The Nursing Workforce Shortage – What’s the Solution?

Ernest Grant, President, American Nurses Association

Contact: Ernest.Grant@ana.org

Introduction

When COVID-19 hit the shores of the United States, there were plenty of indications that the already existing nursing workforce shortage would balloon to crisis proportions. Prior to the start of the pandemic, the nursing profession was (and had been) experiencing multiple shortages due to factors such as: economic downturns; the retirement of older nurses; and younger nurses leaving the bedside to become travelers or Advanced Practice Nurses [APRNs i.e., Nurse Practitioners or Nurse Anesthetists]. The increase in workplace demands as healthcare trends moved from the acute care setting to the broader community, also contributed to the workforce shortage as more nurses were needed to staff these newly created positions. Recent studies have documented an estimated predicted workforce shortage of half a million to 1 million Registered Nurse (RN) jobs in the U.S. by 2030.¹  One report also noted that close to half of the RNs practicing today are 50 years of age or older. ² Once the pandemic hit, these factors and others contributed to the worst nursing shortage ever seen in the U.S. Whereas the nursing shortage has been experienced in all practice areas, this article addresses the experience felt in acute care settings. The shortage is so significant, that in September of 2021, I wrote a letter to Health and Human Services Secretary Xavier Bocerra, asking him to declare the shortage a crisis and to bring all stakeholders together to develop short- and long-term solutions to address this issue.³ Although many issues contribute to the current workforce shortage, I shall address three areas that I see as a concern.

The Drivers Behind the Shortage

First, in addition to factors listed above, there were several other drivers accelerating the current nursing shortage. When the COVID-19 pandemic hit, very little was known about the mode of transmission. One obvious factor was that older adults seemed to be the most vulnerable. As hospitals began to fill up with the COVID-19 population, older nurses began to realize that they were just as vulnerable, especially given the lack of sufficient personal protective equipment (PPE). Many older nurses made the decision to retire early to protect their health and the health of their family members. Thus, we had the dilemma of nurses choosing to retire outpacing the number of new nurses entering the nursing field; this not only created a huge workforce drain, but also a huge knowledge, or brain, drain as well. The brain drain is also thought to contribute to younger nurses leaving the bedside because there is no one to precept them in their new work environment.

Second, as hospitals continued to fill up with COVID-19 patients, nurses and other members of the healthcare team were asked (and in some cases mandated) to work overtime, leading to excessive physical and mental burnout across all age groups. The American Nurses Foundation (ANA) conducted a fourth “Pulse of the Nation’s Nurses Survey series on Mental Health and Wellness” at the two-year mark of the pandemic.⁴  Over 9,000 nurses participated in the survey, which highlighted such factors as:

• 34% of nurses are either not or not at all emotionally healthy (of note, 51% of those respondents were between the ages of 25 and 34 years)
• 50% of nurses indicated they intend to stay in their position in the next six months, with 21% saying they intend to leave and 29% saying they may leave.

When asked why, nurses named the negative effect work has on their health and well-being (48%), staffing shortages, and lack of support from their employer (41%).

• Resiliency was mixed among nurses; nurses rated their ability to recover with an average score of 6.64 on a scale of 0-10.

Because a state of emergency had been declared across the U.S., employers could impose mandatory overtime to meet staffing demands. The downside to this and other such measures was the unforeseen consequences that, if left unchecked, increased fatigue (whether mental or physical) and the likelihood of performance errors (poor judgments, increased medication errors and complications, increased mortality, etc.). As the health of the individual continues to become diminished (physical ailments, poor diet, poor sleep patterns, detachment, depression, and irritability, etc.), there is the real potential of burnout. Burnout may be linked t0 absenteeism, increased job vacancies, substance abuse, or suicidal ideation.

A third reported reason for the nursing workforce shortage is nurses’ dissatisfaction with their work environment. Nurses were viewed as heroes at the onset of the pandemic. As the pandemic wore on and burnout among all healthcare professionals increased, nurses began to feel they were not valued or appreciated by their employer or institutions. They registered complaints about feeling unsafe or that their workplace was not considered a safe environment. There were documented reports of nurses being bullied or assaulted by patients and their family members, or even their own colleagues. In some cases, nurses did not feel supported by their employer when such incidents were reported. In the latest survey of The Current Pulse of the Nation’s Nurses COVID-19 Survey series (June-July 2022), nurses reported that the incidences of bullying, incivility, and violence are increasing, with most incidents involving patients and their families.⁵ This creates an environment in which nurses would rather walk away than remain in a challenging setting. Additionally, some nurses chose to move to a different role due to the insufficient number of nurses available to staff a unit. This staffing shortage may increase the desire of even more nurses to leave their employer due to the increased workload created by the departure of other nurses.

In late spring of 2022, the American Nurses Association (ANA) conducted a series of listening sessions with its constituent state nurses associations to discuss the nursing staffing shortages. More than 20 states were represented at these sessions and each state reported some level of nurse shortages in various care settings. Additionally, the ANA, American Association of Critical Care Nurses (AACN), the American Organization of Nursing Leadership (AONL), the Institute for Healthcare Improvement (IHI), and the Healthcare Financial Management Association (HFMA) launched the National Nurse Staffing Task Force. The Task Force has worked to develop short-term actionable strategies to address the nurse staffing crisis. Some strategies or solutions were set up as “low-hanging fruit” opportunities and the priority areas identified were healthy work environments, innovative care delivery models, work flexibility and scheduling, total compensation, stress injury continuum, and Diversity, Equity and Inclusion.

