Nurses play a key role in our healthcare system. Without them, there would be potentially dangerous scenarios that would occur on a regular basis. So, it might come as a surprise that we are in the midst of a nursing shortage and that the shortage is expected to get worse. Why is this happening? What impact will it have? How can it be corrected?
There are around 3.4 million employed licensed nurses across the country. This makes nursing the nation’s largest healthcare profession. While this might seem like a large number, there is actually a shortage of registered nurses (RNs) and nurse practitioners (NPs) nationwide with nearly 200,000 vacant positions at any given time. Per the American Association of Colleges of Nursing, this shortage is only expected to worsen. According to the Bureau of Labor Statistics, there will be a need for over 1 million new nurses by 2024. At this rate, by 2025 the deficit is expected to be over twice as large as any nurse shortage we’ve ever had since the introduction of Medicare and Medicaid in the mid-1960s.
A Health Resources and Services Administration (HRSA) report called, “The Future of Nursing” estimates that the need for RNs will increase to over 3 million by 2030. The shortage varies depending on which part of the country you’re in. Areas that are rural, especially in southern and western parts of the country, are highly susceptible to nursing shortages because smaller hospitals in rural areas are unable to compete with larger systems in cities that can pay higher wages. According to the National Rural Health Association, the nursing shortage will contribute to as many as 700 rural hospitals closing over the next ten years. However, hospitals are not the only places affected. There are many public schools that currently don’t have full-time nurses in their employ.
There are several factors that are causing the nursing shortage. One of the big ones is the increase in our aging population as Baby Boomers reach retirement. We currently have more people over age 65 than at any other time during our history. Between 2010 and 2030, the number of people over the age of 65 will increase to 69 million. This means that 20% of Americans will be a part of this group. This number is expected to become 88.5 million people by 2050. The reason that this is so impactful on the nursing shortage is that according to Medicare data over two-thirds of their beneficiaries over the age of 65 have multiple chronic conditions, like heart disease, cancer, stroke, and diabetes.
The National Council on Aging states that about 80% of older adults have at least one chronic condition and 68% have at least two. This means that aging adults generally need more care. These diseases typically require the higher level of care that RNs provide, so there will be greater demand for the healthcare services that they provide.
In addition, some of the Baby Boomers who will be retiring are nurses. Between now and 2024, the number of nurses retiring is around 700,000. By 2030, that number is expected to reach 1 million, which is a third of our current nursing workforce. The biggest cohort of registered nurses joined the workforce before the 1970s. Due to the recent downturn in the economy, many nurses held off retiring, but now that the economy has rebounded some retirements are starting. One survey found that 73% of older nurses intend to retire in the next 3 years. For those who don’t, they face the daunting task of bringing new nurses up to speed and giving them tips and tricks to make it as a nurse.
Filling these vacancies won’t be easy because nursing schools are experiencing a shortage of teachers and, therefore, available classes. This means nursing schools are able to enroll and graduate fewer students. In 2017, more than 56,000 qualified applicants were turned away by schools. In 2018, 75,000 qualified applicants were turned away.
Part of the reason there is a nursing faculty shortage is that nurse educators must have advanced degrees that require a higher level of education (usually a doctoral degree), be an expert in their field, and be willing to take a pay cut since they typically make less money than they would if they worked in a clinical capacity for a hospital, a corporation or the military. This is especially true for smaller, private, or rural institutions. Also, the current median age of nursing instructors is in the 50s, so many of them will also be retiring soon. Since it takes time for individuals to earn a doctoral degree, it won’t be a quick process to replace people in these positions either.
In addition, nurses tend to stay in the same areas where they go to school, so rural and poorer areas will have a harder time getting nurses to go to their schools without the appropriate amount of faculty. This means that potential students will go to, and stay in, cities where this won’t be an issue.
Another barrier beyond getting into nursing school is getting the necessary training that’s needed after. As hospitals and clinics close because they can’t stay in business due to the nursing shortage, this means that the number of places available where nurses who are being trained can gain practical experience is lessened. This lack of clinical sites is significant because, without hands-on experience, nurses are entering the field lacking a critical understanding of what it’s like to take care of patients in the actual setting. Classroom hypotheticals can’t replace the stress of how life-and-death decisions feel in real time.
Due to the lack of clinical site availability, many teaching hospitals and healthcare education programs are turning to simulation technology. While virtual situations allow nurses to make mistakes and learn without actually having a patient’s health in their hands, it’s not a full substitute for physically being in the environment of a hospital and dealing with intense, stressful situations that can occur during any given nursing shift. In addition, many healthcare providers don’t like hiring newer nurses because of their lack of experience. When you consider that people who have around 40 years of experience will soon be replaced with people who have almost no experience, this is a real concern.
