The country has experienced nursing shortages for decades, but an aging population means the problem is about to get much worse, writes Rebecca Grant on the Atlantic. Read on:
Five years ago, my mother was rushed to the hospital for an aneurysm. For the next two weeks, my family and I sat huddled around her bed in the intensive-care unit, oscillating between panic, fear, uncertainty, and exhaustion.
It was nurses that got us through that time with our sanity intact. Nurses checked on my mother—and us—multiple times an hour. They ran tests, updated charts, and changed IVs; they made us laugh, allayed our concerns, and thought about our comfort. The doctors came in every now and then, but the calm dedication of the nurses was what kept us together. Without them, we would have fallen apart.
Which is just one reason why the prospect of a national nursing shortage is so alarming. The U.S. has been dealing with a nursing deficit of varying degrees for decades, but today—due to an aging population, the rising incidence of chronic disease, an aging nursing workforce, and the limited capacity of nursing schools—this shortage is on the cusp of becoming a crisis, one with worrying implications for patients and health-care providers alike.
America’s 3 million nurses make up the largest segment of the health-care workforce in the U.S., and nursing is currently one of the fastest-growing occupations in the country. Despite that growth, demand is outpacing supply. According to the Bureau of Labor Statistics, 1.2 million vacancies will emerge for registered nurses between 2014 and 2022.* By 2025, the shortfall is expected to be “more than twice as large as any nurse shortage experienced since the introduction of Medicare and Medicaid in the mid-1960s,” a team of Vanderbilt University nursing researchers wrote in a 2009 paper on the issue.
The primary driving force in this looming crisis is the aging of the Baby Boomer generation: Today, there are more Americans over the age of 65 than at any other time in U.S. history. Between 2010 and 2030, the population of senior citizens will increase by 75 percent to 69 million, meaning one in five Americans will be a senior citizen; in 2050, an estimated 88.5 million people in the U.S. will be aged 65 and older.
And as the population ages, demand for health-care services will soar. About 80 percent of older adults have at least one chronic condition, and 68 percent have at least two, according to the National Council on Aging. A USA Today analysis of Medicare data revealed that two-thirds of traditional Medicare beneficiaries older than 65 have multiple chronic conditions, a number that will only continue to climb.
“The aging population and chronic disease are creating the perfect storm driving demand for nurses.”
“People with chronic diseases clearly use more health-care services, and people who are older have more chronic disease,” said Julie Sochalski, an associate professor at the University of Pennsylvania School of Nursing. “The aging population and chronic disease are creating the perfect storm driving demand for nurses.”
But swelling demand is only part of the problem. Like the patients they serve, the country’s nurses are also aging. Around a million registered nurses (RNs) are currently older than 50, meaning one-third of the current nursing workforce will reach retirement age in the next 10 to 15 years. Nearly 700,000 nurses are projected to retire or leave the labor force by 2024.*
“The biggest cohort of registered nurses joined the workforce before the 1970s,” when career choices for women were more limited, said Pam Cipriano, the president of the American Nurses Association (nursing is still overwhelmingly female). As a result, the field now skews older.
“Many nurses held off retiring during the downturn in the economy, she added, “but now the retirements are starting.”
Filling the vacancies left by retiring nurses isn’t a simple one-for-one proposition.
But filling the vacancies left by retiring nurses isn’t a simple one-for-one proposition. Nearly 155,000 new nursing graduates entered the workforce in 2015.* While the number of new nursing students and graduates is growing, the nursing-education system hasn’t kept pace, effectively creating a bottleneck in which only so many aspiring nurses can access the training they need. According to an American Association of Colleges of Nursing report, “U.S. nursing schools turned away 79,659 qualified applicants from baccalaureate and graduate nursing programs in 2012 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.” Once again, aging is a factor: Many nursing faculty members are approaching retirement, but without them, nursing schools can’t expand their cohorts.
“As those numbers [of nurse educators] drop, schools have to maintain critical student- to-teacher ratios,” Cipriano said. “Preparation for most nurse faculty is a doctoral degree, and you can’t just replace someone in that position. The trajectory of timeline to fill jobs that nurse faculty are retiring from is much longer.”
In many areas, the barrier to entry isn’t nursing school, but the training that comes afterwards. Sochalski said that where she works in Philadelphia, there are a handful of nursing schools, but a limited number of hospitals and clinics, meaning a limited number of clinical places where fledgling nurses can gain practical experience.
