The Nursing Shortage in the United States
“During budget crunches, some organizations look at nurses as avoidable costs. We view nurses as cost avoiders.”
I applied to a nursing program nearly 10 years ago with the allure that there was an ongoing nursing shortage throughout the entire country. I was intrigued by the need for more candidates in the profession, the promise of job security, and the plethora of diverse career opportunities associated with nursing.
Little did I know that I would be plagued 10 years later by the same problem that drew me to the profession.
If you Google “nursing shortage,” you’ll find pages of articles, some published decades ago and others published just hours ago, all discussing and questioning the persistence of this problem. Some articles question the reality of a shortage, others pick apart root causes and even offer potential solutions. It kind of feels like this whole ‘nursing shortage’ is old news, so how do we change the story?
I learned early on that the only way to get answers is to ask questions. So I’ve done that. And no one really seems to be able to articulate what the actual issue is. So I decided to do my own research. And I have concluded that the problem does exist, is quite complex, and varies by city, state, care setting, and facility.
The real problem is that there isn’t just one problem.
So I’ve started with my own confirmed and lived problem.
Why are we consistently short staffed at a prestigious, nationally-ranked hospital in one of the highest ranked cities to live in, where nurses are compensated more than nearly any other city in the entire world?
I decided to put on my nursing cap (so to speak) and approach this in a way that I never thought I would voluntarily do again: through a nursing care plan with a problem-focused nursing diagnosis. Bear with me, it’s been awhile.
The Format for a Problem-Focused Diagnosis
Let’s start with the “problem” and what we already know:
(Problem) related to (related factors) as evidenced by (defining characteristics) == Nursing shortage related to (related factors) as evidenced by (defining characteristics)
Related Factors
Chronic Disease
The U.S. population is getting sicker and should it continue on its current blazing path, widespread chronic disease will require a great deal of medical attention across multiple care settings. This applies not only to the aging population, but to the pediatric population, as well. Diabetes, obesity, allergies, and respiratory conditions, to name a few, are becoming more prevalent earlier in life.
One in four Americans has multiple chronic conditions. This number rises to three in four Americans aged 65 and older.
Increasing Age of the Population
It is inevitable that people age but we’re now in a situation where a large percentage of the U.S. is reaching an age of retirement and health vulnerability. The aging population requires more medical attention at the same time that more of the nursing population is hitting retirement age.
The average age of a nurse in the U.S. is 47 years old. Roughly 10,000 Baby Boomers will turn 65 today, and about 10,000 more will cross that threshold every day for the next 19 years.
Recruiting & Hiring
Employers experience high costs and long times to fill open positions. The time to fill positions, from recognized need to job offer, varies from weeks to multiple months with most falling somewhere closer to the latter. Recruiters are expensive and agencies are often even more costly.
The average time to recruit an experienced RN ranged from 55 to 119 days depending on specialty. The current RN Recruitment Difficulty Index is 86 days, which is representative of the average time to fill an experienced nurse vacancy regardless of specialty.
Cost, Budgets, & Numbers
Today, staffing for the delivery of care by nurses is determined by numbers with budget being the main one.
Labor is a health facility’s largest expense at 60-70% of the entire budget.
Nursing specifically accounts for a huge chunk of that.
Nurses often aren’t considered “revenue generating employees.” Rather, they’re viewed as the opposite – a cost allocated to a room or a certain number of patients.
Nurses are considered a “cost.”
The inherent business model driven pressures within facilities to drive down “costs” is top-down from administration and only further perpetuates the issue.
There are various ways to determine budgeting for staffing nurses and fulfilling unit needs. It can be determined based on acuity, nurse-patient ratios, average daily census, midnight census, various analytics of historical data, hours per patient day (HPPD) or various formulas comprised of combinations of these methods.
Some people are quick to blame HPPD but the issue seems to be more in the inconsistency and validity of the resulting "formula."
The real problem is the rigidity within these numbers and targets. They fail to capture ever-changing acuity levels or the true unpredictability of a census. They’re too insensitive or inflexible to account for solutions to inevitables such as the nature of sickness, growth and expansion, maternity leave, floating, staff turnover, and unanticipated changes in acuity.
Staffing based on acuity tends to get hairy because it is often based on specific patient characteristics or diagnoses but ultimately ends up being too imprecise in terms of generalizing to the entire population of patients and can change rather rapidly. Some facilities have tried to account for this variability with per diem nurses, travel nurses, and on-call nurses, yet these temporary solutions are costly and thus not sustainable.
Lack of Nurses
Obviously, right? Yes, there is a sheer lack of nurses. There are fewer enrollments in nursing schools and thus fewer entering the workforce. But let me clarify, there is a lack of the right types of nurses in the right places.
