Nursing shortage:

Consequences and
solutions
You’ve heard about the nursing shortage, but what does it really mean
for your practice and your patients?
By Amanda Perkins, DNP, RN

We’re facing the challenge of an impend- each year until 2029. Over the last 9 years,
ing nursing shortage, made worse by we’ve seen approximately 60,000 RNs
shrinking nursing faculty and fewer avail- leave the nursing workforce each year. As
able seats in nursing programs. There are of 2018, 55% of nurses working in the US
29 million nurses worldwide, with 3.9 are older than age 50; within the next 10
million in the US. It has been projected to 15 years, 1 million RNs will be eligible
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that nursing will be one of the top profes- for retirement (see By the numbers).
sions for job growth until the year 2029. This article discusses the nursing short-
It’s expected that the RN workforce will age, including contributing factors, the
increase by 7%, or 221,900 nurses, in the effect on patients and nurses, and the way
10-year period from 2019 to 2029. This is in which nurses can positively impact the
in addition to 175,900 projected RN jobs nursing shortage.

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 Contributing factors Americans, with nearly 80 billion baby
A variety of factors contribute to the nurs- boomers reaching retirement age. This will
ing shortage, including working conditions, lead to increased patient care demands on
increased number of patients, violence in nurses and is compounded by the fact that
the healthcare system, retirement of experi- three out of four people older than age 65
enced nurses, difficulty retaining new grad- have multiple chronic diseases. Currently,
uate nurses, lack of seats in nursing pro- people older than age 65 living in the US
grams, and a nursing faculty shortage. are at the highest number they’ve ever
been. With a nursing shortage, we may not
Working conditions be able to effectively meet the needs of pa-
The nursing shortage is negatively affect- tients seeking healthcare.
ing the profession by causing nurses to
work short-staffed and under increased Violence in the healthcare system
amounts of stress. This raises the risk that A common occurrence in healthcare, work-
current nurses will choose to leave the place violence can occur on a spectrum
profession. The workload for many nurses that starts with threats and progresses to
is intense and demanding, leading to these assault or even homicide. The types of
nurses feeling both physically and emo- workplace violence that nurses may en-
tionally exhausted. Problems with the cur- counter occur when the perpetrator is a
rent work environment include increased current or former employee; a patient,
demand; lack of support; inadequate au- family member, or friend; associated with
tonomy; strained work relationships; and an employee, but not affiliated with the
lack of fairness, incivility, and respect. organization; or not associated with em-
Working in difficult environments leads ployees or the organization. Violence com-
to an increased likelihood of nurse turn- mitted by a patient, family, or friend is the
over, further impacting staffing issues and most common type experienced by nurses.
increasing the difficulty of the work envi- The increased violence seen in health-
ronment. Research has shown that job satis- care facilities is often due to the high
faction is highly associated with the inten- amount of stress associated with illness
tion to leave a nursing job. Poor staffing and being in the healthcare setting. The
and increased patient assignments are asso- highest rates of workplace violence are
ciated with nurse burnout, dissatisfaction, seen in the ED. Workplace violence is often
and decreased retention rates, all of which underreported; in fact, many nurses think
will contribute to the nursing shortage. that violence is an expected part of the job.
People working in healthcare are more
Increased number of patients likely to be assaulted than police officers
Another factor affecting the work environ- or prison guards and account for nearly
ment is the increasing number of aging 50% of nonfatal injuries due to assault in
the workplace. Dealing with workplace
violence can lead to nurse burnout,
By the numbers increased incidence of nurses leaving the
• 7%—expected RN increase by 2029 profession, and fewer nurses in the work-
• 60,000—number of RNs leaving the workforce each year force because of injuries and turnover.
• 55%—nurses older than age 50
• 1 million—number of nurses eligible for retirement in the next 10 to 15 years Retirement of experienced nurses
• 30% to 50%—attrition rates for new graduate nurses in the US
The average RN is age 50 or older, and
• 17.1%—1-year turnover rate for new graduate nurses
approximately one-third of the nursing
• 33.5%—2-year turnover rate for new graduate nurses
• $37,700 to $58,400—cost of replacing an RN
workforce may be eligible for retirement
in the next 10 to 15 years. In addition to