Many health-care providers also shy away from recruiting these newer nurses, Cipriano explained. “When we think about nurses replacing retiring nurses, there is an experience gap,” she said. “People like me who have 40 years of experience will be replaced by individuals with three to five years of experience. Employers need to focus on the fact that they have a responsibility and a burden to ensure that new nurses can maintain expertise and wisdom at a patient's side.”
* * *
It seems as though every expert, group, or academic study has a different take on just how dire the nursing shortage will become. Ed Salsberg, a researcher at the George Washington University School of Nursing who studies nursing-workforce issues, said the country’s evolving health-care system is one variable that may affect projections.
“The health-care delivery system has put in a lot of effort to make the system more efficient and effective, to reduce unnecessary use of health-care services and reduce hospital readmissions,” Salsburg said. “We don’t know for sure whether this is going to increase or decrease demand for nurses. It’s one of the big questions as we look towards the future.” Thus far, he explained, the Affordable Care Act has not contributed significantly to the rising demand for nursing services, because most people newly insured under the ACA skew young and healthy.
To Salsburg, America is not facing a national nursing shortage so much as grappling with a “problem of distribution”—some health-care markets in the U.S. have a plentiful supply of nurses, with other regions feeling the scarcity more acutely.
“Lo and behold, for the past 20 to 30 years, California has only produced 50 percent of the nurses it needed.”
In a 2012 paper titled “United States Registered Nurse Workforce Report Card and Shortage Forecast,” researchers forecasted RN job shortages in each state and assigned a letter grade accordingly. They predicted that the number of states meeting the criteria for a “D” or “F” will increase from five in 2009 to 30 by 2030. All 12 states projected to receive an F are in the South and the West: Florida, Georgia, Texas, Virginia, Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, and New Mexico.
Vernon Lin, one of the authors of this study and a professor at the Cleveland Clinic Lerner College of Medicine, said he has experienced the nursing shortage throughout his career, across states and healthcare systems.
“When I was working in Long Beach, we had over 20 nursing vacancies at any one time. And this was in sunny southern California, close to the beach, for a job with federal-government benefits,” Lin said. “I began to look into the situation and, lo and behold, for the past 20 to 30 years, California has only produced 50 percent of the nurses it needed.”
Like unhappy families, each shortage pocket is unique. In states like Florida and Arizona, the aging population is the real culprit; in other states, the gap is largely due to a limited number of nurse-education opportunities. Lin said that nursing supply is “mostly local,” meaning nurses tend to stay in the same markets where they go to school. Fewer schools means fewer nurses. Unsurprisingly, rural and poorer areas have a harder time recruiting nurses than urban magnet hospitals, which can offer higher-paying jobs and lifestyle perks.
The Rapid City Regional Hospital in South Dakota recently began closing beds due to a shortage of experienced RNs. Lori Wightman, the newly hired chief of nursing for the Regional Health System, said the number of closed beds at RCRH adjusts day to day, based on the number of nurses available for each shift.
“Closing beds really is a last resort,” Wightman said. “The first thing we have to consider is patient safety. There are standards of practice for what nurse-to-patient ratios should be.”
Those standards can represent the difference between life and death. When nurses are stretched too thin, they have less time and energy to devote to each patient. Overworking leads to fatigue and burnout, which threatens the quality of care and increases the incidence of error. Past research has found links between insufficient nursing staffing and higher rates of hospital readmission and patient mortality. Higher patient loads are also linked to higher rates of nurse turnover, which can costly, disruptive, and potentially harmful to patient safety. Conversely, more and happier nurses can mean better care and better outcomes.
When facing a nursing shortage, hospitals have a handful of options beyond closing beds.
When facing a nursing shortage, hospitals have a handful of options beyond closing beds. They can ask their nurses to work more hours or offer financial incentives for those who pick up extra shifts, though for the reasons outlined above, this may not be a safe option. Many hospitals offer financial incentives to nurses who work additional shifts. Some companies also rely on temporary “travel nurses” who typically work for around 13 weeks at a time, but they come at a premium.
“Now nurses can move all over the country because of demand, and our job is to show them what a great place [South Dakota] is to work,” Wightman said.
Beyond a good salary, strong cultural fit, flexible hours, and manageable expectations, Wightman said nurses also want to work in places where they can practice to the full scope of their license. Each state has different guidelines for what each type of license allows a nurse to do. For example, nurse practitioners are more limited in in South Dakota than in some neighboring states, and may choose not to take a job in South Dakota as a result. Wightman said national licensure for nurses, Wightman believes, would make it easier to address deficits.
