This article is featured in the July 2018 edition of our allnurses Magazine...
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History of the shortage
In March 2000, the National Sample Survey of Registered Nurses conducted by the Division of Nursing of the U.S. Department of Health and Human Services Bureau of Health Professionals revealed several interesting facts about the future of nursing:
The average age of a registered nurse increased from 42.3 to 43.3 years between 1996 and 2000 (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000).
The number of licensed nurses in 2000 was nearly 2.7 million, which was a 5.4 percent increase since the last study. However, this was the lowest reported annual increase by the department since 1977 (Spratley et al., 2000)
The RN population under the age of 30 dropped from 25.1 percent in 1980 to only 9.1 percent in 2000 (Spratley et al., 2000).
By 2014, The U.S. Health Resources and Services Administration released "The Future of the Nursing Workforce: National and State-Level Projections, 2012-2025." In this report, 34 states were projected to have a shortage of nurses by 2025 (U.S. Department of Health and Human Services, 2014). This would create a total deficit of 808,000 nurses across the United States for the same period (U.S. Department of Health and Human Services, 2014).
While portions of the data were correct from these original studies, there have been significant changes that could not have been predicted. Let's discuss the factors at play with the current state and future outlook of the nursing profession.
Factors for Consideration
It's not enough to merely accept we that are in a nursing shortage. We must strive to understand the positive and negative factors that have affected us as a profession.
According to our 2018 Salary Survey results, with more than 16,800 participants, nurses between the ages of 50-59 made up the largest group of working nurses (25.12%), up from the 2017 results (21%). The next two largest groups included nurses between the ages of 30-39 years (23.7%) and ages 40-49 years (22.6%). The 2017 results for both of the last two age groups are down from the 2017 results (27%).
Our results indicate that the majority of our nursing population is in the middle-age of life and getting older. As we look to the future, we must consider how our aging nursing workforce will keep up with the demands of the healthcare industry.
While the baby boomers have continued to work longer than expected, we saw a new group take an interest in nursing as a career that no one saw coming - the millennials. As we look to the future, Generation Z is starting to choose careers and enter college. How does this impact our future?
Boomers, Millennials and Gen Z
Some of the predicted nursing shortage data had baby boomers and millennials pegged incorrectly. Nurses under the age of 30 accounted for 12.72% of the nurses polled in our 2018 survey, down from 16% in the 2017 survey. The over 60 group accounted for 16% of the nurses polled. This is an increase of 7% in this age group compared to our 2017 survey results. Could the millennials fill the void the baby-boomers will leave?
According to an article published by Health Affairs, millennials are becoming nurses at nearly double the rate of baby boomers (Auerbach, Buerhaus, & Staiger, 2017). However, the pending retirement of the baby-boomers is upon us, with a projected decrease of 1.3 percent loss per year between 2015-2030 (Auerbach et al., 2017). While the millennials have helped fill the positions of the baby boomers, don't hold your breath just yet. The rate of RN's taking the licensure exam plateaued between the years of 2013-2016 (Gooch, 2017). So, what's next? Should we look to the next generation - Generation Z?
Yes, the nursing workforce is still in need. According to the New York Times, Gen Z outnumbers the millennials by one million (Williams, 2015). This generation is currently finishing up their high school careers and choosing college majors. This generation may be what the future of nursing needs.
Men still hold a significantly small portion of the nursing jobs in the United States. According to the U.S. Census Bureau in 2013 the number of male registered nurses more than tripled between 1970 (2.7%) and 2011 (9.6%). The number of male licensed practical and licensed vocational nurses more than doubled from 3.9 percent to 8.1 percent for the same period.
While they hold a small portion of the total number of nurses, the trend of men entering the field of nursing has helped with the nursing shortage. They also create diversity within our profession that past generations have not seen.
The Affordable Care Act
The nursing shortage was in effect long before the Affordable Care Act (ACA) was passed in March 2010. Before the ACA, 48.6 million or 15.7% of Americans were uninsured (Bradley University, 2016). After the ACA, this number fell to 9.2%, which is the lowest uninsured rate in 50 years in the United States (Bradley University, 2016).
This is good, right? More people are insured, which should equate to a healthier American population. Unfortunately, the future of healthcare is still uncertain.
Medicare enrollment is projected to increase by 50% over the next 15 years due to our aging population (Bradley University, 2016). More people than ever before will continue to be insured in the U.S. Forty-seven percent of healthcare workers have reported that emergency room use has increased due to more people having coverage for these services under the ACA (Bradley University, 2016).
The increase in patients with insurance was not factored into the original prediction for nursing shortages. The ACA continues to impact the future of nursing by creating the following:
More jobs - As more people are insured, more nurses will be needed to care for patients. Previously uninsured people with long-term health conditions need education on disease processes, medications, self-management, and proper diet (Thompson, 2017).
