Where Did All the Nurses Go - and Where Can I Find Them?
For years, organizations across the country requiring a large nursing workforce have struggled with labor shortages. Debates surrounding squeezed wages in lieu of corporate profit and a lack of resources have dominated headlines. Fast forward to today, and an already strained healthcare industry has been pushed to the edge due to the unprecedented challenges of the Coronavirus pandemic.
The country’s hospitals, medical offices, clinics and other healthcare access points requiring nursing staff face a fierce battle for recruiting and retaining the same experienced talent.
This begs the question, “Where have all the nurses gone, and how can recruiters find them?”
An Aging Population
Like most of the Western world, America has an aging population. In fact, the U.S. has the third-highest aging population in the world.
According to the Urban Institute, the number of Americans aged 65 and older will more than double over the next 40 years, reaching a staggering 80 million by 2040.
As people age, the country’s demand for healthcare increases. Not only does this strain healthcare services, but as the number of nurses entering retirement surges, a large and primarily unfulfilled pool of vacancies is left behind.
As the wave of retiring baby boomer nurses grows, filling the gaps in the pipeline becomes harder. Since 2012, roughly 60,000 retired nurses have left the workforce each year. Between now and 2030, it’s estimated that 1 million nurses will retire and roughly half will retire as early as 2022.
To prevent a worsening shortage, the U.S. Bureau of Labor Statistics projects the need for 1.1 million new registered nurses to fill the gap. This mass exodus was not unforeseen, with shortages documented in 2015 and projections of staff deficits discussed as far back as 1990.
However, with a smaller, younger generation and a steep increase in the cost of education, it’s no surprise there’s a concerning lack of talent in the pipeline. Before the pandemic, nurses were told to “do more with less” as healthcare staff was stretched thin and burned out from increased workload and fewer resources.
Of more than 418,000 nurses who left the profession in 2017, more than 30% of them said they left due to burnout caused by stressful environments and inadequate staffing. On average, 13% of nurses change jobs in the first year, and 37% say they “feel ready” for a change.
Educational and Financial Obstacles
Student interest in nursing hasn’t dipped. Many students still express an interest in pursuing a career in the profession. However, several educational and financial obstacles seem to deter them, contributing to the shortage. Per NurseJournal.org, the gap between available jobs and people graduating from nursing school continues to expand.
In addition, education costs have increased. Although grants and scholarships are there to help those in need, there is not enough to go around.
The average price of a four-year nursing degree is between $90,000 to $250,000. But the average nurse’s salary sits at approximately $75,000 a year; in addition, student loan debt for nurses averages around $47,000. Although a career in nursing is still highly preferred, particularly among millennials, the financial burden is too much for many.
A lack of qualified nursing faculty members is also a contributing factor to the shortage. According to a report by the American Association of Colleges of Nursing (AACN), “US nursing schools turned away 80,407 qualifications from baccalaureate and graduate nursing programs in 2019 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.”
Attracting more faculty is proving difficult, and many smaller, private and rural institutions are feeling the pain. Providing enough financial incentives to entice people to teach often isn't possible, leaving institutions unable to offer prospective nurses the training they need.
A ‘Quick Fix’
Low staffing levels lead to lower patient satisfaction. Without adequate numbers of experienced nurses on hand, patient care suffers. In hospital settings, this can contribute to increased mortality rates and/or complications following surgical procedures.
When faced with a shortage of anything, the obvious solution is to fill the gap. In the U.S., this is usually done by hiring more temporary or supplemental nurses through agencies. It’s estimated that agency nurses make up around 30% of the workforce in the U.S. While there's no doubt that agency nurses are professional and adequately trained, a study from Castle (2009) showed that an increase in temporary staff puts more pressure on permanent staff.
After all, senior staff are responsible for orientation and providing guidance for new workers. When new team members come in at a high volume, the time available to permanent nurses decreases, which has a ripple effect on the quality of patient care.
The apparent solution is recruiting new, long-term staff members to improve retention; however, this has become increasingly hard. Nursing is a notoriously stressful job, and as such, many nurses turn to agency work for more flexibility and increased pay. By working with agencies, nurses can work part-time to balance other commitments.
