National Nursing Shortage: Policy Analysis and Solutions

Introduction: Identifying the Nursing Shortage Crisis

The healthcare industry is afflicted by a wide array of internal problems, policy issues, and systemic flaws. Included among them are the prohibitively high costs of medical treatment, the inaccessibility of healthcare coverage for many system users, and the frequency of preventable occurrences such as medical error and health system negligence. One of the root problems in the healthcare system — a mounting crisis that impacts all of these and other areas of the industry — is the shortage of registered nurses and healthcare workers in general.

In the face of rising demands for healthcare providers, the industry is experiencing record gaps in its ability to treat patients. Projections suggest that this condition will only worsen, with ratios of nurses to patients becoming less and less optimal over time. This is particularly problematic given the population trends that threaten to strain the economy in the coming years. As the population of retirees grows to include the enormous Baby Boomer generation, the nation's productivity and, by consequence, its healthcare system will be increasingly reliant on the far smaller succeeding Generations X and Y. This means that gaps between healthcare providers and the patient population are likely to grow without some significant shift in current trends.

According to Cullen et al. (2010), "in 2008, the American Health Care Association's report of vacancies in long-term facilities and the American Hospital Association's report of hospital vacancies combined relayed an even larger shortage of 8.1%. By 2025, the shortage in RNs is projected to grow to an estimated 260,000 FTEs, twice as high as any U.S. nursing shortage since the 1960s" (Cullen et al., 2010). This alarming trend provides a rationale for the present analysis, which examines the way these ratios impact job performance for healthcare professionals, health outcomes for patients, and efficiency for healthcare facilities overall.

These national figures are reinforced by similar patterns at the state and local level. In Texas, a staffing shortage is projected to reach a shortfall of 71,000 nurses by 2020, according to Roberson (2010). At present, vacancy rates of 5% have shrunk to 2% as a result of the recession and efforts to recruit new nursing students — a temporary improvement that is expected to reverse by the projected date. A comparable pattern has emerged in Houston, where, according to Perin (2008), "the area is already struggling with an ongoing nursing shortage of 4,000 to 5,000 full-time RNs, and the HWS study shows that the vast majority of the RN pipeline locally will be inexperienced new graduates, indicating hospitals will have a growing problem hiring experienced nurses" (Perin, 2008).

Background: Social, Economic, Ethical, and Political Factors

Social Factors

At the root of the nursing shortage is a number of convergent sociological trends, including those relating to immigration, demographic shifts, and population aging patterns. Cullen et al. indicate that myriad social factors may be identified as having contributed to the initiation of the shortage and to what projections suggest will be a resurgence of far greater severity in the next decade. Cullen et al. report that "research suggests that the current shortage is the product of several trends including: steep population growth in several states, a diminishing pipeline of new students to nursing, a decline in RN earnings relative to other career options, an aging nursing workforce, and an aging population that will require intense health care services" (Cullen et al., 2010). These trends all point to a strong imperative for policy action and identify several areas where regulatory oversight might prevent projected shortfalls. Critically, a survey conducted in 2006 projected that 55% of nurses surveyed intended to retire between 2011 and 2015, with job dissatisfaction frequently cited as a major cause for this anticipated decision.

Economic Factors

Leavitt et al. (2012) underscore the economic consequences of inadequate nurse-to-patient ratios, indicating that the direct correlation between fewer nurses and less desirable health outcomes is accompanied by a number of peripheral economic costs. Leavitt et al. note that "inadequate nurse staffing could be linked to increases in rates of infection, morbidity, and mortality — outcomes that can increase institutional costs and jeopardize an institution's reputation and future business" (Leavitt et al., 2012). Another often-overlooked cost is the lost productivity of a labor force experiencing poorer healthcare outcomes and, as a result, greater susceptibility to illness, sustained ailment, or inadequately treated injury — leading to increased work absences and lower overall productivity.

