We live in a country with the third highest population in the world. Over 320 million people live here, and vital to the health and wellbeing of each one of us are the 3.9 million registered nurses who keep our hospitals, nursing homes, and doctor’s offices running.
But, what does the next five years hold for the profession, and how will the industry deal with an aging population and workforce?
690,000 staff shortage
The American Nurses Association (ANA) predicted that 1.1 million new nurses would be needed by 2022, both to fill the employment gap created by a nursing workforce approaching retirement and a growing over-65 population. Individuals in this demographic cost hospitals up to three times more ($18,424) than working-age individuals ($6,125) on average.
Combining the ANA’s projections with current nurse numbers and retirement predictions, we calculated that the country will need 4,579,275 nurses in total by 2022 to keep up with required demand.
To get a picture of just how close we are to hitting that target, we analyzed data from the American Association of Colleges of Nursing (AACN) and the National Council of State Boards of Nursing (NCSB) to calculate an expected workforce figure based on current graduation and immigration trends.
Worryingly, our calculations revealed that only 3,889,227 registered nurses may be working in the US by 2022. That total includes 457,413 new nurses from a combination of new graduates and foreign-educated nurses. After retirements, that leaves a massive employment gap of 690,048 nurses between the required and expected workforce. So why is there such a disparity?
An aging workforce
Projections from the American Nurses Association’s predict that by 2024, 700,000 nurses will have retired. That’s an average of 100,00 a year, meaning by 2022, up to 500,000 nurses may have left the workforce.
These astounding figures have occurred because of many long-term factors. Firstly, nurses typically stay in their jobs a long time. This has meant, historically, there can be sustained periods when it is difficult for new nurses to find work because of a lack of fluidity in the workforce.
Technology has also made the physical parts of nursing less intense, meaning nurses have been able to work longer than in the past. Additionally, the 2008 recession forced many of the baby boomer generation of nurses who had previously planned on hanging up their uniforms to hold off, but over the next few years they will start retiring as well.
With a generation now set to retire in bulk, now is the time for new nurses to enter the workforce. Millennials are predicted to be twice as likely to be registered nurses than the baby boomer generation, so is the system set up to take this influx of new young nurses?
A struggling education system
The biggest challenge in recruiting, training, and employing a generation of new nurses is the education system’s ability to cope with the volume of applicants. While we have some of the finest institutions in the world, many are simply struggling to accommodate the number of qualified applications they receive every year.
In 2016, there were 65,138 graduates in entry level nursing programs*. To predict the total number of graduates by 2022, we looked at the average annual increase (2,455) to project a cumulative total of 442,383 new nurses in five years’ time.
This figure simply isn’t high enough to meet demand. Thankfully, there is plenty of interest from qualified applicants, but work still needs to be done to ensure schools have the facilities and staff to take them on.
52,208 applicants who were fully qualified for entry-level nursing programs were rejected in 2016. Based on our projections, that could mean a further 354,569 more qualified applicants getting rejection letters by 2022.
In a survey of nursing colleges by the AACN, the reasons institutions gave for rejecting candidates ranged from having insufficient clinical sites (37.5%) to an insufficient number of faculty (27.9%). Some of the other reasons included: overall budget cuts (9.7%), insufficient classroom space (7.5%), and insufficient enrolment capacity for specific programs (4.6%). Put simply: Schools want to take on more nurses, but to do so, they may need support.
We analyzed data from the HRSA on the grants they award to assist nursing programs every year and the numbers are staggering. Overall funding to nursing programs has hit an astounding $62 million in 2017 already, compared to just $243,000 in 2008. HRSA grants are awarded to “organizations to improve and expand health care services for underserved people.” This huge funding increase is a direct indicator of just how much financial support nursing programs today need just to survive, and these funding levels may need to grow even more if the sector is to thrive.
More foreign nurses?
One partial solution to the impending crisis could be to increase the number of internationally educated nurses we allow into the country. America has a long history of welcoming nurses from Canada, Mexico, and many other countries from all over the world. It is, however, hard to know what to expect from 2017 and beyond, with regulations on the H1-B visas nurses require to apply for work in the country already being tightened by the current administration.
Internationally educated nurses are not only required to apply for visas, but to take the NCLEX examination, which determines if they are prepared for entry level nursing in the US. To begin understanding how many new foreign nurses start work in the country each year, we analyzed examination statistics from the National Council of State Boards of Nursing which gives us a picture of how many foreign educated nurses are applying to work here, and how many are successful in their application.