Nurse-Patient Ratio Changes - The increase of insured people in the United States could mean a higher number of admissions, creating a higher nurse-patient ratio (Thompson, 2017). An increase of patients could add strain on hospitals, clinics, and other healthcare facilities (Thompson, 2017).
Higher Demand and Pay - Average pay projections for registered nurses have increased steadily since the passage of the ACA (Thompson, 2017). This is the law of supply and demand in action. As the need for nurses increases, we will have the ability to demand higher pay.
Nurse Practitioners - Nursing is not the only healthcare profession experiencing a shortage. There is a projected shortage of physicians as well. One way to combat the lack of physicians is the use of Nurse Practitioners (Bradley University, 2016). Many practices employ at least one Nurse Practitioner and will likely hire more in the future.
Nurses Leaving the Profession
As if the issues of nursing supply and demand were not enough, nursing has another problem - many nurses have plans to leave the workforce soon. According to the results of our salary survey, 35.39% of the nurses polled have plans to leave the nursing workforce within the next 15 years. But, why?
The top two reasons, which accounted for nearly 70% of respondents, included age and retirement. This correlates well with the aging nursing workforce.
However, the next three results in our survey are concerning. Job dissatisfaction was given as the reason for plans to leave the nursing profession by 7.66% of respondents. Another 4.65% reported that nurse-patient ratios were a factor influencing their decision to leave nurse. Finally, another 3.76% cited plans for career change as the reason for leaving. These three results account for 16% of those leaving the profession.
What does this mean? A 2015 article on nurse.org explained that lack of ability to move to areas of need, disillusionment with the profession, a fast work pace and workplace bullying are factors that many new nurses don't think about until they are working and find themselves dissatisfied with the profession (Dent, 2015). One study evaluated nurses intention to leave the nursing workforce related to "horizontal violence," better known as workplace bullying (Armmer, 2017). This study found that newer nurses were more likely to leave the profession while more tenured nurses felt they could just find a new job in light of workplace bullying (Armmer, 2017).
Nurse-patient ratio conversations have been an important topic in legislation lately. Many nurses understand the harmful effects of high nurse-patient ratios on burnout, increased risk of nursing errors and lower quality of care. One study evaluated the impact of wage, work environment, and staffing on nurse outcomes (McHugh, M. & Ma, C., 2014). McHugh and Ma (2014) found that while wage was important, interventions that improve the work environment and maintain staffing levels are more critical to attracting and retaining nurses in the workforce. For a more in-depth look at the importance of nurse-patient ratios, take a look at the spring issue of the AllNurses magazine.
As more nurses leave the workforce due to dissatisfaction, we must each do a personal inventory of our feelings, actions, and biases against other nurses.
Nursing Faculty Shortage and Enrollment
According to the American Association of Colleges of Nursing (AACN), nursing schools across the country are struggling to expand nursing student capacity to meet the rising demand of healthcare following reform (American Association of Colleges of Nursing, 2017). The AACN (2017) projected a 3.6 percent increase in enrollment in entry-level baccalaureate programs in 2016. However, this increase will not keep up with the anticipated demand for nursing services.
This touches on the need for nurses, but what about those people who educate nurses? You guessed it, another shortage.
An article in Becker's Hospital Review (2018) reports that nursing schools rejected over 56,000 qualified applicants from undergraduate nursing programs in 2017. Many of these applicants were top of their high school graduating classes (Knowles, 2018). The article goes on to report that nursing schools are struggling to provide the clinical space and class size accommodations needed to keep up with the number of applicants and the nursing workforce needs (Knowles, 2018).
Concerns over an inadequate number of nursing faculty further complicate this issue. According to the 2018 AllNurses Salary Survey, the average salary for an educator is $80,164. While higher clinical nursing salaries are good, it may be keeping some nurses from considering a career as a nursing instructor. The current annual national faculty vacancy rate in nursing programs is over 7 percent today (Knowles, 2018). This equates to about two teachers per nursing school, or a shortage of 1,565 teachers across the United States (Knowles, 2018).
Nursing school and faculty issues pose more concerns for the future. Even if future generations chose nursing as a profession, will nursing schools be able to keep up with the demand? How can we educate new nurses without qualified instructors? The future of our profession feels shaky.
Shortage by State
When you consider the nursing shortage, you may only look at the big picture or total number of nurses needed. Another interesting factor that must be considered is the location of the shortages. Not all states are projected to have a nurse shortage. According to Nursing@Georgetown, sixteen states will experience a nursing shortage by 2025.
The most substantial nursing shortage will be seen in Arizona, followed by North Carolina and California (Nursing@Gtown). Meanwhile, states like Ohio, Pennsylvania, and New York will experience a surplus of nurses (Nursing@Gtown).
