This paper examines the growing nursing shortage in the United States, projected to reach a deficit of one million nurses by 2020. It argues that the primary driver is not a lack of nursing school enrollment but the high rate at which new graduates leave the profession. The paper details the workplace stressors new nurses face — including overwhelming caseloads, inadequate preparation, and horizontal violence from colleagues — and documents their psychological toll. It then presents preceptorship programs and mentoring relationships as evidence-based solutions, emphasizing that hospital organizations must fund and prioritize these supports to improve retention and address the shortage.
Nursing shortages are increasing at an alarming rate. By the year 2020, the deficit of nurses was expected to reach one million and affect 44 states plus the District of Columbia (AACN). Hospitals have been hardest hit because of the shortage of bedside registered nurses. This is not the first time a nursing shortage has occurred. During the 1980s there was a nursing shortage, but for different reasons than the present one. At that time, not enough people were entering nursing, and as enrollments increased, the shortage decreased. Now, however, the nursing shortage is primarily due to nurses leaving their jobs because of disillusionment (Block, Claffey, Korow, & McCaffrey, 2005).
Between 1992 and 2000, the number of registered nurses who changed to non-nursing jobs increased by 28% (Block, Claffey, Korow, & McCaffrey, 2005). According to Butler and Hardin-Pierce (2005), during their first year of work 53% of new nurses will change jobs. In public teaching hospitals the turnover rate is as high as 55%. The result is a critical shortage of bedside nurses. The impact on patient care can hardly be overstated — in 24% of hospital deaths, understaffed nursing was found to be a contributing factor (AACN).
New nursing graduates may start out excited and enthusiastic, but soon they encounter the reality of the workplace. Expectations for caregiving have changed significantly. Length of stays, for example, are dramatically shorter, and only very sick people are in the hospital (Ellerton, 2003). Many new nurses feel under-prepared. They experience great anxiety about making mistakes and possibly harming their patients. Many feel they lack the knowledge to communicate effectively with doctors and with family members, leaving them feeling inadequate for the job.
The reality of the workplace is a shock. In school, students were instilled with high ideals, but the workplace requires them to carry a larger caseload of patients with serious medical problems. The process of learning can take from six months to a year, yet new nurses are under pressure to function effectively in the real world immediately (Cosentino, 2003).
New graduates report that they do not feel confident or competent; they make errors because of heavy workloads and responsibilities; they are constantly confronted by new situations, procedures, and surroundings where they do not know what to do; their preceptors are inconsistent; they do not know anyone on staff; run-ins with disgruntled nurses and other staff members are disturbing; there is not enough staff to do the job properly; and other nurses are not willing to help them. They also report feeling anxious, overwhelmed, intimidated, disappointed, disgusted, sad, angry, and guilty (Butler & Hardin-Pierce, 2005). It is no wonder they quit.
Part of the problem, unfortunately, is the disturbing and sometimes abusive treatment new nurses receive from their colleagues. During the first three months of employment, when the nurse is still a novice, he or she may experience "horizontal violence" in the workplace. The term refers to conflicts with other nurses who treat the new nurse with hostility and psychological harassment. Verbal abuse and threats, intimidation, humiliation, excessive criticism, innuendo, exclusion, denial of access to opportunities, and intentional withholding of information may all occur (Butler & Hardin-Pierce, 2005). The effect on the new nurse includes intimidation, absenteeism, and the decision to abandon nursing as a career.
Butler and Hardin-Pierce report a survey of new nurses conducted in 2003. On the Impact of Event Scale, used to measure psychological stress, 58% of new nurses reported symptoms consistent with post-traumatic stress disorder. Thirty-four percent reported incidents in which they were verbally abused, treated rudely, humiliated, or unjustly criticized. Other unpleasant experiences included sexual harassment, racial slurs, and verbal threats. Dean-Barr (2003) points out that experienced nurses may view their workplace environment as full of problems that never get resolved, and they may come to see inexperienced nurses as part of the problem.
Although nursing schools try to prepare students for real-life practice, theory needs hands-on experience to become meaningful. Simulated scenarios are helpful, but they are not the real thing (Cosentino, 2003). Capstone courses attempt to teach students how to think like professional nurses (Butler & Hardin-Pierce, 2005), but experience remains the best teacher. The new nurse should not be left to muddle through alone.
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