Another long-term strategy is to open up the paths to a degree. In the Institute of Medicine’s “The Future of Nursing” report, the authors recommended that nurses should achieve higher levels of education and training, and called for the proportion of nurses with baccalaureate degrees to increase to 80 percent by 2020. While it would seem that more highly educated nurses is something to strive for, Salsburg said this could potentially exacerbate shortages. Many aspiring nurses, particularly those in rural and poorer areas, enter the field with an associate's degree and pursue an advanced degree later. Given that nurses tend to stay local, providing viable educational opportunities in these communities is key.
Other strategies to address the nursing shortage include incentives for nurses to become nurse educators.
“We don't want to cut off access to education in rural communities where, in many cases, an associate's degree in nursing is the only local nursing education opportunity,” Salsburg said. “The associate’s degree has to be seen as a pathway to nursing.”
Other strategies to address the nursing shortage have included public-private partnerships and incentives for nurses to become nurse educators. Johnson & Johnson recently launched the Campaign for Nursing’s Future, an effort that uses TV commercials, videos, a website, and brochures to tout the benefits of “this rich and rewarding career.” And two years ago, the University of Wisconsin (UW) announced the $3.2 million initiative to provide fellowships and loan forgiveness for nurses who agree to teach in the state after graduation from nursing school.
Cipriano said the American Nurses Association is currently lobbying Congress to increase funding for Title VIII of the Public Health Service Act. The provision allots federal grants for nursing schools and organizations to advance their educational programs, promote diversity in the field, repay loans for nursing students who work in facilities with critical shortages, train geriatric nurses, and more.
“We saw this money reduced by $2.15 million this year, and when you adjust for inflation, we’ve seen a 30 percent decline in that money since 1971,” she said. “To maintain our supply and the pipeline, Title VIII is critical.” But even as the threat of a more severe shortage looms, an increase in funding remains uncertain. The only certainty, in fact, is this: There will always be a need for nurses, the medical professionals that make otherwise harrowing experiences bearable for patients and their families.
Five years ago, my mother was rushed to the hospital for an aneurysm. For the next two weeks, my family and I sat huddled around her bed in the intensive-care unit, oscillating between panic, fear, uncertainty, and exhaustion.
It was nurses that got us through that time with our sanity intact. Nurses checked on my mother—and us—multiple times an hour. They ran tests, updated charts, and changed IVs; they made us laugh, allayed our concerns, and thought about our comfort. The doctors came in every now and then, but the calm dedication of the nurses was what kept us together. Without them, we would have fallen apart.
Which is just one reason why the prospect of a national nursing shortage is so alarming. The U.S. has been dealing with a nursing deficit of varying degrees for decades, but today—due to an aging population, the rising incidence of chronic disease, an aging nursing workforce, and the limited capacity of nursing schools—this shortage is on the cusp of becoming a crisis, one with worrying implications for patients and health-care providers alike.
America’s 3 million nurses make up the largest segment of the health-care workforce in the U.S., and nursing is currently one of the fastest-growing occupations in the country. Despite that growth, demand is outpacing supply. According to the Bureau of Labor Statistics, 1.2 million vacancies will emerge for registered nurses between 2014 and 2022.* By 2025, the shortfall is expected to be “more than twice as large as any nurse shortage experienced since the introduction of Medicare and Medicaid in the mid-1960s,” a team of Vanderbilt University nursing researchers wrote in a 2009 paper on the issue.
The primary driving force in this looming crisis is the aging of the Baby Boomer generation: Today, there are more Americans over the age of 65 than at any other time in U.S. history. Between 2010 and 2030, the population of senior citizens will increase by 75 percent to 69 million, meaning one in five Americans will be a senior citizen; in 2050, an estimated 88.5 million people in the U.S. will be aged 65 and older.
And as the population ages, demand for health-care services will soar. About 80 percent of older adults have at least one chronic condition, and 68 percent have at least two, according to the National Council on Aging. A USA Today analysis of Medicare data revealed that two-thirds of traditional Medicare beneficiaries older than 65 have multiple chronic conditions, a number that will only continue to climb.
“The aging population and chronic disease are creating the perfect storm driving demand for nurses.”
