Yves here. As the ranks of nurses are being decimiated by Covid burnout and contagion fears, the US isn’t even close to being able to replace them. And you can be sure the same hospital system execs that are refusing to ante up with hardship pay on the assumption that nurses are disposable also believe that of course they’ll be able to hire enough down the road because markets.
And while it might be possible to augment doctor ranks by hiring more MDs who got their degrees overseas, how many nurses would move relocate abroad, giving up family and friends, to live in an increasingly third-world-y US in a not terribly well paid job?
By Rayna M. Letourneau, Assistant Professor of Nursing, University of South Florida. Originally published at The Conversation
Despite a national nursing shortage in the United States, over 80,000 qualified applications were not accepted at U.S. nursing schools in 2020, according to the American Association of Colleges of Nursing.
This was due primarily to a shortage of nursing professors and a limited number of clinical placements where nursing students get practical job training. Additional constraints include a shortage of experienced practitioners to provide supervision during clinical training, insufficient classroom space and inadequate financial resources.
Although the 80,000 may not account for students who apply to multiple nursing schools, it clearly suggests that not all qualified students are able to enroll in nursing school.
I am a nurse researcher, professor of nursing and founding director of WIRES, an office at the University of South Florida that focuses on the well-being of the health care workforce. I’ve found that the nursing shortage is a complex issue that involves many factors – but chief among them is the shortage of faculty to train future nurses.
Growing Demand for Nurses
There are not enough new nurses entering the U.S. health care system each year to meet the country’s growing demand. This can have serious consequences for patient safety and quality of care.
Nationally, the number of jobs for registered nurses is projected to increase by 9% between 2020 and 2030.
Some states project an even higher demand for registered nurses because of their population and their needs. Florida, for example, will need to increase its number of registered nurses by 16% over the next decade.
The U.S. Bureau of Labor Statistics estimates there will be about 194,500 openings for registered nurses each year over the next decade to meet the demands of the growing population, and also to replace nurses who retire or quit the profession. This means the U.S. will need about 2 million new registered nurses by 2030.
In addition to a shortage of registered nurses, there is also a shortage of nurse practitioners. Nurse practitioner is identified as the second fastest-growing occupation in the next decade, after wind turbine technicians, with a projected increase of 52.2%. Nurse practitioners have an advanced scope of practice compared with registered nurses. They must complete additional clinical hours, earn a master’s or doctoral degree in nursing, and complete additional certifications to work with specific patient populations.
The COVID-19 pandemic has exacerbated the health and wellness problems of the nursing workforce. Despite these problems, student enrollment in nursing schools increased in 2020. The pandemic has not turned people away from wanting to pursue a career in nursing. However, without enough nursing faculty and clinical sites, there will not be enough new nurses to meet the health care demands of the nation.
Need for More Nursing Faculty
Currently, the national nurse faculty vacancy rate is 6.5%. This is slightly improved from the 2019 rate of 7.2%. More than half of all nursing schools report vacant full-time faculty positions. The highest need is in nursing programs in Western and Southern states.
Nursing education in clinical settings requires smaller student-to-faculty ratios than many other professions in order to maintain the safety of patients, students and faculty members. Regulatory agencies recommend at least one faculty member to no more than 10 students engaged in clinical learning.
The faculty shortage is also affected by the fact that many current nursing faculty members are reaching retirement age. The percentage of full-time nursing faculty members aged 60 and older increased from roughly 18% in 2006 to nearly 31% in 2015.
The American Association of Colleges of Nursing reports the average ages of doctorally prepared nurse faculty members at the ranks of professor, associate professor and assistant professor were 62.6, 56.9 and 50.9 years, respectively.
Another factor that contributes to the nursing faculty shortage, and the most critical issue related to faculty recruitment, is compensation. The salary of a nurse with an advanced degree is much higher in clinical and private sectors than it is in academia.
According to a survey by the American Association of Nurse Practitioners, the median salary of a nurse practitioner, across settings and specialties, is $110,000. By contrast, the AACN reported in March 2020 that the average salary for master’s-prepared assistant professors in nursing schools was just under $80,000.