The Proposed Solutions

So, what is the answer to help address and alleviate the nursing workforce shortage? Many solutions have been proposed, such as mandated staffing ratios, increased rate of pay or hiring additional staff or travel nurses, and increased enrollment in nursing programs. All of these solutions may have their benefits, but the heart of the matter remains that there is not a one-size-fits-all solution. There are many different causes for the workforce shortage in different areas of the country, such as rural versus urban issues, critical access facilities versus academic medical centers, etc. Personally, I think a vital question asked during the June-July survey is a good starting point. The survey pointed out that 31% of the respondents selected the item “Genuinely listen to my voice and respond to my needs” as one of the top three ways to improve work satisfaction. Since the start of the pandemic, I have been encouraging chief nursing officers and other members of the C-Suite to host town hall meetings with their employees and to actively  listen to what they are saying. Attempting to fix the problem without consulting those who are directly affected by that fix will ensure that the crisis continues. By hosting town halls, C-suite executives can gather data (much like what we do when applying the nursing process) to begin to solve the problem. One important factor to consider while gathering that data is that there may be a variety of solutions offered. What one nurse may view as a solution (i.e., higher wages) may not be what appeals to another nurse (i.e., safe work environment). It is crucial to ask each nurse what it will take for them to feel valued and an important, vital member of the healthcare team. It is critically important that senior nurses are listened to and are asked questions such as, “what keeps you here; what can we put in place to continue to keep you here and attract others?”

Nursing salaries should be taken into consideration when addressing the workforce shortage.  Many hospitals began to pay attention to this when nurses began to leave their facilities in droves to work as travelers (sometimes working in the same facility they left) and receive pay that was five  to 10 times their previous hourly rate. A Nursing Solutions Inc. (NSI); report found that the average cost of turnover for a nurse at the bedside is over $40,000. That same report noted that in 2020, the turnover rate for staff RNs was 18.7 percentage points higher than in 2019.⁶  In an effort to stem the mass exodus, and as travel funds began to eat into budgets, many hospitals have set up “intracare” travel agencies within their institutions and hospital systems, as well as offering bonus pay programs. This is a temporary stop-gap measure but it still does not address the root of the problem. Using the results of the National Nursing Staffing Task Force listed above is a good starting point as well.

Another solution proposed to alleviate the workforce shortage is to increase the number of nursing programs or to have existing programs admit more students per class or semester. Petitions have been made to Congress and state government leaders to increase funding for such programs, faculty, or building space. Whereas such measures may increase the number of graduates, the reality is that a gap remains in the number of new graduates per year (approximately 200,000) and the number of available jobs. Because of the documented shortage of faculty and educational and clinical space, it will be difficult to meet the continued rising demands on the profession as healthcare expands beyond the acute care setting. We cannot depend on the yearly graduate numbers to backfill our way out of this shortage. Most graduates of nursing programs are of the millennial or Gen Z generations; these are individuals who seek more flexibility in their chosen careers and often seek out opportunities to try different things.

Perhaps further exploration of a redesign of nursing care delivery with a focus on staff well-being may be in order, one that improves and incorporates nursing competency and empowerment and results in better patient outcomes. This can be achieved without deskilling in areas where nursing knowledge, intuition, and critical thinking skills reign supreme. Some acute care facilities have returned to the concept of the “Team Nursing” model in which a group of RNs, LP/VNs and nursing assistants work together as a team to address all aspect of care for a group of patients. This model may help to address the nurse-patient ratio conflicts and embrace technology and innovation  to assist with care and promote well-being and satisfaction among the staff.  Because of the number of individuals involved in the care, and the high level of efficiency this model promotes, nurses may feel that they are better able to provide and meet more of the patient/family care needs.

Finally, it is vital that employers put in place a system that provides for a better work environment, scheduling, appropriate compensation packages, and prioritization of patient safety to attract and retain nurses today and in the future. It is also imperative that the type of nurses and their required competencies to meet patient care demands and requirements are taken into consideration, and that appropriate compensation and other efforts such as continuing education offerings are considered. Nurses deserve appropriate compensation in the form of salaries, wages, incentives, and payment models commensurate with their knowledge and education and with the safe, quality care that they provide to their patients and communities.

There is no one-size-fits-all solution to solving the current nursing crisis, the result of years of neglect, cover-up, and patchy fixes. If the nursing profession and the future of healthcare is to survive, all parties must come to the table with an open mind and a desire to address short- and long-term measures that will eventually lead to a resolution.

References

1. Zhang, Xiaoming, Tai, Daniel, Pforisch, Hugh, and Lin, Vernon W.; United States Registered Nurse Workforce Report Card and Shortage Forecast: A Revisit; American Journal of Medical Quality 2018, Vol. 33(3) 229–236.
2. Impact of the COVID-19 pandemic on the hospital and outpatient clinician workforce: challenges and policy responses (Issue Brief No. HP-2022-13). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. May 2022.
3. ANA President’s Letter to HHS Secretary Bocerra – accessed Nursingworld.org, August 23, 2022
4. “Pulse of the Nation’s Nurses Survey series on Mental Health and Wellness” at the two-year mark of the pandemic. American Nurses Foundation. Accessed via Nursingworld.org
5. “Pulse of the Nation’s Nurses Survey series on Mental Health and Wellness” June-July 2022. American Nurses Foundation. Accessed via Nursingworld.org
6. Nursing Solutions Inc. (NSI); National Health Care Retention & RN Staffing Report Published by: NSI Nursing Solutions, Inc. nsinursingsolutions.com. March 2022