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The Growing Shortage of Nurses and Its Impact on Patient Care

Elizabeth R. Handley-Samick

Department of Nursing, Youngstown State University

NURS 6900: Healthcare Issues and Trends

Dr. Susan Lisko

April 10, 2023

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Abstract

The United States nursing shortage has been an issue that dates back to the 1930s. Attempts to

improve the shortage have been made multiple times, mainly through government funding that

enables more people to obtain a nursing education and join the workforce. However, funding has

only temporarily improved the number of actively working registered nurses (RNs). The nursing

shortage has been found to negatively impact patient care, with an increase in the number of

medical errors made, as well as an increase in patient mortality. These poor outcomes are very

worrisome for healthcare providers and spark the need to find a more permanent solution to

improve the nursing shortage. Methods that improve retention and entice those who have left the

profession to return to the workforce may solve the nursing shortage. Retention can be improved

by increasing job satisfaction through compensation, benefits, and growth opportunities. In

addition, mandating patient-to-nurse ratios has been found to reduce nurse burnout.
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The Growing Shortage of Nurses and Its Impact on Patient Care

According to Rosseter (2022), “the RN workforce is expected to grow from 3.1 million in

2021 to 3.3 million in 2031, an increase of 195,400 nurses” (para 2). However, when the

estimated retirement of nurses and the number of nurses that leave the profession are considered,

it is estimated that there will be 203,200 job openings for registered nurses (RNs) each year

through 2031 (Rosseter, 2022). This is a drastic disparity between the supply of nurses

graduating from school and the demand from hospitals and other medical facilities/companies.

From an economic standpoint, the supply of nurses may be where the balance is lacking, as there

are not enough nurses entering the workforce to meet the demand (Huston, 2020). However, the

demand for nurses is higher than ever with increased technological advancements, healthcare

changes, and patient acuity (Whelan, 2011). Whether it is a supply or demand issue, the nursing

shortage has a devastating impact on patient care, such as increased errors, increased patient

mortality/morbidity, increased provider stress, and burnout, which worsens the cycle of nurses

leaving the profession.

Historical Aspects

The nursing shortage dates back to the 1930s during the Great Depression. The hospitals

were busier with more complex patients during this time, but the hours nurses could work were

reduced. This resulted in a need for an increased number of nurses to deliver care. At the start of

the shortage, the demand for nurses was too high for the number of nurses working in the

profession. This became a supply issue when World War II started in 1939 (Whelan, 2011).

It is estimated that about 77,000 nurses left the workforce during the war to assist with

military needs. At the time, this was about 25% of the nurse population. In response, the hospital

systems attempted to admit and train more students to become nurses. However, not as many
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people were interested in nursing as they had hoped due to the low salary nurses made at the

time, the long hours they were expected to work, and the living conditions they were expected to

reside in. This resulted in the federal government intervening and providing money to subsidize

nurse education. A small amount of money was initially given with little success, and in 1943,

the Bolton Act was created to provide $160 million for nursing education and support of nursing

students. This provided free education, as well as free uniforms for nursing students. In addition,

the schools that received this fund had agreed to shorten their education program, which resulted

in more students finishing school quickly. The program was very successful, with 160,000 nurses

participating and joining the workforce (Whelan, 2011).

In addition to the Bolton Act, more licensed practical nurses (LPNs) were staffed in

hospitals to help alleviate the supply shortage of nurses. Hospital administrations could have

staff more quickly as there was a shorter training program for LPNs, and the cost for this training

was lower than that of an RN. In addition, admission into an LPN program was less rigorous,

which enabled more people to be admitted and subsequently increased staffing (Whelan, 2011).

After World War II, many RNs who assisted with the war did not return to their prior

roles in civilian hospitals. The supply shortage of nurses worsened as demand increased, with a

documented 26% increase in hospital admissions between 1946 and 1952. To make matters even

worse, the money from the Bolton Act ran out, resulting in fewer nursing school admissions.

Hospitals then continued to put their efforts into recruiting new students, as they had in the past,

rather than working on retaining nurses (Whelan, 2011).

Since then, the federal government passed the 1964 Nurse Training Act, which again

provided funding for nurse education, increasing the number of nurses enrolled in nursing

education programs. In addition, when Medicare and Medicaid were introduced in 1965,
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guaranteed payment from the federal government was ensured through these programs, which

left room in hospital budgets to begin offering nurses better salaries. This also resulted in an

influx of nurses joining and rejoining the workforce (Whelan, 2011).

Today, the nursing shortage seems cyclical, with staffing being adequate at times and

inadequate at other times. While providing shorter RN education programs increases the speed at

which nurses can enter the workforce, the demand for American health care is increasing daily

and will likely continue to rise (Whelan, 2011).

Nursing Implications

Patient safety is one of the main components of a healthcare system that is scrutinized

when the quality of care is reviewed. Patient safety can be ensured by preventing medical errors

and evaluating patient discharges and outcomes.

When a patient is admitted to the hospital, the provider they spend the most time with is

their RN. The RN acts as a liaison between the patient and other medical team members, and

they may be one of the first people to notice when a medical issue needs to be addressed. In fact,

some studies have found an association between the number of RN hands-on patient care hours

per day and a shorter length of stay in the hospital (Needleman et al., 2002). With this in mind, it

could be assumed that when there is a shortage of nurses working in a medical facility, there is a

more significant opportunity for an issue to be missed. As the number of patients a nurse is

assigned increases due to low staffing on a hospital unit, the likelihood of a sentinel event also

increases. In a surgical patient setting, it was found that “each additional patient per nurse was

associated with a 7% increase in the likelihood of dying within 30 days of admission” (Aiken et

al., 2002, p. 1987). This is very concerning for patient safety, as patient mortality is the gravest

result a patient could have after or during a hospital stay.

