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The Nursing Shortage Crisis in the United States: Implications and Solutions

Rachel Millard

Youngstown State University

NURS 6900: Healthcare Issues and Trends

Dr. Valerie O’Dell

October 28, 2022

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Abstract

The nursing shortage has been an ongoing issue in the American healthcare system for decades.

As medical and technological advancements take place and the demand for healthcare increases,

so does the need for more nurses. According to the U.S Bureau of Labor and Statistics (2022),

there are projected to be approximately 203,200 annual job openings for nurses between the

years 2021-2031. In this paper, the history and implications of the nursing shortage will be

examined. Causes of the nursing shortage have been linked to unsatisfied working conditions,

the aging population, the aging nurse workforce and the lack of nurse educators. This paper

investigates the consequences resulting from the nursing shortage and the potential solutions on

how to rectify it. The implications that were analyzed in this paper include patient safety,

burnout due to the changing roles of the professional nurse, the lack of nursing in the political

arena, economic ramifications and state policy changes. In conclusion, potential solutions to the

current nursing shortage crisis were identified such as re-designing the workplace, recruiting

nurse educators, providing greater educational opportunities and lobbying and advocating for

nursing and healthcare reform.

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The Nursing Shortage Crisis in the United States: Implications and Solutions

Nurses make up the largest section of healthcare professionals and are crucial to the

foundation and operation of our healthcare system. Currently, there are approximately 29 million

nurses and midwives worldwide. Of those 29 million nurses, 3.9 million reside in the United

States (Haddad et al., 2022). As medical advancements take place and the demand for healthcare

increases, so does the need for more nurses. The nursing shortage has been a continuing concern

within the American healthcare system for decades. The shortage was deemed a global nursing

crisis in 2002 and has only amplified within the past few years, especially since the beginning of

the COVID-19 pandemic (Nantsupawat & Turale, 2021). According to the US Bureau of Labor

Statistics (2022), there are to be a projected 203,200 average annual openings for registered

nurses between 2021 and 2031, with employment projected to grow about 6%.

Historically, the nursing shortage can be linked to unsatisfied working conditions, the

increasing elderly population, the aging registered nurse workforce and the lack of nurse

educators. Due to the lack of nurses, the American healthcare system and its patients have

suffered. As research emerged, it was evident that safe nurse-to-patient ratios were crucial to

patient safety (Huston, 2020). The nursing shortage continues to pose as a major threat to the

American healthcare system. Implications from the nursing shortage have impacted patient

safety, the role of the professional nurse, lack of nursing representation in the political arena,

economic hardships and policy changes (Huston, 2020). The healthcare system needs to focus on

how to retain nurses and encourage others to join the nursing workforce in order to sustain a

functional and safe environment for all.

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Historical Aspects of the Nursing Shortage

Understanding the history behind the causes of the nursing shortage will help

stakeholders identify and prioritize solutions. One of the most significant yet commonly

overlooked factors leading to the nursing shortage is job dissatisfaction. Registered nurses (RN)

are more likely to leave their place of employment and seek jobs elsewhere or leave the

profession completely due to job dissatisfaction (Huston, 2020). According to Park et al. (2016),

studies have found that intentions to leave an RN position often relate to the lack of managerial

support and unsafe staffing. Other factors that influence unsatisfied working conditions include

long shifts, low autonomy, mandatory overtime, working on holidays and weekends, insufficient

pay and the physical and mental strains associated with nursing (Huston, 2020). The COVID-19

pandemic only exacerbated these issues which steered more nurses to leave their jobs and the

nursing profession. Nurses have reported being discouraged and burnt out after a year of caring

for critically ill patients with COVID-19 and seeing many of them perish. On top of dealing with

COVID-19, nurses still had the usual caseloads of people needing interventions. While the

demanding nature of the RN role intensifies, more nurses are experiencing burnout and leaving

their job (Nantsupawat & Turale, 2021). The American Hospital Association reported that the

yearly national average turnover rate for nurses is at a staggering 18.7% (2022). Although job

dissatisfaction is one of the reasons nurses are leaving the profession, another is the aging

population and how it demands the need for more nursing care.

Haddad et al. (2022) states, “In 2029, the last of the baby boomer generation will reach

retirement age, resulting in a 73% increase in Americans 65 years of age and older” (para. 4).

Geriatric patients commonly have more than one comorbidity and usually require more

healthcare services. As medical advancements and technology develop, the geriatric population
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and life expectancy continue to grow. Currently, the United States has the highest number of

citizens who are older than 65 compared to any other time in history. Due to the population

surviving longer, more nurses are needed to deliver healthcare services (Haddad et al., 2022).

