The US Nursing Shortage: Opportunity to Close the Gap

AUTHORS:
Bensson Samuel, MD, PhD, DBA, CHCQM, CPE¹ • Nicole Oliver, RN, BSN, MBA²

AFFILIATIONS:
¹Medical Director of Inpatient Services/Hospitalist Program, War Memorial Hospital, Sault Sainte Marie, Michigan
²Senior Director of Nursing Services, War Memorial Hospital, War Memorial Hospital, Sault Sainte Marie, Michigan

CITATION:
Samuel B, Oliver N. The US nursing shortage: opportunity to close the gap. Consultant. Published online July 15, 2021. doi:10.25270/con.2021.07.00004

Received February 27, 2021. Accepted March 2, 2021.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Bensson Samuel, MD, PhD, DBA, CHCQM, 500 Osborn Boulevard, Sault Ste. Marie, MI 49783 (bsamuel@wmhos.org)

As frontline health care professionals, registered nurses (RNs) play a critical role in the provision of patient care and support, as well as administrative duties such as recordkeeping and directing nursing care systems. Moreover, they ensure that hospitals and other health care facilities are in the best position to achieve their goals and missions. Although nursing is the largest health care profession in the United States, with approximately 3.8 million RNs practicing in 2020, the United States currently faces a shortage of RNs.¹ It is projected that by 2022, there will be 100,000 new RN job openings per year—more than any other profession.²

With the ongoing COVID-19 pandemic, the growing aging population, and the increasing prevalence of chronic diseases, there is a strong need for more RNs now and in the future.

Current Trends in Nursing

Overall, the current and future shortage of RNs varies by state (Figure 1). The shortage of nursing in relation to the demand will only increase with time.³ A contributing factor to this shortage might be the age of RNs in the United States (Figure 2). The US Bureau of Labor Statistics projects that more than 500,000 RNs will retire by 2022, leaving a shortage of 1.1 million RNs across the country.² Although the number of RNs is anticipated to increase 15% by 2026, the increase is not enough to close the gap.¹

Figure 1. Supply and Demand of RNs by 2030
 

Figure 2. Age Distribution of RNs in the United States
 

In an effort to encourage medical students to join nursing programs, federal and state agencies, as well as universities, are offering incentives.^4,5 NursingCAS, an American Association of Colleges of Nursing (AACN) strategy, provides a centralized nationwide registration for nursing students. In addition, financial incentives are being offered in some states to increase RN program registration.⁶

Another factor contributing to the trend in nursing might be the salary ranges, which vary by state, years of service, roles and duties, qualifications, and other factors (Table). Health care professionals are among the highest-paid occupations in the United States, but nurses do not rank as high as specialists.⁷ The annual mean wage for RNs is highest in California, Hawaii, Massachusetts, Alaska, New Jersey, Maryland, Rhode Island, and Washington⁸ (Figure 3). RNs in Central states, such as South Dakota and Missouri, receive the lowest annual mean wage.⁸

Figure 3. Annual Mean Wage of RNs by State, May 2020
 

The COVID-19 pandemic has also impacted the nursing profession over the past year. The US health care system is one of the hardest-hit industries by the COVID-19 pandemic. Since the onset of the pandemic in 2020, health care professionals have treated millions of patients with COVID-19.⁹ As frontline workers, RNs have had complex and increased responsibilities. Longer shifts, experiencing patients’ suffering, and scarcity of resources had a major impact on health care professionals overall and the RN retention rate specifically.¹⁰ Because of this, work-related stress, burnout, depression, low job satisfaction, and exposure to the virus have increased, leading to a higher turnover rate.¹⁰

Reasons RNs Leave and Proposed Solutions

Low salaries coupled with factors such as burnout, lack of work-life balance, and dual roles as parents are the major reasons why RNs leave their jobs. Currently, the average RN turnover is estimated to be 19.1%, which varies by region as well as the nursing specialty.¹¹ The high turnover rate reduces the quality of health care services and limits hospitals’ operating abilities. Therefore, some solutions have been proposed.

Salary

RNs are choosing other, better-paying positions or roles over those that offer lower salary, which may mean relocating out of their home state. (Figure 3). The supply of nurses was not evenly distributed, with the smaller hospitals experiencing greater shortages explained partially by the lower salaries.¹² Another factor is better employment contracts that offer higher hourly rates, including contracts with travel nurse companies. Many RNs are also returning to school to obtain a nurse practitioner certification, which offers better salary and often better benefits such as vacation time, retirement match, and continued education assistance. From 2019 to 2020, only 39,000 new nurse practitioners had graduated.¹³

As a solution to this issue, institutions can consider providing a retention bonus. Research suggests that retention bonuses help RNs feel that they are valued by their employer, as well as boost morale and foster loyalty.¹⁴ Although the COVID-19 pandemic has caused financial challenges for the health care sector, organizations that have a culture of providing merit bonuses such as end-of-year, years-of-service, or employee-of-the-month bonuses should consider still doing so. Additionally, offering current staff a recruitment bonus can help hire more RNs, as well as improve current staff engagement and satisfaction.

Burnout

Burnout contributes to more than 50% of workforce turnover in all industries.¹⁵ In nursing, many factors contribute to burnout, including managing complex patients, administrative duties and responsibilities, treating and managing the aging Baby Boomer generation as well as the growing prevalence of chronic diseases, and working long shifts¹⁶ with little sleep. Many health care facilities across the country are understaffed, which has led to an increase in workload for other health care providers.¹⁷ As such, the nurse-to-patient ratio is unbalanced.¹⁸

One solution to this issue is to consider increasing the number of ancillary staff, who can provide support to RNs.¹⁹ Utilizing certified nurse aids or care technicians is key to supporting RNs and allowing them the time to devote to quality patient care, while maintaining the basic needs of the institution.

Work-Life Balance

About 1 in every 10 US adults spends more than 40% of their time at work.¹⁵ RNs also struggle to balance work and life, especially those who are parents. For RNs with children, balancing homeschooling during the COVID-19 pandemic with their nursing duties and responsibilities has been a challenge because of the long shifts mandated during the pandemic. Lack of work-life balance results in stress, which is an occupational hazard that can escalate to mental and physical issues.²⁰

To alleviate this stress, institutions should consider implementing work-life balance practices such as flexible working hours, additional paid time off, or leisure perks to promote social time with friends and family. It offers an environment away from the workplace to mentally decompress.²¹ Institution leaders can consider facilitating a self-activated approach as well. Cultivating a training program that focuses on avoiding burnout can be a starting point for addressing RNs’ needs and creating an effective work-life balance.

Connecting with family is important and can be a tool to mentally destress. However, the COVID-19 pandemic had caused closures of childcare and daycare facilities, which was another challenge faced by RNs who are parents. When parents do not have childcare available, their stress level increases and job productivity decreases. For parents who are RNs, this also leads to a higher occurrence of medical errors.²² To better integrate work-life balance, institutions should consider offering daycare services so that working parents know their children are safe.¹⁵

Conclusion

The shortage of RNs is detrimental to the US health care industry as a whole. Not only does the shortage affect productivity in the institution and patient care and satisfaction, but it also increases the burden on other health care providers and contributes to burnout throughout the industry. As a long-term solution for the shortage crisis, stakeholders in the nursing industry and individual institutions should consider implementing RN retention strategies.

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