The number of internationally educated nurses taking the NCLEX examination for the first time hit a five-year high last year: 11,569 took the exam, 4,495 (39%) passed it. Despite the year on year growth however, it is still well behind the 20 year high of 2007, when 33,768 internationally educated nurses took the exam and 17,559 (52%) passed it.
Perhaps unsurprisingly, pass rates are lower for internationally educated applicants than those educated in the US. The scale of the difference is surprising though. In 2016, only 38.85% of internationally educated nurses passed the exam first time, compared to 85% of those educated in the US.
Whatever the solution is, it’s clear there needs to be drastic changes to meet the demands of our country. Whether that means increasing federal funding to colleges so they can take on more students, a system more reliant on travel nurses who can move to meet demand in different areas at different times, or relaxing immigration requirements, something needs to happen soon if we want to avoid the potential 690,000 nurse shortage nightmare just around the corner.
For more data analysis and graphics, including analysis of huge rises in federal HRSA grants9given to nursing programs since 2008, visit the Sunbelt Staffing blog at :
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TAGS: American Association of Colleges of Nursing (AACN), American Nurses Association (ANA), H1-B visas, HRSA grants, National Council of State Boards of Nursing (NCSB), NCLEX examination, nursing, travel nurses, US nurses shortage
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It’s no secret that nurses work hard. The layperson would shudder at the long shifts most medical staff experience, but nurses take it on without blinking. They continually administer medications, check in with families, advocate for their patients, and work with a medical team for the best results possible within a convoluted medical system.
In stories from across the country, nurses share days where they don’t get a lunch break, have patients on gurneys in hallways, and are jumping from department to department to make up for staffing shortages.
The United States has a massive nursing shortage, and the problem is only set to grow. Due to an influx of patients into our health system, the retirement of baby boomers, and educational bottlenecks, nursing positions aren’t being filled fast enough to keep up with demand.
While on the surface it may seem like a simple supply-and-demand equation, the actual cause and projected effect is much more complicated. WIthout intervention on multiple levels, the problem will not go away.
Who Is the Nursing Shortage Impacting?
Obviously, the burden of a nursing shortage impacts those nurses who are working in the field. As more nurses retire or change careers and fewer nurses enter the field, the work is piled higher on those left working.
When the Affordable Care Act was passed, it gave more Americans access to healthcare services and consequently increased the number of patients seeking care. According to Bradley University, 92 percent of emergency rooms report patient overcrowding. That translates to increased wait times for patients, but it also means more evaluations for nurses and higher pressure to treat patients efficiently.
Short-handed nurses under pressure are at a higher risk for making mistakes. A study performed in Denmark found that readmission rates rose as nursing staff diminished, indicating that patients were discharged prematurely or not treated entirely before being sent home. The study further noted that patients in nursing homes, where the draw of nursing employment is not as strong as in hospitals or clinics, saw an astonishing 13 percent increase in the mortality rate of older patients.
Patients obviously suffer when nurses feel the time-constraining effects of understaffing. As our population continues to age, the prognosis looks grim: more than 80 percent of adults over 65 have at least one chronic condition. More than 65 percent have two. With baby boomers continuing to age, the percent of the population requiring regular care will continue to put pressure on healthcare practitioners.
Doctors are seeing the strain as well. Insurance companies and hospitals create an impossible equilibrium where doctors must decrease the amount of time they spend with patients in order to maintain a profitable bottom line. Nurses feel the strain as more of the workload is transferred to them, as well as picking up any pertinent missing pieces of patient health history that may not have been disclosed to the doctor.
The nursing shortage also has financial impacts for healthcare institutions. Nurses salaries must be competitive to attract applicants. As the shortage fuels burnout and frustration among nurses, turnover rates increase, reportedly costing the healthcare industry at least $4.2 million a year.
Why Is There a Nursing Shortage?
While practitioners, patients, and institutions illustrate that there is an undoubted need for nurses, it’s not for lack of interest. Prospective nurses looking to enter the field encounter a gauntlet of obstacles that make filling the healthcare need that much more difficult.
Students appear to have a high level of interest in nursing careers. They pay well, have strong projected job security, and allow practitioners to do meaningful work — all qualities that millennials have expressed are important.
However, as hopeful applicants send in their transcripts, many are turned away or wait-listed. Some schools have even done away with waitlisting due to excessive demand that has students waiting years before their enrollment.
