The COVID-19 pandemic exacerbated the already critical shortage of nurses due to the compressed budgets and health concerns. Thousands of U.S. health care workers, including nurses, were sent home due to low ED volumes, cancellation of elective procedures, lost revenue, potential exposure to the virus, and or confirmed positive infection.
Although the nursing shortage is not a recent development, one lesson the COVID-19 crisis taught us is that it's high time we fix this problem before it, too, reaches pandemic proportions.
Reasons for the Nursing Shortage
The reasons for the nurse staffing shortage are many and varied, spanning everything from the lack of consistent hours to the absence of retention bonuses to stress due to the pandemic.
Vice President of Client Services at SCP Health Traci Shortt, RN, NP, practiced for many years as an RN before taking on roles in management and administration. From her perspective, hospital finances are often the root of these challenges—including budget cuts, lack of predictable income, and inability to provide fair-market raises.
Hospital Budget Cuts
Shortt indicated that when you look at the situation from a global perspective, the hospital has contracted down to bare minimums with purchase order contracts and supply costs that are relatively fixed, which leaves nurses.
"Nursing is the highest labor cost hospitals have," she said. "Amid a crisis, when the hospital has cut everything, nursing is the only fluid cost left—so they have no choice but to start cutting nurses."
Lack of Predictable Income and Consistent Hours
"Nurses want to have a predictable income and consistent hours," Shortt said. "Most nurses who stay in the profession look to advance their career as an NP or PA and find more predictable sources of income or a higher, more sustainable wage."
Inability to Provide Market-adjusted Raises or Retention Bonuses
Percentage raises in hospitals tend to range between two to five percent, according to Shortt. The market moves faster than raises, which means nurses will seek jobs that in five years, leave them earning more than nurses who remain loyal to one facility based on percentage increases alone.
"Without market adjustments that are consistent or retention bonuses, there isn’t much incentive to keep nurses from going place to place," Shortt explains. "Hospitals will need to consider how to make fair market value adjustments and give retention bonuses to staff—though that has not been well-favored from a budgetary perspective in most healthcare environments."
There are several other reasons for the nursing staffing shortage aside from those Shortt mentioned. They include:
- An Aging Workforce
The nursing workforce is also aging, not unlike the patient populations they serve.
A 2018 survey conducted by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, found that nearly 51 percent of the RN workforce is age 50 or older, which means more than one million nurses will reach retirement age in the next 10 to 15 years.
- Scarce Educational Opportunities, Nursing Programs
Educational opportunities and nursing programs are resource-intensive and scarce. A shortage of nursing schools and faculty means a limited number of places can deliver the classroom and clinical education a nursing degree requires.
The aging workforce statistic, cited above, includes nursing faculty. The decreased amount of faculty can result in not only fewer students but also the overall quality of the program and classes to decline.
- Stressful Work Environments
Hospital budget cuts translate to insufficient nurse staffing, which raises stress levels, impacting job satisfaction, driving many nurses to leave the profession. COVID-19 has amplified the problem severely, particularly in major metro and urban hospitals.
- Hospital Violence
Violence in the healthcare setting also plays a role in the nurse staffing shortage due to the potential for emotional or physical abuse. Job satisfaction and work effort are affected negatively, as physical and emotional insults take a toll on the well-being of the healthcare workers, with nurses being the most vulnerable.
- Nurse Burnout
Some nurses graduate, start working, and then find the demands of the profession take a greater toll than expected. Others may work for a time and experience burnout due to overwork, stress, emotional conflicts, and other factors. (And that was before COVID-19; it’s likely that many nurses have also fallen victim to burnout as a result of the pandemic.)
- Career and Family Priorities
Adding to the shortage problem is the fact that nursing is still majority female, and often during childbearing years, nurses will cut back or leave the profession altogether.
Additional Reading: Nursing Shortage Effect on the Healthcare Industry
Steps to Fix the Nursing Shortage
No single "magic bullet" or one-size-fits-all answer will solve the nursing shortage problem.
