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Addressing the Nursing Shortage in the United States: An Interview with Dr. Peter Buerhaus

The nursing shortage in the United States has reached a crisis point. Hospitals that have been overwhelmed by patients with COVID-19 face an additional challenge because nurses have decided to no longer work in hospital care, have gone to work in temporary positions, or have left the workforce altogether. To understand this problem better, Dr. David Baker, Editor-in-Chief for The Joint Commission Journal on Quality and Patient Safety , interviewed Dr. Peter Buerhaus on January 27, 2022. Dr. Buerhaus is a professor in the College of Nursing at Montana State University and director of the Center for Interdisciplinary Health Workforce Studies. He's one of the leading authorities in the country on the nursing and physician workforces in the United States. Dr. Buerhaus is both a nurse and a health care economist, so he brings a unique perspective and experience to his work in this area.

Dr. David Baker: The COVID-19 pandemic has been devastating in so many ways, but one of the most profound negative consequences has been the strain that it's placed on nurses. How is the pandemic affecting the current nursing supply?

Dr. Peter Buerhaus: Let me just begin by noting that as of today, there have been about 72 million reported cases COVID in the United States, and 872,000 people have died from the disease. Nurses have tried to care for these patients, they've done their best to try to save them, and they have to live with the emotion of having lost a patient. At the same time, nurses have helped save tens of thousands of lives. So I'm just glad we are having this conversation.

I'd like to start with a 40,000-foot-level look at this. The nursing workforce is composed of about 3.5 million registered nurses who are working on a full-time basis and then another roughly 400,000 who are working on a part-time basis. So there's a lot of nurses in the country. About a million RNs are working in inpatient care units, and about a third of those are working in ICUs and emergency departments. We were all shocked at how rapidly that demand for care increased for nurses with the education, the skills, and clinical experience needed to take care of so many very critically ill patients.

Now if we get down closer to ground level, I think the pandemic has decreased the supply of nurses, and it's come about in several different ways. Some nurses have become ill with COVID-19 themselves, and they aren't in the workforce while they're waiting to get cleared, or they've left permanently as a result of having COVID. Others are not in the workforce because they don't want to increase their risk of exposure to the disease and give it to their families. Others aren't in the workforce due to vaccination requirement policies and their beliefs about vaccination. Some nurses are not in the workforce because they are taking care of parents or in-laws, they're raising children and providing home schooling. And some RNs have retired sooner than they had planned. For the first time in 10 years, we saw an overall drop in employment among RNs, LPNs, and nursing assistants about five or seven months into the COVID pandemic.

Dr. David Baker: So, do you think that this is going to have a lasting effect? What do you see coming in the next decade for the nursing supply?

Dr. Peter Buerhaus: Just recently, our team, using data through 2019 just before the COVID pandemic began, we estimated the RN workforce would grow by about one million, reaching 4.5 million in 2030. So this is really good news because these projections take into account the retirement of an estimated 640,000 baby boom RNs who are expected to retire by the end of the decade. We'll be able to replace those RNs and add another million. Now that's the good news. But what concerns me are, are factors that affect entry into the workforce and exit out of the workforce.

We don't know this, but the pandemic could speed up and condense the time for RNs who were planning to retire over the decade and maybe move that up closer. So we could have an accelerated rate of retirement in the next couple of years. We could also see the pandemic leading to younger and middle-aged RNs withdrawing from the labor market for the reasons that I just described.

And depending on the magnitude and timing of these sort of reactions, the exit from the workforce in coming years could disrupt labor markets and have real consequences for employment. They could aggravate shortages or even create new shortages—that's the exit side. The entrance into the labor market is also something I'm concerned about. If the pandemic decreases people's interest in becoming a nurse, this would lead to decreased enrollment in the nursing education programs, and decreased graduations, and ultimately less entry into the nursing workforce.

Decreased entry would have a significant impact on the future, and more so than the retirements. Now if both of these occur, both the exit from retirements and withdrawal of existing nurses and decreasing entrants due to loss of interest in becoming a nurse, then we're setting up the potential for very large and persistent shortages. We would be in big trouble. We would see hospital operations and health care systems being deeply affected, and this would harm patients and harm those nurses who remain in the workforce.

Dr. David Baker: So how can we put the nursing supply on a more stable footing going forward? You've talked about these different factors increasing the supply as well as the exodus of nurses. How do we address those two factors?

Dr. Peter Buerhaus: In the first place, I would suggest that we start to get control of the messaging of nurses and of hospitals. And by that, I mean that I believe that way too much of the current imagery, the tweeting media coverage, the social messaging about nurses and about hospitals is, frankly, just dreadful. It emphasizes unprecedented shortages, their negative effects, and that hospitals are to blame. And I think if we don't counterbalance these negative messages with positive portrayals of nurses, we risk decreasing entry into nursing education programs and not growing the nursing workforce over the decade.

I want to take us back to the 1990s, because there's history that has relevance here. Back in the 1990s, nurses protested vigorously and persistently throughout the country over how hospitals were coping with the growth of HMOs and managed care. The media reported on this extensively, and the imagery that the public saw was very negative. And not surprisingly, interest in nursing as a career dropped over the next six years, and the number of RNs graduating from nursing education programs decreased substantially.

In 1995, we graduated 97,000 RNs each year. But by 2000, we were graduating 30,000 fewer RNs. So this effect of decreasing interest showed up quickly and by the late '90s and early 2000s, we were having a large national shortage of registered nurses. The American Hospital Association reported about 125,000 vacant positions for nurses in 2001. Now that was the last large national shortage of RNs in this country. Now, we need to learn from that experience and start controlling the message about nurses and hospitals. We need to rebalance and put forth more positive portrayals of nurses, or else we could risk repeating the 1990s drop in interest in nursing and in enrollment and graduations.

And I think this is a shared responsibility. Nurses have to take ownership on this, our leadership has to, professional associations, educators, certainly the media, social media, and unions. We need to grow the workforce, so we've got to rebalance current messages.

The second area is to come to a deeper awareness of the implications of the withdrawal from the workforce of our retiring baby boom generation. We've retired about half of the 1.2 million RNs born in the baby boom generation, and over this next decade were going to see the remainder of that generation leave the workforce. And when they do leave, these nurses take with them decades’ worth of knowledge, experience, leadership, and mentorship of younger nurses.

I think our hospitals and other institutions really need to ascertain how many RNs are expected to retire and identify the nursing units, the departments, the patient populations that could be most affected by this retirement. Share that information with hospital leaders, with physicians and other clinicians who could be affected, and seek their involvement in helping to mitigate some of the potential harmful consequences with this.

I think there will be some baby boomers who we want to remain in the workforce longer. Is there something that can be done to engage them, to keep them in so that they would delay their retirement? I think we also want to focus in on bringing the older, soon-to-be-retiring nurses together with younger nurses to impart the knowledge and skills, particularly for taking care of patients with COVID or working in specialty units.

Dr. David Baker: Thanks Peter. You talked about the importance of messaging and controlling the messaging. Is that possible? Last week the New York Times published a video editorial by Lucy Ken and Jonah Kessel about the nursing shortage in hospitals that had nurses talking about these really horrible experiences that they had. It claimed that the most important root cause is chronic under-staffing leading to nurse burnout. So how do we control the messaging in this environment where social media is going to fan the flames of these concerns?

Dr. Peter Buerhaus: I think that there could be discussion among the major health care associations, provider associations, delivery of care associations, payer associations, educators, nurses themselves, about how resources could be pulled together to finance a campaign that brings forward positive images of nurses.

Dr. David Baker: So if part of the solution is increasing salaries for nurses, who should pay? How should those payments flow? I think it will be very difficult for hospitals to increase the salary for nurses without increased pay from payers. How should that be dealt with yet?

Dr. Peter Buerhaus: It strikes me that this is in society's interest that government and payers step up. And I don't think hospitals have the resources or all the resources needed to economically recognize nurses, so I do believe there is a role for government to provide resources specifically earmarked for nurses.

I'm reminded that when the government passed Medicare in 1965, Medicare paid hospitals extra to cover the cost of hiring more nurses needed to care for the influx of older patients. So I think there is a precedent for a step-up by the federal and state governments.

Dr. David Baker: Peter, you've been studying the nursing workforce for a long time. How does the current situation compare to these past crises that you've seen? Is this crisis unique? Are there basic forces that led to the shortages in the past that are being repeated now? Or is this something really fundamentally different today?

Dr. Peter Buerhaus: I think the first thing I would say is, in the years leading up to the pandemic from, say, 2010 to 2020, we were seeing about 70,000 baby boom RNs retiring each year from the workforce. Well, some of these baby boom RNs worked in ICUs, in emergency departments, in critical care units, and in other units that were later transformed to care for COVID patients. Now in some hospitals, this retirement was already causing shortages of nurses in the very units that would then suddenly become under siege by the rapid admission and very ill COVID patients.

Second, I think a unique aspect of the current situation concerns the rapid growth in the number of RNs becoming nurse practitioners, and this has really accelerated over the past 10 years. We've done some research on this and it turns out that the numbers of nurses who have left the workforce to become nurse practitioners led to a withdrawal of about 80,000 fewer RNs between 2010 and 2017. I expect that during 2018 and '19 there were continued losses from the nursing workforce as RNs continued to become NPs

Dr. David Baker: Peter, while we're working on long-term solutions, health care organizations and the staff that work in them have to get through today, and tomorrow, and the months to come. What's your advice on how leaders can help get through the challenges that they face today?

Dr. Peter Buerhaus: I think that in the short run as we are hopefully seeing the current variant, Omicron, spiking and hopefully receding over the next several months. We just have to get through it. We've just got to come to work each day, and we need to help one another, support each other, understand each other, and be kind to ourselves and to others. We're all in it together, and we just have to persevere. But I also think that it would be helpful to anticipate that there will be a time when COVID becomes more in our rearview mirror, we can get back on our feet, we can take some deep breaths.

And at that time, I would hope that hospitals and other care delivery organizations and nurses could come together in a very meaningful way and reflect on what's happened over the past couple of years, discuss what things really worked well, what was the process that led to good decisions, what didn't work, what have we learned about ourselves clinically and personally and organizationally, what are our strengths and weaknesses, an honest assessment. I believe that nurses and hospital leaders all want to get back to some sort of normal. But I don't think we want to go back to a normal that also included things that weren't working. We want to go forward forging a new normal.

I think we really need to reset that relationship, and do it in a way that's mutually beneficial and aimed at a better future for both nurses and hospitals, and of course that benefits the patients that we together serve. If we're going to purposely take the time to reset this relationship, it can be helpful, if organizations could survey their nursing staff and others and ask both questions that were negative and positive, get the full understanding, assess what nurses know, what their knowledge is—there may be some inaccuracies or misperception. What are their attitudes? Take the temperature on both nurses’ and leadership's willingness to change, their willingness to engage, and in listening to each other, and in building a new path forward, to jointly grasp the fuller situation and learn from it.

Dr. David Baker: Great. Well, thank you so much for taking the time to talk with me today. It's really been a pleasure. I really value the comments that you've given us today.

Dr. Peter Buerhaus: Well, thank you, David. I am so thrilled and glad that you took the time, and hopefully there'll be some benefit for nurses and hospitals as a consequence.

This interview transcript has been edited for length. The video interview is available at https://player.vimeo.com/progressive_redirect/playback/678918045/rendition/1080p?loc=external&signature=b5091feabb76a9d59d7c536fbb4b9ab064299f2165d8032aaff22b89fba3e536 .

Acknowledgments

Acknowledgment.

The author thanks Dr. Peter Buerhaus for his interview responses and valuable contribution to this publication.

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Article Contents

Introduction, the current nursing workforce—what do we know, how are shortages calculated and why do shortages of nurses arise, how can nurse shortages be reduced, gap analysis, concluding comment, acknowledgements, conflict of interest statement.

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Global nurse shortages—the facts, the impact and action for change

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Vari M Drennan, Fiona Ross, Global nurse shortages—the facts, the impact and action for change, British Medical Bulletin , Volume 130, Issue 1, June 2019, Pages 25–37, https://doi.org/10.1093/bmb/ldz014

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Nurses comprise half the global health workforce. A nine million shortage estimated in 2014 is predicted to decrease by two million by 2030 but disproportionality effect regions such as Africa. This scoping review investigated: what is known about current nurse workforces and shortages and what can be done to forestall such shortages?

