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The COVID-19 pandemic worsened a national shortage of registered nurses, making it increasingly urgent that policymakers invest in higher education, coordinate strategies to alleviate the pressures on the nursing workforce, and make the entire health care system more equitable and stable.
Building an Economy for All, Strengthening Health, Coronavirus, Higher Education, Women’s Economic Security+2 More
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May 24, 2022
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Since the COVID-19 pandemic began more than two years ago, no region of the United States has been spared an acute shortage of registered nurses. In January, governors across the country, some for the second time, called in the National Guard to assist health care providers, and 1,118 hospitals—more than 1 in 6 hospitals in America1—reported critical nursing shortages.2 As of March 2022, almost every state had taken executive actions to address the shortage,3 such as issuing temporary licenses to put nursing students to work.4
Registered nurses are among the professionals most sought after today. They provide care in every possible health care setting, including hospitals, physicians’ offices, outpatient care centers, and skilled nursing facilities, as well as in behavioral health settings, the home, schools, universities, prisons, and private employer settings. Nurses are not only critical providers of patient care, but they also have an important role in addressing inequities within health outcomes and improving the health of the population as a whole.
May 23, 2022
Marina Zhavoronkova, Bradley D. Custer, Anona Neal, 2 More
Justin Schweitzer, Marcella Bombardieri
At the same time, nursing is a bedrock profession of the middle class and is particularly important for the economic security of women, especially women of color. Last year, there were approximately 3 million nurses working in the United States—the single largest category of health care professionals and the fifth-largest profession nationally, after retail salespeople, home health and personal care aides, cashiers, and fast food workers.5
And yet the United States still needs more registered nurses. Tens of thousands of qualified students are turned away every year from the university degree programs that train students to become registered nurses,6 while nurses are considering leaving the profession in large numbers after bearing too much of the burden of the country’s response to the pandemic.7
These problems have not received the attention they deserve, especially the lack of capacity within institutions of higher education to educate enough nurses. This report examines factors behind the current nursing shortage and discusses why nursing is a crucial occupation for improving health, economic security, and racial equity in this country. It also explores the problems inhibiting higher education from educating more nurses and inhibiting more cohesive management of nursing shortages.
Central to building a strong nursing workforce is a higher education system that has the capacity to supply enough nursing graduates to meet the demands of the health care system. This report recommends that Congress pass legislation that would invest in nursing faculty, clinical placements, and nursing program facilities so that colleges and universities have the resources to enroll and graduate more students. Policymakers should also invest in programs to help nurses who have associate degrees obtain bachelor’s degrees, which would boost the training level, wages, and career trajectories of many nurses of color.
In addition, to create a more organized strategy to address the nursing shortage, this report makes recommendations to establish or designate federal and state-level entities to monitor nursing shortages and advise policymakers and the health care and education sectors.
While this report’s recommendations are focused on the pipeline into the nursing profession, it is just as important for health care employers, policymakers, and others to address the conditions in the workplace affecting retention of nurses. This problem, and approaches that other organizations have proposed to address it, is discussed at the end of this report. (see Appendix)
To learn about the problems constraining the nursing pipeline, the authors studied existing research and conducted confidential interviews with 17 nursing experts, including nursing school deans and faculty from private and public universities and community colleges, nursing professional association leaders, state government officials, nurse union leaders, congressional staff, and others. Their insights provided background information that informed the report’s analysis and recommendations.
COVID-19 has strained the health care system to its seams, and nurses have borne much of that pressure. Remarkably, amid a vast increase in the number of patients, employment levels for registered nurses declined by 3 percent between 2020 and 2021, the largest decline in at least 20 years.8 Chief nursing officers have consistently reported staffing as their greatest challenge throughout the pandemic, with vacancy rates as high as 30 percent.9 The American Nurses Association has urged the U.S. Department of Health and Human Services to declare the nursing shortage a national crisis.10
An acute symptom of the shortage is the rise of travel nurses—registered nurses who are contracted to work short stints at understaffed hospitals across the country for double, triple, or quadruple their usual pay. Travel nursing grew by 35 percent in 2020 and was estimated to grow an additional 40 percent by the end of 2021.11 While health care employers have historically brought in travel nurses during full-time staff members’ parental and medical leaves or in other moments of short-term need, current conditions drive a vicious cycle: Lucrative pay draws nurses away from their usual institutions, increasing those same institutions’ demand for contracted relief.
Low morale and traumatic experiences during the pandemic are also driving some nurses to leave the profession altogether.12 This is compounded by the fact that there are now more opportunities for nurses to leave the bedside, as work is available in other industries such as pharmaceuticals, retail health, and consulting.
