Defining nurse shortages
As a former bedside nurse turned data integrations leader[1], I watch the global trends in healthcare worker shortages with great interest. From my unique perspective, I wanted to better understand what the shortage actually is, as well as what’s causing it. This would allow me and other nurse stakeholders to identify appropriate solutions. Being a “data guy”, I started reviewing industry reports, as well as academic publications, to get a sense of the history of healthcare worker shortage and our current state.
My initial thought was: “shortages are nothing new.” From the perspective of a nursing care team one of the worst things one can do is “to call in sick.” The system has always been fragile, down to the level of being down a single nurse even going back 20 years ago when I started working in a hospital setting. You had to think twice (rather more like 5 times) before you would do that, and even then, the response from the ward management is almost always: “who’s gonna work then?!” Once, I had a very unfortunate fall from the top of a ladder in one of those domestic “fix it myself” situations (which later turned out to be a linear fracture in my shoulder). I called the ward and even then the answer was: “well, we need you for the shift, there is no one who can fill in for you right now. We are sorry.” The precarious situation, exemplified by “just in time” staffing has changed little in those two decades.
Today, having enough nurses to staff hospitals, surgery centers, and medical facilities is at the top of every organization’s priority list. It was bad 20 years ago but is much worse today. Why has it gotten so bad? How is it measured? Is it simply a supply problem - not enough people want to be nurses? Or is there more to it?
The gap in nurse supply
The current nursing shortage is a global phenomenon. With a total estimated global nursing shortage of 5.8 million nurses compared to what is demanded by the medical system[2] . The US stands out as particularly shorthanded, with several trends in a feedback loop worsening the problem. In looking at the current situation in the US a few concerning facts stand out: one million nurses (of the 4.2 million currently working) are expected to retire by 2030. This is mainly because 55% of registered nurses (RN) are over the age of 50. Thirteen percent of newly-licensed RNs change their job after only one year and 37% of new RNs report wanting to change their job after only one year.
In prior years, the U.S. enjoyed steady growth in the RN workforce. This has been the case since the 1970s. This growth has continued and supported the development of new hospitals and health care delivery systems. When this growth was threatened in the late 1990s, as new RN growth stagnated, Millennials embraced nursing and reversed the trend through the early 2000s. Now, during and after the COVID-19 pandemic, the supply of RNs is under threat again. New data, covering the entirety of 2021, show the total supply of RNs decreased by more than 100,000 in one year—a far greater drop than ever observed over the past four decades (Exhibit 1)[3].
Increasing demand for healthcare services, particularly nursing
To make things even less tenable, there is an ever-increasing demand for nurses due to an aging population - the number of Americans 65 or older is around 52 million, according to the Bureau of Labor Statistics[4] . In addition, Americans are living longer than ever. Despite a recent small decline in life expectancy, mostly related to the pandemic, Americans have an average life expectancy of ~76 years. Longer life expectancy plus birth rate trends means that the number of Americans 65 or older will reach 95 million by 2060. In addition, the population suffers from a high rate of chronic health conditions. It is well known in the healthcare industry that chronic conditions are on the rise in the United States [5]. In fact, about one out of two Americans has at least one chronic disease, and nearly one in four have two or more chronic conditions. Chronic diseases have risen with an aging population. I didn't even mention the fact that nursing is taking responsibility in areas where, just recently, physicians were the only providers. Which is great, if combined with proper staffing, of course. It makes perfect sense to me that we need more professionals to deal with more patients.
So, we have an ever-increasing demand for a robust nursing labor force and, on the other hand, an accelerated retirement of experienced nurses.
Key driver of supply: job satisfaction
Why have retirements accelerated and new grad nurses have left their first jobs within a year? Two words: job satisfaction (or more like dissatisfaction), This drives both early retirement as well as fewer nurses entering the workforce in the first place. This trend pre-dated COVID but accelerated with the pandemic.
A recent Medscape survey found that 40 percent of RNs said COVID-19 had negatively impacted their career satisfaction, 25 percent said they would not choose to be an RN if they could do it all over again, and 15 percent of those said they would leave the profession in three years. A 2021 survey of the general public showed a decrease in the public’s willingness to “definitely” recommend a nursing career to a family member compared to an earlier survey. When I compare this to a survey conducted in the United States in 2017 (before COVID-19) we can see the following: most registered nurses (RNs) were either moderately satisfied (48.7%) or extremely satisfied (40.3%) with their primary nursing position.
Knowing this, it is worth examining the key drivers of job satisfaction (or dissatisfaction). In March 2022, the American Nurses Foundation and the American Nurses Association released the results of its COVID-19 Impact Assessment Survey. This survey found that 52% of nurses are considering leaving their current position due primarily to insufficient staffing, work negatively affecting health and well-being, and a perceived inability to deliver quality patient care. In addition, 60% of acute care nurses report feeling burnt out, and 75% report feeling stressed, frustrated, and exhausted.
The following table represents reasons for considering leaving the current nursing position (yet not nursing itself)[6]. As a side note - changing employers often does not improve the overall picture, and very soon one might think about leaving nursing too.
It is worth noting that burnout and lack of staff are factors 2 and 3. As they are very different from the best pay/benefits. In many ways, pay and benefits may be easier for organization’s to impact than burnout as burnout is multifactorial and challenging to quantify and systematically address.
How can we reverse or otherwise address the shortage?
The primary factor that has led to the aging of the RN workforce appears to be the decline in younger women and men choosing nursing as a career during the last 2 decades. This is due to an ever-increasing workload, an aging population, sicker patients, and greater demands for nursing services. Unless this trend is reversed, the RN workforce will continue to age, and eventually shrink, and will not meet projected long-term workforce requirements.
How does one try to solve the workload and burnout issues, as they seem to be among the key factors to impact nurses' satisfaction? Of course, better pay/benefits is always the shortest path to increase satisfaction, but it is also the most problematic one in terms of systems that are often run on a very strict budget. Also, this does not tackle the problems that are grinding the workforce (increasing workload, burnout) in the long run.
Things like increased nurse-to-patient assignments, a lack of voice when it comes to their schedule and shift assignment were some of the nurses’ concerns reported. Nurse retention is often more about the conditions than it is the compensation.
Good workload management can help keep employees healthy, as high workload is a strong predictor for burnout and absenteeism. In order to tackle the issues of burnout and workload one interesting option is to incorporate more capabilities to predict workloads and staffing requirements to balance the staffing plans correctly across the different wards. By applying these types of methods, we would enable optimal shifts assignments and improve the performance and satisfaction of the staff. On a personal note, during my career as a nurse, if I had the security that my shifts were properly staffed (including the correct skill mix) and that we are prepared for anything, even being hit by the perfect storm (as we sometimes were), my professional path, potentially, could have looked very different.
What’s next?
Having unpacked the meaning of nursing shortages, and some of the key factors contributing to it, in the next few articles I will give examples of how this shortage affects actual patient related problems. Also, it would be interesting to see how the workload and staffing issues are being addressed today (if at all). And finally, I will try to think about possible solutions (even if they are still very hypothetical).
References
[1] 7 years in the neurosurgery ICU at Sourasky Medical Center in Tel Aviv, followed by the last 10 implementing medical records and large clinical data pipelines
[2] Drennan VM, Ross F.
[3] Auerbach D.I, Buerhaus P.I, Donelan K, Staiger D.O.
[4] https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage
[5] https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
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