Nursing Shortage: Causes, Barriers, and Evidence-Based Solutions

The Nursing Shortage Problem

Researchers at Phoebe Memorial Hospital gathered information to help them understand an extreme nursing shortage. The shortage they discovered stems from an inadequate number of nurses, producing high turnover rates that potentially compromise patient safety and quality of care. High turnover rates arise from nurses feeling dissatisfied with long working hours and low pay. Data collected reveals that high patient-to-nurse ratios lead to high frustration levels and job burnout (Currie and Carr Hill, 2012, p. 1180). At Phoebe Memorial Hospital, inadequate staffing played a negative role in patient outcomes. Various studies have confirmed that hospitals like Phoebe, which experience high nurse turnover, also have the highest rates of risk-adjusted mortality and severity-adjusted length of stay (Chan et al., 2012).

While there is no definitive way of evaluating the reasons behind the nursing shortage at Phoebe Memorial Hospital, a systematic report may offer potential solutions. Healthcare organizations like Phoebe Memorial face frequent demand for well-trained nurses. In the past, Phoebe Memorial Hospital has encountered nursing shortages when demand to fill job openings exceeded the existing supply of competent nurses.

Typically, such vacancies remained unfilled for lengthy periods until suitable candidates were found. Because these positions took so long to fill, working nurses were required to log longer hours, leading to increased stress and dissatisfaction, and ultimately to higher turnover rates. These higher turnover rates created a cycle in which fewer viable nurses were available to fill a growing number of unfilled positions. Both demand and supply factors contributed to the apparent scarcity. Researchers at Phoebe Memorial found that experienced nurses in key specialties — such as intensive care and neonatal care — are in especially short supply.

On average, nurses at Phoebe Memorial Hospital work eight and a half weeks of overtime every year. Recent studies reveal that nurses on average care for too many patients, work tirelessly on a daily basis, and endure long shifts lasting twelve to sixteen hours. "Thirty-eight percent of nurses in China had high burnout and 45% were dissatisfied with their jobs. Substantial percentages of nurses described their work environment and the quality of care on their unit as poor or fair (61% and 29%, respectively) and graded their hospital low on patient safety (36%)" (You et al., 2013, p. 154). Such strenuous conditions lead to lower quality of care and lower patient satisfaction.

Change in the Workplace

This endless and often brutal cycle surrounds the nursing profession at Phoebe Memorial Hospital. Beyond lower nurse and patient satisfaction and higher turnover rates, the nursing shortage also has significant financial consequences for the hospital. Although estimates vary broadly, the cost of recruiting and training one new nurse for a medical-surgical floor is normally equivalent to 100% of a nurse's annual salary — between $42,000 and $60,000 — and the cost is considerably higher for Phoebe's emergency department. Although the number of registered nurses has grown in recent years, most of that growth is accounted for by nurses over age fifty and foreign-born nurses.

Phoebe Memorial Hospital has been hiring temporary nurses through staffing agencies in order to address its shortages. This practice has raised concerns about the quality and consistency of new recruits, particularly regarding the cost of training short-term staff and the care they provide. Another concern is the potential for tension: agency-hired nurses may not communicate or collaborate as openly as permanent Phoebe Memorial nurses, which can create friction within the nursing staff and among other medical personnel.

While agency-hired nurses provide short-term solutions, these temporary fixes are not a viable long-term answer for Phoebe Memorial Hospital. Without careful planning and the development of evidence-based practices, the nursing shortage will continue to worsen. By 2020, researchers suggested the nursing shortage would increase to even higher levels (Toh, Ang, and Devi, 2012, p. 130). To avoid such a crisis, the Robert Wood Johnson Foundation (RWJF) focused on core issues driving the nursing shortage at Phoebe Memorial — specifically to decrease nurse turnover, increase job satisfaction, and improve the quality of patient care.

Georgia's existing nursing programs alleviate some foreseeable shortages through proper education and training. Nevertheless, in order to address the current shortage — which will inevitably fuel future shortages — Georgia needs to support educational strategies for nursing that go beyond merely updating existing curricula. The additional and necessary step involves developing curriculum and training that utilizes evidence-based practices, which may lead to greater student learning, higher enrollment volumes, and improved entry into the profession, particularly for men and for racial and ethnic minorities.