Just as there are many reasons for the shortage, there is also a wide range of possible solutions that require an "all-hands-on-deck" mentality, including hospital leadership, nurses, and their colleagues — physicians, in particular. Here are seven recommendations you can apply now:
1. Acknowledge Conflicts
"As leaders, it's important that we're in there masked up and gowned up with them and walking through their daily life," said Megan Brunson, RN, president of the American Association of Critical-care Nurses. "It's important that we acknowledge their ethical and moral conflicts, [and] that we take time to talk about it and make sure that they're aware of what resources are available, whether it be resources within your organization like [the Employee Assistance Program] or counseling."
2. Create an Empowering Environment
"[Hospital leadership] should encourage nurses to speak up when they're seeing things that are distressing them now, whether it be care situations or ethical concerns, and [to escalate those issues]," Brunson said. "When you do that, you're asking nurses to be courageous, to speak up, and sometimes that's not easy. So being available as a leader to really encourage them to have that courage is important. "
3. Set Reasonable Work Hours
One of Shortt's concerns was the inconsistency of nurses' work hours.
Hospitals must set realistic work hours and allow for scheduling flexibility that balances personal and professional needs, and that will enable them to decompress between stressful, emotionally demanding schedules. Also, hospitals could offer six-hour shifts to older nurses in order to allow them to continue working and give them the opportunity to train the next generation in manageable way.
4. Promote Career Development
With the new Institute of Medicine recommendations that call for 80 percent of nurses to have a bachelor's degree by 2020, hospitals should help nurses obtain the highest education possible, resulting in greater job satisfaction and the prospect of increased longevity.
To overcome the barriers of limited capacity, HealthAffairs notes that some hospitals are "growing their own" nurses by operating nursing schools, paying for students' education in return for a work commitment, or providing training and flexible hours for current ancillary staff to obtain nursing degrees.
5. Focus on Team-Based Care
There is, currently, a concerted movement toward team-based care that respects the contributions of all staff, nurses included — an essential component in staff satisfaction and another approach to increase longevity and curb the shortage.
6. Offer Market-Based Raises and Benefits
Hospitals must offer competitive salaries to recruit and retain nurses in a high-demand environment. This strategy generally involves across-the-board wage increases for all nursing staff, not just new recruits. To Shortt's point, hospitals may also want to consider offering retention bonuses. Referral bonuses are a worthwhile incentive, as well.
7. Optimize the Nursing Skill Mix
Optimizing the nursing skill mix — an evolved approach to RN staffing — leads to lower costs, improved RN satisfaction, and better patient outcomes said a McKinsey on Healthcare study.
"Traditionally, hospitals have focused on productivity (hours per unit of service, such as patient day) to determine staffing levels," the study reported. "However, this approach creates unintended incentives to reduce the number of staff members on the floor, which then limits the time spent on patient care."
COVID-19 Nursing Shortage Solutions
In an article on the nursing shortage, the Advisory Board offered two suggestions related explicitly to curbing the shortfall during the pandemic:
Relax your definition of "top-of-license" care.
Make sure that the clinical staff is not tasked with anything that could be covered by a non-clinical member of the team.
Think of your clinical staffing pool at the community level, not at the organization level.
The Advisory Board cites the need for a national system to replace the "antediluvian state licensure processes" that limits mobility.
A second efficiency is already at hand, which is the use of "contingent staffing," it said.
Not an Easy Fix
Fixing the nursing shortage will not be easy and, according to Shortt, requires a revamping of the health care system.
One solution she thinks has potential is reverting to a nursing model that functions similarly to the way hospitals now use NPs and PAs with physicians — one that expands staff bandwidth and is cost-efficient.
"Older models, where you had different nursing staff levels — LPNs, nurse techs, and an RN who led a team — goes against the grain of where nursing has advanced to today, using a primary nurse staffing model with a single nurse being responsible for one-to-one care, " she said.
How SCP Can Step In
Our SCP team understands the severe impact the nursing shortage is having on hospital staffing and its subsequent effect on patient care. We also understand that this challenge does not exist in a void—it affects and is affected by a hospital’s provider staffing approach, care model, growth strategy, investment in innovation, performance metrics, revenue cycle efficiency, community reputation, culture, and more. SCP’s comprehensive practice management and patient engagement solutions can improve clinical retention and performance across various roles and departments. If you’re interested in learning more, please let us know.