Although the shortage is deep enough to be approached with national urgency, some states are faring better than others. According to LaborIQ, although the demand for experience nurses exceeds supply across the U.S., these are the top 15 of the largest metros that currently have the best supply of nurses with two to four years of experience compared to demand:
- Akron, OH
- Asheville, NC
- Boston, MA
- Charlotte-Gastonia, NC-SC
- Columbus, OH
- Dallas-Fort Worth, TX
- Dayton, OK
- Detroit-Warren-Dearborn, MI
- Houston, TX
- Miami-Ft. Lauderdale, FL
- Pittsburgh, PA
- Sacramento, CA
- San Antonio, TX
- Seattle-Tacoma-Bellevue, WA
- Washington-Arlington-Alexandria, DC-VA-MD-WV
In 2030 projections from RegisteredNursing.com, the report finds that several states will have an overage of nurses compared to demand, while larger states will still experience a significant shortage.
There are a few trends to consider when analyzing these statistics. For starters, major cities tend to always need a larger supply of nurses, and many city hospitals offer hundreds of positions regularly. Mid-sized cities tend to have the highest local concentrations of nurse employment vs. national nurse employment, and rural communities feel the pinch of nursing shortages more than metropolitan areas.
Shortages and potential growth can be confusing when assessing different areas and studies separately. As such, we need to approach these long-term projections as guidelines and reassess on a regular basis as fresh data becomes available.
The Cost of Living and Workforce Distribution
Several factors can cause states to enjoy an ample supply, or a surplus, of nurses. Trends indicate that nurses, like most workers, will live and work where the cost of living is lower. Based on the annual mean wage of registered nurses and the cost of living in each state, Nevada and Texas emerge as the most popular.
Ohio, which appears several times in the top 15 metros with the most probable supply of nurses, is also attractive for workers. The median salary for a recent graduate registered nurse in Columbus, Ohio, is $61,000. When you consider that research from Best Place gives Ohio a ‘cost of living score’ of 82.6 (anything below 100 is cheaper than the U.S. national average), graduate nurses can afford a higher standard of living in Ohio.
However, if you look at some of the states most affected by the shortage, you’ll see a different story. Projections for 2030 put California at the top of the list. Although the average nurse’s salary is higher here, averaging around $71,500, Best Place put its cost of living score at a staggering 149.9. This makes California a far less cost-effective area for nurses to live and work.
Other states featured in the top 15 also score well for cost of living, growth opportunities and diverse workforces. For instance, Texas, which appears three times in the top 15, is in the 90th percentile for registered nursing salaries when adjusted for living costs. Massachusetts, which also appears in the top 15, is one of the best states for nurses; nurses in the Bay State earned the fourth-highest average salary in the nation.
A shortage of experience is one of the biggest contributing factors to the nursing shortage. An increase in the number of new nurses entering the workforce and the rising rates of retiring, experienced nurses are leaving behind a more novice workforce. This ratio varies from state to state, depending on the median age of the general population and the nursing workforce.
Interestingly, Akron, Ohio, which ranked first in our top 15 states with the most nurses, has a state median age of 36.7 years. Compare this with the median age of 42 in Florida. The density of an aging population can determine the distribution of the nursing workforce, widening the experience-complexity gap in several states.
If the U.S. is to overcome the nursing workforce shortage, there’s lots of work to do. What’s the best next step?
The answer appears to lie in a comprehensive, multi-faceted approach:
- Better education: Lower course fees and more advanced training programs that empower nurses to attain more senior leadership positions.
- Compensation commitment: A healthcare provider organization pledge to increase wages to keep pace with the cost of living will help improve retention rates in the states most affected by the shortage.
- Investment: Financial investment into clinical facilities for trainee nurses is needed, so they can gain more hands-on experience. This will go a long way toward reducing the experience-complexity gap.
Today, the impact of the nursing shortage affects the workforce and patients alike.
How can a healthcare provider organization to fill the gap? In addition to ensuring that working conditions are supportive so that the organization maintains a reputation as a good place to work, proactively attract the experienced nurses you need by offering competitive total compensation packages. Compensation intelligence tools like LaborIQ® can simplify the process of researching the best salary for a given location, education, experience, employer size and industry for over 20,000 job titles and provide compensation benchmarking for improved employee retention.
For the healthcare provider industry overall, the factors contributing to the experienced nurse shortage are complex. To combat the nursing gap, the healthcare industry should tackle several priority areas, from education and financial investment to training.
Although some states have remained unscathed by the shortage, without a widespread, impactful commitment to change, they may soon feel the sting.