The Affordable Care Act (ACA) has helped 16 million previously uninsured people gain coverage since 2010.
Finding people to work in this rapidly growing industry, however, remains an ongoing challenge, namely in the front line of the healthcare industry — the nurse.
The ACA established the National Healthcare Workforce Commission (NHWC), a 15-member committee tasked with identifying barriers in producing new healthcare workers to meet the growing demand.
Dr. Peter Buerhaus, the would-be chair of the NHWC and director of the Center for Interdisciplinary Health Workforce Studies at Montana State University, said supply-and-demand forecasts project major nursing shortages into 2025 that will worsen by 2030.
These projections come with some “angst” and “uncertainty” with how the United States will train quality nurses to meet these future demands.
“At the moment, the current trends are good,” Buerhaus told Healthline. “We need to make sure these nurses have the training and preparation for the changing healthcare field.”
One Million New Nurses Needed by 2020
With a 20 percent increase in new nursing positions and a third of all current RNs expected to retire by 2020, the United States will need another 1.1 million registered nurses and advanced practice registered nurses, such as nurse practitioners, in the next five years.
Those shortages are expected to worsen by 2030, driven partly by people living with multiple chronic conditions such as obesity and diabetes.
When an area doesn’t have enough health professionals, it is designated as a Health Professional Shortage Area (HPSA). These include state and federal facilities, such as prisons or public medical facilities.
Across the United States, there were 6,087 HPSAs as of April 2014. There were 8,073 primary care practitioners needed to better meet the needs of people in those areas.
Larger geographical states like California and Texas have the highest “needs met” percentages, while states such as Connecticut, Rhode Island, Alaska, Missouri, and North Dakota have the lowest percentage of needs met, all under 40 percent. Nationally, that rate is 60.41 percent, according to data from the Henry J. Kaiser Family Foundation.
Florida, where roughly a fifth of the population is over the age of 65, has 252 HPSAs with 42 percent of the practitioners it needs. It will require another 916 qualified and trained individuals to care for its citizens.
Other places are scrambling to hire nurses to make up for current shortfalls. Hospital systems across the country are offering signing bonuses to nurses.
Porter Regional Hospital in Valparaiso, Ind., forks over a signing bonus of $7,500 for nurses with two years of experience. Hospitals in Atlanta are reportedly offering an extra $10,000 and relocation costs for experienced nurses in labor and delivery and catheterization lab nurses, according to WSB-TV.
That’s good news for people in the nursing field, but as they’re aware, it’s an ever-changing field of work.
The Straws That Can Break a Backbone
Often called the backbone of medicine, nurses enter the field with a heartfelt desire to help people.
But all too often, that love is tested with continual stress, frustration, and fatigue as they struggle to do more with less.
“It’s a strong motivation, but when they join these systems, it can be challenging and it can beat them down,” Buerhaus said. “They’re already feeling the pressures of how much work they have to do to still have meaningful relationships with patients.”
In reality, especially in larger scale health systems, nurses are spending less time actually tending to a patient’s needs.
One study of nurses in 36 medical-surgery units found that 19 percent — or 81 minutes — of a nurse’s shift were related to patient care activities. Documenting, administering medication, and care coordination took up nearly three quarters of their time.
Too often nurses are doing their jobs with too few hands on deck.
According to the American Nurses Association, 40 percent of nurses report short-staffing in their hospital units and an increase in overtime, while 54 percent report excessive workloads. In addition, 96 percent say they’re fatigued before their shifts even start.
All these can lead to an increase in medical errors and readmissions while decreasing quality of care and retention of experienced RNs.
One study Buerhaus participated in published in The New England Journal of Medicine showed significant association of patient deaths when staffing levels were eight hours or more below their target levels.
This, Buerhaus said, is part of the “squeezing of the workforce to make a profit each year.”
The Growing Need for Nurse Practitioners
Like others called into nursing, Jill Bohn has a strong desire to help people, namely by decreasing abuse and neglect through education.
A board-certified nurse practitioner (NP) in central Wisconsin, Bohn says after a 10-hour shift, she’ll spend another two or three hours charting a patient’s details, including logging how much a patient urinated or defecated.
All the while, Bohn will often go a full shift without time to get a glass of water or use the bathroom herself.
“It feels impossible to do it and then writing a book about them each shift. That’s a huge dissatisfaction,” she told Healthline.
The increased workload means less time spent with each individual patient. To Bohn, this decreases trust in the sacred relationship between patient and provider.
