The Nursing Shortage: Exploring the Situation and Solutions
The nursing profession is and has been experiencing what is often described as an unendurable shortage of clinical nurses. Organizations are having difficulty recruiting new nurses and retaining current staff.1 The U.S. Bureau of Labor Statistics predicts the demand for registered nurses to grow from two million to 3.2 million between 2008 and 2018, a 60% increase. Ideally, a sufficient number of new graduates will fill the demand; however, according to Benjamin Isgur, Assistant Director of Price Waterhouse Cooper’s Health and Research Institute, the projections aren’t great. Of the 320,000 who applied to nursing school in 2008, only 78,000 graduated and 23% are currently working as nurses.2 After graduation, about 30,000 nurses stay in the field, but 50% leave their first job after two years. Compounding this staffing problem is the increasing age of the nursing population and their anticipated retirement.
Without a sufficient number of nurses, patient care and safety may become compromised, while nurses themselves may be overwhelmed, distressed, and dissatisfied. High patient-to-nurse ratios have been shown to lead to frustration and job burnout, which is linked to higher turnover. 3 An inadequately staffed nursing force has been found to play a negative role in patient outcomes. In contrast, studies have demonstrated that hospitals with low nurse turnover “have the lowest rates of risk-adjusted mortality and severity-adjusted length of stay.”3 In 2007, the Agency for Healthcare Research and Quality (AHRQ) conducted a met-analysis that found “the shortage of registered nurses, in combination with an increased workload, poses a potential threat to the quality of care…Increases in registered nurse staffing was associated with a reduction in hospital-related mortality and failure to rescue as well as reduced length of stays.”4
Nurses of all specialties and institutional roles, and those in administrative and leadership positions in particular, must examine the contributing factors of the current nursing shortage to familiarize themselves with the situation and determine what should be implemented to influence strategies for improvement. The objectives of this evaluation are to express the severity and implications of the nursing shortage, determine current contributing factors, and examine possible solutions, i.e., successful recruitment and retention strategies.
Reviewing the facts
Through review of literature it is easy to see that the nursing shortage is not confined to the United States but is a widespread issue. Canadian nurses, for example, are challenged by the same workforce dilemmas and report being overworked, stressed, and generally ill.5 All over the world, nurses are an integral part of the health care system and make up a significantly large portion of the health care provider population. In the United States, the largest group of nurses is expected to retire by the year 2020, pushing health care facilities’ resources beyond their limits.6 Blakeley and Ribeiro suggest that reasons contributing to a nurse’s early retirement include desire to decrease their workload, freedom and flexibility of schedules, and that senior nurses do not feel valued by their companies.7
Just over a decade ago, in 2000, the estimated pool of registered nurses in the United States was 1.89 million, while the demand was two million—a deficit of only 110,000, or 6%. Yet the gap continues to widen. In 2008, there were approximately 2.6 million working RNs, but it is predicted that by 2020 the shortage will be approximately 808,400 nurses, or 29%.8 The already fragile health care infrastructure is at risk of becoming completely handicapped by ineffective recruitment and retention, lack of nurse educators, and a growing elderly population requiring care.
In addition to the problems faced by seasoned nurses, job dissatisfaction, disappointment, and disillusionment with the nursing practice contribute to new nurses quitting. 9 With regard to disillusionment, it is simply not enough to view nursing exclusively in terms of personal commitment; it requires a “wide-range knowledge of illness, medication and appropriate treatment, comprehensive managerial skills, and emotional strength and sensibility.”10 It is important to portray an accurate and positive employment brand in any discipline, but this is particularly true for the profession of nursing.11 If individuals are expected to become dedicated and productive members of the nursing work force, job satisfaction must play a key role. Developing a retention committee to address high-ranking issues such as improving job satisfaction, approval, and expectations by providing some rewards and recognitions may be an example of positive employee branding.
Next in the series of considerations is a correlation between job satisfaction and autonomy. When nurses perceive they have little or no control within the work setting, they become frustrated and unhappy, and the desire to leave increases.1 Like any employee, nurses want to feel valued, to be recognized for their work, and enjoy the other professional benefits, such as flexible schedules. The top three areas considered by nurses in their decision to stay at their current job, according to Palumbo, McIntosh, Rambur, and Naud, are recognition and respect, a voice in discussion and decisions, and performance evaluation. Compensation ranks fourth, while the recruitment of older nurses falls last on a list of 10.
Dissatisfaction with one’s profession can also be detrimental to one’s personal health. In nursing, this is a notable dilemma. Nurses are consistently found to be among the most overworked, stressed, and sick workers, with more than 8% of the workforce absent each week due to illness.5 It is not so surprising, then, that nurses who report being unhappy in their work environment are also less motivated to perform their duties, experience more absenteeism, and tend to leave their jobs in favor of better career opportunities.
Fortunately, researchers are looking into potential solutions for the nursing shortage as they examine its causes. Their findings offer hope for maintaining and improving a healthy work environment that facilitates safe, quality health care and promotes a desirable professional avenue.
One recent job satisfaction study attempted to determine what entices and retains nurses and other human services employees. Respondents reported valuing, among other things, entrepreneurial opportunities and jobs that facilitate work-life balance. These findings suggest that focusing on an environment that nurtures advancement and autonomy may attract new younger nurses, while shorter shifts, job sharing, and work schedule flexibility would help retain veteran nurses.12 Other studies found comparable results.
Palumbo, McIntosh, Rambur, and Naud sought to examine what both nurses and their health care employers valued in the workplace. They found nurses appreciated recognition and respect. Employers’ focus seemed to center around employee health and safety, while recognition and respect ranked lower.
