Are There Really Enough Nurses?

Rose O. Sherman, EdD, RN, NEA-BC, FAAN

 

 

 

 

 

Like many of you, I watched the NY Times Op-Ed video published last week We Know the Real Cause of Crisis in our Hospitals. It’s Greed. It was painful and emotional to watch nurses talk about how hard their work is right now. I hear the same emotion from leaders in the virtual webinars that I do each week. Staffing shortages have skyrocketed across the country, and few units are even at their core staffing levels. For the last two decades, understaffing has been a historical problem in healthcare as nurse leaders flex up and down, responding to rapidly changing patient volumes. Except for California, which has mandated staffing ratios, most health systems entered the COVID pandemic with core staffing levels cut to a bare minimum. The strategy used was to flex up and down with per diem, agency, and travelers. And this staffing worked (sort of) until the COVID pandemic with patient surges.

Nurses in the video contended that there are enough nurses out there. The accusation made was that they are not hired because of greed on the part of hospitals. My experience working with 60 hospitals over the past 7 months paints a very different picture. Nurse leaders spend 60%+ of their time on recruitment, staffing, and scheduling. Except for a few places in a bubble, health systems across the country can’t hire enough nurses (or travelers or agency staff) to fill their positions. When they do interview candidates – they are new graduates. Some nurse leaders have told me they have no candidates applying at all. One health system I am working with has 1000 requests from nurse managers for new graduates that will enter their residency program. They project only being able to fill about 3/4 of these requests.

An additional challenge is that new graduates are not remaining at the bedside very long. Critical care leaders tell me that recent grads now break residency contracts to travel when they are not fully competent to work in the ICU. Others are back in graduate school within a year. The point is that most nurses in acute care settings today have minimal experience and many make it clear to their leaders that they don’t intend to make it a career.

All of this has led to a hot mess as nurses take on heavier patient assignments and, in some cases, support staff work (intense labor shortages with support staff as well). Not surprisingly, like the nurses in the video, nurses nationwide in acute care are burned out and exhausted as they are now in year three of the pandemic with no clear end in sight. The frustration is building as patient volumes continue to grow. Unlike restaurants that can stop taking reservations, it is a huge deal if a hospital closes beds or goes on diversion and a decision usually cannot be made at the local level.

There is plenty of blame to go around, but we are failing to consider whether there are enough nurses ready, willing, and able to work in acute care. As I review the workforce data, I think we have been overly optimistic for years about the supply of Registered Nurses. We were already on a path to having a critical nursing shortage. COVID accelerated trends that had already begun such as more acutely ill aging patients, significant RN retirements of Baby Boomer nurses, new BSN graduates returning to graduate school earlier in their careers, and nurses seeking employment outside of acute care (with growing opportunities to do so).

I often see the number 4 million actively licensed nurses in the US, but the truth is that we don’t have 4 million nurses who are ready, willing, and able to work in acute care. Nurses often keep their licenses active for years after they retire. Consider the following 2020 workforce data published by the National Council of State Boards of Nursing:

• Only 84.1% of nurses holding active licenses currently work – many of the remaining 15.9% are already fully retired.
• The nursing workforce is rapidly aging, with the median age being 52. 42.5% of the nursing workforce is over 55.
• Only 54% of nurses today work in hospital settings – there are so many other career options that did not exist even a decade ago, and this trend will escalate.
• 64.9 percent of nurses who worked were full-time in 2020 – meaning many of those working had already reduced their hours.
• 19% of the workforce was over 65 in 2020, and a significant percentage of these nurses were already considering retirement.
• The Department of Labor has projected an additional 500,000 nurse retirements by 2022, leaving the country with a potential nursing shortage of up to one million nurses.

The reality is with less than 200,000 RN graduates a year; we can’t backfill our way out of this shortage. As a profession, we bear some of the responsibility of not acting in advance of this tsunami of factors that now jeopardize our ability to provide nursing care. The only way out of this will be to completely redesign how care is delivered, create healthcare environments that focus on staff wellbeing, and reset patient expectations about hospital care. Establishing staffing ratios that can’t be met with the current workforce won’t solve the problem.

So like the nurses in the video, nurse leaders share their frustration and feel extreme guilt about understaffed units but pinpointing the problem as greed is not right either. I now recommend that leaders do staffing updates every Friday on every unit – outline the number of vacancies, number of nurses who have applied, interviews conducted, jobs accepted, and SL/FMLA use. We have not been transparent with the frontline nurses about how serious the problem really is. In the absence of information, nurses fill in the gaps with speculation. The belief that greed is a root cause is fairly widespread from what nurse leaders tell me. What we really have is a wicked problem that will not be easily solved.