One of the major limiting factors in nursing education is low faculty numbers — there simply aren’t enough teachers to educate the would-be nurses. Not only that, but the current faculty’s median age is in the 50s, meaning that many of them will be looking to retire not long from now.
It’s difficult to draw more faculty to schools, as taking a teaching position requires a nurse to have a higher level of education, be an expert in their field, and often, be willing to take a pay cut. For some of the larger schools, providing enough financial incentive to leave a clinical position and move to teaching may be feasible, but for smaller, private, or rural institutions, the financial burden may be too much. Without nurse educators in rural or underserved areas, we are further limiting the accessibility of nursing school to potential students.
Another issue contributing to the bottleneck in nursing education is the lack of clinical sites available. Without hands-on experience, nurses are entering the field lacking a critical understanding of what running codes and assessing patients is like. Hypotheticals cannot replace the stress of how life-and-death decisions feel in real time. Without more clinical learning positions available, nursing programs will not be able to increase the number of applicants they accept.
For those who are accepted into nursing programs, there’s something more to contend with: the cost of schooling. Whether trying to attain a nursing license through an associate, bachelor’s, or master’s program, the costs add up. And on top of it all, those pursuing a specialty have to be prepared to devote years to their professional development. RNs pursuing an oncology specialty, for example, not only have to earn the degree, they also have to invest years of time and money into board certifications and clinical practice hours. It all adds up.
Grants and scholarships like the RN to BSN/MSN Challenge can help with this burden, but unfortunately, there just aren’t enough to go around. Title VIII of the Public Health and Service Act is a federal program that awards grant money to nurses working in underserved regions.
Peter McMenamin, a former American Nurses Association representative, stated to Healthline that, “There’s a direct correlation between Title VIII funding and new nurses.” The article continues on to discuss a bill that would extend grant and loan funding through 2020. Unfortunately, that bill was introduced in 2015 and was passed by the House of Representatives, but not by the Senate.
A similar bill, H.R. 959, was introduced to the House on February 10, 2017 and would extend federal funding through 2022. The bill has not yet gone to vote. If it passes the House and the Senate, federal funding will be extended and enrollment in nursing programs will hopefully see an uptick.
While fingers get crossed for the extension of funding, two other bills stand to undermine some of the financial cushioning for nursing school graduates.
The new tax bill still needs to be reconciled between the versions the House and the Senate each passed, but depending on which way the hand of fate swings, public service loan forgiveness may be eliminated. If the House tax plan is honored, graduate students face higher interest rates and an elimination of student loan interest deductions. Employer-provided tuition assistance would become a taxable benefit, placing an additional burden on employees seeking higher education.
The PROSPER Act (Promoting Real Opportunity, Success and Prosperity Through Education Reform) was proposed in early December and has yet to go to vote, but it has serious implications for those with student loans. Most notably for nurses, Public Service Loan Forgiveness would be eliminated. For those who carry substantial debt, loan forgiveness might be the only light at the end of a 10-year tunnel. Moving forward, repayment options would shrink from eight separate plans to two, severely limiting the options of borrowers.
Part of paying back loans, especially if a nurse is attempting to be eligible for Public Service Loan Forgiveness, is maintaining employment. With the nursing shortage, it shouldn’t seem like a problem. However, while there may be a plethora of positions available, that doesn’t mean all the positions are optimized for retention.
Some things are basic: paying nurses enough and making sure they have the tools to do their job. While many programs are offering signing bonuses and generous salaries to increase hiring during the shortage, the effects of fewer staff members are felt throughout hospitals and clinics.
Fewer nurses means that the ones who are employed experience a higher workload, and often have to cover shifts or work overtime to keep patients covered. The combination of higher pressure and more hours worked can lead to staff burnout, both emotionally and physically.
Compassion fatigue can affect caregivers who aren’t able to take time for themselves or who are too stressed in their work environment. Minimal sleep from picking up extra shifts, combined with the emotional energy required to care for additional patients, can contribute to burnout and inadvertently cause the quality of patient care to decline.
Quality of patient care is also impacted by the experience of the nurses — seasoned veterans of the career will be calmer during codes, understand procedure better, and have a more developed sense of what patients need. While experienced nurses are able to pass along some of this knowledge, more baby boomer nurses are retiring than ever.
AMN Healthcare’s survey found that 73 percent of older nurses intend to retire in the next 3 years. That leaves patients with a much younger, less experienced staff who are seeking mentorship as they get their feet under them. The high retirement number not only contributes to the nursing shortage, but also to the stress and working conditions of those left in the workforce. Those who don’t intend to retire immediately face the daunting task of bringing new nurses up to speed on how individual programs run and giving them the day-to-day tips and tricks to make it as a nurse.