“People with chronic diseases clearly use more health-care services, and people who are older have more chronic disease,” said Julie Sochalski, an associate professor at the University of Pennsylvania School of Nursing. “The aging population and chronic disease are creating the perfect storm driving demand for nurses.”
But swelling demand is only part of the problem. Like the patients they serve, the country’s nurses are also aging. Around a million registered nurses (RNs) are currently older than 50, meaning one-third of the current nursing workforce will reach retirement age in the next 10 to 15 years. Nearly 700,000 nurses are projected to retire or leave the labor force by 2024.*
“The biggest cohort of registered nurses joined the workforce before the 1970s,” when career choices for women were more limited, said Pam Cipriano, the president of the American Nurses Association (nursing is still overwhelmingly female). As a result, the field now skews older.
“Many nurses held off retiring during the downturn in the economy, she added, “but now the retirements are starting.”
Filling the vacancies left by retiring nurses isn’t a simple one-for-one proposition.
But filling the vacancies left by retiring nurses isn’t a simple one-for-one proposition. Nearly 155,000 new nursing graduates entered the workforce in 2015.* While the number of new nursing students and graduates is growing, the nursing-education system hasn’t kept pace, effectively creating a bottleneck in which only so many aspiring nurses can access the training they need. According to an American Association of Colleges of Nursing report, “U.S. nursing schools turned away 79,659 qualified applicants from baccalaureate and graduate nursing programs in 2012 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.” Once again, aging is a factor: Many nursing faculty members are approaching retirement, but without them, nursing schools can’t expand their cohorts.
“As those numbers [of nurse educators] drop, schools have to maintain critical student- to-teacher ratios,” Cipriano said. “Preparation for most nurse faculty is a doctoral degree, and you can’t just replace someone in that position. The trajectory of timeline to fill jobs that nurse faculty are retiring from is much longer.”
In many areas, the barrier to entry isn’t nursing school, but the training that comes afterwards. Sochalski said that where she works in Philadelphia, there are a handful of nursing schools, but a limited number of hospitals and clinics, meaning a limited number of clinical places where fledgling nurses can gain practical experience.
Many health-care providers also shy away from recruiting these newer nurses, Cipriano explained. “When we think about nurses replacing retiring nurses, there is an experience gap,” she said. “People like me who have 40 years of experience will be replaced by individuals with three to five years of experience. Employers need to focus on the fact that they have a responsibility and a burden to ensure that new nurses can maintain expertise and wisdom at a patient's side.”
* * *
It seems as though every expert, group, or academic study has a different take on just how dire the nursing shortage will become. Ed Salsberg, a researcher at the George Washington University School of Nursing who studies nursing-workforce issues, said the country’s evolving health-care system is one variable that may affect projections.
“The health-care delivery system has put in a lot of effort to make the system more efficient and effective, to reduce unnecessary use of health-care services and reduce hospital readmissions,” Salsburg said. “We don’t know for sure whether this is going to increase or decrease demand for nurses. It’s one of the big questions as we look towards the future.” Thus far, he explained, the Affordable Care Act has not contributed significantly to the rising demand for nursing services, because most people newly insured under the ACA skew young and healthy.
To Salsburg, America is not facing a national nursing shortage so much as grappling with a “problem of distribution”—some health-care markets in the U.S. have a plentiful supply of nurses, with other regions feeling the scarcity more acutely.
“Lo and behold, for the past 20 to 30 years, California has only produced 50 percent of the nurses it needed.”
In a 2012 paper titled “United States Registered Nurse Workforce Report Card and Shortage Forecast,” researchers forecasted RN job shortages in each state and assigned a letter grade accordingly. They predicted that the number of states meeting the criteria for a “D” or “F” will increase from five in 2009 to 30 by 2030. All 12 states projected to receive an F are in the South and the West: Florida, Georgia, Texas, Virginia, Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, and New Mexico.
Vernon Lin, one of the authors of this study and a professor at the Cleveland Clinic Lerner College of Medicine, said he has experienced the nursing shortage throughout his career, across states and healthcare systems.
