How Do We Keep the Nursing Shortage From Getting Worse?

September 30, 2021

We go back in time to the country’s last major nursing shortage, examine the underlying pressures on the nursing workforce, and hear how experts say we can avoid things getting even worse.

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Dan Gorenstein: The U.S. is in the midst of a crisis, and it’s bad.

News clip: We’re talking about a nationwide shortage of nurses.
News clip: The dwindling number of nurses caring for the ever growing number of patients. 

DG: Bad for hospitals fighting another surge. Bad for the country’s 4 million registered nurses burnt out after a year and a half on the frontlines.

And bad for patients who may be missing out on critical care.

But the people who have made their careers studying the fluctuations of the nursing workforce have a warning: It could get a lot worse.

Today, a look back at the major nursing shortage that kicked off the 21st century and what needs to happen to avoid a repeat of that crisis.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

*****

DG: Peter Buerhaus remembers what life was like the last time hospitals across the country couldn’t find enough nurses. 

PB: It’s hell. It’s pure hell.

DG: Peter, a professor at Montana State University, has spent the last 30 years studying the nursing workforce.

The roots of the crisis date back to the 1980s.

As other career opportunities opened up, fewer women became registered nurses — the ones who check our vital signs and give us our meds in the hospital. 

Then in the ‘90s, many hospitals reduced their nursing staffs to cut costs.

Much like today, the nurses who remained reported being overworked and understaffed.

PB: It didn’t take long before nurses started to say, “Hey, quality and safety of care is at risk.”

DG: Then, says Peter, the growing problem turned into a catastrophe.

As word of poor working conditions spread, the supply dried up. 

People basically just stopped wanting to join the profession.

PB: Surveys of freshmen showed declining interest. Enrollments into nursing education programs dropped five years in a row. 

DG: By 2001, the American Hospital Association reported 126,000 nursing vacancies nationwide. That was 12% of the country’s nursing positions unfilled.

Peter called this a Category 5 shortage.

It touched hospitals in every state.

PB: Academic teaching hospitals, community hospitals, government hospitals.

DG: Hospital administrators woke up every day unsure where to find more nurses, and they worried that competitors would hire away the few they had.

Some hospitals had to cut hours, close down units, turn away patients.

A string of high-profile studies showed having fewer nurses spelled trouble for patients.

Montage: May 30, 2002. New York Times. Shortage of Nurses Hurts Patient Care, Study Finds. In hospitals with low numbers of registered nurses, patients are more likely to suffer complications…

August 8. Patient Deaths Tied to Lack Of Nurses. The lack contributed to nearly a quarter of the unanticipated problems that result in death or injury to hospital patients.

October 23. Nurse-Patient Ratio Linked to Death Rate. Each additional patient in a nurse’s workload meant an increase of about 7% in the likelihood that the patient would die within 30 days of admission.

DG: Peter wants to be clear: Researchers could never draw a straight line between the shortage and poor patient outcomes.

But fewer nurses on staff did increase the chance patients got hurt.

PB: Patients are at a significantly higher risk of experiencing care that should have been done for them, but missed because the nurse was too busy and at that moment said, “This patient has a higher need for my time.” And when you are tired and you are overworked, you’re at a higher risk of making simple mistakes.

DG: This threat to people’s health sparked a serious response.

Some hospitals recruited nurses from overseas.

Others increased wages.

Congress passed the Nurse Reinvestment Act in 2002 to fund scholarships and nurse retention programs.

And drugmaker Johnson and Johnson launched a $50 million national initiative to improve the image of nursing.

Clip: I am a nurse because I love people. I’m very proud to be a nurse. I want to help and I want to make a difference…

PB: These commercials were on air during the Olympics, during the Super Bowl so they paid a lot of money.

DG: The 2001 recession also played a role, driving older nurses back into the labor market.

Together, it all worked.

Nursing program enrollment rebounded, and it’s continued to grow each year since. 

