The Nursing Shortage

Steven Donahue

Introduction

According to research conducted by the Bureau of Labor Statistics in December of 2013, the United States is at the precipous of a substantial nursing shortage. Their study indicated that the registered nurse (RN) workforce is expected to grow from 2.71 million jobs in 2012 to approximately 3.24 million in 2022, a 19% increase. This considerable growth coupled with an estimated 525,000 nurses retiring within the same time frame, brings the total of nursing openings to just over one-million jobs (1). The shortage is projected to spread across the country, but be most intense in the South and West regions (2, United Stated Registered Nurse Workforce Report Card).

Other professions often endure similar reports about workforce shortages, but shortages specifically affecting the nursing profession are persistent and cyclical. The history of nursing shortages can be linked back to the beginning of nursing as a profession and the first nursing diploma schools, founded in 1873. These diploma schools focused on apprenticeship, and gave young women an opportunity for financial independence and solid employment that was previously not accessible. Physicians and hospitals soon realized the young nurses were a cheap source of labor, and further recruited upper and upper-middle class society for possible nursing candidates. “It may be argued that the first nursing shortage in the U.S. occurred when hospital training schools found the supply from the upper strata of society had evaporated” (3), and the hospitals were required to scramble and recruit nurses with different economic and cultural backgrounds.

Nursing shortages were also prevalent between the years of 1932 and 1952, and exacerbated by the World War II which highlighted an increased need for competent nursing care. In 1943, Congress passed legislation to create the Cadet Nurse Corps, which helped provide an influx of proficient nurses during this shortage. It is estimated that students who graduated form the Cadet Corps provided nearly 80% of the care of hospitalized patents during World War II (3). Documented nursing shortages also occurred in the early 1960’s, early 1980’s, and twice in the 1990’s. Cut?

The cause of more recent nursing shortages have become more complex and difficult to define. Research by Goldfarb et. al. in 2008 described two standards to to define a nursing shortage. First, a shortage occurs when there is not enough nurses to provide a certain level of quality care. Secondly, a nursing shortage exists when there are not enough nurses to fill open positions. Based on this description, the current situation can be simplified and more easily defined as a nursing shortage. The causes, impacts, and potential solutions for the current nursing shortage will be further explored.

Factors Affecting the Nursing Shortage

Societal Demographics

A major cause for the nursing shortage is be related to the increased damand required to care for the aging baby boomer population. Members of the baby boomer generation were born roughly between 1946 and 1964 and created a demographic bubble. Between the years of 2008 and 2018, the 55-year old plus demographic is expected to grow more rapidly than any other age group, and will account for a larger share of the total population (9). Figure 1 below illustrates the age distribution and median age from 1960 to 2010 in the United States, and highlights the increasing median age associated with the baby boomer generation. This demographic disparity will create a challenge for healthcare providers, and require a proportional increase in the professional nursing workforce to accommodate the rising elderly population(4).

Figure 1. Age distribution and median age: 1960 to 2010 (SOURCE)

Demographics of Current Nursing Workforce

The current nursing workforce demographics nearly mirror the United States demographics as a whole. According to a survey conducted in 2013, 55% of the registered nursing workforce is age 50 or older (2, #6), and only 14.8% of nurses are aged 30 or younger.

The current nursing shortage was further complicated by the 2008 economic collapse. The economic collapse had devastating effects on personal finances, with figures showing an average loss of more than 25% of individuals 401K’s for those nearing retirement (aged 56-65) (

http://www.ebri.org/pdf/briefspdf/EBRI_IB_2-2009_Crisis-Impct.pdf)

. This forced many older nurses to remain in their current positions, or required part-time nurses to return to full-time employment. Statistics showed that the downturn in the economy lead to an easing in the shortage in many parts of the country (1), but this is only temporary and may intensify the shortage after these nurses decide to retire.

