Nursing Shortage 1

Running Head: NURSING SHORTAGE

Power to Heal: The Impending Nursing Shortage and How to Resolve It

Hannah N. Charleston

Glen Allen High School

Introduction

The career of nursing has often been swept to the side as a primarily feminine profession,

but with the shortage of nursing occurring, everyone and anyone is needed. Despite being one of

the fastest-growing occupations in the country, with “3 million nurses [making] up the largest

segment of the health-care workforce,” supply is not meeting the demand (Grant 2016). It is

believed that a culmination of problems are coinciding to create the nursing shortage: aging

population, limitations placed on nursing schools, lack of benefits coupled with poor working

environment. Hospitals are having to turn people away and close hospital beds due to lack of

staffing of nurses. The Baby Boomer’s make up the majority of the nurses, meaning they are

reaching retirement age. While it makes the most sense to hire new nurses to replace the old

ones, hospitals are not hiring because they believe it is costing them more, when in reality nurse

turnover is costing hospitals $4.9 to $7.6 million per year (Snavely 2006). If not addressed, the

impending crisis will become a reality. If America wants to maintain their status of having a top-

quality healthcare system, the training of high-performing, high-quality, and highly

compassionate nurses is essential. In this review, the causes of the nursing shortage, as well as

the negative repercussions, are investigated to determine what possible solutions should be made

to make a strong step forward in solving the crisis. Without recognizing the causes of the

impending shortage, the impacts of this on both patients and nurses, and finding effective ways

to solve the issue, the crisis will become a reality.

Implications of the Aging Population

The primary factor contributing to the nursing shortage is the aging of the Baby Boomer

generation. By 2030, it is predicted that there will be a 75 percent increase in the amount of

senior citizens in the United States to 69 million total (Grant, 2016). It will continue to grow as

the elderly population is predicted to “double by 2050, while the working aged class is predicted

to decrease” (Snavely, 2006). With age, comes greater demand for health services and more

reliance on Medicare. “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 (Grant, 2016). The

Affordable Care Act, which expands affordable Medicaid coverage to millions of low-income

Americans, further contributes to the crisis. It has caused more the 8 million more people to be

eligible for health insurance. While this isn’t an entirely bad thing or a predictor of the actual

amount of people that will need health services, it just adds further strain on the health care

system with millions of newly insured patients that may need care (Jacobson, 2015). Along with

the patients, the nurses are aging too. The National Council of State Boards of Nursing reports

that 55% of the RN workforce, alone, is aged 50 or older, resulting in one million nurses being

eligible to retire in 10-15 years (Snavely, 2006). With the retirement of aging baby boomers, who

“comprise 40% of the current total health care workforce,” not just nurses, there will be a

dramatic reduction in RN supply” across the nation (Juraschek, 2012).

What is Happening in the Nursing Schools?

While filling in the spots of the nurses that are retiring may seem simple, the nursing-

education system can’t keep up with the growing demand of the field. “At the beginning of the

2014-2015 academic year, over half of all U.S. nursing schools reported a cumulative total of

1,236 full-time faculty vacancies” (Snavely, 2006). Due to understaffing, insufficient number of
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clinical sites, lack of classroom space, and budget constraints, “U.S. nursing schools [had to turn]

away 79,659 qualified applicants from baccalaureate and graduate nursing programs in 2012

(Grant, 2016). Furthermore, nursing school faculty members are reaching retirement age, thus

reaping the consequences of the aging Baby Boomer population, just like their patients.

Impacts of Nurse-to-Patient Ratios

When nurses have too many patients to tend to, they have less time and energy to devote

to each individual patient, which often means life or death. It is found that “when staffing levels

fall below certain nurse-to-patient ratios, the patients are more likely to suffer or even die”

(Jacobson, 2015). For example, Bonnie Castillo, the director of the Registered Nurses Response

Network at National Nurses United, stated that “If you have several patients, and one is having a

sudden hemorrhage and one is having chest pain and the other is having a stroke or is choking,

you have to have enough nurses that can deal with each of those instances and not place one

above the other” (Jacobson, 2015). It is well known in any career that “overworking leads to

fatigue and burnout, which threatens the quality of care and increases the incidence of error”

(Grant, 2016), but in the medical field, this fatigue can be life-threatening. In a study this March

in Critical Care Medicine, a diverse group of hospitals worldwide were compared, and it was

found that a higher nurse-to-patient ratio correlated with higher patient deaths in intensive care

units. When nurse staffing is inadequate, their ethicality is brought into question, as the higher

workload and stress a nurse is under, the quality of the care goes down (Martin, 2015). Misuse

and misdistribution of nurses become evident through reduced quality of care, poorer patient

outcomes, reduced job satisfaction, high staff turnover rates, and increased care costs (Oulton,

