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There aren’t enough nurses to meet demand and the American Association of Colleges of Nursing (AACN) considers this one of its highest priorities to address.
But it’s not just about "meeting numbers," says Susan Skillman, MS, a research scientist and senior deputy director of the Center for Health Workforce Studies at the University of Washington.
"If a bucket has holes in it, no amount of opening of the spigot will fill that bucket," she says.
"I like to caution folks that the word ‘shortage’ is not a clear problem diagnosis—it’s a symptom. The only way to ‘cure’ it is to first understand its source(s)."
Shortages of educational opportunities
Aspiring nurses need a place to obtain their nursing education, and that requires enough faculty to train them.
AACN says the nation’s nursing schools turned away 80,407 qualified applications in 2019 because of insufficient faculty, clinical sites, classroom space, or clinical preceptors, and budget constraints meant these limitations couldn’t be remedied. Faculty shortages were the main cause, with the association counting a total of 1,637 faculty vacancies across 892 nursing schools that offered baccalaureate and/or graduate programs.
"Qualified students should be afforded the opportunity to become nurses," says Deb Zimmermann, DNP, RN, NEA-BC, FAAN, chief clinical officer and principal of Leaders in Care, a company dedicated to enhancing teamwork in clinical settings. She was just elected president of the American Organization for Nurse Leadership (AONL) for 2022, chairs the AONL Foundation Board of Directors, and co-chairs the AACN-AONL Academic Practice Council.
"If schools of nursing and healthcare organizations partnered with one another, innovative models of education could alleviate some of the faculty shortages," she says. "Joint appointments with schools of nursing for clinical nurses is just one solution that would increase the numbers of faculty and support increasing student enrollment."
A nurse’s education includes clinical training, and right now, finding sites at which to complete that is "really hard," says Skillman. "With online training, students may be left to find their own clinical training sites, and they may pay for that. Then there’s the issue of how much simulation should count in lieu of hands-on clinical training."
Experts say other influential factors include:
- the increasing number of baby boomers who need healthcare
- nurses retiring and burning out, especially after the rigors of COVID-19
- more availability of healthcare for those who previously couldn’t access it, as provided by the Affordable Care Act
- better healthcare that helps contribute to longer life
- the impact of violence in the healthcare setting adding to an already stressful job
- some nurses choosing to have a family and not come back to work, or choosing a new career altogether
Multiple factors contribute to what Skillman calls "an extremely fragmented U.S. healthcare system, composed of lots of different and often competing forces driven by varying incentives."
The pandemic tipping point
"Clinicians continue to battle a pandemic with grace, grit, intelligence, and ingenuity," says Zimmerman.
COVID-19 did highlight the value of nursing, but it was a tipping point, she adds. "The pandemic has been long, and nurses are tired. This has led to increases in turnover and vacancies in nursing, support staff, and in other health-related professions."
It’s clear that COVID-19 impacted nurse workforce numbers, as evidenced by May 2020 Washington State data showing 10 percent of registered nurses had submitted unemployment claims, says Skillman.
Gretchen Berlin, senior partner for management consulting firm McKinsey & Company’s Healthcare Systems & Services division, cites other employment effects. "There were clear periods of workforce tension with many healthcare systems heavily relying on temporary staffing, and there were also periods where demand for services decreased in some geographies enough that we saw furloughs and layoffs," she says.
"Although there were furloughs in the first wave of the pandemic, most organizations are currently facing shortages and using contract labor—and those costs have exponentially increased and further strained the system," says Zimmerman. "COVID-related hospitalizations increased, as have hospitalizations for non-COVID-related conditions."
"What we have seen with COVID-19 is exacerbation of what healthcare systems experience day-to-day, and is also a reflection of broader employment trends," says Berlin.
"Via the Bureau of Labor Statistics, we can see that healthcare is seeing higher vacancies than the national average, but the overall trend and increases mirror the national average for all industries," she says. "The separations rate, including quits and layoffs, in healthcare is actually better than the national average."