Fixing the Faculty Shortage
Innovative strategies are needed to address the nursing faculty shortage. The Title VIII Nursing Workforce Reauthorization Act of 2019 was a start. The act provides funding for nursing faculty development, scholarships and loan repayment for nurses, and grants for advanced nursing education, nursing diversity initiatives and other priorities.
The Build Back Better Act that passed the U.S. House of Representatives in November 2021 includes funding to help nursing schools across the country recruit and retain diverse nursing faculty and enroll and retain nursing students. The act is now before the U.S. Senate.
In addition to national strategies, individual states are addressing the shortage at the local level. Maryland, for example, awarded over $29 million in grants to 14 higher education institutions with nursing programs in Maryland to expand and increase the number of qualified nurses.
Finally, offering faculty salaries comparable to those in clinical settings may attract more nurses to use their expertise to train and expand the next generation of health care workers.
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I’ve a lot of older nurses in my wider family – for my mothers generation nursing was the one career choice* where a woman from a modest background could be independent and travel and make a good living and pension. Some of them were/are scarily formidable ladies who had clocked up an impressive number of countries they’d lived and worked in.
The impression I get from nurses I know today is that they are stymied by the strong preference of hospitals – public and private sector – for immigrant nurses and agency nurses (even when the latter are clearly more expensive). The reason is straightforward – they are seen as more biddable and controllable and create fewer problems for doctors and administrators. I guess this isn’t unique to nursing, but it does seem to be that in many countries – this problem isn’t unique to the US – there is a built in incentive for health authorities to reduce the number of locally trained nurses, so they can then bring in outside staff, preferably from cultures where they are trained from a young age not to question authority.
*assuming you didn’t want to be a nun.
I second Plutonium K. There are two types of jobs in the US; those that refuse to allow foreign trained immigrants to compete for the jobs (Are you listening, lawyers, teachers and architects?) and those t where the workers have limited political power and that are open to foreigners on a “few or no questions asked” (Sheetrock crews, dishwashers and nurses). As for college, I see no reasons to measure inputs that limit supply. Measure outputs (who can pass the practical and written exams). Some of the best nurses I’ve know stared as non-degreed- and they are the ones who stuck to the job. Wall Street trading desks and the NFL wide reciever corp are filled with non-educated people who are simply “Good at the job”).
And as for shortages.. raise the salaries and see what happens.
Take it from someone with post grad educaton; education and degrees are not the same.
Over a decade ago I had a discussion with my brother in law about a future shortage of doctors and nurses.My thinking was that the population was aging and would require more health care. We needed to increase training of doctors and nurses. At that time we were actually closing nurse training schools. Unfortunately my thinking is becoming a reality. A big drawback preventing students entering training in these professions is the cost of their education. Our government needs to provide funds, not loans, so more qualified students can be trained. In the US it seems we wait until something becomes a crises before we act. Better long term planing needs to happen or we will continue to go from one crises to another crises.
There was an article in the local newspaper where the county wasn’t able to hire nurses. Our republican leader blamed unions for the problem. He said wages were locked in because of the union contract.I believe if he wanted to he could open negotiations to raise the wages. This man is on record wanting to close the county nursing home. Probably this is his motivation. Apparently the county is in the process of hiring their third employment agency to solve this problem. A better solution would br to use that money to give the nurses a pay raise.
I work with a nursing school in my day job. There’s a tremendous amount of new outside money pouring into scholarships and into the school via state and fed grants.
The crazy part is that I have seen a tremendous amount of outside money pouring into nursing for years prior to that. HRSA has fully funded paid trainees for years and years now, for instance.
Funding doesn’t seem to be the problem. The problem is likely that the wages don’t match the work and thus you have a “natural” bottleneck.