- There’s an ongoing need for clinical instructors and nurse educators. Without them, the devastating lack of nurses is perpetuated.
According to the American Association of Colleges of Nursing, nursing schools turned away over 64,000 qualified applicants from baccalaureate and graduate nursing programs in 2016 due to factors related to an insufficient number of faculty and clinical preceptors.
- Nearly every nurse leader has spoken specifically to the severe shortage of critical care nurses. There are situations when there is an abundance of acute care nurses and a shortage within critical care, and sometimes vice versa. There’s only so much floating that can be done to alleviate this problem.
- Contingent nurses that can fill gaps related to the aforementioned inevitables (sicks calls, turnover, leaves of absence, etc.) are both scarce and underutilized. As is, they’re either too expensive, cumbersome to employ, or not easily identified.
- There are nurse deserts, or geographical nursing shortages, resulting from a scarcity of nurses in cities and regions that are not as highly compensated or deemed to provide a lower quality of life.
- Many top facilities now require their nurses to have a bachelor’s degree, making it nearly impossible for non-bachelor’s prepared nurses to find jobs as registered nurses. This requirement can also even inhibit experienced nurses from career progression or diversity. Earning a bachelor’s would require them to re-invest valuable time and money, which in some cases turns them away from nursing altogether. End result? Lack of educated nurses.
- As New Grads know very well, and I personally experienced, there is an ongoing lack of experienced nurses. The excitement and pride after passing the NCLEX is quickly dampened when New Grads learn how frustrating and rejecting the marketplace can feel without any “real” experience.
So what’s the big deal?
A lack of something isn’t always a bad thing. Why is the nursing shortage a real problem? Let’s take a look.
Defining Characteristics
A lack of nursing resources has a jenga-like effect.
Safety
Poor nurse staffing leads to poor outcomes. It’s far more cost effective to proactively staff ‘extra’ nurses than to pay for the cost of an adverse outcome, such as a hospital acquired pressure ulcer or an adverse event that ends in a costly settlement. Nurses are more likely to make errors when they are rushed, stressed, and overworked. These situations also cause delays in care which ultimately compromises patient safety.
“46.8 percent of all nurses made a medication error due to high patient to nurse ratios”.
Quality
When nurses are stretched thin, the quality of care that they can deliver is also stretched thin. And thin eventually tears. Decreased quality leads to poor patient satisfaction and outcomes. This affects the safety, budget, and health of our population. For example, if a nurse has decreased time and attention to dedicate to discharge teaching, the inadequate education can lead to poor medication compliance, missed follow-up, or even re-admission.
Retention & Job Satisfaction
A shortage of nurses is a vicious cycle. Nurse burnout ensues when units are consistently understaffed. Burnout in turn results in sick calls and turnover, which further perpetuates the issue. Nurses need to feel that their basic needs as caregivers are being met.
When these needs are met, then nurses are able to meet the complex needs of their patients. So how do we meet these needs? In the form of adequate staffing resources.
Every nurse knows all too well the frustrations of being short staffed. And as everyone knows, negative workplace reputations spread quickly. Nurses don’t want to work at a facility that isn’t committed to their success. A reputation for poor staff satisfaction can in turn make it difficult to both retain and hire nurses.
Currently, turnover for bedside RNs ranges from 4.6% to 26.4%. Based upon feedback, the average cost of turnover for a bedside RN increased by 2.6% to $49,200 and ranges from $38,900 to $59,700.
Decreased/Missed Revenue
The diversion of patients or cancelled procedures are obvious losses to revenue. Delays in discharges that could otherwise translate to admissions is a less obvious consideration. A reputation for long wait times, poor patient satisfaction, and related low quality care will also hurt the bottom line. Decreased revenue in turn results in tighter budgeting for staffing.
Population Health
Without sufficient nurses to care for the aforementioned aging and chronically ill population, the health of our entire nation will suffer. There really is not much more to say about this. Unless you’d be happy being cared for by either less-than-qualified or extremely expensive personnel.
Healthcare Costs
Nurses are more advantageous to employ than other clinicians because of the scope of what they can do and outcomes they can achieve at optimal price points. Nurses are dynamic, flexible, and capable of achieving 90% of all patient care requirements.
The nursing shortage is a multivariate problem that requires a comprehensive approach.
It would be unlikely that a lone intervention would have any sustainable effect on this problem. Rather, these solutions must be integrated and function in parallel.
