Introduction and summary
Since the COVID-19 pandemic began more than two years ago, no region of the United States has been spared an acute shortage of registered nurses. In January, governors across the country, some for the second time, called in the National Guard to assist health care providers, and 1,118 hospitals—more than 1 in 6 hospitals in America1—reported critical nursing shortages.2 As of March 2022, almost every state had taken executive actions to address the shortage,3 such as issuing temporary licenses to put nursing students to work.
Registered nurses are among the professionals most sought after today. They provide care in every possible health care setting, including hospitals, physicians’ offices, outpatient care centers, and skilled nursing facilities, as well as in behavioral health settings, the home, schools, universities, prisons, and private employer settings. Nurses are not only critical providers of patient care, but they also have an important role in addressing inequities within health outcomes and improving the health of the population as a whole.
At the same time, nursing is a bedrock profession of the middle class and is particularly important for the economic security of women, especially women of color. Last year, there were approximately 3 million nurses working in the United States—the single largest category of health care professionals and the fifth-largest profession nationally, after retail salespeople, home health and personal care aides, cashiers, and fast food workers.
And yet the United States still needs more registered nurses. Tens of thousands of qualified students are turned away every year from the university degree programs that train students to become registered nurses,6 while nurses are considering leaving the profession in large numbers after bearing too much of the burden of the country’s response to the pandemic.
These problems have not received the attention they deserve, especially the lack of capacity within institutions of higher education to educate enough nurses. This report examines factors behind the current nursing shortage and discusses why nursing is a crucial occupation for improving health, economic security, and racial equity in this country. It also explores the problems inhibiting higher education from educating more nurses and inhibiting more cohesive management of nursing shortages.
Central to building a strong nursing workforce is a higher education system that has the capacity to supply enough nursing graduates to meet the demands of the health care system. This report recommends that Congress pass legislation that would invest in nursing faculty, clinical placements, and nursing program facilities so that colleges and universities have the resources to enroll and graduate more students. Policymakers should also invest in programs to help nurses who have associate degrees obtain bachelor’s degrees, which would boost the training level, wages, and career trajectories of many nurses of color.
In addition, to create a more organized strategy to address the nursing shortage, this report makes recommendations to establish or designate federal and state-level entities to monitor nursing shortages and advise policymakers and the health care and education sectors.
While this report’s recommendations are focused on the pipeline into the nursing profession, it is just as important for health care employers, policymakers, and others to address the conditions in the workplace affecting retention of nurses. This problem, and approaches that other organizations have proposed to address it, is discussed at the end of this report. (see Appendix)
About this report
To learn about the problems constraining the nursing pipeline, the authors studied existing research and conducted confidential interviews with 17 nursing experts, including nursing school deans and faculty from private and public universities and community colleges, nursing professional association leaders, state government officials, nurse union leaders, congressional staff, and others. Their insights provided background information that informed the report’s analysis and recommendations.
The contours of the nursing shortage
COVID-19 has wreaked havoc on the nursing workforce
COVID-19 has strained the health care system to its seams, and nurses have borne much of that pressure. Remarkably, amid a vast increase in the number of patients, employment levels for registered nurses declined by 3 percent between 2020 and 2021, the largest decline in at least 20 years.8 Chief nursing officers have consistently reported staffing as their greatest challenge throughout the pandemic, with vacancy rates as high as 30 percent.9 The American Nurses Association has urged the U.S. Department of Health and Human Services to declare the nursing shortage a national crisis.
An acute symptom of the shortage is the rise of travel nurses—registered nurses who are contracted to work short stints at understaffed hospitals across the country for double, triple, or quadruple their usual pay. Travel nursing grew by 35 percent in 2020 and was estimated to grow an additional 40 percent by the end of 2021.11 While health care employers have historically brought in travel nurses during full-time staff members’ parental and medical leaves or in other moments of short-term need, current conditions drive a vicious cycle: Lucrative pay draws nurses away from their usual institutions, increasing those same institutions’ demand for contracted relief.
Low morale and traumatic experiences during the pandemic are also driving some nurses to leave the profession altogether.12 This is compounded by the fact that there are now more opportunities for nurses to leave the bedside, as work is available in other industries such as pharmaceuticals, retail health, and consulting.
Nurses of color have experienced even more adversity: Throughout the corona virus pandemic, Asian American and Pacific Islander (AAPI) nurses reported that patients had refused their care—and even that they had been physically attacked.13 Although discrimination against AAPI people is not new, racist perceptions of COVID-19’s origins have contributed to an increased number of attacks on AAPI communities at large.14 A 2020 study found that overall, nurses of color were more likely to care for corona virus patients than white nurses and less likely to have access to adequate personal protective equipment.
The pandemic is not the only problem
The pressures imposed by COVID-19 have piled on top of a host of other challenges. As this report discusses in detail in a later section, the higher education system is training too few nurses. Workforce conditions, although not the focus of this report’s recommendations, are also a major problem. At the same time, demographic factors, such as increased life expectancy and the aging of the Baby Boomer generation, are also feeding today’s nursing shortage. The number of working nurses for every 1,000 Americans ages 65 and over has steadily declined, from 69 in 2003 to 62 in 2021. (see Figure 1)
Figure 1
The average age of nurses continues to rise, meaning more nurses are at retirement age each year. Today, the average nurse is 43.7 years old, up from 38.9 years old in 1978, and the proportion of nurses over age 55 has increased from 13 percent of the nursing workforce to 23 percent over the same period. (see Figure 2)17 According to the National Nursing Workforce Survey, more than one-fifth of the nurses polled in 2020—900,000-plus registered nurses (RNs) and licensed practical nurses, who practice under the supervision of RNs—plan to retire in the next five years.
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