Nursing Shortage: Causes, Impacts, and Change Strategies

Introduction to the Nursing Shortage

The nursing shortage is a pressing problem in many healthcare organizations. Without an adequate number of nurses, patient care and safety may be compromised, while nurses themselves may become overwhelmed, distressed, and dissatisfied. High patient-to-nurse ratios contribute to significant frustration and job burnout, which in turn is linked to higher staff turnover. An inadequately staffed nursing force has been shown to play a negative role in patient outcomes. In contrast, studies have confirmed that hospitals with low nurse turnover tend to have the lowest rates of risk-adjusted mortality and severity-adjusted length of stay.

There is no single precise definition of the nursing shortage, but a clear understanding of the concept helps illuminate the problem. Healthcare organizations are experiencing growing demand for nurses while the supply remains insufficient. Nursing shortages occur when the demand for nurses to fill job openings exceeds the existing supply of qualified nurses. Typically, such vacancies remain unfilled for lengthy periods, producing a genuine scarcity. Both demand and supply factors contribute to this shortage. For instance, experienced nurses in key specialties — such as intensive care and midwifery — are in short supply, while demand for these skills is high across most healthcare settings.

According to the Robert Wood Johnson Foundation, rather than focusing solely on efforts to attract new students into nursing schools, attention must also be directed toward the underlying issues that make healthcare facilities more appealing and functional workplaces for nurses.

Workplace Impact and the Cycle of Shortage

On average, nurses work approximately eight and a half weeks of overtime every year. Current studies continue to show that caring for too many patients and working exhausting long shifts — twelve- and sixteen-hour shifts are not unusual — are associated with medical errors and lower quality of care.

A vicious cycle surrounds the nursing profession. Fewer people are entering nursing, which has led to a shortage. Because of the shortage, nurses who remain in hospital work must care for more patients under increasingly difficult working conditions. Because of these strained conditions, more nurses leave, thus worsening the shortage and making the recruitment of new nurses more challenging.

The nurse shortage also carries significant cost implications. Although estimates vary widely, the cost of recruiting and training one new nurse for a medical-surgical floor is typically equivalent to 100% of a nurse's annual salary — roughly $42,000 to $60,000 — and considerably higher for emergency department positions. While 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. Many hospitals have responded by hiring temporary nurses through staffing agencies to address shortages. This practice raises concerns about the quality, consistency, and cost of care provided by short-term staff. The morale of permanently employed nurses may also suffer when they work alongside agency nurses who receive higher wages and enjoy more flexible scheduling.

These temporary fixes are not viable long-term solutions. Without immediate action, the nurse shortage will continue to worsen. Projections suggest that by 2020 the United States will have significantly fewer nurses than needed, precisely when baby boomers will be in their seventies and eighties.

Stakeholders and Educational Initiatives

Existing nursing programs are able to alleviate some of the projected shortages through approaches that have worked in the past. Nevertheless, in order to adequately address the shortages and all of the challenges identified above, there is a need to support educational strategies for nursing that do more than simply maintain and expand current arrangements. What is necessary are innovations that transform nursing education with the goal of achieving greater student learning, higher enrollment volume, and better access to the profession — particularly for racial and ethnic minorities and men.

Georgia State-Funded Nurse Support Program. Georgia has already taken steps to drive innovation through new initiatives intended to grow the nursing workforce in the state. Beginning in 2016, the Health Services Cost Review Commission (HSCRC) implemented the Nurse Support Program, intended to support initiatives that increased volume in nursing education programs.

Evidence Summary: Stressors, Satisfaction, and Retention

Georgia Consortium for Nursing Education (GCNE). In 2012, public nursing schools came together to discuss the need to prepare nurses for a new future in hospital settings. They collaboratively worked to design, from the ground up, a new nursing curriculum aimed at meeting contemporary workforce demands.

Insufficient staffing and daily workplace hassles are key factors that increase nurse stress levels and push nurses to leave the profession (Liu, 2013). Disruptive behavior and verbal abuse from physicians have also been linked with nurse job dissatisfaction (Reilly, 2012). Everyday hassles — such as time spent searching for medications and supplies — prevent nurses from focusing on meaningful patient care (Rubin, 2015). These straightforward stressors can threaten patient safety and negatively affect nurses' perceptions of their practice environment. Nurse leaders are advised to first address nurses' basic needs for sufficient staffing and the capacity to provide safe nursing care (Groff, 2012).

The practice environment needs identified in the research literature correspond to Maslow's hierarchy of needs, including nurses' need to feel secure in their environment, provide safe care for their patients, have a sense of belonging within their organization, and feel empowered to act in accordance with their professional values (Raines, 2011). Maslow's framework holds that once nurses' basic needs are met, their focus will shift toward higher-level needs such as a sense of belonging, self-confidence, and self-actualization.

In addition to the difficulties faced by experienced nurses, job dissatisfaction and disillusionment also contribute to new nurses leaving the profession (Reilly, 2012). With regard to disenchantment, it is simply not enough to view nursing entirely in terms of personal calling; it requires "wide-ranging knowledge of illness, medicine, and appropriate treatment, complete decision-making skills, and emotional strength and sensitivity" (Nursing Shortage: The Facts and Strategies in Macao Society, 2013). It is important to project an accurate and positive professional image in any discipline, but this is especially true for nursing (Groff, 2012). If people are expected to become dedicated and active members of the nursing workforce, job satisfaction must play an important role. Developing a retention committee to address high-priority matters such as improving job satisfaction, recognition, and opportunities through rewards and acknowledgment may serve as an example of positive workforce engagement.

There is also a clear association between job satisfaction and professional autonomy. When nurses feel they have little or no control within their work setting, they become frustrated and demoralized, and the desire to leave increases (Liu, 2013). Like any professional, nurses want to feel valued, to be acknowledged for their work, and to enjoy professional benefits such as flexible scheduling. The top three factors considered by nurses in their decision to remain in their current positions — as cited by Palumbo, Rambur, McIntosh, and Nafud — are recognition and respect, a voice in discussions and decisions, and performance evaluation (Rubin, 2015). Compensation ranks fourth, while the staffing of older nurses appears to fall near the bottom of a list of ten factors.