2006).
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Impacts of Nurse-to-Patient Ratios on Patients

One study reported hospitals with inadequate staffing are positively correlated with

higher readmission rates. Hospital readmission costs the Center for Medicare and Medicaid

Service approximately $26 billion per year (Snavely, 2006). High nurse-to-patient ratio is

directly with disease like an increased risk of urinary tract and surgical site infections (Snavely,

2006). More infections that have a positive correlation with nurse-to-patient ratio include

ventilator-associated pneumonia, centralline-associated bloodstream infection, and Clostridium

difficile infection (Snavely, 2006). Additionally, a study published in The Lancet in 2014 found

that an increase in a nurse’s workload by one patient increased the likelihood of a patient in that

hospital dying by 7 percent (Jacobson, 2015). When it is found that “lower registered nurse-to-

patient ratios are shown to reduce mortality rate by more than 50%” (Martin, 2015), progress

should be made in regards to health standards.

Reasons for Leaving the Workforce

The stress, uneven sleeping patterns, high nurse-to-patient ratios, and the heavy workload

is causing nurses to leave the practice at higher rates than ever. Research has found that “an

estimated 30%-50% of all new RNs either change jobs within nursing or leave the profession

altogether within the first 3 years of clinical practice” (Snavely, 2006), due to the lack of access

to continuing education, the lack of professional development, the stress, the workplace

environment, the bullying, and the harassment. An overarching factor was a universal lack of

feeling valued for their services. The absence of appreciation leads to 41% of hospital nurses

being dissatisfied with their jobs with 22% planning to leave their career in less than a year

(Outlon, 2006). Unsurprisingly, with nurses younger than 30, the percentage that plan to leave

the workforce skyrocketed to 33%. A big part of the increasing interest in nursing and other
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healthcare careers is millennials’ desire to do work that is meaningful. And in order to stay

motivated in a career, one must feel like the work they are doing is challenging them enough that

they feel they are learning something, and that that something is positively contributing to

society; which is exactly what nursing provides for the coming generation. Unfortunately, nurses

are leaving the workforce due to a lack of learning from their job.

Unforeseen Economic Obstacles

As stated above, even though hospitals and other health-care facilities are aware of the

impending crisis, these employers are hesitant to hire new nurses because of apparent cost and

the experience gap. A nurse with over 40 years of experience leaves and then has to be replaced

with a nurse that may have only 5 years of experience, which causes nervousness, but employers

needs to see the big picture and understand that they have a responsibility to maintain a strong

health-care system and that can’t be done without nurses (Grant, 2016). It may sound simple to

just hire more nurses to replace the nurses that are leaving, but hospitals are not hiring due to the

perceived cost of hiring, when really “the average cost of turnover for a bedside RN ranges from

$36,900 to $57,300 resulting in the average hospital losing $4.9M-$7.6M” (Snavely, 2006).

Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University

of Pennsylvania, has discovered that “hospital administrators are reluctant to hire more nurses

because it is not seen as cost-effective.” When really, the budget problems are coming from

patients returning to the hospital with postsurgical infections and complications due to the lack of

nurses (Jacobson, 2015). Hospital systems like J.W. Ruby Memorial Hospital in Morganstown,

West Virginia is paying more than $10 million annually to hire and retain new nurses

(MacDonald, 2017). Because it is difficult to hire nurses to work in high-need areas, healthcare

organizations are paying $4.8 billion in total towards travel nurses (MacDonald, 2017).
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Regional Differences

The shortage is getting worse due to the migration of nurses away from high-need areas,

in search of better working conditions and quality of life. For example, Zimbabwe, a developing

country, has enough money to hire approximately 2,000 nurses, but nurses are unwilling to work

there due to the poor working conditions. Additionally, in Malawi there are 30 nurses per every

1,000 hospital beds and in Uganda, there are 1 to 2 for every 100 patients (Oulton, 2006). While

comparing the United States nursing shortage to developing African countries appears to be

extreme, the same ideals are reflected in the differences between the rural and urban areas of this

country. Expectedly, very poor and rural areas have a much harder time recruiting new nurses as

opposed to big, urban hospitals that can provide more benefits both inside and outside of work.

In summary, when nurses don’t feel like that they work they do is valued or they don’t have a

vast range of opportunities or the right resources to expand their knowledge, they leave the

profession and choose not to go to the areas that need the most help, thus making the shortage

worse.