How does the nursing shortage affect patient care?
Well, when there aren’t enough nurses, it means that the nurses that are present have heavy workloads and this has been shown to have a negative impact on patient safety. Part of this problem is exacerbated by insurance companies and hospitals creating an environment where doctors must decrease the amount of time they spend with patients in order to maintain a profitable bottom line. Nurses must pick up the slack by doing things that they weren’t expected to in the past, like discovering any pertinent missing pieces of patient health history that the doctor may not have been told.
There have been numerous studies on the effect of understaffed nursing units and departments. In one article, researchers found an alarming connection between high nurse-to-patient ratios and patient mortality. Another study published in the British Medical Journal’s Quality & Safety Journal shows a direct connection between higher patient loads and higher hospital readmission rates. According to a study in the American Journal of Infection Control, there’s a significant correlation between high patient-to-nurse ratios and an increased number of patient infections. As a different study points out, even one additional patient per nurse has a huge impact with a 7% increase in the probability of failure to rescue and the chances of death within 30 days of admission. A study from Denmark confirmed that readmission rates rose when there wasn’t enough nursing staff.
When nurses regularly have high patient volumes with increased acuity levels, they can suffer from high-stress levels, which leads to job dissatisfaction and burnout. One study found that 40% of nurses in hospitals had strong signs of job-related burnout and over 20% were planning on leaving their jobs within a year. Nurses are the last step between a patient receiving the wrong medication or an incorrect dose prescribed by a doctor or a pharmacist. So, having things in place, like mandatory overtime and double shifts, in order to make sure that there are enough nurses to cover a shift doesn’t help in the long term because it significantly contributes to burnout and results in high rates of nursing-related medication errors.
These types of working conditions are playing a large role in nurses experiencing greater fatigue, more stress, potential injury, and ever-increasing job dissatisfaction. Nurses who work under these conditions are at high risk for developing compassion fatigue, which is when caregivers aren’t able to take time for themselves, so they are less focused on their patients. This can include something simple as not getting enough sleep from picking up extra shifts, which can also cause decreases in mental acuity.
According to a national survey of nurses, 50% of respondents said that they were working more hours than ideal for providing the best patient care, 49% said they work in crisis mode, which is trying to do too much too quickly, most of the time and 65% felt that their nursing units used more temporary staff than is best for patient care. While temporary staff, which is usually supplied by travel nurses, can be helpful, it’s also challenging because often these staff members aren’t familiar with the policies and procedures of each particular unit and their contracts are usually only 13 weeks long. So, by the time they get oriented, it’s time for them to move on.
The current national average for nursing turnover is somewhere between 17% – 19%. In addition, over 33% of newly licensed nurses leave the profession within the first two years, and almost 43% leave in the first three years. Nurses are fighting to have guidelines that limit assignments by the number of patients and acuity levels. For example, in 2004, California passed legislation that defined minimum nurse-to-patient staffing ratios. This led to several other states following suit.
Labor is a hospital’s biggest expense according to Moody’s Investors Service. The nursing shortage only causes these expenses to grow. In order to attract more nurses, many hospitals increase their pay rates, offer sign-on bonuses, and boost benefits packages. Obviously, hospitals need nurses, but these policies negatively affect their profit margins. A good example of this is in 2016, the nursing turnover in hospitals was around 16% with a cost per nurse of over $44,000. When you look at this annually, it equates to financial losses of $4.21 million.
Another aspect of cost is increased readmissions of patients, which is around $26 billion a year. Also, in 2017 alone, more than $3.8 billion was paid out in wrongful death lawsuits. An additional consideration is that without adequate numbers of qualified nurses, hospitals sometimes have to temporarily close, or in some cases shut down completely, patient care units, which further reduces revenue streams and decreases cash flow.
Hospitals only have a few options beyond closing beds. Many offer financial incentives to nurses who are willing to work additional shifts, which in the long run isn’t good for the nurses. Others rely on travel nurses, but they come at a premium price. In order to hire more nurses, many hospitals rely on online job posting sites, but this is slow and ineffective. For a typical hospital recruiter to hire just one person, they need to screen 500 online applicants. In addition, the hiring process on average takes 82 days.
Another possible option that many hospitals are taking advantage of is to hire nurses from other countries. Currently, foreign nurses make up about 15% of the workforce. This comes with its own set of issues because nurses attempting to work here often end up frustrated by the visa process, so they give up and go to work elsewhere.