The low level of worker morale and the high rate of consequent turnover in nursing also impose significant costs on the system in terms of training, position vacancies, and overtime payments to retained nurses. According to the Texas Center for Nursing Workforce Studies (TCNWS, 2006), "in 2004, the New York State Education Department calculated that the statewide cost of RN turnover per year would be over $1 billion when the annual turnover rate is 15%. Nationally, the total cost of turnover, at a nurse turnover rate of 20% in U.S. hospitals, is estimated to be $12.3 billion" (TCNWS, 2006).

Ethical Factors

Berkowitz posits that in addition to the practical demands incumbent upon the healthcare industry in addressing staffing shortages, there are substantial ethical imperatives at play. Because of the limited accessibility of healthcare treatment for many portions of the population, staffing shortages that affect the availability of healthcare providers carry important ethical overtones. According to Berkowitz (2012), "fairness and equity are important aspects of policy development. Fawcett and Russell (2001) consider the equity of a policy as the extent to which it allows the benefits and burdens of nursing practice to be equally distributed to all; in particular, equal access to health services" (Berkowitz, 2012).

This suggests that there is a tangible ethical dimension to the research problem identified here. The degree to which staffing shortages disrupt the equal distribution of healthcare access is the degree to which there is an ethical responsibility vested in healthcare providers and the industry as a whole to fill gaps in effective staffing. According to Berkowitz, it is for this reason that policy action is not only of critical practical importance but also necessary for the achievement of ethical equity in the distribution of healthcare services. Given current knowledge of impending threats to nurse-to-patient ratios, there is an additional ethical imperative to act preemptively to prevent the worsening of this staffing crisis.

Political and Legal Factors

Among the critical issues of political and legal importance are the global ranking of the U.S. healthcare system and the implications of socioeconomic disparity for that ranking. According to Greis and Duda (2010), "the nursing shortage has broad implications for the future ability of the U.S. health care system to provide quality patient care. Meanwhile, the U.S. health care system has received a number of recent notorious distinctions. For example, in 2000, the World Health Organization ranked the U.S. health care system thirty-seventh in overall performance. Similarly, others have criticized the U.S. health care system for having significant disparities between high-income and low-income adults in the quality and quantity of care provided" (Greis & Duda, 2010). This underscores the need to bring significant public pressure to bear on public representatives to bridge gaps both in socioeconomic healthcare disparities and in the performance gap between the U.S. and other industrialized nations with more adequate and equitable systems.

Issue Statement and Key Stakeholders

The primary issue identified here is two-fold: there are critical nursing and healthcare staffing shortages throughout the American healthcare system, and despite considerable empirical evidence that these shortages lead to less desirable healthcare outcomes, greater rates of preventable death, and higher incidences of medical error, finding ways to overcome staffing deficiencies remains a top challenge for hospitals.

The key stakeholder in this policy discussion is the public at large. Users of the healthcare system at every level — and especially those in impoverished communities or otherwise underserved healthcare settings — are the most likely victims of understaffed facilities and represent the most important stakeholder group.

Equally important are professional healthcare providers, nurses, and prospective nurse managers, whose stake is particularly vested in improvements to wages, working conditions, training, and recruitment efforts. Nurse educators also hold a central role in addressing the present shortage. As Allen (2008) reports, "the lack of faculty to educate the growing demand for baccalaureate-prepared RNs directly impacts the nursing shortage. The nursing shortage thus directly impacts safe patient care. The main reasons for the lack of faculty to meet the demand for more nurses include the increased age of the current faculty and the declining number of years left to teach, expected increases in faculty retirements, less compensation for academic teaching than positions in clinical areas for master's-prepared nurses, and finally, not enough master's and doctoral-prepared nurses to fill the needed nurse educator positions" (Allen, 2008). This makes nursing educators a key stakeholder group as well.

Other stakeholders include healthcare facility administrators, corporate trustees, and public officeholders, who often have entangled or competing interests relating to the profitability of operations and the political expediency of policy orientation. Various professional advocacy groups, nursing associations, and lobby groups will also vie for influence in any legislative debate relating to the nursing shortage.