Nursing Faculty Shortage

There are a variety of reasons for the current nurse faculty shortage. First, the average age of nuring faculty also nearly mirrors the United States demographics as a whole. According to the

American Association of Colleges of Nurses


(AACN),

the average doctorally prepared professor is 56.8 years old, and the average master’s degree nursing faculty is 55.1 years old. (

http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-faculty-shortage)

. As a wave of retirements over the next decade hits academia, the replacements are both scarce and advanced in age.

Salary differentials between nursing educators and those with similar credentials in the private sector is making it difficult to retain nursing educators. Data colleted in 2012 by the Bureau of Labor Statistics found that a Master’s prepared Nurse Practitioner earned a median salary of $92,670 while a Master’s prepared Associate Professor earned $72,590, a differential of approximately $20,000 (BLS website). This monetary difference, along with an increasingly high loan burden associated with attaining a graduate degree makes the private sector more enticing for new graduates with advanced degrees.

The faculty shortage has had a significant affect on nursing school admission. The AACN conducted a survey in 2012 and determined that U.S. nursing schools turned away nearly 80,000 qualified undergraduate applicants due to a scarcity in faculty, clinical sites, and classroom space (2,#10). Two-thirds of of respondants indicated that faculty shortages were the number one reason for turning away qualified applicants. Furthermore, approximately 15,000 qualified applicants were turned away from graduate programs for the same reason. The nursing faculty shortage then becomes a two-pronged issue. The nursing shortage requires more nursing students, but a nursing faculty shortage creates limitations on how many students can be prepared for employment, and limits the ability to prepare future nursing educators.

Working Conditions & Wages

The nature of the work, physical fatigue, orthopedic issues,and family strain due to working nights and weekends lead many nurses to leave the hospital setting or the profession altogether. In an era of litigation, nurses must also be cognizant that the individual, and not the system may be held liable in case of patient safety errors. This increased accountability without sufficient decision making authority leads to increased stress on the nursing workforce (4).

The nursing profession is challenging and stressful, and many believe that the salary does not reflect the difficulty of the job. According to the Bureau of Labor Statistics, salaries for registered nurses have increased only 4% between 2008 and 2014. While this stagnation may also be indicative of the 2008 economic collapse, the effect of the nursing shortage on wages may not be fully understood until the economy fully recovers.

Nursing Shortage Implications

The pinnacle concern of the nursing shortage is the effect that it may have on patient loads and quality of care. The growing elderly population coupled with the a shortage of nurses will lead to an increase in patient loads. Numerous studies have indicated that higher patient loads lead to a riskier environment for the patient. A study published in 2011 by Dr. Jack Needleman analyzed the records of 197,961 patients, and found that the mortality rate increased from 1-6% if a facility was understaffed (

http://www.nejm.org/doi/pdf/10.1056/NEJMsa1001025

). Another study in 2011 indicated that when the hours per patient day was high (an indicator of proper staffing), the incidents of congestive heart failure, failure to rescue, infections, and prolonged lengths of hospital stays decreased (

http://www.ncbi.nlm.nih.gov/pubmed/21407034)

. Lastly, a study conducted in 2013 observed the relationship between higher patient loads and readmission rates of pediatric patients. The research showed that when the ratio was adjusted by just one patient (5:1), the likelihood for readmission rose 11% (

http://qualitysafety.bmj.com/content/22/9/735.full

). An increase in readmission rates will further aggravate the problem of patient loads, and has a heavy economic toll.

While increased patient loads effect the overall quality of care, they also adversely effect the working conditions of nurses. In a survey conducted in 2005, 75% of respondents believed that the nursing shortage will effect their quality of work and limit the amount of time they can spend with patients. Additionally, 93% of those surveyed believe that the effects of the nursing shortage will cause nurses to leave the profession (2,#11). Another study in 2012 concluded that nurses were likely to attribute staffing insufficiencies as a major factor in job dissatisfaction, stress and burnout.