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a looming nursing shortage, we’re also
facing an upcoming shortage of experi- consider this
enced nurses. This could lead to prob- A new graduate nurse accepts a nursing job on the medical-surgical unit
lems with the quality and safety of pa- of a busy hospital. She’s excited to start her first nursing job but after a
tient care as experienced nurses retire month, she’s questioning her decision to become a nurse and thinking
about leaving the profession. She has had four different preceptors, three
and new graduate nurses enter the pro-
of whom are new graduate nurses themselves with a combined 1 year of
fession while patient care becomes more
experience. She has found it challenging to learn her role working with so
complex. Currently, there are more novice many different nurses, many of whom are unsure of their own nursing role.
nurses and those nearing retirement in She’s also frustrated and stressed out because she recently started caring
the nursing workforce than there are for a full patient load of five acutely ill patients. She feels unable to provide
nurses who fall in the middle, which safe care, is afraid of harming her patients, and feels incompetent. She
hasn’t been the case since 2000. requests a meeting with the unit’s nurse manager and shares that she’s
considering leaving the organization and the nursing profession.
Loss of new graduate nurses The nurse manager listens and asks questions about what challenges
Increased patient care errors are seen the new graduate nurse has faced, requesting that she consider staying
when new staff start at a healthcare facil- for at least another month. The nurse manager then meets with the nurse
educator and they develop an orientation for the new graduate nurse with
ity. This may be due to new graduate
an experienced nurse. The new graduate nurse feels more supported and
nurses lacking technical and critical-
able to care for her assigned patients and decides to stay. This leads to
thinking skills because of a lack of expe- the development of a transition-to-practice program for all new graduate
rience, which is essential for the growth nurses. The program results in improved retention rates and new graduate
of the nurse. Although some estimates nurse satisfaction ratings on the unit.
are predicting that we’ll be able to meet
the growing demands for RNs, this
doesn’t mean that we’ll have the most new graduate nurses are expected to be
appropriate nurses in these new roles. work ready from day 1; however, this is
Since 2012, there has been an estimated an unrealistic expectation that can dam-
loss of 60,000 nurses per year, which has age the nursing profession by increasing
led to new and inexperienced nurses be- stress, burnout, and attrition rates in new
ing placed in roles that they aren’t ade- graduate nurses. In the US, attrition rates
quately prepared for, such as the ICU. for new graduate nurses may be as high
Another potential problem is that a as 30% to 50%. Nationally, the average
lack of experienced nurses may lead to 1-year turnover rate for new graduate
new graduate nurses training and orient- RNs is 17.1%, jumping to 33.5% after 2
ing other novice nurses. This is concern- years. The inability to retain new graduate
ing because practical knowledge and the- nurses is costly for the organization, can
oretical knowledge are different, which is lead to nursing shortages, and may nega-
highlighted in Benner’s Novice to Expert tively impact patient care. The cost of one
theory: novice, advanced beginner, com- RN leaving an organization is approxi-
petent, proficient, and expert. New gradu- mately $37,700 to $58,400. Another way of
ate nurses fall under the category of nov- thinking about lost cost is to remember
ice to advanced beginner. The advanced that the replacement cost for an RN is esti-
beginner, who’s often placed into orienta- mated to be 75% to 125% of their salary.
tion roles, will have basic nursing skills,
but will need continued guidance from Lack of seats in nursing programs
experienced mentors. Although we’ve seen increases in the
Stressors affecting the new graduate number of students enrolling in nursing
nurse include increased responsibility, programs, this increase isn’t enough to
being fearful of asking questions, and a meet current demands. In 2019, there
knowledge-practice gap. In many cases, were 80,407 nursing program applicants

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 turned away because of a variety of fac- work environments promote decreased
tors, such as a shortage of nursing faculty medical errors, increased patient satisfac-
and clinical associates, lack of clinical tion, and improved patient outcomes.
sites, lack of classroom space, and budget In some cases, healthcare facilities
difficulties faced by nursing programs. attempt to combat fewer nurses working
The inability to educate new nurses will by increasing the rates of other staff mem-
further impact the nursing shortage. bers such as licensed nursing assistants.
Although this is thought to save money
Nursing faculty shortage and address staffing issues while main-
Nursing faculty are also facing shortages. taining appropriate patient care, it has
Faculty shortages can negatively affect been associated with higher hospital mor-
the quality of education and lead to a de- tality. It’s important to note that the
clining number of nursing students. Lack increased cost associated with staffing
of faculty is the main contributing factor more nurses is offset by decreased lengths
to denials of entry into nursing programs. of stay, ICU admissions, infections, and
In fact, in most cases, the lack of nurse readmissions.
faculty and clinical associates is the main
factor for turning away nursing students. The impact of COVID-19
The nursing shortage has led to increased A new challenge faced by healthcare or-
pressure on nursing programs to increase ganizations is the nursing shortage that
the number of enrolled students, which has developed because of COVID-19.
isn’t feasible considering the lack of nurs- Since the start of the pandemic, we’ve
ing faculty available to teach. seen nurse-to-patient ratios increasing
The issues faced by nursing faculty while the number of nurses available to
include noncompetitive salaries, unreason- work has decreased. In some organiza-
able work expectations, work responsibili- tions, a 1:1 nurse-to-patient ratio is now a
ties that are unmanageable, and promotion 1:4 ratio. It hasn’t been uncommon for up
and tenure requirements. Another issue to 10% of nurses in a facility to be out
faced by nursing faculty is that many nurs- due to COVID-19 related issues, which
ing administrators in higher education has put considerable strain on a system
don’t have formal leadership training and that was already strained.
are often chosen for their positions based The pandemic hit some organizations
on their ability to teach instead of lead. so hard that they made the decision to
Lack of appropriate leadership may cause allow asymptomatic COVID-positive
poor retention of nursing faculty. nurses to come to work and care for
COVID-positive patients. In some facili-
Patient outcomes ties, nurses exposed to COVID-positive
More RNs in the workforce improves out- people didn’t need to quarantine unless
comes for both patients and nurses. Poor they were symptomatic. Retired nurses
nurse staffing has been associated with in- were even asked to return to work to help
creased preventable deaths, readmission ease the burden. The need for and use of
rates, and hospital-acquired infections and travel nurses also increased to address
decreased quality of care. On the other shortage issues. However, travel nurses
hand, appropriate staffing is associated are often sent to the highest bidder, which
with decreased mortality and infection leaves some healthcare facilities at a dis-
rates, shorter hospital stays, decreased ad- advantage. The stress associated with the
verse care outcomes, and improved pa- current work environment increases the
tient satisfaction. Job satisfaction is also risk of burnout, turnover, and nurses leav-
associated with quality of care. Healthy ing the profession.

