Overview
Nurses constitute the largest single healthcare profession in the United States.  Nurses represent a large and diverse group with differing levels of training and education. This issue module focuses on Registered Nurses (RNs), those who complete an associate degree or higher comprise the largest group.[1] Since World War II, hospitals in the U.S. have had to cope with cyclical shortages of nurses, where the national supply cannot meet demand. Recurrent shortages of nurses in the U.S. health care system affect quality of patient care and is a multifaceted and complex issue, with causes stemming from training as well as compensation and retention.   In 2000, it was estimated that there were 110,000 open nursing positions, meaning that demand exceed the available supply by 6%.[2] In 2008, combined vacancies in long-term facilities and hospital relayed an even larger shortage of 8.1%.[3]  By 2025, the shortage of RNs is projected to reach an estimated 260,000 full-time-equivalents (FTEs), twice as high as any U.S. nursing shortage since the 1960’s. [4]

This most recent shortage has been more severe and has lasted longer than past shortages, but may be coming to an end, due to a combination of an influx of new graduates and the retention of older nurses who have delayed retirement. However, in light of the temporary nature of the easing of the nursing shortage during the recession, many analysts have called for policy-makers to develop long-term solutions to avoid or relieve future nursing workforce shortages.

Causes of Nursing Shortages
The most recent shortage is the culmination of multiple factors 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. [5]  These issues are occurring just as job opportunities within health care are expanding and a majority of nurses are retiring.  Over half of registered nurses intend to retire between 2011 and 2020, a large portion of whom are nurse managers. [6] Reasons for high turnover and early retirement among nurses often include high levels of job dissatisfaction related to scheduling, workloads, and mandatory overtime, and low autonomy. [7]

The Effect of Nursing Shortages on Patient Care
Shortages of RNs negatively affect patient outcomes and contribute to medical errors.[8]  Lower nurse-patient ratios on medical and surgical teams are correlated with lower patient mortality rates. [9]  Furthermore, patients are twice as satisfied with care and have better post-surgery survival odds in facilities where nurses positively rate the work environment, nurse-physician relationships, support, and nurse-patient ratios.[10]  Where standards are weaker or not well enforced and nurse turnover and understaffing are persistent issues, patient mortality rates are higher. [11]  There is also evidence that low rates of nurse retention contribute to preventable patient deaths.[12]

Strategies to Address Nursing Supply
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 recent shortage, however, some experts expect that these are short-term solutions that will have little impact over the long run.

Addressing the nursing shortage requires efforts aimed both at recruitment and retention of nurses, as well as strengthening the 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.  U.S. nursing schools turned away 75,587 qualified applicants from baccalaureate and graduate nursing programs in 2011 due to insufficient number of faculty, clinical sites, classroom space, and clinical preceptors, as well as budget constraints.[13]  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.

Recent federal efforts, including the Nurse Reinvestment Act of 2002 and the Recovery and Reinvestment Act of 2009, focused on both recruitment and retention strategies ranging from education funding to career development initiatives. Additionally, 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, but these new laws have not always resulted in cost effective approaches to improve patient care.[14] Some states have invested millions of dollars towards nursing education programs by increasing capacity and faculty at nursing schools, although with limited success.[15] 

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.[16]  Recommendations include encouraging nurses to practice to the fullest 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 limited 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.  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.

The Patient Protection and Affordable Care Act (ACA) increases the focus on primary and preventive care, thus adding pressure on the nursing workforce.[17] The ACA authorizes expansions of a variety of programs and new programs to increase the size of the health workforce and improve some essential skills. These programs could give nurses opportunities to advance their education and work in underserved communities, including funding investments for advanced nursing education and loan repayment and scholarships. New models of payment for health services and greater emphasis on home and community-based care could increase the role of RNs as case managers, home health providers, and transitional care professionals.

Updated: July 2012