According to Coshow, Davis, and Wolosin, who examined decrements in registered nurse satisfaction mid-career, organizations may benefit from channeling their efforts on retaining nurses by investing in areas that result in higher job satisfaction, such as staffing, fulfillment, benefits, and pay.3 This is vitally important given their application of the Social Exchange Theory. The theory suggests that when “the benefits of maintaining an existing employment relationship are outweighed by its costs, employees will tend to seek out a more rewarding situation.” High turnover is expensive as well, with replacement costing 1.2 to 1.3 times the annual RN salary.13 As previously noted, job satisfaction is related to turnover intent, and a perceived stressful work situation, job tension, and emotional exhaustion increase its likelihood.14
Thus far two main strategies have been used to address the discrepancy between the supply and demand in nursing: first, increased nursing program enrollment, and second, the importation of nurses from other countries. However, the latter treads on controversial grounds, given the dire situations other countries’ nursing pools also share. Thus far, the strategy to increase nursing student enrollment enough to improve the shortage has failed. According to the American Association of Colleges of Nursing, U.S. nursing schools would have to increase the number of graduates by 90% to fill the gap.4
As researchers examine what motivates nurses to remain in their current work environments, they have determined the following: perceived autonomy, workload, recognition, scheduling, managements’ leadership skills, home duties, and peer relationships in the workplace all impact a nurse’s decision to stay. Concentrating on factors that affect nurse job satisfaction and promote retention can only be positive.15 Perceived autonomy, workload, recognition, and related issues deserve focused attention, as they have been found by numerous studies to be important to nurses’ job satisfaction.
Often hindering progress, however, is the gap that exists between what is being done by health care administration and what the clinical staff perceives is being done. What is highest on the clinical staff’s list and what is on the administration’s still seem to vary, despite research efforts. Most corporations’ goals are recruitment and retention, and their approach is to empower their staff to facilitate this within the organization.
A generational divide?
To facilitate improvements in nurse staffing, now and in the future, health care organizations must focus on recruitment, maintenance, and retention. A recommendation derived from a research study by Nogueras suggests policies also need to be developed to increase the recruitment and retention of young adults into the nursing profession.16 The nursing profession should be recognized as a profession that possesses high levels of pertinent scientific and technical knowledge as well as a personable aspect.10 This may appeal to younger people, or perhaps a more diverse applicant pool as well. Finally, it is imperative for nurse leaders to create and sustain an environment where employees are connected to their organization, with a focus on retention as well as recruitment. Other suggestions include examination of the hiring processes, maintaining public relations initiatives, and ensuring employee contributions as part of the recruitment of new nursing staff.11
Nurses report higher job satisfaction if they perceive they are part of a team and feel a sense of belonging, though age is another variable in retention and job satisfaction.3 Senior nurses were less satisfied across all dimensions measured. Researchers suggest organizations focus on aspects that yield higher satisfaction in older nurses such as pay, staffing, and benefits. Multiple studies focus on the retention of veteran nurses, who evidence supports prefer shorter shifts, part-time hours, and assessment of less acute patient populations.7 Younger employees were found to prefer more vacations and flexible scheduling, especially during summer holidays. Klug’s study concluded both older and younger nurses could benefit from programs and policies that support improvements in retention.17 Nurses at any age who perceive their work is appropriately recognized and rewarded tend to show more job satisfaction.7
Predicting the future
Truly, health care is facing losing a huge cohort of nurses in a small time frame very soon. Research has shown that a significant number of nurses intend to leave their current position for a new job or retire early, and in nursing schools, many of those enrolled abandon their studies. Yet, proactive maneuvers could curb the tide, such as designing work environments desirable to older nurses, developing more stringent screening tools for nursing school applicants and more supportive educational programs, and identifying ways to make becoming a nurse educator more desirable. Portraying the nurse educator as a more attractive career choice may lead to increased student enrollment and program development as well.
The retirement of the baby boomer nurses will be difficult to absorb; however, if changes are made based on evidence that supports the retention of older nurses, there is a possibility to ease that burden. But, of course, the profession will need to account for their absence eventually. Health care organizations need to focus on areas such as reward and recognition, which in turn yield high job satisfaction for, and retention of, nurses. Ideally this investment will lead to a positive employment brand that not only entices new applicants, but also affirms the commitment made by nurses of all ages.
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2. Isgur, B. (Panelist). (2008, July/ August). Conference of Statebased Nursing Workforce Centers Explores Retention Issues and Solutions. Sixth National Conference of Workforce Leaders. “Effective Retention Throughout the Career Continuum.” Retrieved from www.NursingWorld.org.
3. Coshow, S., Davis, P., and Wolosin, R. (2009). “The ‘Big Dip’: Decrements in RN Satisfaction at Mid-Career.” Nursing Economic$. 27(1), 15–18.
4. American Association of Colleges of Nursing. (2009, September, 28). “Nursing Shortage Fact Sheet” (9-09.DOC). USA: AACN.
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7. Blakeley, J., and Ribeiro, V. (2008). “Early Retirement Among Registered Nurses: Contributing Factors.” Journal of Nursing Management, 16(1), 29–37.
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15. Davis, B., Ward, C., Woodall, M., Shultz, S., and Davis, H. (2007). “Comparison of Job Satisfaction Between Experienced Medical-Surgical Nurses and Experienced Critical Care Nurses.” MEDSURG Nursing, 16(5), 311–316.
16. Nogueras, D. (2006). “Occupational Commitment, Education, and Experience as a Predictor of Intent to Leave the Nursing Profession.” Nursing Economic$, 24(2), 86–93.
17. Klug, S. (2009). “Recruit, Respect, and Retain: The Impact of Baby Boomer Nurses on Hospital Workforce Strategy—A Case Study.” Creative Nursing, 15(2), 70–74.