While it seems like there is a logical solution to the problem, many nurses are not able to relocate to fill vacancies in other cities or states. We are left with a surplus in some areas of the country and massive shortages in others. Do hospitals and healthcare systems have a solution?
Healthcare systems across the country are attempting to find ways to attract more nurses to their vacancies. According to a recent article on CNN Money (2018) hospital systems like UCHealth that operates nine acute-care hospitals in Colorado, Wyoming, and Nebraska has over 330 openings for Registered Nurses.
To entice nurses to move to their locations, they have offered sign-on bonuses up to $10,000. And, that's not all, they add on stipends for continuing education too. Other hospitals have provided sign-on bonuses, relocations bonuses, and hefty tuition reimbursement packages for employees and their children (Kavilanz, 2018). The University of West Virginia even offers free housing to nurses as part of their commuter program (Kavilanz, 2018).
Bonuses and education stipends only last so long. Would higher nursing salaries make the profession more appealing? Can our current economy support wage increases across all states? Maybe a more important question- can the healthcare industry and patients afford to not have nurses at the bedside?
The Verdict: Myth versus Truth
It seems there is enough evidence to conclude that we are still in the midst of a nursing shortage. But, you must come to your own conclusion.
Many factors have both positively and negatively affected the flux of the shortage. But, the fact remains this is a complicated topic with many moving pieces. As nurses, we must continue to stay abreast of the latest data on the nursing shortage and decide how we can impact the future of nursing.
Spratley, E., Johnson, A., Sochalski, J., Fritz, M., Spencer, W. (2000). The Registered Nurse Population. U.S. Department of Health and Human Services. Retrieved from: https://datawarehouse.hrsa.gov/DataDownload/NSSRN/GeneralPUF00/rnsurvey2000.pdf
U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. The Future of the Nursing Workforce: National- and State-Level Projections, 2012-2025. Rockville, Maryland, 2014. Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nursingprojections.pdf
Auerbach, D., Buerhaus, P., Staiger, D., (2017). Millennials Almost Twice as Likely to be Registered Nurses ss Baby Boomers Were [Abstract]. Health Affairs, 36. Retrieved from https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0386?journalCode=hlthaff
Gooch, K. (2017). Millennials Represent Boon to Nurse Workforce, Join Ranks at Twice the Rate of Baby Boomers. Becker's Hospital Review. Retrieved from Millennials represent boon to nurse workforce, join ranks at twice the rate of baby boomers
Thompson, M. (2017). How the ACA Affects Nurses. National Health Care Provider Solutions. Retrieved from How the ACA Affects Nurses - NHCPS.com
Dent, S. (2017). 4 Reasons Nurses Quit (And What You Can Do Instead). Nurse.org. Retrieved from 4 Reasons Nurses Leave The Profession | Nurse.org
Nurse.org (2017). Nursing Demand by State: 2018 Projections. Retrieved from States With Highest Demand For Nurses | Nurse.org
Nursing@Georgetown. (2017). How Will the Nurse Shortage Affect your State? Georgetown University. Retrieved from How Will the Nurse Shortage Affect Your State? - Blog
Williams, Alex. (2015). Move Over, Millennials, Here Comes Generation Z. The New York Times. Retrieved from Move Over, Millennials, Here Comes Generation Z - The New York Times
American Association of Colleges of Nursing (2017). Fact Sheet: Nursing Shortage. Retrieved from: http://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet-2017.pdf
Armmer. F. (2017). An Inductive Discussion of the Interrelationships between Nursing Shortage, Horizontal Violence, Generational Diversity, and Healthy Work Environments. Administrative Sciences 2017, 7 (4), 34; doi: http://dx.doi.org/10.3390/admsci7040034
Bradley University. (2016). How the Affordable Care Act Affected Nursing. Retrieved from https://onlinedegrees.bradley.edu/resources/infographics/how-the-affordable-care-act-affected-nursing/
Knowles, M. (2018). Nursing School Reject Thousands of Applicants Amid Shortage. Becker's Hospital Review. Retrieved from https://www.beckershospitalreview.com/workforce/nursing-schools-reject-thousands-of-applicants-amid-shortage.html
McHugh, M, Ma, C., (2014). Wage, Work Environment, and Staffing: Effects of Nurse Outcomes. Policy, Politics, and Nursing Practice, 15 (0): 72-80. Doi: https://dx.doi.org/10.1177%2F1527154414546868
Kavilanz, P. (2018). Hospitals Offer Big Bonuses, Free Housing, and Tuition to Recruit Nurses. CNN Money. Retrieved from http://money.cnn.com/2018/03/08/news/economy/nurse-hiring-bonuses/index.html