Published documents from international organisations with remits for nursing workforces, published reviews with forward citation and key author searches.

Addressing nurse shortages requires a data informed, country specific model of the routes of supply and demand. It requires evidence informed policy and resource allocation at national, subnational and organisation levels.

The definition in law, type of education, levels and scope of practice of nurses varies between countries raising questions of factors and evidence underpinning such variation. Most policy solutions proposed by international bodies draws on data and research about the medical workforce and applies that to nurses, despite the different demographic profile, the work, the career options, the remuneration and the status.

Demand for nurses is increasing in all countries. Better workforce planning in nursing is crucial to reduce health inequalities and ensure sustainable health systems.

Research is needed on: the nursing workforce in low income countries and in rural and remote areas; on the impact of scope of practice and task-shifting changes; on the impact over time of implementing system wide policies as well as raising the profile of nursing.

Achieving population health, universal health coverage and equitable access to health care is dependent on having a health workforce that is of sufficient capacity, capability and quality to meet epidemiological challenges and changing demand 1 . The World Health Organization (WHO) predicts increased global demand for health and social care staff with the creation of 40 million new jobs by 2030. 2 Professionally educated nurses are numerically the largest professional group in most countries and comprise about half the global healthcare workforce. 2 In 2014, WHO and the World Bank calculated a global shortage of 9 million nurses and midwives. They predicted this will reduce by 2030 to 7.6 million but it will have a disproportionate impact on regions such as Africa. 3 This scoping review 4 addressed the questions: what is known about the current nursing workforce, how are shortages calculated and why do shortages of nurses arise, what can be done to forestall such shortages in a national and global context and where are the evidence gaps?

A scoping review maps out the breadth of issues, identifying areas for policy and research. 4 The review has drawn on the publications of international organizations with remits for health workforce (WHO, Office of Economic Co-operation and Development[OECD]) and nursing (International Council of Nurses [ICN]), reviews concerned with nursing workforce and shortages identified through database searches (SCOPUS, Medline, CINAHL 1-1-2008–1-12-2018) and follow up of cited literature and key authors. The review excluded literature concerned with midwives and nurse-midwifes.

WHO estimated 21 million nurses/midwives 2 globally in 2014, although there are variations in definition and deployment, which we explain later in this section. Despite the 2008 global financial crisis, the number of nurses has grown in many countries 5 . The absolute numbers range from over 3 million nurses in large countries such China, India and the United States to under 5000 in smaller countries such as Guinea, Iceland and Jamaica 3 . Many countries, however, have very little data on the distribution, types or trends of their nursing workforce that contrasts with information held about the medical workforce 2 .

Nurse shortages have to be considered in the context of international variation in health system development, size of the economy, the population size as well as the presence of other key health professionals, the most important of which is medicine. The international variation in ratio of nurses to population and doctors is illustrated in Table 1 .

Examples of variation by country in ratios of nurses to population and to doctors in 2017 or nearest year data available

Data compiled from four OECD sources 5 , – 8 .

The figures in Table 1 , however, mask some fundamental variations as to who counts as a nurse; not all countries have legislation to protect the title and education level of ‘nurse’ 9 . Registered nurse (RN) academic levels also vary; for example, in Europe RN education is at diploma level in seven countries, e.g. Luxembourg, but at degree level in others, e.g. United Kingdom (UK) 10 . Some countries regulate multiple levels of nurse, such as practical nurses and advanced practice nurses. Regulated practical nurses have different names: enrolled nurse (Zambia), licensed practical nurses (US), nurse assistant (Ghana) and nurse associate (UK). Advanced practice roles are those in which RNs, with additional training, undertake diagnostic and treatment roles traditionally the domain of the doctors. Like practical nurses, these are variously named: nurse clinician (Botswana), nurse officer (Lesotho) and nurse practitioner (US). Advanced practice roles and education are not always regulated, for example as in the UK 11 . Some countries also have nurse anaesthetists who are licensed to provide general and regional anaesthesia independently. Countries that have nurse anaesthetists include: Sweden, 12 the US that has over 42 000 13 and Ghana where, regulated by the General Medical Council, there are 14 nurse anaesthetists to every one doctor anaesthesiologist 14 . The scope of practice of nurses also varies. For example, in some countries, RNs have legal authority to prescribe pharmaceutical drugs independently although there are differences as to which nurses (on registration or with additional education) and which classes of drugs 15 . The extent of the scope of practice and advanced practice roles in any country reflects historical and contemporary issues including shortages or mal-distribution of doctors as well as support or otherwise from medical professional bodies.

Four further points are relevant in considering the global nursing workforce and shortages. Firstly, 90% of nurses are women 2 . Even in countries where there have been active programmes to increase the recruitment of men, such as the US, less than 10% are male 16 . Secondly, in most countries the majority of nurses earn less than the average wage of that country 2 . There is some evidence that male nurses on average earn more than female nurses 16 and that nurses from minority ethnic backgrounds earn less and are under-represented in senior grades than those of majority ethnic origin (see for example evidence from the UK 17 ). Thirdly, the majority of nurses are employed within hospitals (see Table 2 ) despite broader international policy aims of strengthening primary care. Lastly, the majority of nurses are salaried employees although in a few countries some practice as independent, self-employed professionals as in the infirmiers liberales in France (see Table 2 ) 18 . Taking into account these similarities and variations in the education, deployment and scope of practice of nurses, we turn now to consider shortages of nurses and the causes.

Nurse employment in different sectors from five exemplar high-income countries in 2018 or nearest year

Data Sources US Bureau of Labor Statistics 19 , Australian Health Workforce 20 , NHS Digital England 21 , Japan Nursing Association 22 , Ministère des Solidarités et de la Santé 23 .

* National Health Service only, ** Infirmiers liberale in primary care.

Calculating shortages

Definitions of ‘shortages’ in workforce are policy contingent and vary between health care systems. Criteria of ‘hard to fill vacancies’ or trends in ‘volume of current vacant posts’ are often used to describe health systems experiencing financial and demand pressures 24 . The latter measure is used currently in the National Health Service (NHS) in the UK and has been reported to have an upward trend over the previous 3 years 25 . A more prosaic definition of national shortages is whether RNs are on a government’s occupation shortage list for inward migration, as they are for Australia 26 and the UK 27 but not for the US 28 , at the time of writing.

In contrast, there are those definitions of shortages that flow from staff planning projections. These calculate any gap between the numbers of nurses required (demand for) against the future number available to work (the supply). One such example is from WHO and the World Bank in which shortages are defined as lower than the minimum number of doctors and nurses per head of population required to achieve population health targets. 3 The targets in this case being 12 of the infectious disease, child and maternal health and non-communicable health specified in the Sustainable Development Goals 3 . Using national data, WHO/World Bank estimated the 7.6 million global shortfall by 2030 with disproportionate impact on Africa and low-income countries. However, many health care systems have other developments beyond minimum targets that create demand for nurses but few have undertaken nurse staffing planning projections at a national level. Only 5 of 31 high-income OECD member countries have modelled their demand for and supply of nurses to 2025. Of the five, four (Australia, Canada, Ireland and UK) predicted shortages and one, the US, predicted a surplus of qualified nurses 29 .

Models of supply of and demand for nurses

WHO offers a system-wide model for the supply and stock of all types of health professionals 2 . We have adapted the model to focus specifically on the supply and availability of qualified nurses (Fig. 1 ). This illustrates the inflows and outflows to the pipeline of supply, to the pool of RNs and to stock of nurses available for employment as nurses. The model applies at national and sub-national levels, where other patterns become more evident such as internal migration from rural to urban areas. All countries face similar problems in the supply of nurses and other health professionals in remote and rural areas 30 . There are some countries, which have an oversupply of nurses, e.g. Philippines as part of ‘export’ model—whereby working age women (often with children) enter other countries as migrants and work in the health system, sending money home to support their families 31 .

Model of the supply of nurses able and willing to participate in a national nurse labour market (adapted from WHO 2 ).

Model of factors increasing and decreasing the demand for nurses.

Shortages occur when demand for nurses outstrips the numbers of nurses available for employment. An overarching factor influencing demand is the economy; for example, vacant nurse posts were frozen following the 2008 global financial crisis in countries such as Iceland 9 and Kenya 32 . Many factors influence the demand for nurses and we offer a model of these in Figure 2 . However, the extent of the demand for nurses is country and time specific. For example, there was increased demand in Thailand in the late eighties when a strong economy was the catalyst for the growth in private hospitals 33 and currently in the US where state legislation specifies the ratio of RNs to in-patients 34 . The volume of internationally educated nurses in a country maybe an indicator of a shortfall against demand or may be the custom and practice for the supply of nurses. For example, the Netherlands has had less than 1% foreign-trained nurses in its workforce consistently over the past 15 years while others such as the UK, Australia and New Zealand have consistently had over 14% in the same period 5 .

What attracts nurses to jobs and why do they leave?

Individual : skills and interests, career plans, caring/family responsibilities, financial responsibilities.

Job characteristics : remuneration, other financial benefits (e.g. health insurance, pension), hours and pattern of working, type and volume of work, physical and/or emotional intensity of work, variety of work, team working, level of responsibility/autonomy, clinical and managerial support, professional support.

Organization : clinical and employer reputation, type (e.g. private, public), size of organization, size of specialties within an organization, infrastructure to support employees (e.g. child care facilities, meal and social facilities), access to professional and career development activities and/or funding for these.

Location : urban, sub-urban, rural, proximity to family and/or other services such as schools for children.

Macro and meso level factors in the home country with the perceived converse in the country of destination : weak economy, political instability and/or civil unrest, unemployment of nurses, low status of nurses, poor working conditions, few opportunities for nurses for career progression.

Personnel level factors : desire for different cultural, life and/or health system experience, perceived opportunity for better financial rewards, perceived opportunity for improved quality of life for family and children, following already established partner or family network in the destination country, opportunity for career advancement and/or education.

Trying to understand why nurses leave and what retains nurses in their jobs has been a perennial question; the first Lancet Commission into shortages of nurses in the UK was published in 1933 39 . Innumerable literature reviews on the subject in the intervening years demonstrate the interlocking range of factors at individual, organizational and the broader socio-economic level 40 . A recent umbrella review of systematic reviews investigating the determinants of nurse turnover (leaving their jobs) in high-income countries reported that most studies focused on ‘individual’ factors influencing ‘intention to leave’, i.e. plans rather than actual leaving 41 . Most of the evidence reported was at the individual level; high levels of stress and burnout, job dissatisfaction and low commitment was associated with intention to leave. The few studies looking at intentions to remain found this had a strong association with good supervisor support 41 . However, there was an absence of studies that considered the interplay of factors at multiple levels (e.g. individual, job characteristics, organizational characteristics and the wider labour market) on actual leaving rates of RNs or on any subgroups, such as those with caring responsibilities 41 . The International Council of Nurses has also noted there is a paucity of evidence that has considered turnover and retention of nurses in low-income countries 42 . We turn now to consider the evidence for action to solve the shortages and mal-distribution.

The WHO calls for greater investment in all human resources for health and advocates for policy attention across the system of production, regulation and employment 2 . Most commentators on nursing shortages make similar arguments that policy attention needs to be paid to all elements (known as policy bundles) and avoid policy making that relies on oversimplified linear thinking. The evidence to support this comes from high- and low-income countries where programmes that focused only on increasing the numbers entering nurse training, have failed to make an impact on increasing numbers entering the workplace or reducing gaps in priority areas with a history of shortages. Subsequent analysis has identified multiple reasons for this failure including: insufficient infrastructure for clinical education, weak regulation of education standards and few posts to apply for, see for example the review from Sub-Saharan African countries 43 . This is not to argue that increasing numbers entering nurse training is inappropriate, but should be seen as one lever among a policy bundle, including for example, retention measures. The UK and the US provide interesting comparisons, in that one (the UK) has reduced nurse training numbers over the past 15 years, has significant numbers of vacancies and plans to rely on internationally trained nurses over the next few years, while the other (the US) has significantly increased nurse graduates over the past 15 years and does not count nursing as a shortage occupation 44 .

Drawing on commentaries and WHO strategic direction statements for strengthening the nursing and midwifery contribution Table 3 describes policy actions to scale up and sustain the nursing workforce at different levels of the health care system.