An angle from Germany & Denmark’s healthcare systems:
Germany’s kinda private, kinda public health care (roughly 10% is privately insured, 90% is in compulsory membership in dozens of for-profit-but-kinda-regulated ‘public’ insurance companies) and the MBA/neoliberalisation of hospitals means that:
– doctors are revenue sources (the more of them you have, the more services are you allowed to bill to the private / ‘public’ insurers.)
– nurses are costs (the less/lower paid of them you can make do with without backlash, the lower your running costs)
– Germany’s previous health minister Spahn (CDU) promised +13000 new ICU beds sometime 2017ish. Post covid we are now -6000.
– given that new goverment (SocialDems, Greens, Liberals) won’t be able to change that & Merkel’s CDU constitutes a large fraction of the opposition it’s now only the far left (Linke) and far right (AfD) that bemoan this vocally.
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In Denmark’s nearly completely state-run health care system the profit motive is reduced, but there are equally nutty MBA ideas around like forcing hospital departments to perform x% more (3-4 % p.a. usually) services with non-increased budgets. Nurses are currently striking because of promised & non-delivered salary increases and general over-working.
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On the big scheme, health care budgets are barely increasing with inflation, while aging population, equipment, patented pharmaceutical costs and the ever increasing digitisation projects are growing fast in cost. What’s gonna give?
– A predominantly female working profession (correlation between high % females in a profession and average low pay)
Messed up.
Yves wrote:
Tens or hundreds of thousands of nurses — that’s how many. In the past fifty years the U.S. has imported waves of nurses from the Philippines, Jamaica, Haiti you name it. When I was last in a rehab facility in Brooklyn, none of the nurses was U.S.-born; the most thoughtful among them was from the Ivory Coast.
I’m not saying that the U.S. medical system’s reliance on immigrant nurses is a good thing. Those nurses are nurses the sending countries educate but then don’t get to utilize.
Filipino nurses is pretty much a trope. The chain of migration is so long, many already have professional, personal, and familial connections to the US. Going to the US is also a better bet than going to a Gulf State, and other Asian countries are less welcoming culturally and linguistically.
Filipino nurses were hit hard by the early COVID surges – especially since many are concentrated in NYC and Northern New Jersey. See https://www.sciencefriday.com/segments/filipino-nurses-america-medical-system/
Check out the nursing subreddit r/nursing if you want to be a fly on the wall as nurses discuss their jobs. It ain’t pretty.
Find an older nurse who doesn’t have foot, ankle, knee or hip pain. Some of that is due to time on one’s feet. Some is due to the pressures that can lead to eating and smoking as coping mechanisms, where the latter may not quite offset the former in that brutal calculus of survival on and off the ward.
Somewhere in all of this there must be assumptions about how many nurses are needed, how long they stay in the profession and when they leave or retire. If you therefore need to replace X nurses per year you can plan capacity on that basis. The trouble is that, in every country I’m aware of, health professionals are leaving in unprecedented numbers. And whereas people can leave very quickly, it takes years to train their successors if you are suddenly trying to ramp up. A family member working in the NHS commented to me that the government is putting a lot more money now into recruiting paramedics, not least because many foreign nationals are going home. But it’ll be a year at least before any of them are the remotest use even for mundane things. In general, I don’t think a surge capacity for training exists anywhere in today’s cost-conscious health sectors.
Er… um…nurses aren’t widgets. Who knew?
Well that can’t be right. I’m sure that they are listed on a PMC’s spreadsheet somewhere – in a column marked under ‘Disposable Assets.’
My place of employment has a library, most of the books are about popular management philosophies.
I read most of them twenty years ago, only a few really stick in my memory.
The ones I’ve been thinking about lately are about productivity in general, but use the manufacturing facility as the setting for sort of folksy illustrations of concepts.
The one concept I remember well was the necessity of protecting important ‘assets‘ with buffers that prevent systemic bottlenecks that impede production.
The surprising lesson was in part that insisting that these ‘assets‘ be busy all the time in order to assure maximum ‘productivity’ could be counter-productive.
The example used in one of the books entailed managers being offended to find some of their highest paid employees reading newspapers while on the job.