“When I was working in Long Beach, we had over 20 nursing vacancies at any one time. And this was in sunny southern California, close to the beach, for a job with federal-government benefits,” Lin said. “I began to look into the situation and, lo and behold, for the past 20 to 30 years, California has only produced 50 percent of the nurses it needed.”
 | ||
| A nurse checks on an infant in the neonatal intensive-care unit of the Holtz Children's Hospital in Miami. |
Like unhappy families, each shortage pocket is unique. In states like Florida and Arizona, the aging population is the real culprit; in other states, the gap is largely due to a limited number of nurse-education opportunities. Lin said that nursing supply is “mostly local,” meaning nurses tend to stay in the same markets where they go to school. Fewer schools means fewer nurses. Unsurprisingly, rural and poorer areas have a harder time recruiting nurses than urban magnet hospitals, which can offer higher-paying jobs and lifestyle perks.
The Rapid City Regional Hospital in South Dakota recently began closing beds due to a shortage of experienced RNs. Lori Wightman, the newly hired chief of nursing for the Regional Health System, said the number of closed beds at RCRH adjusts day to day, based on the number of nurses available for each shift.
“Closing beds really is a last resort,” Wightman said. “The first thing we have to consider is patient safety. There are standards of practice for what nurse-to-patient ratios should be.”
Those standards can represent the difference between life and death. When nurses are stretched too thin, they have less time and energy to devote to each patient. Overworking leads to fatigue and burnout, which threatens the quality of care and increases the incidence of error. Past research has found links between insufficient nursing staffing and higher rates of hospital readmission and patient mortality. Higher patient loads are also linked to higher rates of nurse turnover, which can costly, disruptive, and potentially harmful to patient safety. Conversely, more and happier nurses can mean better care and better outcomes.
When facing a nursing shortage, hospitals have a handful of options beyond closing beds.
When facing a nursing shortage, hospitals have a handful of options beyond closing beds. They can ask their nurses to work more hours or offer financial incentives for those who pick up extra shifts, though for the reasons outlined above, this may not be a safe option. Many hospitals offer financial incentives to nurses who work additional shifts. Some companies also rely on temporary “travel nurses” who typically work for around 13 weeks at a time, but they come at a premium.
“Now nurses can move all over the country because of demand, and our job is to show them what a great place [South Dakota] is to work,” Wightman said.
Beyond a good salary, strong cultural fit, flexible hours, and manageable expectations, Wightman said nurses also want to work in places where they can practice to the full scope of their license. Each state has different guidelines for what each type of license allows a nurse to do. For example, nurse practitioners are more limited in in South Dakota than in some neighboring states, and may choose not to take a job in South Dakota as a result. Wightman said national licensure for nurses, Wightman believes, would make it easier to address deficits.
Another long-term strategy is to open up the paths to a degree. In the Institute of Medicine’s “The Future of Nursing” report, the authors recommended that nurses should achieve higher levels of education and training, and called for the proportion of nurses with baccalaureate degrees to increase to 80 percent by 2020. While it would seem that more highly educated nurses is something to strive for, Salsburg said this could potentially exacerbate shortages. Many aspiring nurses, particularly those in rural and poorer areas, enter the field with an associate's degree and pursue an advanced degree later. Given that nurses tend to stay local, providing viable educational opportunities in these communities is key.
Other strategies to address the nursing shortage include incentives for nurses to become nurse educators.
“We don't want to cut off access to education in rural communities where, in many cases, an associate's degree in nursing is the only local nursing education opportunity,” Salsburg said. “The associate’s degree has to be seen as a pathway to nursing.”
Other strategies to address the nursing shortage have included public-private partnerships and incentives for nurses to become nurse educators. Johnson & Johnson recently launched the Campaign for Nursing’s Future, an effort that uses TV commercials, videos, a website, and brochures to tout the benefits of “this rich and rewarding career.” And two years ago, the University of Wisconsin (UW) announced the $3.2 million initiative to provide fellowships and loan forgiveness for nurses who agree to teach in the state after graduation from nursing school.
Cipriano said the American Nurses Association is currently lobbying Congress to increase funding for Title VIII of the Public Health Service Act. The provision allots federal grants for nursing schools and organizations to advance their educational programs, promote diversity in the field, repay loans for nursing students who work in facilities with critical shortages, train geriatric nurses, and more.
“We saw this money reduced by $2.15 million this year, and when you adjust for inflation, we’ve seen a 30 percent decline in that money since 1971,” she said. “To maintain our supply and the pipeline, Title VIII is critical.” But even as the threat of a more severe shortage looms, an increase in funding remains uncertain. The only certainty, in fact, is this: There will always be a need for nurses, the medical professionals that make otherwise harrowing experiences bearable for patients and their families.
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