Despite being new to the field, nurses may change career paths within a few years, citing workplace bullying or other stressful conditions as their reason. In some cases, nurses are faced with ethical dilemmas or matters of practitioner autonomy that they feel inhibit their ability to treat within the best interest of their patients — 75 percent of nurses report feeling like they don’t have enough authority. When situations like this arise and are not addressed satisfactorily, nurses may leave programs feeling like they are unable to fulfill their duties.
Minimizing the Nurse Shortage
There’s a lot of work to be done if the U.S. is to effectively mitigate the nursing shortage. Policy, both at the federal and institutional level, stands to play a large role in the change. In some cases, attitude or expectation shifts may be necessary.
Primarily, the US needs to increase the number of potential nurses in educational programs, as this will directly impact the number of nurses available to enter the workforce. It is estimated that by 2025, the workforce will need more than half a million new nurses, which in turn means that programs need to provide openings for as many applicants.
Educational opportunities will only grow with the addition of funding and faculty, though the first does impact the second. Universities need to reassess their programs and see where they can afford to increase salaries in order to attract faculty. Non-monetary incentives, such as access to campus resources or publishing connections, will also be necessary to retain top teaching staff.
From a federal perspective, the government needs to increase Title VIII funding and retain the possibility of Public Service Loan Forgiveness. The elimination of either program will hamstring an already struggling effort and create an even larger practitioner deficit. Making grants and funding available to those from impoverished or rural areas will create a larger pool of talent to draw from.
Before entering the field, nurses need experience making stressful decisions in real time. Many teaching hospitals and healthcare education programs are turning to technology for answers. Using simulation mannequins, computer programs, or virtual reality situations allows educators to put nurses in controlled situations to test their knowledge under pressure.
Simulation technology may be the best answer to creating more opportunities for field training new nurses without taking time or energy from practicing nurses. Virtual situations allow nurses to make mistakes without the high-stakes environment of having a patient’s health in their hands.
Where possible, the availability of clinical rotations needs to increase. Hands-on training is essential for up-and-coming nurses, and the current number of opportunities is far too low. Care facilities will need to update programs to allow for shadowing and teaching.
Experienced nurses may find the addition of observers to be a hindrance to their daily tasks, but until more nurses are trained in a hands-on way, there will not be more competent, comfortable nurses coming to lighten the load. In conjunction with asking experienced nurses to devote even more time and energy to their professions, facilities need to improve the quality of life available to their staff.
Quality of Life Improvements
While many articles remind nurses of how to cope with stress and fatigue using healthy strategies, advice like “get adequate sleep” and “take breaks while at work” can be frustrating if schedules don’t allow for it. Rather than asking nurses to do what feels impossible within their circumstances, employers need to accommodate their nurses’ basic needs and listen to their feedback.
Several programs across the country provide examples of doing just that. Funded by grant money, nursing programs are turning inward to invest in their nurses and find out what needs to happen to reduce turnover and keep a happier staff. In one instance, a program retained 95 percent of the charge nurses who participated in a program to help develop their own resources.
Competitive pay, flexible schedules, and plentiful training resources will aid programs in retaining and developing their nursing staff, as well as drawing new hires. As retention increases, facilities will lose less money through turnover and be able to focus their financial resources in other areas that need improvement.
As a temporary solution, the United State may look towards hiring nurses from other countries. Currently, foreign nurses make up approximately 15 percent of the workforce. While foreign nurses may dull the growing pains in the short term, it’s only a temporary fix — the United States will still be responsible for systemic overhauls to internally mitigate the situation.
Nurses attempting to work in the US may be frustrated by the visa process, as H1-B visas can be complicated to obtain. Working with the government to ensure the success of their prospective employees can cost facilities time and money. During this time, immigrants may opt to settle in a different country with a simpler process.
Once set to work, American hospitals still have to contend with quality of life and retention issues among their foreign hires. Many nurses are still unhappy with the working conditions in the United States and will make attempts to leave before their contract is up.
Clearly, neither the blame nor the burden of repair lies in any one place. In order to combat the effects of the United State’s nursing shortage, healthcare facilities will need to work with newcomer and veteran nurses to develop effective training solutions. Combined with supportive government measures and funding, the future of patient care faces a reduced mortality rate and a happier workforce.