As the average age of the population continues to rise, so does the number of nurses

reaching retirement age each year. As a result, nurses will be retiring at a faster rate than they

can be replaced (Huston, 2020). According to Zhavoronkova et al. (2022), “The average nurse is

43.7 years old, up from 38.9 years old in 1978, and the proportion of nurses over age 55 has

increased from 13 percent of the nursing workforce to 23 percent” (para. 14). Within the next 10-

15 years about one-third of the working RN population will be at retirement age (The

Association of Colleges of Nursing, 2020). In addition, an even more senior population within

the nursing workforce are the nurse educators. The American Association of Colleges of Nursing

has reported the following statistics:

The average ages of doctorally-prepared nurse faculty holding the ranks of professor,

associate professor, and assistant professor were 62.6, 56.9, and 50.9 years. For master's

degree-prepared nurse faculty, the average ages for professors, associate professors, and

assistant professors were 57.1, 56.0, and 49.6 years (2020, para. 2).

By 2025, one-third of the current nursing faculty is expected to retire (The American

Association of Colleges of Nursing, 2020). Due to the large number of retiring nurses and

faculty shortages, nursing schools across the country are forced to limit student capacity (Huston,

2020). In 2019, 80,407 qualified applications from nursing programs across the country were

rejected due to an insufficient number of faculty, clinical sites, clinical preceptors, and budget

constrictions (American Association of Colleges of Nursing, 2020).

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Implications of the Nursing Shortage

One of the most significant implications that have resulted due to the nursing shortage is

the negative effect on patient safety. Without adequate staffing and no nationally mandated

nurse-to-patient ratios, nurses have been forced to take on more patients and increase their

workload. A study revealed that a patient’s risk of contracting a hospital-acquired infection

increased by 15% in facilities with low staffing levels compared to hospitals that had adequate

staffing (Shang et al., 2019). The American Association of Colleges of Nursing reported that

increasing a nurse's average workload by just one patient, resulted in a 7% increased risk of the

patient dying within 30 days of admission (2022). Due to nurses being overworked and

understaffed, medical errors and reduced quality of care pose a greater risk. Consequently, the

third leading cause of death in the United States is medical errors (The Global Patient Safety

Crisis, 2021). While patient safety has been compromised due to the nursing shortage, the role of

the nurse has also been affected.

Due to the nursing shortage, nursing responsibilities have altered throughout the years.

Hospitals across the country have been implementing mandatory overtime to try and rectify

staffing issues. Mandatory overtime can result in fatigue which leads to a multitude of negative

consequences. Occupational injury, illness, burnout, reduced quality of care and medical error

are potential outcomes due to the fatigue and burnout nurses experience (Huston, 2020).

Thompson et al. (2017) reports that nurses have one of the highest non-fatal injury rates of all

occupations which is a consequence of long work hours and demanding work conditions. Due to

poor working conditions and mandatory overtime, some nurses experience burnout and talk

negatively about nursing as a career. Many nurses report that they would not recommend the

profession to others because of the exhausting and demanding nature of the job (Huston, 2020).
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As more nurses become discouraged and leave the profession, the power and leadership of

nursing in politics suffer.

To make a difference in healthcare, nurses need to have representation in the political

arena. Inadequate representation in policy-making and reform negatively affects the power of the

nurse. Unfortunately, only about 17% of nurses in the United States belong to collective

bargaining units. Only 5.5% of nurses belong to the American Nurses Association, whose

mission is to protect and advance the nursing profession (Huston, 2020). Even before the

nursing shortage crisis, some nurses have looked at nursing as just a job and not a career. Some

nurses have little interest in professional issues outside of their working environment. With the

nursing shortage crisis and more nurses reporting burnout and lack of interest, there is an

increase in inadequate representation of nurses in policymaking and reform (Huston, 2020). Not

only is the nursing shortage affecting nursing leadership, but economic repercussions have also

taken a toll on the healthcare system.

Last year, the typical cost of turnover for an RN was estimated to be $46,100. This

resulted in the average hospital losing between $5,200,000 and $9,000,000 (Nursing Solutions

Inc., 2022). Within the past year, hospitals on average have lost 2.7% of their RN workforce.

