Background Brief

Registered nurses (RNs) constitute the largest single healthcare profession in the United States. [1] Since World War II, hospitals in the United States have had to cope with cyclical shortages of nurses. In 2000, the national supply of FTE registered nurses was estimated at 1.89 million while the demand was estimated at 2 million, a shortage of 110,000 or six percent. By 2020, the shortage is projected to grow to an estimated 340,000. This shortage is not just in hospitals, but also in nursing homes, which project that they will need 66% more RNs in 2020 based on 1991 data.

In 2002, many national reports attempted to quantify the nursing shortage and explain the threat this problem poses to health care delivery. According to a report released by the Health Resources and Services Administration within the U.S. Department of Health and Human Services, the number of states with a shortage of RNs is expected to grow from 30 states in 2000 to 44 states in 2020. Surveys and studies published in 2002 in the New England Journal of Medicine, Journal of the American Medical Association, and by the Joint Commission on Accreditation of Healthcare Organizations all confirm that the shortage of RNs is influencing the delivery of health care in the U.S and negatively affecting patient outcomes.

This and other 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, low job satisfaction and poor working conditions that contribute to high workforce attrition rates, and an aging population that will require intense health care services. These issues are occurring just as the majority of nurses are retiring and job opportunities within health care are expanding.  However, there have been recent trends of people entering the nursing profession at a later age and an increased overall interest in nursing.

Typical solutions to address past nursing shortages have included wage increases and recruiting 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 described above, 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. Recruitment refers to the need to continuously attract new entrants into the nursing profession. Strategies include wage increases and international recruitment discussed above, as well as improving financial aid in the form of scholarships and loans, and targeting underrepresented and nontraditional groups such as minorities and men. [2] They also include advertising campaigns and promotions to advance messages about the rewards of a nursing career, such as the $20 million “Campaign for Nursing’s Future” recently undertaken by Johnson & Johnson.

Retention 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. High levels of job dissatisfaction related to scheduling, unrealistic workloads, mandatory overtime, and hospital administrators’ lack of responsiveness to nurses’ concerns have resulted in high turnover and early retirement among RNs.

Some states have made efforts to ensure safer working conditions for nurses by passing legislation concerning minimum staffing ratios and prohibiting mandatory overtime practices. California is a prominent example. In 1999, the California legislature enacted a law mandating patient-to-nurse ratios for its hospitals beginning in 2003. As many as 19 other states have introduced similar legislation. Moreover, as of December 2002, eight states had implemented laws or regulations that ban or limit mandatory overtime, and twenty-one more had introduced legislation or regulation.

The chief federal response addressing the current nursing shortage—the Nurse Reinvestment Act of 2002—includes both recruitment and retention strategies. The law authorizes 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.

Numerous professional nursing associations supported the Nurse Reinvestment Act and it received additional support from other professional bodies, including the American Hospital Association, the American Medical Association, the American College of Physicians, and the American Society of Internal Medicine. On February 18, 2003, both chambers of Congress passed the $397.4 billion FY 2003 Omnibus Appropriations bill and thus the Nurse Reinvestment Act (PL 107-205) was enacted and funded. The FY 2003 appropriations amounted to $113 million, a $20 million increase over FY 2002.

These state and federal initiatives indicate that professional organizations, health care institutions, and other experts have succeeded in alerting policy makers 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, it is likely that the scope and scale of initiatives—particularly, the level of financial resources from public and private sources—will need to be significantly expanded to reverse current trends.

As policymakers debate the issues related to the nursing shortage, discussion will likely focus on several key issues:

• How and why is this current nursing shortage different from previous shortages? Do the policy options address the current problems or are they responding to historical problems?
• How does the nursing shortage affect the quality of care for patients?
• Is assuring an adequate nurse workforce a federal responsibility? What is the correlation, if any, between the availability of nurses in the health workforce and the nature and funding of federal discretionary nursing programs?
• What other federal policies affect the demand for and supply of nurses?
• What is the nature of states “safe staffing” legislation? Why are states addressing the nursing shortage this way? Does this policy have potential unintended consequences? Will an inability to find enough qualified RNs force hospitals to eliminate beds and reduce access to care?
• Do state nursing policies affect the supply of nurses from state to state? If so, how?

[2] The problem of minority underrepresentation is particularly acute: While the percentage of nurses from racial and ethnic minorities grew from 7% in 1980 to 12% in 2000, this lags significantly behind the proportion of minorities in the general population, which is about 30% (HRSA, 2000).