Overview

Registered nurses (RNs) constitute the largest single healthcare profession in the United States. Since World War II, hospitals in the United States have had to cope with cyclical shortages of nurses, where national supply cannot meet demand. Recurrent shortages of nurses in the United States health care system affects quality of patient care and is a multifaceted and complex issue, with causes stemming from training as well as compensation and retention.  Although estimates vary, many analysts have concluded that the U.S. has been facing a nursing shortage for decades[i].  In 2000, it was estimated that there were 110,000 open nursing positions, meaning that demand was 6 percent higher than the available supply.[ii] In 2008, American Health Care Association’s report of vacancies in long-term facilities and American Hospital Association’s report of hospital vacancies combined relayed an even larger shortage of 8.1%[iii].  By 2025, the shortage in RNs is projected to grow to an estimated 260,000 FTEs, twice as high as any US nursing shortage since the 1960’s.[iv]

However during the recent recession the supply of nurses in the field has bounced back slightly.  This is likely due to the fact that retired and experienced RN’s went back to work and increased their hours from part-time to full, especially when spouses had lost jobs. These trends, however, are expected to be only temporary.  A 2008 study projected that based on the increasing age of the current workforce and the need for RN’s throughout the health care system that a “large and prolonged shortage of nurses is expected to hit the US in the latter half of the next decade”.[v] Considering the acute economic factors responsible for the partial relief of the nursing shortage during the recession, many analysts have stated that policy-makers must focus solutions on longer-term predictions of shortages.

What is causing the nursing shortage?

Research suggests that the current shortage is the product of several trends including: steep population growth in several states, a diminishing pipeline of new students to nursing, a decline in RN earnings relative to other career options, an aging nursing workforce, and an aging population that will require intense health care services.[vi]These issues are occurring just as the majority of nurses are retiring and job opportunities within health care are expanding.  The 2006 Nursing Management Aging Workforce Survey, found that 55% of registered nurses intended to retire between 2011 and 2015. Nurses reported high levels of job dissatisfaction related to scheduling, workloads, mandatory overtime, and lack of responsiveness to concerns as major reasons for high turnover and early retirement among RNs.  

How does the nursing shortage affect patient care?

Multiple surveys and studies confirm that the shortage of RNs influences the delivery of health care in the U.S and negatively affects patient outcomes and increases medical errors.[vii]The ratio of nurses to patients was found to be important, with lower nurse-patient ratios on medical and surgical teams correlated with lower patient mortality rates.[viii] There is also evidence that patients have twice the satisfaction with care and  have better post surgery survival odds in facilities where nurses rate the nursing environment as good, with respect to nurse-physician relationships, support, and nurse-patient ratios.[ix]    Where standards are weaker or not well enforced and nurse turnover and understaffing are persistent issues, patient mortality rates are higher.[x]  There is also evidence that low rates of nurse retention contribute to preventable patient deaths in the United States.[xi]

What strategies are proposed to address shortage?

Historical solutions to address past nursing shortages have focused on wage increases and recruitment of nurses from other countries, such as Canada, English-speaking Caribbean and African countries, Great Britain, India and the Philippines. Given the complex causes of the current shortage, however, experts increasingly recognize that these short-term solutions will have little impact.

Addressing the current shortage requires efforts aimed both at recruitment and retention of nurses, as well as capacity of nursing schools.  These strategies include supplying educational facilities with sufficient faculty and funding, improving financial aid to students in the form of scholarships, and targeting underrepresented and nontraditional groups such as minorities and men. Increases in faculty for nurse training programs and facilities are considered to be essential.  In 2009, over 42,000 qualified applicants were unable to enter nursing programs due to a lack of faculty.[xii]   Additional strategies focus on both retaining current nurses and encouraging those who have left nursing careers to reenter the workforce. Improving workplace conditions and enhancing the education and professional development of nurses are primary retention strategies.

In the past decade, the chief federal response addressing the current nursing shortage —the Nurse Reinvestment Act of 2002—included both recruitment and retention strategies. The law authorized the following provisions: loan repayment programs and scholarships for nursing students; public service announcements to encourage more people to enter the nursing profession; career ladder programs for those who wish to advance within the profession; best practice grants for nursing administration; long-term care training grants to develop and incorporate gerontology curriculum into nursing programs; and a fast-track faculty loan repayment program for nursing students who agree to teach at a school of nursing. More recently, the 2009 Recovery and Reinvestment Act included substantial funding for nursing education and retention, with over $200 million towards federal Nursing Workforce Development Programs which distributes funds across the country.

The 2010 Patient Protection and Affordable Care Act also includes a number of funding strategies for improving nursing supply and retention. The Act expands funding for advanced education nursing grants, diversity grants, and a Nurse Education Loan Repayment Program which repays 60% of nursing student loans in exchange for two years working in a facility with a significant nursing shortage (National Nurse Service Corps). It also supports new nurse-managed clinics under the Public Health Service Act, where RNs can provide reliable local primary care and preventative services. [xiii] Nurses will also be eligible for positions on the National Healthcare Workforce Commission, which will evaluate healthcare delivery systems and make recommendations to Congress. Many of the bills programs will call upon a new force of nurses. The Nurse-Family Home Visit Provision for example is a $1.5 billion program to be implemented over the next 5 years. It supports nurses visits to low-income first-time mothers in the home for the first two and half years to help with pregnancy and child care.

In addition to federal efforts, some states have made efforts to ensure better working conditions for nurses and patient safety by passing legislation that sets minimum staffing ratios and prohibits mandatory overtime practices. In 2004, the California legislature enacted a law mandating patient-to-nurse ratios for its hospitals, however studies of patient health outcomes revealed that there was not significant improvement to patient care given the extra costs of maintaining these ratios[xiv].  States like Arizona have invested millions of dollars towards nursing graduates by increasing capacity and faculty at nursing schools (Arizona’s Partnership in Nursing Education, 2005), but even after $20 million towards nursing schools the state still faces critical shortages.[xv] Public-private partnerships have also opened the door to additional state initiatives, such as Pennsylvania’s investment of $750,000 to address nursing shortages in 2008, which was matched by $870,00 in private-sector funds.[xvi]

The 2010 IOM/Robert Wood Johnson Foundation report entitled “The Future of Nursing” outlined a number of recommendations for changes in nursing to help meet the growing demands of healthcare in the 21^st century.[xvii]  Report recommendations include: encouraging nurses to practice to the extent of their education and training, improving educational programs for nurses at every level to accommodate interest and funding of applicants and progression toward advanced degrees, and supporting nurses to become key members in the discussion of healthcare reform.  In addition to resources and faculty supply, the report finds that problems with supply and retention of nurses also stem from their perceived role in the healthcare system, often excluded from decision-making boards and distinguished as separate from other healthcare professionals. The report finds that the inclusion of their unique perspective on the front-lines at every level of the health delivery system would be invaluable, and might improve morale and satisfaction amongst nurses, a major contributor to early retirement and turnover. Structural, legal, and cultural changes would need to be implemented in order for this goal to be fully realized, but the report points out that these changes would also be critical to sustaining the nursing supply in the future.

These public and private initiatives indicate that professional organizations, health care institutions, and other experts have succeeded in raising awareness to the problems associated with a shortage of a skilled nursing workforce. If forecasts of a massive gap between the supply and demand for nurses in the future are correct, however, the scope and scale of initiatives—particularly, the level of financial resources from public and private sources—will likely need to be significantly expanded to reverse current trends.