“The burnout rate is sky high,” she said. “People are leaving the profession to be a hairdresser because of the stress.”
While the majority of the nation’s 122,050 NPs work in the offices of physicians, 48,000 are working in hospitals, outpatient care centers, colleges, and home healthcare services.
Experts say seeing a doctor for a common ailment will become less common and more patients will see a nurse practitioner for primary care.
Although both professions can prescribe medications and order tests — their scope varies by state — NPs require less training and are typically paid less. (The median pay for an NP was $95,350 in 2014, while a family practice physician earned $180,180.)
This makes NPs more sought after in a value-based for-profit healthcare system. Experts say the need for them will increase exponentially.
To fill the gaps, estimates show 58,500 new NPs will need to be trained and ready for 2022. That includes 37,100 to fill new positions and another 21,400 as replacements.
But some of the areas that have the highest demand for nurse practitioners don’t always pay the highest.
Northeastern Mississippi’s nonmetropolitan areas have the highest demand, but only pay $88,060 in median annual income, while Columbus, Ind., has half as many positions but pays a median of $146,450, according to the U.S. Bureau of Labor Statistics (BLS).
Unlike some registered nurse programs that only require an associate’s degree, nurse practitioners must have their master’s degree. In 2009, this meant an average of $44,393 in debt for graduate studies alone.
Increasing the number of NPs may come with an extra degree of difficulty, as there’s a push to have NPs complete a Doctor of Nursing Practice on top of their master’s degree, adding more time and expense to pursuing the field. Organizations like the American Association of Colleges of Nursing (AACN) support this move.
Wisconsin attempted to mandate that all NPs receive doctorates, but it failed because of the nursing shortages. That shortfall includes those able to teach and train would-be nurses.
The training and education involved to become an NP came with many personal sacrifices for Bohn, a mother of three girls, the oldest of whom just started driving.
She’s considered the 18-month doctorate program and transferring to academia if the clinical side becomes too much stress on her family life.
“I fall asleep at night wondering if I did the right thing,” she said.
But whether there would be enough available professors to teach her remains another looming concern.
Nursing Schools Short on Faculty
The nation’s nursing schools are also facing a shortage of faculty members.
Kyle Mattice, president of health services for the Execu|Search Group, a healthcare staffing and recruitment company, said the nursing faculty shortage is the largest component in the clinical nurse shortage.
“There aren’t enough schools producing enough graduates,” he told Healthline. “There’s plenty of interest, but not enough seats.”
In 2014, 13,444 qualified applicants were turned away from master's programs, and another 1,844 qualified applicants were turned away from doctoral programs primarily due to faculty shortages, according to the AACN.
According to the BLS, there will be a need for 34,200 more postsecondary nursing instructors and teachers by 2022. Of those, 24,000 will be new positions and 10,200 will be to replace current instructors.
“It feels like that shortage is right now,” said Marie Nolan, Ph.D., associate dean of academic affairs at Johns Hopkins University, one of the nation’s top nursing schools. “We’re like every business and are feeling it now that baby boomers are retiring.”
Nolan had to hire five new faculty members for the school’s nursing program and it took a year to do it. She was looking for a combination of people who were experts in their field or people just finishing their Ph.Ds.
“It’s a reality that our very seasoned faculty are retiring. We’re trying to overlap,” Nolan told Healthline. “It’s difficult to lose people with that kind of experience, but the new people coming in are amazing.”
But besides keeping staffing levels up, it’s also about changing curriculum to reflect the changing healthcare field and the different positions nurses will play in it.
This fall, Johns Hopkins added a Master’s Entry into Nursing program, which allows students who hold a bachelor’s degree in another field to enroll in the full-time, five-semester program. Upon completion, students can then take the National Council Licensure Examination (NCLEX) and become registered nurses.
Overall, the school keeps enrollment at 120 in its master’s entry program each spring and fall semester. Nolan says this is done to keep faculty accessible and keep quality above all else.
“We feel nurses need to be one of the most educated people on the team,” she said. “No one practices medicine alone anymore.”
At Winona State University in southern Minnesota, William McBreen, dean of the school’s nursing program, has seen 40 percent of the school’s nursing faculty retire since he took the position in 2008.
Even more are expected as the average faculty member is in their 50s and the school has a steady undergraduate nursing program of 150 students.
