated at 2 million—a shortage of 6 percent. This shortage is expected to grow steadily to 12 percent in 2010, when it will accelerate, increasing to 20 percent in 2015 and 29 percent in 2020.1

Factors driving the growth in demand include population growth, a larger proportion of elderly Americans requiring more care, and medical advances that increase the need for highly trained clinical staff. Further, the nursing workforce itself is aging, averaging a little over 47 years.2 Of particular interest to surgeons, only about 4 percent of the licensed registered nurses are perioperative nurses, whose average age is slightly higher. In addition, about 20 percent of perioperative nurses are expected to retire within the next five years.3

It takes an average of 90 days to fill vacancies for clinical care in hospitals where the demand is greatest for nurse specialists, including perioperative nurses. To cope, many hospitals are creating in-house training programs to develop their own pool of perioperative nurses. Unless these trends are reversed, it has been predicted that the expanding nurse shortage will be felt acutely by surgeons in such areas as emergency departments, critical care units, and in the operating room.

Driving forces and trends

Many factors contribute to the short supply of registered nurses:

  • An aging workforce has resulted from a decline in the overall number of nursing school graduates, the higher average age of recent graduating classes, and the aging of the existing pool of licensed nurses. As a result, the professional career of registered nurses has shortened, and increased rates of retirement can be expected in coming years.1
  • Fewer nurses are being trained. Declines in nursing graduates are seen across all types of programs—diploma, associate degree, and baccalaureate. While the trend appears to be reversing for associate and baccalaureate programs, the change may not be sufficient to meet projected needs.
  • Relative earnings have declined for nurses in recent years, and salaries play a role in recruitment and retention. While actual earnings for registered nurses increased steadily from 1983 to 2000, when adjusted for inflation, average salaries have remained relatively flat since 1991.1
  • Cost containment strategies implemented by hospitals over the past two decades have seriously affected the industry's ability to retain and recruit qualified workers. Job satisfaction continues to be a problem, with low staffing levels and heavy workloads among the problems cited most often.

Impact on patient care

Evidence is growing that a shortage of nurses affects the quality and safety of patient care. For example, nurse researchers at the University of Pennsylvania found that in hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted mortality and failure-to-rescue rates. Further, nurses working in these environments are more likely to experience job "burnout" and dissatisfaction.

In a report issued by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in August 2002, the authors examined the shortage of nurses in U.S. hospitals and found that low nursing staff levels were a contributing factor in 24 percent of 1,609 hospital reports of patient deaths or injuries since 1996.

A study, published in the New England Journal of Medicine in May 2002, examined 799 hospitals in 11 states, and found that the number of hours of care provided by registered nurses each day in hospitals is associated with patient outcomes. Among surgical patients, a higher proportion of care provided by registered nurses was associated with lower rates of urinary tract infections, and more hours of care per day were associated with decreased fail-to-rescue rates.

College views

Surgeons view nurses as partners—on the patient care units and in the perioperative area, and especially in the critical care units and operating room. Our patients' best interests lie in the education and retention of nurses as members of the surgical care team. Emphasis must be placed on the positive relationship that exists between surgeons and the nurses with whom they work by promoting a professional workplace environment and an atmosphere of mutual respect.

The American College of Surgeons strongly supports a variety of approaches to induce promising men and women, including those from minority populations, to pursue careers in nursing. We urge hospitals to develop and promote career pathways in which nurses are rewarded financially and participate in policy development.

To increase the number of nurses, schools of nursing should increase the number of qualified faculty and expand student clinical experiences. Additional educational opportunities and the flexibility and financial resources to pursue them should be made available to allow nurses to attain advanced education, skills, and status. The American College of Surgeons supports federal efforts to improve understanding of the supply and demand issues involved and new legislation to enhance our nation's investment in nurse education and training.


  1. U.S. Dept. of Health and Human Services: Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020. Health Resources and Services Division, Bureau of Health Professions, National Center for Health Workforce Analysis, July 2002.
  2. American Hospital Association Commission on Workforce for Hospitals and Health Systems: In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. April 2002.
  3. Personal communication with Candace Romig, Director of Government Affairs, AORN, October 2001.

Reprinted from Bulletin of the American College of Surgeons
Vol.89, No. 1, January 2004