Karen Lasater: I do really clearly remember hearing from seniors who were getting basically any job offer they wanted, sign-on bonuses at any hospital they wanted to be at.

DG: Karen Lasater started nursing school in 2006.

By the time she graduated four years later, those signing bonuses were long gone.

The national shortage was over because, once again, enough people wanted to get in the game.

KL: Nursing has become more and more an attractive profession.

DG: But Karen — now an assistant professor of nursing at the University of Pennsylvania — says all the renewed enthusiasm we’ve seen over the last 20 years has only papered over structural challenges that have stuck around, waiting to be exposed.

KL: This is really a chronic problem, which the pandemic is bringing to light.

DG: When we come back, why hospitals struggle to keep nurses and what steps those hospitals could take to prevent a repeat of that category 5 nationwide shortage.

MIDROLL

DG: Welcome back.

The current nursing crisis is clearly affecting the care hospitals provide.

News clip: Part of the emergency department at the Rhode Island Hospital was forced to close due to a nursing shortage.
News clip: The shortage driving long wait times for care unrelated to COVID in some places.
News clip: That strain forcing Summa Health to reduce its hospital bed capacity by 20%.

DG: We don’t have a great sense of how many nurses we’re down nationwide, but a recent report from the Association of American Medical Colleges paints a scary local picture.

240 vacancies in a Little Rock hospital. 470 at one in Dallas. 760 in Birmingham.

The pandemic has exacerbated these shortages, but the fuel was there — structural kindling just waiting for a match. 

One issue, says Montana State Nursing Professor Peter Buerhaus, is that 60,000 to 70,000 Baby Boomer nurses have retired each year going back to 2010.

PB: With them, they took lots of years of experience and knowledge and clinical judgment, leadership, mentorship.

DG: Two, more nurses are pursuing advanced degrees.

Peter’s research shows the number of nurse practitioners has more than doubled since 2010 and shrunk the pool of bedside nurses by 80,000.

In the short-term, hospitals are turning to familiar tactics: recruiting from overseas, offering five-figure signing bonuses and, of course, urging everybody to get vaccinated.  

University of Pennsylvania nursing professor Karen Lasater says the best way to avoid the shortage we saw 20 years ago may be for health care leaders to address one of the most vexing problems.  

KL: In the late 1990s, the estimates of hospital nurse burnout was about 40%. Before the pandemic, the estimates were about 50% of nurses. Now we’re up to 60% of nurses are burnt out, just in a year’s time.

DG: Historically, researchers have struggled to pinpoint how many nurses actually quit due to burnout.

But a recent national study found that’s why a third of nurses left their jobs back in 2017, and Karen found similar results when she surveyed out-of-work nurses in Illinois and New York just this spring.

Karen says many nurses end up leaving their jobs because they’re dissatisfied, frustrated with understaffing and not having enough time to do what they like most — care for patients.   

KL: Nurses say they love their work and they love what they do, but that it’s just not sustainable for them to stay working in hospitals because of this disconnect between what they know they can be doing for patients and what they are able to do for patients.

DG For some hospitals, addressing burnout could be as simple as hiring more nurses. 

New York and Illinois are considering legislation modeled after California that caps the number of patients a nurse can see.

But adding staff could be harder than it sounds given all these localized shortages and may not be the answer at all hospitals. 

Another way to boost morale and keep nurses around — let them have more responsibility and clinical autonomy. 

Karen still remembers her first clinical rotation 15 years ago, watching the nurses on a traumatic brain injury unit. 

KL: I saw that it was the nurses who were running the show, and everything that touched these patients came through the hands of nurses. And I remember coming home from that, and I still get a little choked up thinking about it now because I just, it opened my eyes to the work of nursing and that patient’s lives are in the hands of nurses.

DG: Hospitals who give nurses more authority  to provide higher levels of care are often the exception, says Karen. 