Case Studies

In a report completed by Stephen Juraschek and his team of researchers created a grading

scale for states and their projected nursing shortage by 2030. They based their case off of data

from the Centers for Medicare and Medicaid Services and the U.S. Census Bureau to create the

demand model and the supply model was created on the assumption that the propensity for

individuals to choose a career in nursing to remain constant. Then, based on the difference

between the demand and supply of RN jobs per 100,000 people each state was given a letter

grade based on the difference between the national mean and each state’s ratio.
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The average national grade is 2.21 in 2009 and 1.13 in 2030” (Juraschek, 2012). All of

the states projected to get an “F” are all in the South or West of the United States. The 12 “F”

states are Florida, Georgia, Texas, Virginia, Alaska, Arizona, California, Hawaii, Idaho,

Montana, Nevada, and New Mexico (Juraschek, 2012). “In 2030, states with the largest
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shortages (ie, the largest number of RN jobs) will be California (193,100 jobs), Florida (128,364

jobs), and Texas (109,779 jobs)” (Juraschek, 2012). The shortage is projected to impact southern

and western states the most because of the Baby Boomers. Many of them retire to states with

warmer weather, which is why the states in the South have the most “F” grades, as the supply

will not be able to meet the predicted demand. The models used incorporate workforce dynamics

to forecast future nursing supply and demand and project that there will be a national shortage of

300, 000 to 1 million RN jobs in 2020 (Juraschek, 2012). Because the shortage feels so distant

from many, this cases study shows how real the problem truly is, especially when looking at

individual states like Virginia.

Possible Solutions

Many solutions that are in place now, are only going to temporarily fix the problem; they

are a mere bandage covering up a deeply complex crisis. Any effective solutions will be a

combination of the five following priority areas: policy intervention, macroeconomics and health

sector funding, workforce planning and policy, positive practice environments, and retention and

recruitment (Oulton, 2006). One possible solution to the nursing crisis is to create a national

licensure, rather than state licensure because every state has different guidelines for what nurses

are allowed to do, as some states may be more limiting and restrictive than others (Grant, 2016).

Another potential solution is to “open up the paths to a degree” (Grant, 2016). Many nurses only

enter the field with an associate’s degree, when having a baccalaureate degree would open up an

immense amount of more opportunities. Other solutions involve incentivizing nurses to work in

the high-need areas. Hospitals are getting so desperate to recruit nurses that they are offering

“five-figure signing bonuses, free housing, college tuition for employees and their children”

(CNN Wire, 2018). “Because the nonprofit health system can’t find all the nurses it needs
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locally, it has been seeking out candidates from other states — and sometimes other countries”

(CNN Wire, 2018). Two major health systems, UCHeatlh and Inova Health are paying new

recruits and providing benefits with the purpose of making new nurses want to stay in high-need

areas.

“To entice these new recruits, it has offered relocation allowances and signing bonuses of

up to $10,000, said Kathy Howell, chief nursing executive for UCHealth. It provides

nurses with up to $4,000 a year to invest in continuing education. And it offers the

Traveler RN program, which allows nurses to do a 13-week rotation at different

UCHealth facilities” (CNN Wire, 2018).

Inova Health System, specifically, is offering “candidates who have at least two years of critical

care experience and live more than 50 miles from one of its six Washington-area hospitals a

$20,000 sign-on bonus and up to $20,000 in reimbursable relocation costs” (CNN Wire, 2018).

West Virginia’s WVU Medicine “will start offering tuition reimbursement for employees and

their children” (CNN Wire, 2018). While these benefits may be working right now, nurses are

using these benefits to sustain them for two to three years, then leaving and moving to more

desirable areas, like urban hospitals. “A better approach would be to invest in improving the

work environment for nurses and offering better pay, career development and hours to help make

sure they don’t burn out, she said” (CNN Wire, 2018).

Conclusion

Countless research has been done on what is the root cause of the nursing shortage, when

it is one of the fastest growing careers in our society. The main causes have dwindled down into

the aging of the Baby Boomer generation, the limited capacity of nursing schools, the
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consequences of high nurse-to-patient ratios, and poor working conditions paired with a lack of

benefits. Like any human, nurse need to feel valued. The question regarding how to resolve the

impending crisis is one with not a single, clear answer. In order to create a true long-term

solution, society needs to understand that the nursing shortage happens in a cyclical pattern. But

also, we need to take elements from solutions already in place, and use them in cohesion with a

larger focus on bettering working environment and culture, as well as allow nurses to feel valued

through greater benefits and more opportunities to advance. Nurses are truly the backbone of the

healthcare industry as they are there not only to save patients, but also form bonds that create a

mutual sense of trust and affection between the patient, their families, and themselves. They not

only heal broken bones, but also heal feelings, they heal families, they heal hearts.
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