Rather than trying to find a quick fix, facilities need to focus on improving the quality of life available to their staff. One important step is to listen to their nurses and accommodate their basic needs by offering competitive pay, flexible schedules, and plenty of training resources. This will not only help to retain nurses but to attract new ones. By retaining more of their nursing workforce, facilities will lose less money through turnover and be able to shift their financial resources to other areas that need improvement.
In addition, facilities need to encourage nurse autonomy, which means that nurses can practice to the full scope of their license. In some areas, nurses have to deal with ethical dilemmas related to their ability to practice autonomously, and many feel it inhibits their ability to treat within the best interest of their patients. One study found that 75% of nurses report feeling like they don’t have enough authority. When this happens, and it’s not addressed adequately, nurses feel like they are unable to fulfill their duties and will go somewhere else to work.
Part of the issue with this is that each state has different guidelines for what nurses are allowed to do. One way to address this would be to have a national licensure for nurses because then the standards would be the same across the country and it would it make it easier for nurses to go to places that have an increased need.
In addition to retaining nurses, there needs to be a solution to train new ones. One of the necessary solutions is to expand the current capacity of nursing schools nationwide by hiring more faculty. In order to do this, it means that experienced nurses currently working in the field will need to further their schooling. Since this is an expensive undertaking, universities will need to increase the salaries of nursing faculty and offer non-monetary incentives in order to make it worth the time, effort, and financial resources that each individual would need to undertake to become a faculty member.
Another component is that HRSA’s “The Future of Nursing” report recommends that 80% of nurses should have a Bachelor of Science in Nursing because they feel that it will help nurses successfully handle the challenges of a changing healthcare industry and that more education nurses have benefits patients. One study demonstrated that for every 10% increase in the proportion of BSN-prepared nurses is directly linked to a 4% decrease in the risk of death among patients. Since a good portion of nursing programs are Associate’s level, this means that nurses will need to go back to school while working in order to meet this important goal.
Currently, we can’t make it mandatory for nurses to have Bachelor’s degrees from the start because this will only exacerbate the shortage. This is why it’s essential to provide a path towards continuing education for nurses who already are working. Since nurses tend to go to school and then work locally, it’s vital in rural areas to provide viable educational opportunities in order to address the shortages in these communities.
Another strategy is public-private partnerships. For instance, Johnson & Johnson launched the Campaign for Nursing’s Future. This program uses a website, TV commercials, videos, and brochures to showcase the benefits of “this rich and rewarding career.” In addition, schools and states should follow the example that the University of Wisconsin set. They are using a $3.2 million initiative to provide fellowships and loan forgiveness for nurses who agree to teach in the state after graduating from nursing school. This would be incredibly helpful because many who are accepted into nursing programs, have to contend with the cost of schooling.
Offering grants and scholarships, like the RN to BSN/MSN Challenge, is one valuable tool, but there aren’t enough of these programs nor the faculty to support them. Obviously, part of having student loans is paying them back, which is done by maintaining employment. Sure, there are plenty of positions available, but not all of them are optimized for retention. Many facilities offer signing bonuses and generous salaries to increase hiring, but the work environment isn’t the greatest because the effects of fewer staff members are still present, so eventually nurses leave.
Several pieces of legislation designed to help with student loan forgiveness and grant funding for nursing programs are currently up in the air. Some would not have a positive impact. One would raise interest rates for graduate students and would eliminate student loan interest deductions. Also, employer-provided tuition assistance would become a taxable benefit. A different proposal, the PROSPER Act (Promoting Real Opportunity, Success and Prosperity Through Education Reform) would eliminate Public Service Loan Forgiveness. For some nurses, loan forgiveness is the only light at the end of the tunnel.
In addition, repayment plan options would go from eight down to two. The American Nurses Association (ANA) is lobbying Congress to increase funding for Title VIII of the Public Health Service Act, which apportions federal grants for nursing schools and organizations to advance their educational programs, promote diversity in the field, repay loans for nursing students who work in facilities with critical shortages and provide training in nursing specialties with increased needs. In the last year, the money provided via Title VIII was reduced by $2.15 million, and when you adjust for inflation, there has been a 30% decline in the money since 1971. This needs to be corrected because Title VIII is critical to helping solve the nursing shortage.
Without intervention on a multitude of fronts, the problems causing the nursing shortage won’t go away. This will continue to strain overburdened nurses and increase the risk of poor patient outcomes. This is evidenced by the fact that one out of every ten deaths is attributed to medical errors, which are more likely to occur when there aren’t enough nurses to take care of patients. The solution to the nursing shortage isn’t going to be a quick one because it takes time to train new individuals. So, in the meantime, it’s essential for facilities to take care of the nurses that they have and for universities, private companies, and the government to do all that they can to assist in creating the right environment to allow nurses to succeed. Our health depends on it!