Exemplars of policy areas to address improved supply, retention and productivity of nurses

The policy solutions have to attend to the demand as well as the supply side, i.e. to increase RN productivity (for example, working to the full extent of their license, task shifting to assistants, using technologies and community health workers) as well as to produce more and retain more RNs. However, documented evaluations of the impact of the implementation of policy bundles on the nursing workforce are rare not least because of the inter-sectoral nature of enactment and the relatively long period between policy decisions, implementation and outcome. Even where there are evaluations of implementation of policy actions to address shortages, such as the WHO strategy for remote and rural areas, these focus on the medical profession not nurses 45 .

At the micro level (organization/service delivery level), good human resource management practices are known to reduce the rates of voluntary turnover in all industries 46 . An umbrella systematic review considered interventions to reduce turnover rates of nurses (i.e. to retain them in their posts) in high-income countries 47 This review found relatively weak evidence for most interventions but there was strong evidence of positive impact for transition programmes and support for newly qualified nurses 47 . There was also evidence that nurse manager leadership styles that were perceived as encouraging work group cohesion were also effective in reducing turnover 47 . Positive working environments are those that not only ensure the nurses well-being but sustain or increase their motivation in their work. There is some evidence that many RNs (like many physicians) in high-income countries consider that they are not working to the full scope of their training and are undertaking work that could be undertaken by others 44 . However, task shifting, shifts in jurisdiction and changes in skill-mixes in teams raises questions of adequate preparation, patient safety and cost effectiveness—all of which require consideration within specific contexts. For example, a growing body of evidence in high-income countries demonstrates a relationship between RN staffing levels and patient safety in acute in-patient hospital settings. Recent research on in-patient hospital care in the UK demonstrates that lower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital and that use of nursing assistants does not compensate for reduced RN staffing 48 . There are significant gaps in evidence for the most effect ways of increasing RN productivity as well as attracting and retaining RNs in the workplace that requires attention to be given to the macro and overarching issues in every health system.

The first major gap is in relation to nursing workforce planning. Workforce planning at a national level is an inexact science and is often absent for nursing, which is in contrast with medical manpower planning. To plan for solutions, you need to understand the scale of the problem, which in the case of nursing, is limited by the significant evidence gaps. For example, at the national level, nursing workforce data is often incomplete and based on historical activity rather than projections. The 2016 WHO resolution on human resources for health urges all countries to have health workforce-related planning mechanisms and has introduced national health workforce accounts with core indicators, including ratio of nurses to population, for annual submission to the WHO Secretariat 1 . However, this could be considered the minimum requirement for benchmarking rather than proactively modelling the future demand for nurses, the availability and supply of nurses and planning to meet the gap or shortfall. This then flags the next gap—the evidence to base the planning decisions on.

The second major gap is the evidence informing policy decisions about interventions that work to attract, equitably distribute, retain and sustain a nursing workforce against the requirements of any health care system. It is noteworthy that the WHO guidance for scaling up and retaining all health care professionals 2 is predominantly evidenced from studies of doctors, thus further emphasizing this gap in the evidence. The demographic profile, status, education, career options and remuneration levels for these two professions are very different and assumptions that evidence from one professionally is automatically applicable and relevant to the other is contestable and at worst misleading.

Overlaying these gaps in knowledge there is an issue, common across many countries as noted by WHO 2 , that the profession of nursing has not been valued and given the policy attention congruent with its scale. Having a weak voice and influence in national and international health workforce policy development has inevitable consequences, which in this context means that fewer levers are available to address shortages and action is slow. At the time of writing, there is a global WHO-sponsored campaign called Nursing Now (2018–20) ( https://www.nursingnow.org/ ) that supports country-specific campaigns and activities to raise the profile of the nursing profession, develop leaders for governments and to make change at a systems level. This is involving nurses in policy making, particularly with regard to increasing and retaining the nursing workforce. The response to, and impact of, these calls for country-specific campaigns is yet to be evaluated.

This review has demonstrated that that the nature and size of the professionally qualified nurse workforce is shaped by the societal context of individual countries—political choices that influence decisions about resource allocation to health systems, demographics (labour market pressures on working age, particularly of women), image of nursing and its positional power in relation to medicine, demands for care/health and social inequalities. Understanding nursing shortages and acting on them requires attention to the gaps in knowledge and evidence but also the wider societal context of nursing.

This review was undertaken without external funding.

The authors have no potential conflicts of interest.

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What’s Really Behind the Nursing Shortage? 1,500 Nurses Share Their Stories

• Survey Results
• What Is the Nursing Shortage?
• Reasons Nurses Quit
• Hope For the Future
• What Nurses Need Now
• How to Take Action

Winner of the Gold Award for the Digital Health Awards, Best Media/Publications Article, Spring 2022

Update 10/10/2022

The findings of  Nurse.org's 2021 State of Nursing Survey revealed some harsh truths about the profession but also spoke to the strength, perseverance, and passion that nurses have for their work. Nurse.org has relaunched the State of Nursing survey in 2022 with the aim to capture a complete picture of the true state of the profession - from how nurses feel about work, how nurses are being treated, how nurses feel about the future of nursing, nurse's mental wellbeing and what nurses think needs to change within the profession. Take the survey now (it takes less than 10 minutes.)

>> Take Nurse.org's NEW 2022 "State of Nursing Survey" and let your voice be heard about issues in nursing that matter most. 

January 26, 2022

If the past two years have taught the world anything, it's that nurses are NOT okay. The truth is that despite the 7 pm cheers, the commercials thanking nurses for their dedication and selflessness, and the free food from major retailers – the overwhelming majority of nurses are burnt out, underpaid, overworked, and underappreciated.  

With millions of nurses worldwide, Nurse.org wanted to truly understand the current state of nursing and give nurses a voice to share their thoughts, feelings, and apprehensions about the nursing profession. We surveyed nearly 1,500 nurses to find out how they felt about the past year and get to the real reasons behind the nursing shortage . The responses were heartbreaking, but not without hope.  

Nurse.org teamed up with nurse-centric companies to give away 100s of prizes during the month of May. Subscribe to our newsletter to learn more!

What We Found: Nurses Are Struggling

Nurses are struggling. Regardless of practice specialty, age, or state of practice – the answers were all the same. Nurses, NPs, and APRNs are all struggling and need help.  

Only 12% of the nurses surveyed are happy where they are and interestingly, 36% would like to stay in their current positions but changes would need to be made for that to happen. Nurses report wanting safe staffing, safer patient ratio assignments, and increased pay in order to stay in their current roles.  

Nurses didn’t hold back when discussing their feelings regarding the current state of nursing:  

• 87% feel burnt out 
• 84% are frustrated with administrators 
• 84% feel they are underpaid 
• 83% feel their mental health has suffered 
• 77% feel unsupported at work 
• 61% feel unappreciated 
• 60% have felt uncomfortable having to work outside of their comfort zone in the past year 
• 58% of nurses have felt frustrated with their patients 
• 58% of nurses have felt unsafe at work in the past year 

The numbers don’t lie. It’s astounding that a profession continually recognized for its compassion, strength, and resilience is suffering . And the suffering is universal.  

One nurse responded with the following, “I have been an RN for 34 years and in my specialty of nursing for 31 years and I am burned out.” 

What Is the Nursing Shortage and Why is it Happening?

You’ve likely heard about the nursing shortage, but what does that mean and why is it happening? 

According to the U.S. Bureau of Labor Statistics (BLS) , the employment of registered nurses is projected to grow 9% from 2020 to 2030.  Approximately 194,500 openings for registered nurses are projected each year, on average, over the decade. However, this number was projected prior to the pandemic, and before the mass exodus of bedside clinical nurses. As a result, it’s likely substantially lower than what the real demand for nurses will look like.

The American Nurses Association (ANA) reports that the increased need for nurses spans beyond the current pandemic. In fact, they sent a letter to the U.S. Department of Health and Human Services (HHS) on September 1, 2021, urging the country to declare the current and unsustainable nurse staffing shortage to be a national crisis. 

The ANA attributes the needs for thousands of nurses to the following:  

• The Affordable Care Act made access to health care services possible for more people
• Increased focus “primary care, prevention, wellness, and chronic disease management” 
• Aging baby-boomer population
• Growing interest in community-based care

Why Are Nurses Really Leaving The Bedside? 

However, those stats don’t address some of the systemic issues nurses face every day, particularly in the midst of a pandemic. That’s why we asked nurses why they are really leaving the bedside.

What we heard is that, overwhelmingly, the number one reason nurses want to leave the bedside is because of unsafe staffing ratios. This leads to a never-ending cycle of shortages: nurses face unsafe staffing ratios so they decide to leave the bedside, this results in even fewer nurses available to care for patients, so the downward cycle continues.

Essentially, nurses are dealing with an increased workload with fewer resources. Typically, pre-covid ICU nurses would experience a 1:1 or 2:1 patient-to-nurse ratio. Now ICU nurses throughout the country are experiencing a 3:1 or 4:1 patient-to-nurse ratio which exacerbates staff burnout and unsafe nursing practices.  

One nurse reported, “With increased patient census, staffing ratios are very unsafe especially with high acuity patients. Having 4+ critically ill patients not only puts licenses at risk but the patients do not benefit at all. We’re just running around doing tasks, not providing adequate care.”

Unsafe Staffing Ratios Are Just Part of the Problem

While a big piece of the puzzle, unsafe staffing issues are, unfortunately, one part of a long list of issues plaguing nurses today. 

 Nurses are leaving the bedside because of issues like: 

• Inadequate staffing ratios 
• Not getting equal pay for equal experience 
• Not receiving hazard pay during a pandemic 
• Not having adequate back up 
• An inability to take breaks, sick days, or even turn down extra shifts 

To learn more about the nursing shortage and learn ways you can get involved, check out the full report here . 

Despite All This, Nurses Still Have Hope

70% of nurses still think that nursing is a great career and 64% still think that new nurses should join the profession. 

“If you’re a student considering becoming a nurse, please know that you are not walking into a doomed profession. You will never meet anyone who is more determined, more resourceful, or more ready to jump in and lend a helping hand than a nurse." 

--– Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org

If you’re a nurse, you know that nursing isn’t just a profession, it’s a calling. It’s devastating to see that so many nurses are suffering in their quest to heal and give care, but it’s heartening to know they are not without hope. 

What Nurses Need Now 

If you’re a nurse, know that your job is simply to put yourself first. If we want to solve the nursing shortage (and we do!), it can't happen without nurses recognizing that they are NOT the problem. 

"The problem is not with nurses or nursing; the problem is that nurses have been so busy taking care of others that no one has taken care of them. And we’re here to change that--and by entering the nursing profession, you will be part of the solution too”

 – Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org 

The truth is nurses need a lot more to be incentivized to stay practicing clinically at the bedside. Nurses reported needing:  

• Higher pay 
• Safe nurse-to-patient ratios 
• Hazard pay 
• REAL mental health resources 
• Adequate staff support 
• Support programs for new nurses

4 Ways to Support Nurses and Take Action

While we may not be able to make this change at an individual level, collectively, we can amplify the voice of nurses and shed some light on the issues that they are facing every day. Together, we have the power to create meaningful, lasting change for current and future nurses.  Here's how to get involved: 

1. Sign the Pledge

Sign the pledge seen below and encourage your friends & colleagues to do the same. While you’re at it, print it out and post it in your break room. 

2. Spread the Word 

Change can’t happen unless we get the word out about what’s really going on. Share what you’ve heard and what you’ve experienced, and encourage others to do the same. 

3. Contact Your Elected Officials 

It’s time for elected officials to stand up for nurses. Write them a letter. Call their office. Demand change for nurses. Click here to get the contact information for your local and state Officials. 

4. Download and Share the Report

Get even more in-depth insights into what’s going on with the state of nursing and the issues that nurses face today, click here to download the full State of Nursing report or read about the best and worst specialties for nurses during COVID . 

“If you are a current nurse considering leaving the profession, be assured that you are not alone in your struggles. If all you’ve had the energy for is keeping your head down and getting through your shifts, sleeping, and getting up to do it all over again, know that you are doing enough. It’s not your responsibility to solve the nursing shortage.” 

– Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org 

Find Nursing Programs

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

Plus, get exclusive access to discounts for nurses, stay informed on the latest nurse news, and learn how to take the next steps in your career.

By clicking “Join Now”, you agree to receive email newsletters and special offers from Nurse.org. We will not sell or distribute your email address to any third party, and you may unsubscribe at any time by using the unsubscribe link, found at the bottom of every email.

Nursing in 2023: How hospitals are confronting shortages

When we tabulated the results of our first nationwide nursing survey almost two years ago , we were surprised to see such a high reported likelihood of nurses planning to leave their jobs—and we did not expect this trend to persist for such an extended period of time.

About the authors

This article is a collaborative effort by Gretchen Berlin , Faith Burns, Connor Essick, Meredith Lapointe, and Mhoire Murphy , representing views from McKinsey’s Healthcare Practice.

But that is what has happened in the wake of the COVID-19 pandemic. In fact, we have seen some of this reported anticipated turnover actually occur, as well as a decrease in the overall active nursing workforce. And there is still cause for concern: today, 31 percent of nurses still say they may leave their current direct patient care jobs in the next year, according to our most recent survey. That said, we are cautiously optimistic that some of the practices implemented by healthcare organizations to improve the experience of nurses are bearing fruit.

In this article, we share the latest data from our September 2022 frontline nursing survey of 368 frontline nurses providing direct patient care in the United States (see sidebar, “About the research”). We offer these insights as resources for organizations as they continue their journeys of attracting, supporting, and retaining a vibrant workforce, as well as promoting longer-term workforce stability.

What’s been happening in the nursing workforce

About the research.

Nursing turnover continues to be a substantial challenge for healthcare organizations as the number of individuals with the intent to leave their jobs remains high. In our most recent nursing survey, 31 percent of respondents indicated they were likely to leave their current role in direct patient care, a figure that has stabilized over the past six to 12 months yet is still higher than the 22 percent rate observed in our first survey in February 2021 (Exhibit 1). 1 Gretchen Berlin, Meredith Lapointe, and Mhoire Murphy, “ Surveyed nurses consider leaving direct patient care at elevated rates ,” McKinsey, February 17, 2022; Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Molly Viscardi, “ Nursing in 2021: Retaining the healthcare workforce when we need it most ,” McKinsey, May 11, 2021. Our research further shows that the intent to leave varies across settings. For example, inpatient registered nurses (RNs) have consistently reported a higher intent to leave than the average of all surveyed RNs. In our most recent pulse survey of inpatient RNs, we saw intent to leave rise again, from 35 percent in fall 2022 to over 40 percent in March 2023.

Recent analysis of studies comparing intent to leave to actual turnover show that both jumped meaningfully over the course of 2021. A study from Nursing Solutions Inc. (NSI) showed that actual reported hospital and staff RN turnover increased from 18 percent in fiscal year 2020 to 27 percent in fiscal year 2021; the same March 2022 study reported that the workforce lost about 2.5 percent of RNs in 2021. 2 2022 NSI national health care retention & RN staffing report , NSI Nursing Solutions, March 2022. In the latest NSI report (March 2023), turnover reduced to 23 percent in fiscal year 2022 but still remains elevated compared with prepandemic levels. 3 2023 NSI national health care retention & RN staffing report , March 2023. A Health Affairs study published in April 2022 found that the RN workforce fell by about 100,000 by the end of 2021, which is a “far greater drop than ever observed over the past four decades.” This decline was particularly pronounced among midtenure nurses (aged 35 to 49). 4 David Auerbach, Peter Buerhaus, Karen Donelan, and Douglas Staiger, “A worrisome drop in the number of young nurses,” Health Affairs Forefront, April 13, 2022. In terms of where they are going, nurses are both leaving the profession entirely as well as simply changing employers or roles. About 35 percent of respondents to our most recent survey who indicated they were likely to leave said they would remain in direct patient care (that is, at a different employer or role). The remainder said they intended to leave the bedside for nondirect patient care roles to pursue different career paths or education or to exit the workforce entirely.

With this persistently high turnover and the corresponding gathering storm in US healthcare , it is more important than ever for healthcare organizations to design and deploy initiatives that respond to and address workforce needs. Most healthcare organizations have learned that attracting and retaining nursing talent in the postpandemic era will require a more nuanced understanding of what nurses are looking for in a profession and an employer.

Our four frontline nursing surveys over the past two years have enabled us to glean insights into factors contributing to both attrition and retention. Frontline nursing respondents have consistently ranked elements of flexibility, meaning, and balance as the most important factors affecting their decision to stay in direct patient care (Exhibit 2). Recognition, open lines of communication, and embedding breaks into the operating model (for example, during shifts, between shifts, and formal paid time off) have consistently been rated as the top initiatives to support well-being.

The nursing workforce has evolved over the course of the pandemic, and the strategies aimed at attracting and retaining tomorrow’s workforce have evolved as well. To start, structural solutions  that help to ensure a manageable workload—for example, consistent support staff, a safe environment, reduced documentation and administrative requirements, predictability of schedule, and ability to take paid time off—continue to be critical. Surveyed nurses who left a direct patient care role in the past 18 months indicated that not being valued, unmanageable workloads, and inadequate compensation were the top factors in their decision to exit (Exhibit 3). There are no one-size-fits-all solutions, but many healthcare organizations have adapted their approaches and carried out interventions that appear to be yielding results.

What stakeholders can do in the short term

Our most recent survey found that 75 percent of nurses who left a job in the past 18 months reported that not being valued by their organization was a factor in their decision. In addition, 56 percent of total respondents reported that appropriately recognizing nurses for their contributions was the most effective initiative to support well-being. Surveyed nurses suggested various ways to respond to the recognition gap, including simple acknowledgement, appreciation of excellence, and reinforcement through broader workplace culture and support in the field.

Many healthcare systems have found ways to implement the nurses’ suggestions. While more research is needed to understand the full impact of these efforts, they may be helpful short-term starting points in the attempt to show support for the workforce.

At the Orlando VA Medical Center, “Employee Well-Being Centers” were set up to address the burnout and stress caused by the pandemic. Setting up a dedicated quiet space with amenities like virtual-reality headsets, aroma therapy, and sound machines, as well as snacks and beverages, resulted in a measurable positive impact on Employee Whole Health engagement scores and decreased feelings of burnout, higher retention, and increased overall well-being. As a result of these improvements, the program has expanded to more than ten medical centers across the Veterans Health Administration network. 5 “Employee well-being centers and carts,” VA Diffusion Marketplace, accessed April 2023.

Some health systems have employed digital tools to ensure that tailored recognition can be delivered in a timely and meaningful way. For example, nurse managers at the Orange Coast Medical Center in Fountain Valley, California, were using sticky notes, mining emails, spreadsheets, and other manual processes to remind them which nurses did what to deserve recognition or to schedule meetings to help other nurses improve their work. While meaningful, these recognition processes were time-consuming for nurse managers. 6 “Frontline nurses are burning out. This digital health start-up is trying to change that," Laudio, May 13, 2022.

To sustain both this type of in-the-moment recognition and to reward bigger milestones, Orange Coast implemented the Laudio technology platform, which enables frontline leaders to monitor and manage team activity and performance. Use of this system has shown that one meaningful, or high quality, interaction per team member per month can reduce turnover by 36 percent. 7 “Frontline nurses are burning out. This digital health start-up is trying to change that," Laudio, May 13, 2022. In addition to keeping track of events and alerting managers about matters to engage in with specific nurses, Laudio can send digital cards and notes to nurses to acknowledge high performance.

Safety is also increasingly top of mind for nurses, as troubling incidents involving visitors and patients have risen. 8 Christine Porath and Adrienne Boissy, “Frustrated patients are making health care workers’ jobs even harder,” Harvard Business Review , May 14, 2021. In our most recent survey, 42 percent of nurses indicated that not having a safe working environment was an extremely or very important factor affecting their decision to leave direct patient care, up from 24 percent in March 2022.

To address safety concerns and incivility, UMass Memorial Medical Center in Worcester, Massachusetts, developed a patient and visitor code of conduct. At the entrances to facilities, visitors are asked to sign an agreement to adhere to a code of conduct that formalizes parameters and expectations of behavior. In addition, UMass created talking points for employees to use to respond to and de-escalate contentious situations. In just over a month of piloting the program, the hospital collected 56,000 signed agreements and only asked four visitors to leave the premises. 9 Christine Porath, “Frontline work when everyone is angry,” Harvard Business Review , November 9, 2022.

In addition to deploying more effective strategies to support and retain employees, healthcare executives can look at ways to better attract talent in the near term. To recruit staff, health systems should ensure that their value proposition is aligned to the workplace elements that nurses consider most important—especially when differentiating on compensation is less feasible. Aya Healthcare, a healthcare-talent software and staffing company, found that hospitals seen as a great place to work paid less to secure talent throughout the pandemic. In fact, hospitals seen as great places to work had labor compensation rates 11 percent lower than those without this advantage. 10 April Hansen, “The value of a good reputation (or the cost of a bad one…),” The Staffing Stream, April 8, 2021.

What stakeholders can do in the medium term

In the medium term, finding ways to incorporate flexibility into work schedules is an initiative that 63 percent of surveyed nurses ranked as the most effective for their well-being. We saw similar responses regarding nurses’ decision to stay in their current position: 86 percent cited a flexible work schedule as the reason, which ranked second after “doing meaningful work.” The nature of nurses’ work—typically specialized and always in demand—may make providing schedule flexibility seem daunting. But health systems have pursued several creative ways to address the issue.

The nature of nurses’ work—typically specialized and always in demand—may make providing schedule flexibility seem daunting.

For example, the Mercy health system launched Mercy Works on Demand, a systemwide on-demand platform that allows its full- and part-time nurses as well as other experienced nurses to select when they work. Through the platform, Mercy has hired about 1,100 individuals they are calling gig nurses and have improved overall fill rates by two percentage points. 11 Kelly Gooch, “How Mercy embraced a gig mindset for nursing,” Becker’s Hospital Review, December 5, 2022. But flexibility means different things to different people, which has increased complexity for employers. Charting a path forward will require a nuanced understanding of the employee value proposition as well as what options resonate with the workforce.

Job flexibility is at the center of many health systems’ strategies to not only attract new talent but also to welcome back nurses who left during the pandemic. Henry Ford Health has been able to bring back 25 percent of the nurses who left by offering flexible opportunities. Nursing leaders worked closely with Henry Ford Health’s human resources department to design flexible options such as the ability to work in different settings (for example, inpatient, outpatient, or virtual) or to work only on weekends. The health system also created fixed-term positions for nurses who didn’t want full-time permanent jobs, with the option to transition to permanent roles once their term was up. 12 Mackenzie Bean and Erica Carbajal, “How Henry Ford rehired 25% of nurses who left during the pandemic,” Becker’s Hospital Review, February 15, 2023.

As in other industries, the flexibility to work remotely has become increasingly important to some nurses. Trinity Health launched a virtual-care model, allowing more experienced nurses to continue providing patient care but away from the bedside. The new virtual model opens the door to nurses who may be physically tired from the demands of in-person care and to those who prefer to work from home. In addition, this program has enabled the virtual nurses to provide support to teams at the bedside and to improve patient experience by giving them more chances to interact with a nurse. The program is being rolled out across Trinity’s 88 hospitals nationwide. 13 Giles Bruce, “Trinity Health plans to institute virtual nurses across its 88 hospitals in 26 states,” Becker’s Hospital Review, January 13, 2023.

What stakeholders can do in the long term

As health systems look beyond retaining the current workforce and meeting the expected demand for nursing talent, they could have a role to play in building a longer-term pipeline through investing in new-graduate nurses and in the infrastructure required to ensure successful onboarding into the profession.

For example, Dignity Health has invested heavily in longer-term pipeline building through a joint venture between Dignity Health Global Education and Global University Systems. The partnership offers online academic degrees to further the education, training, and development of the healthcare workforce. The joint venture spans technical, professional, executive, and leadership training and provides a range of flexible, accessible, and affordable education opportunities for healthcare workers to advance their careers. It also has a scholarship fund to remove financial barriers for education and to increase equity in healthcare. Dignity Health Global Education now has one of the most comprehensive nursing residency programs, available in 21 states. 14 “Dignity Health and Global University Systems announce joint venture to expand global education for health professionals,” Global University Systems press release, January 30, 2019.