Looking backward
"Many employers have been ‘feeling’ a tension in nursing staff for decades, which has varied over time and by site of care," says Li Han, expert associate partner at McKinsey & Company. "As nursing employment options have increased, increasing the number of outpatient sites of care, there has been a natural pull in some areas away from the inpatient bedside."
In 2010, for example, some forecasted easing of the nursing shortage occurred, which had already been going on for years at that point due to the economic downturn, she says.
"In response to that, AACN, AOLN, the American Nurses Association, and National League for Nursing released a joint statement cautioning against slowing down the inflow of new RNs given the projected increase in demand for services," Han says.
Looking forward
It’s clear what motivated the nursing shortage, but only concrete, realistic ideas can "fix" it, say healthcare advocates.
Start with three main goals, says Berlin. First, increase the supply of RNs; second, utilize them appropriately in the workforce; third, relieve excessive demands forced upon them by today’s healthcare environment.
"In terms of the first, more people need to be interested in pursuing nursing as a profession, both straight out of high school, or as a career switch for non-traditional students, and structure needs to be provided so nurses stay in the profession," Berlin says. "This starts with understanding why there might be issues with the current attraction to the profession and retention in the long term."
"Balance and a reasonable workload, a healthy work environment, meaningful recognition, and opportunities for promotion for expertise at the point of care are important," says Zimmerman. "Nurses were challenged with work and home schooling during the pandemic."
Finally, Berlin says, the pandemic motivated the industry to further explore what team-based care delivery really looks like. "That included drawing a firmer line between when an RN or physician is needed, or when support staff such as nursing assistants can provide select support. Some acute care systems are refining the skill mix for different types of care delivery to alleviate pressure upon RNs."
Zimmerman adds, "Organizations are putting in place safeguards to prevent past failures, with two standouts: the return to team-based care to accommodate the high-volume, high-risk care needs of patients overloading the health system, and role development to accommodate specialized demands. Team nursing accommodates caregivers with varied skill sets who are supported and mentored by experienced RNs while optimizing providers’ talents. Presumably, team nursing offers peer support and built-in efficiency factors to accommodate intense tasks such as patient proning."
Skillman believes increased focus on efficiency would also ease the strain of this nursing shortage. "When you hear the word, ‘shortage,’ that should be the beginning of the story," she says. "If we don’t have the bodies to fill slots the way we have been doing it, maybe we need to look at other ways to get people the care they need. There’s a ton of unnecessary care delivered in the system—and medical error is one of the largest killers in the healthcare system. We should look at evidence for the most efficient, effective care we can deliver."
Moving toward solutions
Right now, things are not just all talk and no action.
Healthcare systems are doing many things to increase hiring numbers, says Han. These include tuition reimbursement, housing assistance, flexible working schedules, subsidized childcare, and integrated education programs that involve going from school straight to the unit afterwards.
Zimmerman says, "Nurses are ready to participate in healthcare redesign and institute models of care that demonstrate improved clinical outcomes, expand access to care, break down racial barriers, and incorporate patient-centered approaches to care."
Additionally, the Edge Runners initiative from the American Academy of Nursing, Magnet Recognition Program® from the American Nurses Credentialing Center, and Future of Nursing: Campaign for Action have all identified promising innovations to expand with appropriate funding and payor support, she says. And the AONL Foundation sponsors think tanks on new models of care and staffing.
The "Earn While You Learn" model is helping expand faculty and student numbers, Zimmerman says. It’s been adopted in several states, such as Virginia, so students can earn money while participating in hands-on clinical learning that’s part of an apprenticeship model of teaching and learning. Some hospitals are also using electronic intensive care units (e-ICUs), another form of telemedicine, along with other advanced technology to maximize human resources.
"Are we using nurses the best way, especially if we don’t have them in the numbers we are used to having them?" asks Skillman. "This is going to continue to drive some innovation, desperation, creativity, and good, hard thinking. Getting ‘more’ is only part of the solution."
This article first appeared on Health eCareers. Reprinted with permission.