Interventions & Solutions
Technology
Technology is weaved through every aspect of our lives. Every other industry leverages technology to decrease cost and friction and increase efficiency and experience. We can get food delivered, clothes dry-cleaned, a getaway booked, and dogs walked with the push of a button. Yet in healthcare we’re still using paper, pencils, whiteboards, people, fax machines, and push-button telephones where alternative technical solutions exist.
Healthcare delivery has the biggest need for this type of on-demand, real-time technology. Factors related to this nursing shortage can be alleviated or eliminated altogether by leveraging technical solutions.
- Workforce: If you can decrease the cost and time (which ultimately is a cost) to source and hire nurses, you save money.
Technology can help to optimize the already limited workforce and increase the capacity of what already exists. Most nurses work three days a week. And most nurses are also willing to pick up extra shifts as they fit into their schedules. Hospitals
If you can decrease the cost and time (which ultimately is a cost) to hire nurses, you save money. Savings can then be redistributed into budgeting for nurse staffing, employing digital platforms, and maintaining a flexible workforce. Technology, as mentioned above, is the driving force to achieving this.
- Digital platforms: can source these needs and serve nurses in a more efficient, timely, precise, and cost-effective manner than humans can. Hospitals don’t want to spend money on additional software. But this is a case of “you have to spend money to make (or save) money.” The cost is easily mitigated through increased staffing efficiency, maximization of resources, and reduction of nurse burnout.
- Transparency: Education/awareness of the professional potential within nursing – Many friends tell me that if they had known all of the potential career paths that a nurse has access to then they would have become nurses too.
- Flexibility: Give nurses flexibility – break down barriers to be able to work at different hospitals, easily pick up shifts, etc. Do we really need to be spending hours on duplicative modules and orientation? Nurses are all for safety, but there is definitely room for efficiency in safety and orientation.
Dr. Dan Weberg, Kaiser Permanente's former National Senior Director for Nursing Innovation and Leadership, is a big believer in the role of technology in the future of nursing and healthcare. He believes that everyday life is the new care setting, team are linked to people and populations (not hospitals or other care facilities), and personal health is enabled by technology:
"The legacy systems have failed to meet these evolving needs in a meaningful way, and thus consumers, students, tech giants, and others have seized the opportunity to apply their innovation skills to healthcare."
Perception
The perspective and perception of the nursing profession needs to change. Nurses need to be regarded as the revenue-generating, highly valuable professionals that they are. In this (overwhelmingly self-contained) game of healthcare, nurses are the key partners in achieving any success metric from quality care outcomes to revenue and everything in-between. Nurses need to be viewed and treated as true partners whose voices, ideas, and accomplishments directly contribute to the bottom line.
Not convinced that a perception shift can have much of an impact on this persisting problem?
Consider the story of one hospital that hasn’t been touched by the nursing shortage. Hackensack University Medical Center in New Jersey is like Silicon Valley during 2008. There has been a waiting list of nurses wanting to work there. What gives?
“We […] knew that the key to attracting and retaining nurses is regarding them as professional partners, and that has remained our philosophy over the years," says Toni Fiore, MA, RN, CNAA, executive VP for patient care and CNO. “We have never, ever cut a nursing position. During budget crunches, some organizations look at nurses as avoidable costs. We view nurses as cost avoiders.“
The proof is in the pudding: the hospital boasts a near 0 vacancy rate and a satisfaction rate among nurses in the 97th percentile.
Training
Inexperienced nurses are expensive but beyond valuable. Facilities experience a huge return on their investment in training new graduate nurses if they can manage retention. There needs to be more facilities that are stepping up to the plate to take on this responsibility.
The quicker nurses are learning through experience, the quicker they’re experienced and able to fill needs. Some facilities partner with institutions that conduct ‘transition to practice programs’ which decreases the cost to train for facilities and enables inexperienced nurses to position themselves better in a dense marketplace. Another emerging solution to training nurses is through technology: virtual reality and simulation labs enable nurses to learn more practical application and apply learning in real time.
Incentive:
It doesn’t come as a huge surprise that there is a lack of nurse educators. This isn’t specific to nursing, as it is also a persisting problem for education in general. Nurses need to feel motivated and incentivized to become nurse educators or clinical instructors. The perception of this role must be supported by its importance. Educators are shaping the future of our nation. They are responsible for educating and preparing our future workforce.This critical role needs to be reflected in compensation and career trajectory.
In addition to nurse educators, nurses need to be incentivized to commit to work in less dense or poorly compensated regions. The education sector achieves this through programs like Teach for America or Americorps. Some loan programs offer loan forgiveness if nurses commit to doing this, but it’s rather loose.
This is a complex problem with many interdependent solutions. One thing I am confident about is that change will come, nurses will be further empowered, and healthcare (as well as the health of the people of this world) will be better off because of it.