The commitment to building a longer-term talent pipeline has expanded beyond individual health systems. Many city and regional partnerships have developed across the United States, bringing together critical stakeholders across the healthcare ecosystem to train and upskill unemployed and underemployed job seekers into healthcare occupations. For example, the Birmingham Region Health Partnership, the result of close collaboration among government, healthcare employers, and other community partners, including Birmingham Business Alliance and Innovate Birmingham, won a $10.8 million grant from the Good Jobs Challenge to train and place over 1,000 jobseekers in the region. 15 “Birmingham receives $10.8 million ‘Good Jobs Challenge’ grant,” Birmingham City Council press release, August 3, 2022. Similar collaborative partnerships exist in Chicago, Baltimore, Philadelphia, among others, to build a pipeline of healthcare workers and to create meaningful career opportunities for historically excluded job seekers. 16 BACH Quarterly Newsletter , Baltimore Alliance for Careers in Healthcare, accessed April 2023; “Cutting the ribbon on new West Philadelphia Skills Initiative Headquarters,” University City District, March 29, 2023; CHWC Overview & Update - February 2021, Chicagoland Healthcare Workforce Collaborative, updated March 10, 2021.

Other stakeholders are taking action at a national level. In 2022, the US Department of Labor budgeted $80 million to encourage not-for-profit organizations, educational institutions, and tribal organizations to apply for grants of up to $6 million each to train current and former nurses to become nursing educators and frontline healthcare workers to train for nursing careers. 17 “DOL Nursing Expansion Grant Program: Total funding available: Up to $80 million,” US Department of Labor Employment and Training Administration, 2022. The program emphasizes increasing workforce diversity and building partnerships with community-based organizations and training institutions.

Retaining the current nursing workforce while looking ahead to the longer-term talent pipeline will be critical to meeting the projected shortfall in registered nurses. There isn’t one answer to the challenges confronting healthcare organizations, and indeed, they have begun taking steps to address nurses’ stated needs through short-, medium-, and longer-term strategies that attract, strengthen, and grow a vibrant nurse workforce. There is more to be done, especially in taking account of the voices of the front line and addressing the core drivers behind why nurses are planning to leave. We are optimistic that the issues facing the nursing profession can be addressed, but this will require consistent and dedicated attention from many parties.

Gretchen Berlin , RN, is a senior partner in McKinsey’s Washington, DC, office, where Faith Burns is a consultant; Meredith Lapointe is a partner in the Bay Area office, where Connor Essick is a consultant; and Mhoire Murphy is a partner in the Boston office.

The authors wish to thank the nurses, physicians, and staff on the front lines who are caring for patients and communities. They also wish to thank Beth Bravo, Stephanie Hammer, Thomas Pu, Brooke Tobin, and Catherine Wilkosz for their contributions to this article.

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Nursing Shortage Fact Sheet

The U.S. is projected to experience a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age and the need for health care grows. Compounding the problem is the fact that nursing schools across the country are struggling to expand capacity to meet the rising demand for care. The American Association of Colleges of Nursing (AACN) is working with schools, policy makers, nursing organizations, and the media to bring attention to this healthcare concern. AACN is leveraging its resources to shape legislation, identify strategies, and form collaborations to address the shortage.

Download Fact Sheet [PDF]

Current and Projected Shortage Indicators

• According to the Bureau of Labor Statistics’  Employment Projections 2021-2031 , the Registered Nursing (RN) workforce is expected to grow by 6% over the next decade. 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. The Bureau also projects 203,200 openings for RNs each year through 2031 when nurse retirements and workforce exits are factored into the number of nurses needed in the U.S.  
• The Advanced Practice Registered Nurse (APRN) workforce, including Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives, is expected to grow much faster than average for all occupation, by 40% from 2021 through 2031, according to the  BLS’ Occupational Outlook Handbook . Approximately 30,200 new APRNs, which are prepared in master’s and doctoral programs, will be needed each year through 2031 to meet the rising demand for care.  
• According to the  United States Registered Nurse Workforce Report Card and Shortage Forecast  published in the September/October 2019 issue of the  American Journal of Medical Quality , a shortage of registered nurses is projected to spread across the country through 2030. In this state-by-state analysis, the authors forecast a significant RN shortage in 30 states with the most intense shortage in the Western region of the U.S.  
• In April 2022, Dr. David Auerbach and colleagues  published a nursing workforce analysis  in  Health Affairs , which found that total supply of RNs decreased by more than 100,000 from 2020 to 2021 – the largest drop than ever observed over the past four decades. A significant number of nurses leaving the workforce were under the age of 35, and most were employed in hospitals.  
• The Institute of Medicine in its landmark report on  The Future of Nursing  called for increasing the number of baccalaureate-prepared nurses in the workforce to at least 80% to enhance patient safety. The current nursing workforce falls short of this recommendations with only 65.2% of registered nurses prepared at the baccalaureate or graduate degree level according to the  latest workforce survey  conducted by the National Council of State Boards of Nursing.

Contributing Factors Impacting the Nursing Shortage

Nursing school enrollment is not growing fast enough to meet the projected demand for RN and APRN services.

Though enrollment in entry-level baccalaureate programs in nursing increased by 3.3% in 2021, AACN did report drops in both PhD and master’s nursing programs by 0.7% and 3.8%, respectively. These trends are raising concerns about the capacity of nursing schools to meet the projected demand for nursing services, including the need for more nurse faculty, researchers, and primary care providers.

A shortage of nursing school faculty is restricting nursing program enrollments.

• According to AACN’s report on  2021-2022 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing , U.S. nursing schools turned away 91,938 qualified applications (not applicants) from baccalaureate and graduate nursing programs in 2021 due to insufficient number of faculty, clinical sites, classroom space, and clinical preceptors, as well as budget constraints. 

A significant segment of the nursing workforce is nearing retirement age.

• According to a  2020 National Nursing Workforce Survey  conducted by the National Council of State Boards of Nursing found that the average age for an RN is 52 years old, which may signal a large wave over the next 15 years.  
• In a  Health Affairs  blog  posted in May 2017, Dr. Peter Buerhaus and colleagues project than more than 1 million registered nurses will retire from the workforce by 2030.

Changing demographics signal a need for more nurses to care for our aging population.

• The  U.S. Census Bureau reported  that by 2034, there will be 77.0 million people age 65 years and older compared to 76.5 million under the age of 18. With larger numbers of older adults, there will be an increased need for geriatric care, including care for individuals with chronic diseases and comorbidities.

Amplified by the pandemic, insufficient staffing is raising the stress level of nurses, impacting job satisfaction, and driving many nurses to leave the profession.

• According to data published in Nurse.com’s  2022 Nurse Salary Research Report , 29% of nurses across all license types considering leaving in 2021, compared with 11% in 2020.Among nurses who are considering leaving the profession, higher pay was the most influential motivation to stay, followed by better support for work-life balance and more reasonable workload.  
• In March 2022, the American Nurses Foundation and the American Nurses Association released the results of its  COVID-19 Impact Assessment Survey , which found that 52% of nurses are considering leaving their current position due primarily to insufficient staffing, work negatively affecting health and well-being, and inability to deliver quality care. In addition, 60% of acute care nurses report feeling burnt out, and 75% report feeling stressed, frustrated, and exhausted.  
• In September 2021, the American Association of Critical-Care Nurses reported  survey findings  which show 66% of acute care nurses have considered leaving nursing after their experiences during the pandemic.

Impact of Nurse Staffing on Patient Care

Many scientific studies point to the connection between adequate levels of registered nurse staffing and safe patient care.

• In November  2021, new research in Nursing Outlook examined  Variations in Nursing Baccalaureate Education and 30-day Inpatient Surgical Mortality . Researchers found that having a higher proportion of baccalaureate-prepared nurses (BSN) in hospital settings, regardless of educational pathway, is associated with lower rates of 30-day inpatient surgical mortality. The findings support promoting multiple BSN educational pathways.  
• In the July 2017 issue of  BMJ Quality & Safety , the international journal of healthcare improvement, Dr. Linda Aiken and her colleagues released  findings from a study of acute care hospitals  in Belgium, England, Finland, Ireland, Spain, and Switzerland, which found that a greater proportion of professional nurses at the bedside is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding assistive personnel without professional nurse qualifications may contribute to preventable deaths, erode care quality, and contribute to nurse shortages.  
• In a study published in the journal  BMJ Quality & Safety  in May 2013, researcher Heather L. Tubbs-Cooley and colleagues observed that higher patient loads were associated with higher hospital readmission rates. The study found that when more than four patients were assigned to an RN in pediatric hospitals, the likelihood of hospital readmissions increased significantly.  
• In the August 2012 issue of the  American Journal of Infection Control , Dr. Jeannie Cimiotti and colleagues identified a significant association between high patient-to-nurse ratios and nurse burnout with increased urinary tract and surgical site infections. In this study of Pennsylvania hospitals, the researchers found that increasing a nurse’s patient load by just one patient was associated with higher rates of infection. The authors conclude that reducing nurse burnout can improve both the well-being of nurses and the quality of patient care.  
• In a study publishing in the April 2011 issue of  Medical Care , Dr. Mary Blegen and her colleagues from the University of California, San Francisco found that higher nurse staffing levels were associated with fewer deaths, lower failure-to-rescue incidents, lower rates of infection, and shorter hospital stays.  
• In March 2011, Dr. Jack Needleman and colleagues published findings in the  New England Journal of Medicine , which indicate that insufficient nurse staffing was related to higher patient mortality rates. These researchers analyzed the records of nearly 198,000 admitted patients and 177,000 eight-hour nursing shifts across 43 patient-care units at large academic health centers. The data show that the mortality risk for patients was about 6% higher on units that were understaffed as compared with fully staffed units. In the study titled “Nurse Staffing and Inpatient Hospital Mortality,” the researchers also found that when a nurse’s workload increases because of high patient turnover, mortality risk also increases.  
• A growing body of research clearly links baccalaureate-prepared nurses to lower mortality and failure-to-rescue rates. The latest studies published in the journals  Health Services Research  in August 2008 and the  Journal of Nursing Administration  in May 2008 confirm the findings of several previous studies which link education level and patient outcomes. Efforts to address the nursing shortage must focus on preparing more baccalaureate-prepared nurses in order to ensure access to safe patient care.  
• In March 2007, a comprehensive report initiated by the Agency for Healthcare Research and Quality was released on  Nursing Staffing and Quality of Patient Care . Through this meta-analysis, the authors found that the shortage of registered nurses, in combination with an increased workload, poses a potential threat to quality. Increases in registered nurse staffing was associated with reductions in hospital-related mortality and failure to rescue as well as reduced length of stays.  
• A shortage of nurses prepared at the baccalaureate level is affecting health care quality and patient outcomes. In a study published September 24, 2003, in the  Journal of the American Medical Association (JAMA),  Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a “substantial survival advantage” if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%.

Efforts to Address the Nursing Shortage

• AACN is committed to working with the education and healthcare community to create a highly educated nurses in sufficient numbers to meet the needs of the nation’s diverse patient population. To address the nursing shortage, AACN is advocating for federal legislation and increased funding for nursing education (Title VIII, FAAN Act); promoting a post-baccalaureate nurse residency program to aid in nurse retention; encouraging innovation in nursing programs, including the development of fast-track programs (second-degree BSN and MSN programs; baccalaureate to doctoral); and working with partner organizations to highlight careers in nursing, including those requiring graduate level preparation.  
• Since 2010, AACN has operated  NursingCAS , the nation’s centralized application service for nursing education programs that prepare nurses for entry-level and advanced roles. One of the primary reasons for launching NursingCAS was to ensure that all vacant seats in schools of nursing are filled to better meet the nation’s need for RNs, APRNs, and nurse faculty.  
• In June 2022, the National Council of State Legislatures issued a  brief  profiling different legislative approaches states are using to address the nursing shortage, including adapting scope of practice laws and offering financial incentives for preceptors,  
• In a report on  How To Ease the Nursing Shortage in America  released in May 2022, the Center for American Progress calls for bold policies toward solving the nursing shortage to ensure that more patients with access to safe, high-quality nursing services. The report highlights how federal and state policymakers can address the shortage through coordinated planning, action, and investment.  
• Many statewide initiatives are underway to address both the shortage of RNs and nurse educators. For example, in October 2022, the University of Minnesota and Minnesota State joined forces to create  Coalition for Nursing Equity and Excellence , which will work with every school of nursing in the state, healthcare providers, and others stakeholders to increase enrollment in nurse education programs, expand equity in the nursing workforce, and increase student success. Additional initiatives are also underway in  Florida  and  Louisiana  among other states.  
• Nursing schools are forming strategic partnerships and seeking private support to help expand student capacity.