Many nurses chafe at needing a doctor’s permission to order a test or adjust a patient’s oxygen level.

KL: It has the potential to be quite demoralizing when you’re doing such profound work in service of people, and the employer that you work for, even with the best intentions, doesn’t seem to connect or demonstrate an understanding of the value you’re providing as a nurse.

DG: Peter for his part, sees a potential silver lining in our current shortage. 

Hospitals are desperate for nurses right now.

It’s a moment, he says, when administrators could very well be more open to the needs of this workforce.

PB: I think hospitals are in a position to say to their nurses, “Look, we know there have been some long-term issues that we did not attend to that created burnout for you, that created stress, and we want to come back and rectify those.

DG: Many nurses unions have grown stronger during the pandemic and are pushing hospitals to improve conditions.

Karen says research shows when nurses are in hospital leadership and have good relationships with doctors — patient mortality drops.

But even with modest progress, Peter still worries we could be on the road to another  Category 5, that the constant stream of negative stories we hear about nursing could be having a corrosive effect.

PB: If we start creating the view that, “I don’t think I want my son or daughter to go into nursing anymore. I’ve seen what happens.” Or people say, “I’m not going to do that. There’s so many shortages. I’ll work so hard.” We may decrease entrance into nursing education programs. 

DG: The steady march of new nursing grads ended the last shortage and has sustained this workforce for two decades.

Peter warns if that goes away, the country could easily head into a national calamity.

He says the lesson of the last big shortage is not to take our pipeline for granted.

I’m Dan Gorenstein, and this is Tradeoffs.

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Episode Resources

Additional Research and Reporting on the Early 2000s Shortage:

Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors (U.S. Government Accountability Office, 7/10/2001)

Nursing Shortage: Are bad working conditions causing deaths? (Biran Hansen, CQ Researcher, 9/20/2002)

The nursing shortage in the United States of America: an integrative review of the literature (Heather Janiszewski Goodin, Journal of Advanced Nursing, 7/25/2003)

Patient Deaths Tied to Lack Of Nurses (Sheryl Gay Stolberg, New York Times, 8/8/2002)

Nurse-Patient Ratio Linked to Death Rate (Associated Press, 10/23/2002)

Additional Research on Nurse Staffing and Burnout:

Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction (Linda Aiken, Sean Clarke, Douglas Sloane, Julie Sochalski and Jeffrey Silber; JAMA; 10/23/2002)

Chronic hospital nurse understaffing meets COVID-19: an observational study (Karen Lasater, Linda Aiken, Douglas Sloane, Rachel French, Brendan Martin, Kyrani Reneau, Maryann Alexander and Matthew McHugh; BMJ Quality & Safety; 8/18/2020)

Prevalence of and Factors Associated With Nurse Burnout in the US (Megha Shah, Nikhila Gandrakota, Jeannie Cimiotti, Neena Ghose, Miranda Moore and Mohammed Ali; JAMA Network Open; 2/4/2021)

Additional Research and Reporting on Nursing Workforce:

What A Dearth Of Nurses Means For The Country And COVID (Michelle Harven, 1A, 9/14/2021)

‘Nursing Is in Crisis’: Staff Shortages Put Patients at Risk (Andrew Jacobs, New York Times, 8/21/2021)

Supply and Demand Projections of the Nursing Workforce: 2014-2030 (U.S. Health Resources and Services Administration; 7/21/2017)

Episode Credits

Guest:

Peter Buerhaus, PhD, RN, FAAN; Professor, Montana State University College of Nursing; Director, Center for Interdisciplinary Health Workforce Studies

Karen Lasater, PhD, RN; Assistant Professor of Nursing, University of Pennsylvania

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions.

This episode was produced and mixed by Ryan Levi.

Special thanks to:

Joanne Spetz

Additional thanks to:

Bianca Frogner, Matthew McHugh, the Tradeoffs Advisory Board and our stellar staff!