Their students, however, are feeling the plus sides of the nursing shortage. Some are receiving a job offer a semester before graduation. Seven years ago, when hospitals were seeing fewer retirements in fear of the economic downfall, that wasn’t the case.
“Nurse jobs will always be there,” McBreen told Healthline, “but walking right into their dream jobs has kind of been the variable.”
Many students who are completing their undergraduate degree in hopes of becoming an RN will go on to be advanced practice nurses, including nurse practitioners, nurse anesthetists, and nurse midwives. Those careers also typically a pay a third more than an RN, whose median pay was $65,470 in 2012.
“There’s no question of the expansion and increased needs in those advanced practices,” McBreen said. “They represent quality in terms of service, but they can augment the care of a physician.”
While there are good places to recruit faculty from, such as the Mayo Clinic in nearby Rochester or Gundersen Lutheran Health System in LaCrosse, Wis., rural schools across the country are having a more difficult time.
“To meet the salary requirements of someone in the clinical setting can be a challenge for some,” McBreen said.
Peter McMenamin, a senior policy fellow with the American Nurses Association, said a major hurdle in staffing the vacancies is the big pay cuts that occur when qualified nurses move from clinical practice to a university setting.
While the average nurse practitioner makes $91,310 or more, your average assistant professor with a master’s degree in a nursing school averages $73,633.
“I’m an economist, not a nurse, so that doesn’t make sense to me,” McMenamin told Healthline.
Besides money for faculty, there are limited federal eduction funds for students.
The largest source of federal funding for nursing education, Title VIII of the Public Health Service Act, needs legislative attention, McMenamin said.
Over its history dating back to 1964, substantial increases in Title VIII funding has been followed by increases in the number of new nurses entering the profession. The number of nurses decreases when funding also decreases.
Funding and new entrants were basically level from the late 1980s through 2000. With substantial funding increases in both 2002 and 2010 Title VIII funds were tripled. New nurses who passed their National Council Licensure Examination rose from 70,000 to nearly 150,000 in 2014.
“There’s a direct correlation between Title VIII funding and new nurses,” McMenamin said. “The output doubles.”
Rep. Lois Capps, a Democrat from California, introduced H.R. 2713 in June, which fund the nursing loans and grants to 2020. According to GovTrack.us, which isn’t affiliated with the federal government, the bill has a 1 percent chance of being enacted.
What Will Happen if America Is Short of Nurses
In turn, generations are increasing in size. While the baby boomers are the largest generation currently living at almost 75 million, generation X isn’t much smaller, and millennials are expected to peak at 81 million in 2036.
As these generations age — living longer with more chronic conditions needing care — it will put even more strain on the healthcare system. Some estimate that by 2030, an additional 3 million people will be eligible for Medicare.
“The problem will not stop when Baby Boomers age into Medicare,” McMenamin said.
This means even more registered nurses, nurse practitioners, and others will be needed to care for the growing and aging populations.
“The nice thing is that this isn’t happening in 2016,” McMenamin said. “There’s time to plan.”
The full ramifications of the latest nursing shortage remain up in the air. Similar to the nursing shortage that peaked during WWII and into the 1960s, some anticipate increased enrollments in nursing schools, shorter training periods, and using less-educated professionals to fill in the gaps.
This move, however, can often result in more mishaps and frustration with the profession, causing trained nurses to pursue other careers because of the stress, according to several professional nurse organizations.
As U.S. nursing schools continue to lag behind in producing enough graduates to meet the demand, a new influx of foreign-educated nurses is expected to enter the healthcare system, creating a billion-dollar nursing emigration market.
Those currently in the nursing field say they already operate under a do-more-with-less mentality and ultimately it’s the patient that suffers. But a system that relies more on advanced-degree nurses than physicians offers more options for nurses.
“Right now, nurse practitioners are doing well in cost-conscious healthcare systems,” Buerhaus said. “In the future, those standards of finding value will be more challenged.”
No matter what methods are involved to fix the problem, the consensus is that too few nurses means the healthcare system will suffer.
A 2010 paper published in the Journal of Clinical Nursing determined shortages aren’t created by a lack of bodies, but by nurses who are unwilling to work in the conditions available.
It found that the actual causes of nursing shortages are inadequate workforce planning and allocation, an undersupply of new staff, poor recruitment, retention policies, and ineffective use of available nursing resources, such as poor use of skills, poor incentive structures, and inadequate career support.
“Failure to deal with a nursing shortage — be it local, regional, national or global — will lead to failure to maintain or improve health care,” the authors state.