Definition/Introduction
Nurses are a critical part of healthcare and constitute the largest segment of the health profession. According to the World Health Statistics Report, there are approximately 29 million nurses and midwives globally, of whom 3.9 million are in the United States. Estimates indicate that more than 1 million additional nurses are needed by 2020.[1][2] According to the American Nurses Association, more registered nurse jobs are available through 2022 than any other profession in the United States. According to an article in Nursing Times, the United States Bureau of Labor Statistics projects that more than 275,000 additional nurses are needed from 2020 to 2030. Employment opportunities for nurses are projected to grow at a faster rate (9%) than all other occupations from 2016 through 2026.
Issues of Concern
The nursing profession continues to face shortages due to a lack of potential educators, high turnover, and inequitable workforce distribution. The causes of the nursing shortage are numerous and of concern.[3][4][5][6][7][8] Some potential reasons are explored below.
Aging Population
Overall, the population is aging, with the baby boom generation entering the age of increased need for health services. Currently, the United States has the largest number of Americans aged 65 and older than at any other time in history. In 2029, the last of the baby boomers reach retirement age, resulting in a 73% increase in Americans aged 65 and older, from 41 million in 2011 to 71 million in 2019. As the population ages, the need for health services increases. In reality, older adults rarely contend with a single morbidity; more often, they manage multiple diagnoses and comorbidities that necessitate ongoing care. The population is living longer as a whole, leading to increased use of health services. Many once-terminal disease processes are now survivable in the long term. Treating these long-term illnesses can strain the workforce.
Aging Work Force
Like the populations they serve, the nursing workforce is also aging. There are currently approximately 1 million registered nurses aged 50 or older, meaning that one-third of the workforce could be at retirement age within the next 10 to 15 years. This number includes nurse faculty, which presents a unique challenge: training more nurses with fewer resources. Nursing faculty shortages lead to enrollment constraints, reducing the number of nurses a nursing school can produce. A decrease in faculty can result in fewer students, and the overall quality of the program and its classes may decline.
Nurse Burnout
Some nurses graduate and begin working, only to determine that the profession is not what they expected. Others may work for a while, experience burnout, and leave the profession.[9] Turnover in nursing seems to be leveling off, but only after years of steady climbing in rates. Currently, the national average turnover rate ranges from 8.8% to 37.0%, depending on geographic location and nursing specialty.
Career and Family
Adding to the shortage problem is that nursing remains predominantly female, and many nurses, particularly during childbearing years, reduce their hours or leave the profession altogether. Some may eventually return, but others may move to a new job.
Regions
Current shortages and potential growth can be confusing when examining the United States regionally. Some regions have a surplus of nurses and limited growth potential, whereas other areas struggle to meet the local population's basic needs. Nursing shortages vary widely by region. Greater shortages are observed across different places, depending on the nursing specialty. Some areas exhibit significant deficits in critical care nurses, labor and delivery, and other specialties.
Growth
The fastest growth potential in the United States is projected for the West and Mountain regions, with slower growth in the Northeast and Midwest. A higher need is observed in areas with large retirement populations. Despite these differences, every state is projected to have at least an 11% growth through 2022.
Violence in the Healthcare Setting
Violence in the healthcare setting plays a role in the nursing shortage, and the ever-present threat of emotional or physical abuse adds to an already stressful environment. Job satisfaction and work effort are adversely affected, as physical and emotional insults take a toll on the well-being of healthcare professionals.[10] Emergency department and psychiatric nurses are at a higher risk due to their patient population. A study conducted in Poland between 2008 and 2009 concluded that nurses are the most vulnerable group to workplace aggression in healthcare settings. Verbal abuse in the form of being spoken to by a person using loud vocal tones was the most common form of violence nurses were subjected to. Inpatient nurses experienced more insults than those in outpatient settings. Health care workers are at high risk of violence in all parts of the world, with between 8% and 38% suffering some form of violence in their careers.
Clinical Significance
All of these potential reasons for nurses' departure from the profession contribute to nursing turnover, thereby affecting staffing ratios. Staffing ratios are of clinical concern.[11]
Staffing Ratios
When bedside nurses, rather than managers, decide acceptable nurse-to-patient ratios, job satisfaction increases, turnover rates decrease, and intention to leave their chosen profession declines. Appropriate staffing levels may decrease errors, increase patient satisfaction, and improve nurse retention rates. Nursing shortages lead to errors, increased morbidity, and mortality. In hospitals with high patient-to-nurse ratios, nurses experience burnout and dissatisfaction, and patients experience higher mortality and failure-to-rescue rates than in facilities with lower patient-to-nurse ratios. Some states have begun to pass legislation to limit patient-to-nurse ratios. Despite this, when staffing is short, ratios go up to meet the need.
Nursing, Allied Health, and Interprofessional Team Interventions
Technology
The introduction of electronic medical records and other technological advances can also affect nurses' retention in the profession. While some specialties, such as nursing informatics, are expanding rapidly, this exacerbates the shortage by diverting nurses from direct patient care. Some seasoned nurses struggle with technology and leave the profession at an earlier age.
Empowerment
Organizations must be creative in meeting nurses' needs while providing the best and safest care to patients. An environment that empowers and motivates nurses is necessary to rejuvenate and sustain the nursing workforce. Empowering autonomy in staffing-ratio decisions, while accounting for high volume and acuity, may reduce burnout and the desire to leave the workforce. Many organizations have sought Magnet Certification to enhance nursing processes and achieve high levels of safety, quality, and patient satisfaction.[12]