Recent Articles on the Nursing Shortage

• Buerhaus, P.I., Staiger, D.O., Auerbach, D.I., Yates, C., & Donelan, K. (2022, January).  Nurse employment during the first fifteen months of the COVID-19 pandemic.   Health Affairs , 41(1).
• Buerhaus, P.I. (2021, September/October).  Current nursing shortages could have long-lasting consequences: Time to change our present course.   Nursing Economics , 39(5), 247-250.
• Firth, S. (2022, May 16).  More Support Needed to Shore Up Nurse Pipeline, Experts Say .  MedPage Today .

Updated: October 2022

Robert Rosseter [email protected]

Post-Pandemic Nursing Shortage Affecting Aspiring Nurses

Nurses are a critical part of the healthcare system. During the COVID-19 pandemic , many saw how much nurses contribute to the care and protection of patients.

What has also become evident is a growing nursing shortage. COVID-19 has highlighted the gaps in healthcare and created an increasing demand for bedside nurses. In the United States, it is projected that 1.1 million nurses are needed to replace retiring nurses by 2022. Globally, the need is closer to 13 million.

The shortage has pros and cons for nursing students. One pro is being able to find a job quickly after graduation. A key disadvantage, though, is that nursing programs have fewer openings. For students, this means acceptance into a program may be more challenging.

The nursing shortage has many consequences. First, let’s address a few frequently asked questions before diving into what it may mean for prospective nurses.

Frequently Asked Questions on the Nursing Shortage

It’s important to correct some misconceptions about what has caused the shortage and how it might affect healthcare. Identifying the challenges the nursing workforce faces may help with potential post-pandemic nursing solutions.

What Is Causing the Nursing Shortage?

To ensure hospitals are fully staffed, we must identify why there is a nursing shortage . Professional nursing organizations and published studies have identified the following factors:

• Aging population: An aging population has strained the workforce. Older adults typically have more than one chronic disease . Many illnesses that were once terminal are now considered chronic.
• Aging workforce: Nurses are also reaching retirement age. At the start of the pandemic, some nurses retired, and others were given an early retirement package , increasing the shortage.
• Nurse burnout: The consequences of nurse burnout on patient care may be severe. Data show that high workload, low staffing, and long shifts are triggers.
• Family obligations: The majority of nurses are women. According to the U.S. Bureau of Labor Statistics (BLS), 12.6% of working nurses are men. Villanova University reports 20% of its incoming nursing students in 2021 are men. With the lack of family care benefits, a high number of women nurses who are also working parents may cut back or leave the profession to raise their families.
• Nursing educators: There’s a major bottleneck in nurse teaching . A shortage of nursing faculty limits the students a program can accept. Retirement, moving into the private sector, and a lack of incentives to become nurse educators affect the faculty shortage.

What Is the Current Status of the Nursing Shortage?

According to the American Nurses Association (ANA), more jobs will be available in nursing in 2022 than in any other profession. This shortage will have a significant impact on patient care. The BLS projects a 9% job growth rate for registered nurses (RNs) from 2020-2030, slightly higher than average.

The Department of Health and Human Services estimates at least seven U.S. states have the most severe nursing shortages. These include:

• South Carolina

Even before 2020, there were statewide initiatives to address the shortage of bedside nurses and nurse educators .

What Does the Nursing Shortage Mean for Healthcare?

Several key factors affect staffing needs . These include the level of patient illness, patient number, and staff skills and expertise (seasoned nurses versus new graduates). Patient outcomes are affected by staffing shortages. High nurse-to-patient ratios can lead to medication errors and higher morbidity and mortality rates.

Data also show that a patient’s risk of infection increased by 15% when the unit was understaffed. Higher nurse-to-patient ratios can also increase readmission rates in the pediatric population.

Staffing shortages, paired with a global pandemic, can increase nurse burnout and patient dissatisfaction. A staffing shortage also impacts the hospital’s level of reimbursement . Though the pandemic created a massive need for more nurses, it also reduced funding for hospitals, resulting in staff layoffs .

At the pandemic’s start, hospitals canceled elective surgeries to prioritize COVID-19 patients. Many non-COVID patients avoided hospitals. This led to decreased hospital funding and administrations furloughing nursing staff, further contributing to staffing shortages.

The Nursing Shortage on a Global Scale

Nursing shortages are not limited to the U.S. The International Council of Nurses (ICN) Policy Brief published in 2020 shows that 27.9 million nurses were working worldwide. However, the ICN estimates there was a shortfall of 5.9 million nurses.

Unfortunately, 89% of the shortages were in low- and lower-middle-income countries. Additionally, 17% of nurses expect to retire by 2030. The report shows that 4.7 million nurses are needed to maintain the current workforce. To address the global nursing shortage, 10.6 million more nurses must replace retiring nurses. (This 10.6 million estimate doesn’t take into account the loss from COVID-19.)

Retirement is only one of the challenges. Each factor contributing to the nursing shortage must be addressed to help fill the gap.

Global Impacts of COVID-19 on the Nursing Shortage

COVID-19 has not only highlighted disparities in healthcare but further contributed to the nursing shortage. In 2020, healthcare professionals used technology to provide care for people at home such as telehealth nursing . While this helped expand the reach of healthcare, it cannot replace the care of a bedside nurse.

Some countries have encouraged retired nurses to return as a volunteer nurse or reinstate their licence to help relieve the nursing shortage. Some have even mandated inactive nurses back to the bedside.

An ICN survey found that nearly 90% of national nurses’ associations were concerned that heavy workloads, burnout, and stress were factors for the growing nursing shortages. Nurses were either retiring or moving into the private sector where stress was lower.

Infection rates and deaths are also contributing factors to the nursing shortage. Because of their close contact with patients severely ill with COVID-19, millions of nurses have also been infected. Nearly 3,000 deaths have been recorded in 60 countries. In the U.S., after 12 months, there were 3,561 deaths of healthcare workers ; 32%, or 1,136, were nurses.

The ICN estimates that as a result of all contributing factors up to 13 million nurses are needed to fill the gap.

COVID-19 Is Increasing Nurse Burnout

No job or career is stress free. Every decision a nurse makes may impact the lives of their patients.

COVID-19 has added to this stress. The ICN expects the added burden will increase burnout and post-traumatic stress disorder, which “could have potentially significant detrimental effects, especially on the nursing workforce.”

Nurse burnout is a mental, physical, and emotional state of exhaustion, often triggered by work-related stressors. Nurses who experience burnout initially feel detached and disengaged. As the condition progresses, they may begin to use food, drugs, or alcohol to cope. Some nurses have physical symptoms, such as headaches or stomach problems.

Nurse burnout can lead to health conditions like insomnia, heart disease, high blood pressure, and Type 2 diabetes. Burned-out nurses risk providing low-quality care, leading to mistakes and even death. One study from Marshall University found that when nurses took care of more than four patients in a shift, there was a higher correlation of burnout and a 7% increase in mortality for each additional patient.

An online survey found a key contributor to burnout during COVID-19 was a decreased feeling of well-being. The survey also evaluated staff resilience, or “the ability to cope with and adapt positively to adversity.” Several factors were associated with decreased well-being, including a low measure of resilience, feeling personal protective equipment was inadequate, and believing the workload had increased.

A study from India found that the higher a nurse’s resilience, the lower the risk of burnout. The ICN report expresses significant concern over the burden that COVID-19 had placed on the healthcare system, writing:

— “In January this year, ICN raised significant concerns about the mass trauma that is being experienced by nurses during COVID-19 pandemic, and the medium to long term effects that trauma will have on the nursing workforce. These issues and risks combined do not bode well for long-term nurse retention in an already overstretched and vulnerable workforce. The COVID-19 pandemic has the potential to increase the number of nurses reaching the point of burnout, and increase the number leaving the profession, which could have a damaging impact as early as in the second half of 2021.”

Hostile Working Conditions Fueled by COVID-19

During the COVID-19 pandemic, nurses faced spikes in workplace physical violence and verbal abuse as patients’ families felt helpless with sick loved ones in the hospital.

One study researched nurses’ experiences with workplace violence. The researchers used an online survey of RNs working in hospitals to calculate the frequency of physical violence and verbal abuse from February to June 2020. The purpose was to help describe the type of violence that nurses may be experiencing during the pandemic.

They found 44.4% nurses reported physical violence and 67.8% reported verbal abuse. The rate of violence was higher in nurses caring for COVID-19 patients than in nurses who did not care for COVID-19 patients. The researchers recommend that hospital administrators recognize nurses’ increased risk of workplace violence and the urgent need to carry out preventive strategies.

Another data sampling of nurses working in Iran found similar results. Researchers measured “incivility” in nurses working in seven training hospitals. Some nurses reported that patients’ families were uncooperative because of their lack of knowledge of healthcare practices. Once educated, their behavior seemed to change.

The interviews also revealed that emotional and physical abuse has increased during the pandemic, elevating an already stressful environment.

What the Shortage Means for Future Nurses

It might appear as if the shortage opens the field for nursing graduates to find a job right after school. However, there is good and bad news. Job opportunities will differ depending on the geographical area.

Many states with significant shortages have rural areas where it may be difficult to attract experienced, skilled nurses. Job opportunities may also depend on experience and skill level.

The Shortage Impacts Nurse Working Conditions

Nursing shortages have a high impact on working environments, patient outcomes, and the long-term health of nurses, leading to longer shifts and higher nurse-to-patient ratios. This shortage increases stress, fatigue, and the risk of injury to nurses. It can also reduce patient care.

Another effect of understaffing is nurses quitting because of heavy workloads and the stress of caring for dying patients. According to one estimate in 2018, the cost of turnover per nurse was $44,000.

The shortage of nurses also depends on the nursing specialty . Higher shortages are measured in labor and delivery, critical care nursing, geriatric nursing, and nurse educators.

Before the pandemic, the nursing shortage’s most significant factors were aging, burnout, wage disparities, and regional needs.

Some Regions Have Higher Demand for Nurses Than Others

The fastest growth potential are in the West and Mountain regions of the U.S. Some experts anticipate slower growth in the Northeast and Midwest regions. This aligns with the U.S. Health and Human Services’ list of states with the largest nursing shortage gap. As the population ages, there will also be growth potential in areas with high retirement populations . This includes Florida, California, and Texas.

Despite regional differences, the BLS estimates the overall growth rate for nurse practitioners to be an outstanding 52% from 2020-2030. This is much faster than the average job growth rate. While there continues to be a shortage of bedside nurses, the BLS estimates the growth rate for RNs to be 9% during the same decade, just above average. This may be a result of challenges faced in nursing education.

Interest in Nursing School Increases, but Applicants Are Turned Away

The pandemic seemed to inspire a career in nursing. According to a study from the American Association of Colleges of Nursing (AACN), student applications surged. Enrollment to bachelor of science in nursing (BSN), master of science in nursing (MSN), and doctoral nursing programs in fall 2020 increased.

While the interest was high, 80,521 qualified applicants could not be admitted. They included:

• 66,274 who applied to BSN programs
• 1,376 to RN-to-BSN programs
• 8,987 to MSN degree programs
• 3,884 to doctoral programs

Applicants were not accepted primarily because of a shortage of teaching faculty and clinical sites for nursing students.

According to AACN , nursing schools turned away 80,407 qualified applicants in 2019 for some of the same reasons like a shortage of clinical and classroom space. Another report identified a shortage of 1,637 educators in 892 nursing schools. Many of the empty faculty positions required or preferred a doctoral degree.

There Are Global Initiatives to Increase the Nursing Workforce

The ICN has encouraged national nurses’ associations and governments to address the nursing shortage. According to their estimates, 74% of associations have reported that their countries are committed to addressing the problem, and 54% are addressing the need to retain working nurses.

Nursing associations have recorded a 20% increase in the number of nurses who left the profession in 2020. This raises concerns about the emotional and physical trauma experienced by nurses during the pandemic and increases the expected nursing shortage gap.