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In addition to patient mortality, medication errors have also been linked to the nursing

shortage. Many errors are made in the hospital. However, medication errors are the most

detrimental to a patient’s safety and the most prevalent error in hospitals. Medication errors can

harm the patient and lead to an increased length of stay, higher hospital bills, and a lack of trust

between the patient and their providers (Huston, 2020). To prevent these medication errors,

secondary stops have been put into place for high-risk medications, such as requiring a dual sign-

off and visual prompts given by the medication-dispensing machine. Despite these preventative

measures, medication errors still occur, and one of the main reasons for this is the nursing

shortage and high patient-to-nurse ratios. These findings were confirmed in an emergency

department when 94 nurses were selected to fill out a questionnaire regarding medication errors.

Results of this study showed that about half of the participants had reported making a medication

error at some point in their careers. A shortage of nursing staff and fatigue from a high workload

were both associated with these errors (Ehsani et al., 2013). If the nursing shortage is improved

and patient ratios are not as high, the frequency of these medication errors would likely decrease,

and patient safety would be improved.

A shortage of nurses working in the hospital means that the nurses working must make

up for this shortage by taking on the responsibility of more patients. This is often mentally and

physically exhausting for RNs as there are often no times for breaks during a 12-hour shift, and

there is much stress that can come from the expectations associated with taking care of additional

patients. Fatigue and burnout are often the results of this. In a way, fatigue, burnout, high-patient

ratios due to short staffing, and medication errors are cyclical. Higher patient ratios lead to high

emotional exhaustion and job dissatisfaction resulting in nurses leaving the profession (Aiken et

al., 2002). Thus, worsening the nursing shortage further and leading to more patient errors.
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Proposal of Resolution

Resolving the nursing shortage will be challenging, and there is a long road ahead. As we

have discussed, funding has been attempted to enable more people to go to nursing school and

enter the workforce. However, plenty of RNs are actively working in hospital systems today,

with there being around three million licensed nurses and 2.6 million of those nurses actively

working. It may be time for hospital systems to work on retention and keeping nurses in the

profession or bringing those back who have left rather than seeking to train new nurses

continuously. Properly compensating nurses, providing good benefits, and providing growth

opportunities may help nurse job satisfaction and entice people to stay within the profession

(Whelan, 2011).

In addition, implementing mandatory patient ratios may help reduce the stress and

burnout that causes nurses to leave their profession. California is the only state in the United

States that legally requires hospitals to maintain a minimum nurse-to-patient ratio. Other states

have made efforts to improve staffing by requiring hospitals to have a staffing policy and

committees responsible for staffing. These states include Connecticut, Illinois, Nevada, New

York, Ohio, Oregon, Texas, and Washington D. C. (Huston, 2020). According to Huston (2020),

these “ratios have improved nurse retention, raised the numbers of qualified nurses willing to

work, reduced burnout, and improved morale” (p. 164). As with most things, there are pros and

cons to implementing mandatory patient ratios. For instance, a higher cost is associated with

mandatory ratios due to having to pay additional staff. However, one could argue that

continuously training new staff and offering sign-on bonuses to nurses to onboard at select

facilities is also a great expense.

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The nursing shortage is an issue that has been around for almost 100 years, and it is likely

to be an issue that persists for many years. In the past, the issue seemed to stem from a supply

discrepancy. However, the demand for nurses has been far more significant in recent years than

the supply. With the increasing technological advancements and changes in healthcare, as well as

patient acuity, the demand for nurses to meet these new requirements is ever-increasing.

However, demand cannot be changed, and recognizing this as the primary issue may not

necessarily influence the shortage issue of today (Whelan, 2011). Working to retain nurses

currently in the profession and regain nurses who may have left the profession in the past is an

excellent place to start. This can be done through improvements in compensation and benefits

and by providing growth opportunities. In addition, a further examination into and

implementation of mandatory patient ratios may also help with retention and reduce nurse

burnout. Using these tactics, the nursing shortage may be less severe, and better patient outcomes

may occur. In addition, a decrease in medical errors and patient mortality may also occur.
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References

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse

staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16),

1987–1993. https://doi.org/10.1001/jama.288.16.1987

Ehsani, S. R., Cheraghi, M. A., Nejat, A., Salari, A., Esmaeilpoor, A. H., & Nejad, E. M. (2013).

Medication errors of nurses in the emergency department. Journal of Medical Ethics and

History of Medicine, 6(11), 1–7.

Huston, C. (2020). Professional issues in nursing: Challenges and opportunities (5th ed.).

Wolters Kluwer. 

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing

levels and the quality of care in hospitals. New England Journal of Medicine, 346(22),

1715–1722. https://doi.org/10.1056/nejmsa012247

Rosseter, R. (2022, October). Nursing Shortage. American Association of Colleges of Nursing.

Retrieved April 10, 2023, from https://www.aacnnursing.org/news-information/fact-

sheets/nursing-shortage

Whelan, J. C. (2011). Where did all the nurses go? Nursing, History and Health Care. Retrieved

April 10, 2023, from https://www.nursing.upenn.edu/nhhc/workforce-issues/where-did-

all-the-nurses-go/