Long story short, after many mistakes in assessing the ‘problem‘ they found out that the free time that allowed for reading the news paper was evidence of a buffer that assured these important employees were available to do the jobs only they could do, and this buffer protected the smooth operation of the rest of their workforce.
The free-time/buffer also allowed time for the important employees to teach their fellow workers, and lend a skilled hand when ‘real‘ problems came up.
I’m probably missing important details of this story, but I’ve seen enough real-world manipulation of workers by managers who believe everyone should be ‘busy‘ to understand that this is not necessarily the case.
What I’m getting at is the oft sighted issue of under-staffing on the part of nurses, near the top in their complaints about working conditions.
It seems obvious to me that hospital management is making mistake in trying to wring-out the most of their nursing staff because under-staffing means nurses have less, to no time to contribute to the buffer functions that nurses can represent to the rest of the hospital systems.
I would guess, for example that most doctors understand that nursing staff represent a buffer that protects their time, and effort.
I would also guess that time spent teaching is experienced as one of the more rewarding parts of the job, and that working in an under-staffed environment means not much time to teach.
I don’t think I’m guessing when I say that nurses are also concerned that under-staffing short-changes patient care, in some cases dangerously.
I have had a few nurses I know leave hospital environments because the short staffing meant they were incredibly busy all the time, and that put patients at risk. Putting patients at risk puts their licenses and livelihoods at risk, so they left. Clinical jobs in Drs Offices pay as much or more than a hospital, why stay?
A note on short staffing… hospitals in areas that were not hard hit initially laid off nurses in the ER and other settings because there were fewer patients while everyone was at home. The hospitals in my area never restaffed to the higher levels even as patients ticked back up, and told nurses to take care of more patients, thus imperiling the the nurses’ licenses.
I am sure they will staff up for the next JCAHO inspection, but that is a good way off. For profit medicine is a great system.
I failed to mention that in a properly staffed facility, nurses provide a buffer for each other, with too little staff, there is no one to turn to when you need a hand.
In a sane world, for profit medicine would be illegal.
Gee if there were some sort of proxy for value in our society that could be adjusted to increase the supply of nurses.
It could be increased to respond to shortages.
Admitting students who are more likely to stick with the profession is another approach to addressing the shortage. The university where I teach recently upped the GPA and academic requirements for admission to nursing while little if any effort is made to admit those most likely to serve long careers. It shouldn’t be that hard to determine those likely to stick with the profession and factor that into the admissions process. It’s unlikely that over-reliance on academic credentials is helpful.
In my ten years as a nurse I have had the misfortune of reading too many things written with this exact same Doctorate Nursing Researcher tone and cadence. We agree on the problem certainly but her proposed solutions are suffering from a fixation on academic credentials. I am forever grateful to all the nurses with many years of experience that I have worked alongside who helped me grow as a professional. And now these are the same nurses who are part of The Great Pandemic Bedside Exodus. Where are none of them going? Education. Look, for most of them teaching the next generation would be the perfect and also most satisfying next job, but on paper and in the eyes of the universities they are simply not qualified for the role. Unless they get a Master’s degree.
And after 20+ years working, who is going to want to invest the additional time and money into more college?? I feel strongly that nursing is not some independent academic profession, but instead a blue collar trade and we would all be better off if that was the accepted understanding.
Yes, the idea that the answer to the nursing shortage is more nursing PhDs (I assume that’s what ‘doctorally prepared’ means) seems… questionable.
The university where I worked for the past seven years has a nursing program, but like all 4-year nursing programs in the state of California, the program is always “impacted” and turns away numerous applicants. I always suggested that the best way to become a nurse was to do the ADN (Associate Degree in Nursing) program at one of the community colleges (they are also full up, but you have a better chance of enrolling). It would save money and the training was top notch. Then – and here’s the sticky part – one would then transfer to a bachelor’s in nursing completion program. That’s because, in order to have a viable career in nursing, now, an RN must have the four year degree. There is a program called the Magnet program that is raising the bar for nurses. Being a Registered Nurse with a two year degree is career killing. The metric was, I believe, 85% RNs with four year degrees by 2025, going to 100%. Imagine being an experienced RN and now having to go back to school for a four year degree (BSN). That’s not only an insult – what about the costs. I left the university at the outset of Covid, so I’m out of touch with what is currently now going on with nursing. Reading all this, I’d say nothing good.
