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 Boomers 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. Without recognizing the causes of the impending shortage, the

impact of this disaster will be felt by both nurses and patients, and this crisis will become

America’s reality.
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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 registered nurse (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).

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

clinical sites, lack of classroom space, and budget constraints, “U.S. nursing schools [had to turn]
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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 on Nurses

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,” but in the medical field, this fatigue can

be life-threatening (Grant, 2016). In a study conducted in March 2017 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 linked

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

when a nurse spreads his or her self too thin, the quality of care decreases while the stress

increases. (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

all cause 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
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the workforce skyrocketed to 33%. A big part of the increasing interest in nursing and other

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

need 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.” In reality, 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,
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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).

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. In Uganda, there are 1 to 2 for every 100 patients (Oulton, 2006). While in

comparison to the United States, developing African countries' nursing shortage appears to be

more extreme, the same disparities are present between rural and urban areas. 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 the 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
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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.

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

Montana, Nevada, and New Mexico (Juraschek, 2012). “In 2030, states with the largest

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

for 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
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“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

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. In order to lure in 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

consequences of high nurse-to-patient ratios, and poor working conditions paired with a lack of
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benefits. Like any human, nurses 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 they also heal feelings, they heal families, and they heal hearts.
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References

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o-recruit-nurses/.

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Nurse Staffing on Hospital Financial Performance: Competitive Versus Less Competitive

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http://doi.org/10.1097/HMR.0b013e318257292b.

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