Patient and medical facility operations are being strongly affected by the ongoing shortage of nurses. By the year 2025, the United States is projected to experience a nursing shortage of 260,000 Registered Nurses; this would be twice the magnitude of any nursing shortage experiences since the 1960’s.1 With over 3 million Registered Nurses in the United States making up the largest workforce of the healthcare industry, this growing supply cannot keep up with the demand of patients that need their care, due to:2
- The aging Baby-Boomer population will increase 75% to 69 million by the year 2030, with 1 in 5 U.S. Citizens being considered a senior citizen
- 2 out of every 3 Medicare beneficiaries have multiple chronic conditions, a number that will continue to climb in the coming decades
The passage of the Patient Protection and Affordable Care Act in 2010, resulting with the potential of more than 32 million Americans gaining access to healthcare services, including those provided by RNs and Advanced Practice Registered Nurses (APRNs), has resulted in additional demand.3
An Aging Workforce
The demographics of the aging of American citizenry is reflected in the Registered Nursing workforce as well. According to a 2013 survey conducted by the National Council of State Boards of Nursing, 55% of the RN workforce is age 50 or older, which will result in an ongoing decline of available nurses as more reach retirement age over the next decade.4 Projections show that more than 1 million Registered Nurses, or one-third of the entire nursing workforce, will reach retirement age within the next 10 to 15 years.5
Education Challenges
Over three out of every four physician prefer a Registered Nurse with a Bachelor’s Degree than those with an Associate’s Degree.6 However, the shortages discussed above also affect the educational institutions. In recent years, over 79,000 qualified nursing applicants have been turned away annually from baccalaureate and graduate nursing programs due to:
- Insufficient number of faculty
- Insufficient clinical sites
- Insufficient classroom space
- Insufficient clinical preceptors
- Budget constraints
In general, nearly two-thirds of the nursing school point to faculty shortages as a reason for not accepting all qualified applicants into their programs.7 While nursing enrollments have increased 2.6% per annum, this increase is not sufficient to meet the projected demand for nursing services.
Patient Affectations of the Nursing Shortage
The additional patient load on a nurse has been quantified in terms of patient well-being. For example, recent studies have proven that each additional patient per nurse on medical-surgical units was associated with a 5% lower likelihood of surviving an In-Hospital Cardiac Arrest (IHCA) to discharge. Furthermore, patients cared for in hospitals with high patient-to-nurse ratios had a 16% lower likelihood of IHCA survival in hospitals with better work environments.11 The patient-to-nurse ratio beyond cardiac events in terms of morbidity and the ability to rescue a patient in a crisis has also been shown to be directly correlated to staffing volume of nurses:12
Rate per 1,000 Patients Morbidity Rate Failure to Rescue
Average Number of Patients per Nurse = 4 18.2 per 1,000 79.5 per 1,000
Average Number of Patients per Nurse = 6 20.0 per 1,000 86.2 per 1,000
Average Number of Patients per Nurse = 8 22.0 per 1,000 93.4 per 1,000
Solutions to the Nursing Shortage
Given the projected nursing shortage, task shifting to overworked Registered Nurses creates unsafe patient care environments, especially in acute care hospitals. To avert this situation, Registered Nurses need the ability to be able to delegate to others, such as:
- LPNs
- Nursing assistants
- Community health workers
A transformed nursing education system that is able to respond to changes in science and contextual factors, such as population demographics, will be able to incorporate needed new skills and support full scopes of practice for non-APRNs to meet the needs of patients.13 However, legal enforcement can also bring this about beyond the delegation of some tasks, as has proven successful in California. In 2004, California became the first state to implement minimum nurse-to-patient staffing ratios. The ratios were designed to improve patient care, nurse retention, and working conditions for nurses by lowering the demands on an individual nurse. Subsequent studies have shown that safe-staffing ratios may be an effective way to combat nursing shortages and fill vacancies by attracting students to the profession and encouraging experienced nurses to return to the profession, in addition to saving lives. Soon after the nurse-to-patient ratio regulations went into effect in January 2004, the California Board of Nursing reported being inundated with RN applicants from other states. That year, applications for nursing licenses increased by more than 60 percent. By 2008, vacancies for Registered Nurses at California hospitals plummeted by 69%.14 Subsequent analyses of both nurses and nurse managers agreed that the ratio legislation achieved its goals of improving recruitment and retention of nurses, reducing nurse workloads, and improving the quality of care.15 These solutions prove that the shortage is not simply solved by hiring more nurses, but managing the crisis as a constraint of resources for the betterment of not only nurses and healthcare professionals, but most importantly, for their patients.
References
1 Beurhaus, P, et al, “The Recent Surge in Nurse Employment: Causes and Implications,” Health Affairs, July/August 2009.
2 Grant, Rebecca, “The U.S. is Running out of Nurses,” The Atlantic, February 3, 2016.
3,7“Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing,” American Association of Colleges of Nursing, 2012-2013.
4Jill S. Budden, PhD; Elizabeth H. Zhong, PhD; Patricia Moulton, PhD; and Jeannie P. Cimiotti, DNSc, RN, “Highlights of the National Workforce Survey of Registered Nurses,” Journal of Nursing Regulation, Volume 4, Issue 2, July 2013.
5The U.S. Nursing Workforce: Trends in Supply and Education, Health Resources and Services Administration, April 2013.
6 What is behind HRSA’s projected supply, demand, and shortage of registered nurses? Rockville, MD: HRSA, 2004.
7Raphael, Todd, “Nurse Turnover in Hospitals,” Eremedia, June 8, 2011.
8,9 “Nonfatal Occupational Injuries and Illnesses Requiring Days Away From Work, 2011,” U.S. Department of Labor, Bureau of Labor Statistics, 2012.
10 Linda Aiken, Sean Clarke, Douglas Sloane, Julie Sochalski, Jeffrey Silber; “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Satisfaction,” The Journal of the American Medical Association, Volume 288 (16), 2002.
11McHugh MD1, Rochman MF, Sloane DM, Berg RA, Mancini ME, Nadkarni VM, Merchant RM, Aiken LH; American Heart Association’s Get With The Guidelines-Resuscitation Investigators; “Better Nurse Staffing and Nurse Work Environments Associated With Increased Survival of In-Hospital Cardiac Arrest Patients.,” Medical Care, 2016 Jan;54(1):74-80.
12Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Robyn B. Cheung, PhD, RN; Douglas M. Sloane, PhD; Jeffrey H. Silber, MD, PhD, “Educational Levels of Hospital Nurses and Surgical Patient Mortality,” Journal of the American Medical Association, 2003;290(12):1617-1623.
13The Future of Nursing: Leading Change, Advancing Health, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine, The National Academies Press, Washington, D.C., October 5, 2010.
14 Robertson, Kathy, “Nurses (still) wanted,” Sacramento Business Journal, January 13, 2008.
15 Aiken, Linda, et al, “Implications of the California Nurse Staffing Mandate for Other States,” Health Services Research, Volume 45, Number 4, August, 2010.