One of the great joys is seeing these lofty administrative goals foisted upon us from on high come crashing down to earth, pulled by the strength of the gravity of real world conditions. Magnet BSN requirement…say hello to nursing shortage + pandemic. Anyways I tell anybody who asks to get Associates Degree and then if needed any hospital these days will pay the majority of cost for BSN.
I agree with getting the Associates Degree in Nursing (or perhaps an EMT-Paramedic or LPN) before enrolling at a university. Starting at a 4-year school and applying to nursing in the 2nd year risks not getting admitted and having nothing to fall back on from two years of coursework. Less than the top half of the university class is typically admissible to most nursing programs – it’s not easy. Most BSN’s start with an Associates degree.
The federal government (and those it grants rights to) creates money into the system. A couple of possible choices (out of many):
1. Create money to directly create an educational system to get medical professionals necessary for the population.
2. Create money to create debt so that any extra productivity and wealth developed can be extracted by favored individuals / corporations / etc.
3. Create a shortage thereby further increasing extractive possibilities as well as limiting who has “access” to medical resources. Added bonus creates a revolving door cycle back to no# 2.
4. Extract resources directly from other nations on the other nations’ / individuals / communities’ dime at no real cost to the federal government. If medical professional cannot be utilized in a medical capacity, it’s still all good because that (over-)educated widget can be utilized to create additional wage worker competition elsewhere.
Anecdotal data here.
The two RNs in my family are out. Always dealing with understaffed, overworked, underpaid. Both in their fifties. Covid just made it that much worse
Another RN I know switched to being a traveling nurse because the pay is almost an order of magnitude better, and is done with being an RN as soon as their student debt is paid. He’s in his thirties.
A community college I worked at until recently (Covid annihilated enrollment, and therefore my teaching position) is a good example of how unscrupulous machine politicians (who control the institution) can take something absolutely real and deeply concerning — the nursing shortage — and leverage them for deeply corrupt purposes in this banana republic America we live in.
Their angle was essentially, as an institution with no endowment and that relies on student tuition to pay the bills (said tuition often from Fannie Mae or VA student loans), to get as many “customers” as possible. Thus they set up a deeply cynical advertising campaign throughout greater Boston area, the thrust of which was — “Become a nurse! Earn up to $80,000 a year!”
Now, this comm. college is absolutely and de jure controlled by the Mayor’s office of the significant Boston area municipality that is the actual owner of the college, a situation, to my knowledge, only existing elsewhere in the country on certain American Indian Reservations. This is rightly viewed by the powers that be in the Accreditors’ offices as a threat to the independence of the school — to whit: —
In order to bring in the nursing students and therefore their attendant income, all prerequisites, whatsoever, to become a nurse were dropped by the College, in a deeply cynical bait and switch to often actually illiterate (in English) and innumerate individuals who will simply not be able to become nurses. To effect this policy change, the Mayor’s office put his sister-in-law — also the sister of both the Chief of Police and the State Senator — Boss Tweed stuff, this is! — in charge of the nursing program.
Her background? An Associates Degree in Business Administration, from the very college in question! That’s it! No scientific background whatsoever. She then ran the program into the ground, causing not just one, but two, mass exodi of nursing faculty, among the kindest and loveliest and most intelligent colleagues I have ever had. After the Commonwealth of Massachusetts suspended the nursing program after a precipitous decline in test scores from students, she was shunted out of that position, failing upward to a position as Registrar, in which she produced three different mutually wrong academic calendars every year. She moved up to control the local satellite campus here in Cranberry Country, and, quelle surprise, survived the Covid layoffs.
And this is why you cannot get anyone to teach nursing there worth a damn.