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What can we do?
The threat of a nursing shortage isn’t go- Utilizing LPNs
ing away without hard work and change. In the past, LPNs played an important role in the acute care setting;
Nurse administrators/managers, leaders, however, in recent years they’ve been phased out. In some organizations,
and those providing direct patient care the LPN role is making a comeback because of the nursing shortage.
can work together to make a positive dif- Before the 1970s, LPNs and RNs weren’t differentiated. In the 1980s, LPNs
ference. Nurse managers and leaders can started to move out of the acute care setting and into other nursing roles. In
fact, between 1984 and 2005, LPNs in the acute care setting decreased by
take the following steps to combat the
nearly 50%, which led to fewer LPN educational programs. With the nursing
nursing shortage:
shortage taking hold, it may be time to bring LPNs back to the acute care
• be aware of the workforce within the setting. LPNs could be used to fill staffing shortages in many different
healthcare facility settings. Incorporating LPNs is also time saving because traditional LPN
• determine which units will be most programs last 1 year compared with 2 to 4 years for RN programs. Nurse
affected leaders within schools of nursing can push to develop LPN and LPN-to-RN
• share information obtained programs to help combat the nursing shortage.
• speak with nurses who are close to re-
tiring about ways to keep them working
• be prepared for nurse managers and Nurse managers and leaders should
leaders to retire. determine how many nurses are of retire-
Nurses working in well-staffed facili- ment age and current retention rates for
ties rate the quality of care higher, are less the facility and each unit. Any informa-
likely to report poor patient safety culture, tion obtained should be shared with the
and are more likely to recommend the entire organization. When speaking with
facility to others. Appropriate staffing also nurses close to retirement, nurse manag-
leads to decreased rates of burnout and ers and leaders can help retain these nurs-
improved retention. One way to address es by offering schedule changes, unit
staffing levels in a healthcare organization changes, and/or decreased hours. The
is to increase the number of LPNs work- best way to determine what the nurse
ing (see Utilizing LPNs). needs or wants is to sit down and have a
Leaders need to create healthy work discussion with them. When preparing for
environments within the healthcare organi- the retirement of nurse managers/leaders
zation, including well-developed policies and clinical nurses, training for replace-
and procedures that consider the organiza- ment staff should begin early.
tion, employees, and patients. Multiple Addressing workplace violence by
studies have shown a correlation between a identifying those at high risk for perpe-
healthy work environment and job satisfac- trating violence, such as patients who are
tion. Components of a healthy work envi- agitated or impaired, can lead to less
ronment include effective communication, nurse turnover. Nurses should be trained
collaboration, and decision-making in addi- to identify potentially dangerous situa-
tion to appropriate staffing, transformation- tions, use de-escalation techniques, and
al leadership, and meaningful recognition. implement interventions if a patient
Healthy work environments improve staff becomes aggressive in the healthcare set-
performance, satisfaction, and retention. ting. Overall, policies and procedures
When working to develop healthy work regarding workplace violence aren’t well
environments, nurse leaders should consult established; nurses at all levels can help
with nurses to determine what works well develop new policies and improve current
and what areas can be improved. Positive policies and procedures, including man-
work environments lead to healthier nurses datory behavioral management courses
who perform at high levels and are com- focused on managing potentially aggres-
mitted to the organization. sive patients.

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 To improve the preparedness of new nursing workforce and patient care.
graduate nurses, clinical facilities can Through teamwork and diligence, nurses
partner with schools of nursing to at all levels can work together to tackle
improve clinical experiences. Nurse man- these issues and effectively address the
agers and leaders should work to improve nursing shortage. ■
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taking leadership roles in higher education. Amanda Perkins is an Associate Professor of Nursing at Vermont
Tech in Randolph, Vt., and a Nursing made Incredibly Easy! Editorial
Board Member.
Teamwork needed The author has disclosed no financial relationships related to this
This article highlights a variety of issues article.

that can have detrimental impacts on the DOI-10.1097/01.NME.0000767268.61806.d9

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