Additionally, there will continue to be a 3-4 year gap in the nursing shortage before new graduates are ready to enter the field. During this period, national nursing associations worry that the added workload and stress will increase the number of experienced nurses who leave.

Changes Need to Be Made to Ensure On-the-Job Safety for Nurses

The stories of front-line nurses caring for COVID-19 patients have inspired many to apply to nursing programs and join a career that focuses on the care and protection of others. To close this shortage gap, the ICN has made several suggestions:

• Protect the safety and well-being of the current and future nursing staff
• Provide psychosocial support to bedside nursing staff
• Commit time and finances to long-term strategies that increase the number of nurses in the workplace
• Invest in the recruitment, retention, education, and training of nurses
• Improve wages and working conditions so local nurses do not leave for high-income countries
• Prioritize fair pay for all nurses

Nurses Can Advocate for Changes Too

Nurses need to advocate for changes at the local and federal levels. To that end, ANA has developed an activist toolkit with action plans nurses can use to support for their profession.

ANA offers one-click options of writing to legislators to encourage change or thank them for their efforts. Top federal priorities include the opioid epidemic, workplace violence, safe staffing, and health system transformation. Nurses can learn more about each effort through the site.

The Post-Pandemic Future Remains Uncertain

The future of the nursing shortage is uncertain. Higher than expected numbers of nurses are leaving the profession from:

• Rising stress that triggers burnout
• Physical and verbal abuse in the workplace

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Suburbanization Problems in the USSR : the Case of Moscow

• Référence bibliographique

Gornostayeva Galina A. Suburbanization Problems in the USSR : the Case of Moscow . In: Espace, populations, sociétés , 1991-2. Les franges périurbaines Peri-urban fringes. pp. 349-357.

DOI : https://doi.org/10.3406/espos.1991.1474

www.persee.fr/doc/espos_0755-7809_1991_num_9_2_1474

• RIS (ProCite, Endnote, ...)

Résumé (fre)

La suburbanisation n'existe pas en URSS au sens des phénomènes décrits dans les villes occidentales. Cependant on observe certains transferts limités d'activités industrielles exigeantes en espace ou polluantes, voire même de centres de recherches, vers les zones suburbaines ou des villes-satellites. Mais ces déconcentrations répondent à une logique de planification administrative. En outre, les Moscovites hésitent à aller habiter dans ces centres d'emploi, de crainte de perdre les privilèges liés à l'autorisation d'habiter Moscou (la propiska) et du fait des communications insuffisantes avec la capitale. Le taux de croissance de la population moscovite reste supérieur à celui du reste de l'oblast. Par contre le développement de datchas de seconde résidence est très important dans l'oblast de Moscou, en particulier aux alentours des stations de chemin de fer. L'abolition du système de propiska pourrait transformer les datchas les plus proches de Moscou en résidences principales.

Résumé (eng)

The suburbanisation does not exist as such in the USSR with the meaning one has of the phenomena in Western cities. Though one may notice some limited transfers of industrial activities demanding a lot of space or polluting ones, even research centres, towards the suburban areas or satellite-towns. But these déconcentrations correspond to an administrative planification logics. Moreover the Muscovites hesitate before going and living in these employment centres, because they are afraid of loosing the privileges linked with the authorisation to live in Moscow (the propiska) and because of insufficient communications with the capital. The growth rate of the Muscovite population remains higher than this of the remainder of the oblast. To the contrary developing of datchas for second residences is very high in the Moscow oblast, especially in the vicinity of a railway station. The abolishment of the «propiska» system might transform the datchas nearer to Moscow into main residences.

• Economic structure [link]
• Suburbanization of activities [link]
• Suburbanization of population [link]
• Conclusions [link]
• Literature [link]

Liste des illustrations

• Table 1. Employment structure, % [link]
• Table 2. Annual rate of population increase, % [link]
• Fig. 1. Spatial distribution of country-cottages and gardening associations in the Moscow region [link]

Texte intégral

Galina A. GORNOSTAYEVA

Moscow University

Suburbanization Problems

in the USSR :

the Case of Moscow

Suburbanization processes typical to cities in Western Europe, the USA and other countries are not observed in the USSR or they are distorted to such an extent that they may not be compared with existing standards. This states the question how Soviet cities-succeeded in escaping this stage of urban development. In order to answer this question, we should first summarize the main aspects of Western suburbanization.

Firstly, it is well known that the urbanization processes are linked to structural changes in the economy. Thus the transition from the stage of concentration to this of suburbanization is associated with industrialization, and the transition to the third stage - déconcentration - is related with the rapid growth of employment in the non-industrial sphere. Secondly, a suburbanization of economic activities can be distinguished. It applies in the first place to the building and iron- working industry, transports, engineering and chemical works. These are polluting and requiring extensive areas. This suburbanization of industry is caused by the following factors: rising demand for land from firms ; worsening of transport

tions in the inner cities ; demand for lower land costs and taxation levels in suburbs ; rapid growth of road transports; state policies regulating the growth of large cities ; migration of the labour force to the suburban zones. Scientific and educational activities are also transferred from the centre to the suburbs.

The third important aspect of suburbanization applies to the population. In the suburbs two opposite flows of population meet ; one is centripetal, coming from non- metropolitan regions, the other is centrifugal, coming from the central city. The reasons for the migration to the suburbs are as follows : declining living standards in large cities (overcrowding, slow housing renewal, environmental problems, etc.); growth of motorization of the population, development of communications (telephone, telex, fax, computer) ; intensifying decentralization of working places ; lower land prices in the suburbs ; state support for the intensification of real estate development in the suburbs. The above-mentioned factors and reasons for suburbanization are altered in the Soviet cities. Let us explore them, by taking for example the largest one - Moscow.

Economic structure

The employment structure in the USSR reveals sharp differences from those in developed urbanized countries. The USSR is characterized by a high share of employment in agriculture, industry, construction and a low share in the non-industrial sphere (tab. 1).

A correlation analysis of the percentage of urban population and employment in the different spheres of economic activity reveals that the share of urban population in the USSR is higher than in countries with the same percentage of persons employed in agriculture.

TABLE 1. EMPLOYMENT STRUCTURE,

Source: personal calculations.

The urbanization processes in the Moscow Capital Region (MCR) are more intensive than in other regions of the USSR. Structural changes are more obvious here : the share of employment in the non-industrial sphere increases more substantially and the percentage of persons employed in industry and agriculture is lower than in the whole country. However the MCR cannot therefore be compared with a metropolitan region in a Western country. Although Moscow is the most advanced agglomeration in the USSR, it lags is far behind the major world cities in terms of development and it is at the very start of the post- industrial stage of its structural and urban transformation.

The structural «anomaly» of the USSR as a whole and of the MCR in particular is explained by the enforced process of industrialization (starting from the thirties) at the expense of the peasantry (thus, there is not only a booming industrial employment in cities, but also worsening living and working conditions in villages and forced collectivization having triggered off the massive rural emigration). As a result, the share of urban population in the USSR is higher than expected, based on changes in the economic structure. While urbanization in the developed countries was due, among

other causes, to an increasing labour efficiency in agriculture, this remained quite low in the USSR. Therefore the employment share in agriculture is overstated in comparison with countries with a similar percentage of urban population, and even this considerable part of the labour force is unable to feed the whole population of the country.

The share of agricultural employment in the mcr increased from 7,4 % to 7,6 °7o between 1980 and 1985 (as a result of Moscow attractiveness and the better living standards in its surrounding villages), whereas it continued to decline in other parts of the Central region. The population growth in villages adjacent to Moscow is especially intensive, though labour efficiency in localities near Moscow is higher than in the other oblasts. In spite of this, Moscow oblast provides only 61 % of milk, 34 °/o of potatoes, 45 % of vegetables and 23 % of meat needed by the population in Moscow city and oblast (Argumen- ty i facty, 1988, N50, p. 3). The structural anomaly is not only related to processes in agricultural sphere but also in industrial sector. As a result of the low economic mobility of socialist firms and of the absence of market relations, the industrial development was extensive,

without significant increases of the labour

productivity.

Thus the employment transfer from the

agricultural to the industrial sector, their

extensive development and their low labour

productivity are intrinsically related with the political definition of productiorfrela- tions and course of structural economic transformation.

Suburbanization of activities

Moscow and Moscow oblast show divergent economic structures and changes (tab. 1). In Moscow the employment share in the non-industrial sphere in Moscow is growing more rapidly, whereas the share of industrial employment is decreasing. In Moscow oblast the part of transport and communication infrastructure, retail trade, administration, housing (presently less developed than in Moscow) is increasing. Some stages in the transformation of activities in the mcr's settlements may be pointed out here. The stage of industrialization and reconstruction after World War II is characterized by the swift industrial development and the active restructuration of the Moscow and Moscow oblast economy. New industries have been built (motor-car and aircraft assembly, machine-tool industry, organic synthesis, etc.), around Moscow research and production potential. Nevertheless, this restructuration is extensive, since traditional industries don't curtail production. It favours the heavy concentration of modern functions in Moscow. There is no transfer of firms outside Moscow. Suburbanization of industrial activities did not occur because of the state owning the means of production and of thé socialist form of production relations. When research and technological progress are slowing down, these firms become inefficient and spatially immobile. The period 1956-1970 is marked by an intensive development of the region scientific sphere and by the rise of « satellite » urban policy. The new centres were specialized in modern branches of machinery and research-engineering activities and were undoubtedly very attractive for the population. Therefore towns like Dubna were growing rapidly. While the aim was to redirect part of Moscow population

growth, they display a quite specific relation with the capital. For instance, Muscovites working in Pushchino cannot reach their job every day because they lack transport facilities. Nevertheless, they don't wish to move and register their passports in the city in which they actually work, since they would have to give up their Moscow registration and then lose all Moscow privileges (see further). These new centres are isolated from information sources in Moscow. Poor telephone communications, lack of computers and telex systems hamper contacts and teamwork with colleagues in the city. It seems that material resources for experimental work in research centres are not sufficient to compensate for lack of information and communications. At the same time, poor transport links with Moscow and the other towns of Moscow oblast isolate the scientists from the higher standard of culture in the centre and from a well developed social infrastructure. An original home-work relation can be observed in Dubna: the Muscovites get the second registration of passports and live there in hostel apartments during 4 or 5 working days, during the weekends they go back to Moscow, where their families are living. The change of functions in Moscow oblast towns is still going on. Inside the towns of the first circle adjacent to Moscow, the share of employment in the non-industrial sectors and transport is growing. Inside the towns of the second circle (suburban zone) these changes lead to an increasing potential of non-industrial, industrial and construction functions. Finally, in the outlying parts of the region the further grovth of construction and industrial functions is observed and the organization potential is intensifying in some towns. The mcr towns display a crawling concen-

tration of the regional most important functions and their extension outside the boundaries of Moscow to the towns of the suburban zone. But the déconcentration of functions in the mcr is not only of natural- economic character. It also results from the state urban policy. Déconcentration is not related to the search for more advantageous sites for firms and institutions as regards to economic or social relations (the availability of cheaper labour force or more comfortable living conditions, etc.), nor is it sustained by the expansion of transport and communication facilities. Thus, this déconcentration is independent from curtailment of any function in central Moscow, whose potential is still growing, and it is also completely inadequate regarding the continuing concentration of population (see below). All this, together with the slow economic and territorial mobility of firms, is an obstacle to the economic restructuration of the region, and to the reorientation of Moscow and its suburbs to non-industrial activities and to progressive scientific and informational work. The mass labour-consuming functions still remain in Moscow and its suburbs, but they are inevitably cut off from modern types of activities.