Due to the national staffing shortage, hospitals have resorted to hiring supplemental staff such as

agency nurses and travel nurses, which can be costly. During the height of the pandemic,

hospitals were experiencing such critical staffing issues that they were offering travel nurses

hourly rates as high as $225 per hour. The average cost difference between a staff nurse and a

travel nurse is approximately $210,000. For every 20 travel nurse positions eliminated, hospitals

could save on average around $4,200,000 annually (Nursing Solutions Inc., 2022). Not only does

the nursing shortage affect the economy, but it forced some states to reform their legislature.
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In response to the COVID-19 pandemic and the rapidly growing nursing shortage crisis,

government action was needed to keep the healthcare system afloat. In May of 2021, the state of

Ohio passed House Bill 6, which gave temporary RN licenses to those who had not yet taken and

passed the National Council Licensure Examination for Registered Nurses (NCLEX). The law

required the Ohio Board of Nursing to issue a temporary license to those who had completed a

nursing education program. It was required that no more than two years could pass before

submitting the examination application. Other requirements included no previous NCLEX

failures, no criminal records and no failed drug tests. New hires only had until July 2021 to take

the NCLEX exam before their temporary license expired (Ohio Board of Nursing, 2021). Even

with temporary changes in legislation, more permanent solutions need to be addressed.

Proposal to Resolve

Although the nursing shortage is currently deemed as a healthcare crisis, there are ways

to rectify the situation. The need to encourage more young professionals to join the workforce is

crucial to compensate for the large number of nurses leaving the profession. Re-designing the

workplace, recruiting nurse educators, greater access to education, lobbying and advocating are

all ways to battle the nursing shortage.

Nursing can be mentally and physically draining. Re-designing the workplace is an

important factor in retaining nurses and trying to encourage others to join the profession. Huston

(2020) suggests using team lifts and specialty beds and equipment to decrease work-related

injuries. Leaders can implement other incentives such as empowering other nurses to create their

own schedules, benefits packages that recognize senior nurse leadership, implementing teaming

nursing, giving a monetary reward to nursing staff for mentoring new nurses and establishing

patient care models that encourage nurse autonomy (The 2021 American Nursing Shortage: A
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Data Study, 2021). Implementing changes like this can have a significant impact on employee

retention.

Encouraging higher education can also help retain nurses. Due to the lack of nurse

educators, nursing programs are forced to put a cap on how many students can be enrolled. By

offering fellowships or tuition forgiveness in exchange for teaching services, schools can not

only promote higher education but can also get more faculty in the classroom so more students

can be enrolled (Huston, 2020). Earlier this year, President Biden signed into law a COVID relief

package passed by Congress. This package was a direct response to the nursing shortage and

offered investments into the nursing workforce and nursing education. One major goal of this

relief package was to encourage more young professionals to enter the healthcare field. The

package offered $100,000,000 for state-run loan repayment programs which repay the loans of

registered nurses, advanced practice nurses and physicians. To be eligible for loan repayment,

one must agree to work for a set period of years in an area where there is a healthcare

professional shortage (Reinecke, 2022). Not only does this relief package help encourage more

healthcare professionals to seek higher education, but it then redistributes them to areas of need.

Lastly, lobbying and advocating is another great way to empower nurses. Having their

voices heard and getting involved can heavily influence change in the healthcare system (Huston,

2020). Nurses can offer insight into policy-making and use their professional knowledge to help

implement effective decision-making such as mandated nurse-to-patient ratios. All aspects of the

nursing profession are affected by policy issues including safety, quality, healthcare standards,

education and workforce conditions (Huston, 2020). Getting involved in committees at work and

through state and national associations is a great place to start when trying to become involved in

policy change and advocacy. Other ways nurses can have their voices heard is to participate in
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workforce planning surveys, data collection opportunities and join a professional organization. A

few organizations that specifically focus on nurse advocacy and health improvement are the

American Nurse Association, Sigma and the International Council of Nurses (Huston, 2020).

Conclusion

The nursing shortage has been an issue in our healthcare system for decades (Huston,

2020). Factors such as workplace dissatisfaction, the aging population, the aging RN workforce

and the lack of nurse educators have all contributed to the shortage. Patient safety concerns,

burnout due to the changing roles in the nursing profession, economic repercussions and policy

changes have followed due to the lack of nurses. To rectify the situation, legislators and policy-

makers must focus on encouraging others to join the healthcare profession. Re-designing the

workplace and providing educational opportunities such as offering fellowships or tuition

forgiveness in exchange for teaching services are some ways to help incentivize nurses to stay in

the profession and encourage others to join (Huston, 2020). Getting involved in professional

nursing organizations that promote nurse advocacy and better health for all will help give power

back to the nurse and encourage policy change and healthcare reform. The nursing shortage is a

major issue in today's healthcare, but if nurses band together and make their voices heard, change

can be achieved.
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