The nursing shortage will ultimately effect patient loads, working conditions, and quality care for the patients in all nursing sectors. If propoer strategies are not developed, the increased stress associated with the shortage may lead to greater turnover in the profession, which only compounds the shortage issue.

Strategies to Address the Nursing Shortage

Addressing the General Nursing Shortage

One way to entice new nurses in to the field has been to make the cost of education more affordable. On the federal level, the Nursing Education Loan Repayement program has been initiated and pays for 60% of a students loans in exchange for a two year commitment to a geographic area determined to have a critical shortage. Many hospitals have reimbursement programs for nurses looking to advance their education in exchange for a future working commitment. While this may entice more new nurses, economists warn that government and other subsidies may interfere with the free market, and may actually depress nursing wages. One possible solution to the free market interference is pay for performance programs. Rather than give subsidies to specific nursing students, pay for performance programs give subsidies to facilities that provide a high quality of care. Since quality care is intinsically tied to nursing performance, this would increase the economic value of nurses, thus improving wages, work environments, and retention (3).

In addition to nursing faculty shortages, insufficient clinical sites play a huge role in limiting the student capacity of nursing schools. Increased coordination and strategic partnerships between universities and the private sector can help expand student enrollment. For instance, a joint venture between the Minnesota VA Health Care System and the University of Minnesota in 2013 has helped expand the schools BSN program. In this agreement, the VA committed $5.3 million dollars to expanding clinical placement sites within their facilities and funded additional faculty for the University. By teaming with the University of Minnesota, the VA received enhanced care for their patients.

A better work environment can help attract new nurses and limit the amount of nurses who “burn-out” and leave the profession. Strategies to better the nursing work environment must focus on the emotional and physical stresses of the profession. Research has shown that limiting heavy lifting, decreasing walking, and providing easy access to equipment and information will keep nurses from leaving the profession (From #4 Goodin, 2003) Additionally, “increasing autonomy, re-allocating work in a more patient centered way, creating systems to recognize achievement in the areas of mentoring nurses, educating patients ans personal growth in practice, creating meaningful internal labor markets, and enhancing supervisor and administrative reports” (Morgan and Lynn, 2009). In order to combat further nursing turnover and burn-out, hospitals and nursing facilities must focus on nurturing an environment that provides these qualities. This is even more important when increased nursing turnover costs hospitals millions of dollars per year in recruiting and training new nurses.

Further research in 2009 found that organizational constraints and high patient loads adversely affected job satisfaction. Supporters of mandated patient-nurse ratios believe that mandatory ratios will increase positive patient outcomes, increase job satisfaction, and ultimately combat the nursing shortage. Currently, thirteen states have staffing laws for hospitals, but only California has mandated minimum nurse-patient ratios. It should be noted that the American Nurses Association does not necessary support mandated patient-nurse ratios, but rather supports a legislation model which empowers the nurses to create staffing plans specific to each unit, giving the nurses autonomy to make staffing decisions that are best given the fluidity of hospital admissions (

http://www.nursingworld.org/mainmenucategories/policy-advocacy/state/legislative-agenda-reports/state-staffingplansratios)

.

Addressing the Nursing Faculty Shortage

One major issue plaguing the nursing faculty shortage is the inability to recruit BSN prepared nurses in to the education realm, and has been noticed on both the state and federal level. In January of 2014, Wisonsin announced the “Nurses for Wisconsin Initiative”, which provided 3.2 million dollars in fellowships and loan forgiveness for nurses who agreed to pursue advanced degrees in nursing education and teach in the state after graduation (1). On the federal level, in December of 2013, the U.S. Department of Health and Human Services provided 45.4 million dollars in funding to provide low interest-loans for nurses pursuing nurse education degrees (Macdonald, 2013 see citation below).

In order to attract more nursing educators, the pay discrepancy between the private sector and nursing educators must be addressed.

References

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