The idea of alleviating Moscow's development appeared from the very beginning of its rapid growth, since the excessive concentration of population and employment led (as in the other major world cities) to environmental discomfort, worsening of transport, strip-holding of land and other congestion signs. In market economies, the firms react to alterations of economic or social conditions by their mobility: some

of them close, other relocate in more convenient places. In the USSR, the problem of firm transfer (unhealthy or unprofitable firms) becomes unsolvable because of the special type of production relations. Economic and territorial passivity of firms is apparent in the difficulties of erecting industrial buildings and dismantling machinery and equipment, in the low turnover of the means of production. The same problem exist regarding the labour force. Firms transferred to the suburban towns of Moscow oblast are encountering great difficulties in recruiting staff in sufficient numbers and of required skill. The local labour force is rather weak, while the Moscow workers wouldn't leave the capital to follow their firm, because they are afraid of being deprived of passport registration in Moscow. From the social point of view, giving up a Moscow registration is more significant to people than losing their job. The processes going on in the mcr are therefore not quite comparable with those in the Western world. The market economy is more «lively» and replacement of functions has the character of territorial waves. Some functions disappear while new ones emerge. In the mcr, the waves are replaced by stratification. New functions do not replace the old ones, but joining them. At the same time, this process of relative déconcentration of functions overpass the process of stable concentration of population. In the mcr, the modern branches are gravitated closely to Moscow, where skilled workers are retained by their registration advantages. Suburban towns have to be satisfied with commuters or specialists from the outlying regions of the USSR.

Suburbanization of population

The urbanization structure of the region is characterized by the predominance of its main centre - Moscow. The share of the capital in the total Moscow oblast population was as follows: in 1929 - 44,3 Vo, in 1939 - 51,6 %, in 1959 - 54,9 %, in 1979 -54,5 Vo, in 1985 - 57,3 % (Moscow Capital Region, p. 137.). Within the agglomeration, the share of Moscow is still higher, in 1959 it was 75,5 % and in 1985

- 67,3 % (ibid., p. 141), whereas in the highly developed capital regions of the world the agglomeration counts one half or less of the total population and of the economic potential, the second half being concentrated in the suburbs (Gritsay, p. 71). Moreover, the growth rate of Moscow population is higher than that of Moscow oblast (tab . 2).

TABLE 2. ANNUAL RATE OF POPULATION INCREASE,

Migrations are of great importance to the mcr. The internal migration of rural population to the cities is rather substantial, and the immigration flow from the rest of the USSR is not compensated by the decrease of rural population in the mcr. The nearer a town to Moscow, the larger the migration share in its total population increase.

The dynamics of population in the mcr has a specific character. In agglomerations of the developed countries the principle of the «broken glass» summarizes the suburbanization process. When, for some reasons, the centre loses its attractiveness the urban population moves to suburbs in search of higher living standard. In Moscow agglomeration the principle of the «overfilled glass» is operating. People wanting to live in Moscow cannot enter the city and are forced to settle near it. In Moscow immigration undoubtedly prevails over emigration, confirming the extreme territorial differentiation in conditions, level and way of life. As a rule, commuting is oriented from suburbs to Moscow (600 thousand persons come to Moscow and only 200 thousand leave it), but it accounts only for 12-15 % cf the total employment in Moscow's economy. Moreover, these commuters are not Muscovites but potential new inhabitants of the capital (striving for passport registration and domicile in Moscow).

Moscow became the most attractive place for living and an intensive flow of ruined rural residents as well as residents from other regions of the country were rushing -to Moscow. These processes were generated not only by the inception of the country structural economic transformation,

but also by the policy of special privileges for Moscow. These privileges came into being after the establishment of a centralized distribution system. Such a system involves the assignment of a priority level of foodstuffs and manufactured goods to each territory. Moscow was awarded the highest priority level. From the very beginning, better living standards and higher income for certain population categories were established there. In the thirties the artificial differentiation in living standards was confirmed by imposing restrictions to passport registration in the capital, and also by the division of administrative bodies into Moscow and Moscow oblast authorities. In the period 1925-30 dozens of new large firms were located in Moscow, but housing was insufficient at that time. Therefore, a great number of migrants from every corner of the country came to get a job in Moscow and settled in cottages in the nearby countryside. Soon, these settlements in the nearby countryside. Soon, these settlements turned into urban ones. For example, towns like Mytishchi and Luberstsy developed rapidly, and even Muscovites moved there when the railways were electrified. This was clearly the outset of a suburbanization process, but it stopped as soon as the restrictions on passport registration in Moscow were imposed and the social barrier between Moscow and Moscow oblast was established. In the period 1930-40, new industrial developments were banned from Moscow and firms drawn towards the city were located on the outskirts thus causing a rapid growth of the old and new towns. Although the development of cottages as second residence near Moscow started even before the revolution, since the en-

vironmental degradation of Moscow was practically completed at that time, they became the main resorts of those years. They had flourished in the districts with privileged natural conditions and convenient transport services (not further than 2 km from a railway station). In the period 1930-40, this sprawl of leisure housing carried on - cottage settlements expanded into an entire belt of scattered one- storeyed buildings. But at the same time, urban multi-storeyed housing also increased and after World War II these multi- storeyed buildings were found in the cottage settlements of the leisure zone. In the period 1950-60 a network of gardening associations was established. In those

years the most convenient land near Moscow had already been built on. The gardening plots allotted to the Muscovites were located in the remote parts of the mcr, outside the suburban zone, and very frequently they were on improper territories. Because of their remoteness, the difficulties in cultivation and building, the lack of infrastructure, these plots cannot become effective leisure resorts. More frequently Muscovites use them for fruit and vegetable growing.

The desire of the Muscovites for having a second residence in the suburbs can be interpreted as an unfulfilled suburbanization tendency. This desire has the same, mainly environmental, causes as suburbaniza-

tion in Western countries. The cottages within the reach of Moscow's traffic and having access to appropriate infrastructure and amenities, might become the principal residence of Muscovites if passport registration is abolished. The restrictions of passport registration in Moscow fixed in the thirties were devised as an administrative solution against the effects of Moscow's unique attractiveness and not as a means of eliminating the attractiveness itself. For this reason, Moscow became even more attractive, like a forbidden fruit. The consequences were both the concentration of the upper strata of society in the city and the extensive development of industry, resulting in a growing shortage of unskilled labour.

The shortage of regular workers in Moscow is sometimes explained by the increasing number of working places. An adequate planning of the «limiters» (1) system is then put forward as the solution for controlling the growth of Moscow is found in (Glushkova, 1988, p. 43). To be frank, about twenty industrial units and more than one hundred scientific institutions were already created in the seventies alone, in spite of the industrial building ban in Moscow, only a few firms moved outside the city in return. New industrial units easily find staff, since they offer new machinery, relatively good working conditions and higher wages. New scientific and administrative institutions are in a similar position. But the situation is totally different in the old industrial units, with rundown equipment and a high level of manual tasks. Those units suffer from a staff shortage. Moreover, as in any other city, there is a social mobility in Moscow, in most cases improving - from manual up to mental, from unskilled up to highly skilled work. Furthermore, the prestige of a higher education (university) is overestimated in Moscow, whereas the prestige of the manual professions has declined as a result of the stagnation of reinvestments in industry, the high share of manual labour (40 %), and also favouritism and

crowding in the administrative staffs. The attractiveness of an upper class position is therefore overestimated, and social mobility activated. Since Moscow cannot admit free «immigrants» the lower strata of the social structure are vacant and there appears a shortage of unskilled labour force. The lower strata of the social structure were filled in with « limiters ». Available employment in Moscow was not the cause of an organized immigration flow, but represented the only possible way to register the passport there. Roughly half of these people drawn into Moscow's economy left their jobs. «Limiters» get the right to register their passports in Moscow and take up their residence in new houses when their contract expires. They usually quit their job as soon as possible in search of better working conditions (Glushkova, 1988, p. 42). The nature of unskilled work in Moscow and the associated working conditions are so unattractive that it is nearly impossible to find Muscovites willing to perform them.

The institution of passport registration raised many problems. Thus the « limiters » are recruited in social groups not needing most of the advantages of a large city, their psychology and value system differ sharply from native Muscovites. The direct environment of the hostels where «limiters » live, has a pronounced criminal character. Fictitious marriage in order to register the passport in Moscow has become a widespread practice.

Moscow's environmental problems can hardly be solved as long as passport registration exists. The population is literally locked up within the city boundaries. Notwithstanding the environmental stresses, the Moscow privileges prevent the Muscovites from leaving the city. The urban districts not saturated with harmful industrial units are the most prestigious. The social and economic causes of Moscow's extensive growth reveal that its problems are a reflection of the ones facing the USSR. The concentration of economic, social and management functions in Mos-

cow in Soviet times materializes the strong centralism of the particraty and weighs down on the city's development. Low labour efficiency in agriculture and sheer desolation of villages on the one hand, rapid but extensive industrialisation together with forced increasing social attraction of Moscow, confirmed by the restrictions on passport registration, on the other hand, were the key factors of the mcr's polarization during decades. Together with objective factors found in other large cities of the world, subjective factors related to the Soviet political and economic system influence Moscow's growth.

The objective factors are as follows: the diversity of employment in the capital, the emergence of new types of occupations, the concentration of high-skilled and creative labour, the higher living standards, the large educational and cultural opportunities.

The subjective factors are the higher supply level of foodstuff and manufactured goods different than in other regions (the existence of meat-rationing system in many regions of the country and its absence in Moscow establishes a significant threshold not only in terms of supply but also in the outlook of the population); the lack of communications and individual motorized transport (in the rsfsr one counts 47 cars per 1000 urban inhabitants against 560 in the USA) (Argumenty i facty, 1988, N47, p. 2); the craving for joining the upper social classes and for accessing neighbourhoods with a high quality of life; unjustified promotion of upward social mobility releasing «the ground floors» of Moscow's economy; continued growth of employment due to the extensive economic development and the low economic and territorial mobility of firms. Today, the hierarchy of priorities for selecting a residence within the mcr and the whole country is as follows. Food supply comes first. The supply of manufactured

goods, the opportunities to obtain better and larger living quarters and to accede to a prestigious employment with a wage increase, social promotion, well developed consumer services come next. And only at the end of the scale appears the opportunity to fulfil cultural needs and education. Thus, there is a process of «pseudo- urbanization» characteristic of the Soviet economic and social system, superimposed on the process of «natural» urbanization. By natural urbanization we mean the process related to economic development and to the natural difference between rural and urban ways of life. The specificity, the structural changes and the hierarchy of city functions shape the migration flows conditioned by natural urbanization. «Pseudo-urbanization» points to «the scum» of the process, that may complete the economic and socially conditioned urbanization. The «pseudo-urbanization» is generated by a disproportionate development of the country's economic structure (hypertrophie share of industry; economic and political reforms have triggered off a massive flow of the peasantry towards the cities, related not with the rising but with the lowering of labour efficiency in agriculture, with impoverishment of the countryside and hence with the urge towards the centres of relative well-being), and by the territorial inequalities in standards of living, artificially created and maintained by the institution of passports and registration.

The suburbanization of population cannot be observed in the MCR. The centripetal tendencies mentioned above resulted in rapid growth of Moscow and its suburbs, as well as in some stagnation of its periphery. Thus Moscow agglomeration is now in the first stage of development, the stage of «crawling» concentration where centrifugal forces are very weak. This situation will last as long as the barrier in terms of standards of living exists between Moscow and Moscow oblast.

Conclusions

This study has reaffirmed the general lack of suburbanization in the Soviet cities. Some signs of suburbanization like the

transfer of some activities from Moscow to the suburbs, the concentration of population in towns and villages near the central

city and commuting, differ significantly pie and firms will emancipate, only if the from the Western cities. The process of ur- existing political and economic system in banization will take its normal course, peo- the USSR is dismantled.

Argumenty i facty, 1988, N47, p. 2 Argumenty i facty, 1988, N50, p. 3

GLUSHKOVA V.G. Questions of Interrelated Settlement in Moscow and the Moscow Region, Problems of Geography, vol. 131, Moscow, 1988, pp. 40-56.

GRITSAY O.V. Western Europe : Regional Contrasts at the New Stage of Scientific-Technological Progress, Moscow, 1988, 148 p.

Moscow in Figures. 1980, Moscow, 1981, 220 p. Moscow in Figures. 1985, Moscow, 1986, 240 p.

National Economy of Moscow Oblast. 1981-1985, Moscow, 1986, 271 p.

National Economy of the ussr. 1985, Moscow, 1986, 421 p. Yearbook of Labour Statistics. 1987, Geneva, 1987, 960 p.

Moscow Capital Region: Territorial Structure and Natural Environment, Moscow, 1988, 321 p.

(1) Limiters are unskilled workers, hired in an organised way by Moscow firms; after working there for several years of working they get the right to register

their passports and to take up their residence in Moscow.

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