Stakeholders and State-Level Initiatives

Georgia has already taken steps to drive innovation and change through new programs intended to raise the number of nursing students and working nurses in the state. Beginning in 2016, the Health Services Cost Review Commission (HSCRC) planned to implement the Nurse Support Program at Phoebe Memorial Hospital, designed to support initiatives that increase student enrollment in nursing education programs. The Georgia Consortium for Nursing Education (GCNE) hosted a public event in 2012 at which public nursing schools came together to discuss the need to address the nursing shortage for affected hospitals like Phoebe Memorial Hospital. These institutions then worked collaboratively to plan a new nursing curriculum from the ground up.

Insufficient staffing and daily workplace pressures increase nurse stress levels and push many nurses to leave the profession (Liu, Lam, Fong, and Yuang, 2012, p. 1). Disruptive behavior and verbal abuse by physicians have also been linked to nurse job dissatisfaction. Among nurses who wish to advance their education, there is growing difficulty in applying for and completing nursing programs. "Other barriers facing students who seek to further their education include a significant outlay of time and money, personal and family issues related to these challenges, and the complexity of the application process" (Reilly, Fargen, and Walker-Daniels, 2011, p. 11).

Evidence Summary

Nurse leaders are advised to first address basic needs — such as adequate staffing — before moving on to more complex issues that require greater planning and resources. Daily stressors are often the most critical first step toward fixing the nursing shortage. "The strongest predictor of nurse job dissatisfaction and intent to leave is that of stress in the practice environment. Good communication, control over practice, decision making at the bedside, teamwork, and nurse empowerment have been found to increase nurse satisfaction and decrease turnover" (Groff-Paris and Terhaar, 2010, p. 6).

Day-to-day hassles — such as medication administration and care transitions at the end of shifts — prevent nurses from delivering consistently high-quality patient care. Rita Rubin documented the passage of a bill intended to establish minimum nurse-to-patient ratios and reduce workload burdens on existing nurses. "The National Nursing Shortage Reform and Patient Advocacy Act, introduced March 25, would establish minimum registered nurse-to-patient ratios in hospitals, protect nurses' rights to advocate on behalf of their patients, and invest in training and retraining nurses to address the nationwide shortage" (Rubin, 2015, p. 1787). Other measures intended to improve patient care and reduce nurse workload include checking and documenting medicines and materials used for each patient. These straightforward practices can reduce stressors and increase patient safety by eliminating potentially harmful errors and improving nurses' awareness of patients' current medications and treatments.

The practice environments identified in certain studies correspond with Maslow's hierarchy of needs, reinforcing the idea that nurses must feel secure in their environment in order to provide quality care. For nurses to feel secure, they need a sense of belonging within their organization and some degree of autonomy and authority in their role (Raines, 2010). Maslow's framework suggests that once nurses' basic needs are met, their focus will shift toward higher-level needs — a sense of belonging, increased self-confidence, and self-actualization (Groff-Paris and Terhaar, 2010).

In addition to the difficulties faced by experienced nurses — including job unhappiness, dissatisfaction, and disillusionment with nursing practice — the constant training of new nurses compounds the problem, making it easy to understand why a nursing shortage persists (Reilly, Fargen, and Walker-Daniels, 2011). With regard to professional disenchantment, it is insufficient to view nursing purely in terms of patient care; it requires an understanding of what nurses actually do: "a wide range of knowledge of illness, medicine and appropriate treatment, complete decision-making skills, and emotional strength and responsiveness" (Liu, Lam, Fong, and Yuang, 2012, p. 8).

It is necessary to acknowledge the kind of impact that a profession like nursing has on the general public. Such a discipline is not only difficult to sustain but also to advance in — both academically and professionally (Groff-Paris and Terhaar, 2010). Hospitals and academic institutions share a responsibility to create better working conditions and improved curricula so that nurses and nursing students can perform their roles without the stressors that currently plague the profession.