Nurses of color have experienced even more adversity: Throughout the coronavirus pandemic, Asian American and Pacific Islander (AAPI) nurses reported that patients had refused their care—and even that they had been physically attacked.13 Although discrimination against AAPI people is not new, racist perceptions of COVID-19’s origins have contributed to an increased number of attacks on AAPI communities at large.14 A 2020 study found that overall, nurses of color were more likely to care for coronavirus patients than white nurses and less likely to have access to adequate personal protective equipment.15
The pressures imposed by COVID-19 have piled on top of a host of other challenges. As this report discusses in detail in a later section, the higher education system is training too few nurses. Workforce conditions, although not the focus of this report’s recommendations, are also a major problem. At the same time, demographic factors, such as increased life expectancy and the aging of the Baby Boomer generation, are also feeding today’s nursing shortage. The number of working nurses for every 1,000 Americans ages 65 and over has steadily declined, from 69 in 2003 to 62 in 2021. (see Figure 1)16
The average age of nurses continues to rise, meaning more nurses are at retirement age each year. Today, the average nurse is 43.7 years old, up from 38.9 years old in 1978, and the proportion of nurses over age 55 has increased from 13 percent of the nursing workforce to 23 percent over the same period. (see Figure 2)17 According to the National Nursing Workforce Survey, more than one-fifth of the nurses polled in 2020—900,000-plus registered nurses (RNs) and licensed practical nurses, who practice under the supervision of RNs—plan to retire in the next five years.18
The pandemic has dealt a historic blow to the health care system, but it did not create the nursing shortage. Indeed, the professionalization of modern nursing was a response to health care staffing shortages that led to high mortality rates among British soldiers during the Crimean War.19 British nurse and statistician Florence Nightingale engaged 38 women in the formation of a nursing corps that standardized sanitary interventions in patient settings. This framework became the foundation for nursing schools in the United States,20 and in 1873, the first “Nightingale schools” opened in New York, Connecticut, and Massachusetts.21
At the profession’s inception, the pool of potential nurses was always limited—both a response to and a driver of occupational segregation.22 As evidenced by Nightingale’s claim that women were better at the nurturing aspects of patient care,23 nursing was intentionally designed as a pathway for women to enter the workforce. Today, nursing continues to be 87 percent female. Men were not allowed to be members of the American Nurses Association until 1930 and were not allowed in the Army Nurse Corps until 1955.24
People of color have also faced significant barriers to entering and working safely in the nursing profession. In the late 19th century, the first nursing schools in America denied admission to Black students and, later, hospital and university-based programs continued to segregate students by race. This segregation remained in place into the mid-20th century—a point in time when only 200 of the approximately 1,200 nursing programs in the nation had at least one African American student.25 While nursing schools are significantly more diverse today, nursing students of color continue to experience discrimination, lack of support and mentorship from faculty, feelings of exclusion and isolation from peers, and bias in grading.26
Over the course of the 20th century, the nursing profession changed dramatically. Larger numbers of women and workers of color entered the workforce, expanding the labor pool for what was perceived to be a woman’s profession. Efforts to organize nurses and the enactment of Medicare and Medicaid led to improved wages in many workplaces.27 Consequently, the nursing workforce grew from 640,000 in 1967, to 1,272,900 in 1980, to approximately 3 million today.28
Yet as evidenced by calls to address nursing shortages throughout the 20th century, supply was often still not sufficient to meet demand.29 Pay and working conditions have often been factors, as have major historical events. For example, during World War II, 25 percent of civilian nurses joined military efforts, creating extreme shortages in domestic health care settings.30
In times of shortage, Congress pursued a mixture of policy solutions that increased resources for nursing education, including through Title VIII of the Public Health Service Act (1944),31 the Health Professions Educational Assistance Act (1963),32 and the Nurse Training Act (1964).33 Combined, this legislation invested in building and renovating nursing schools, while lowering the costs of training for students. As a result, the number of nurses nearly doubled from 1974 to 1983.34
Despite recurring nursing shortages, the United States has not adopted a coordinated approach to preventing or responding to the issue, nor has it designated responsible entities at federal and state levels to do so.
Because of nurses’ roles at the bedside and in overall population health—and because of the economic potential that the profession offers to nurses—policymakers need to prioritize solving what is broken in this field, and do so with racial equity at the forefront.
Nursing shortages have a significant impact on patient outcomes. Fewer nurses means that each nurse must care for more patients, which can lead to errors and reduced ability to monitor patients; conversely, adequate staffing levels can result in reduced mortality, shorter hospital stays, and reduced incidence of adverse patient events such as infection.35 These improved patient outcomes also bring significant cost savings to health care institutions and taxpayers.36
At the same time, a diverse and well-supported nursing workforce is critical to addressing social determinants of health (SDOH). SDOH are the nonmedical factors that influence an individual’s health, such as economic stability, access to education, health care access and quality, environment, and social context.37 As the largest segment of the health care workforce and one that works in many community settings, including public health departments, nurses are well-positioned to identify needs and resources related to SDOH across an increasingly diverse population with its own complex needs.
Also key is that nurses from underrepresented or disadvantaged backgrounds are more likely to serve in medically and economically under-resourced communities themselves. Moreover, having similar racial and ethnic backgrounds or languages may improve communication and trust between nurses and patients, leading to improved health outcomes for individuals and populations.38
Despite a history of discrimination in the nursing field—including segregated hospitals and nursing schools—the profession today is relatively diverse. Workers of color represented 31 percent of all registered nurses in the U.S. labor force in 2021, compared with just 16 percent 43 years earlier. (see Figure 3) Asian nurses are overrepresented in the nursing workforce compared with the total employed population, Black or African American nurses are almost on par, and Hispanic or Latino nurses are underrepresented. Men make up 13.3 percent of the nursing workforce.39
The nursing profession pays solid wages, which is critical—and rare—for a profession that disproportionately employs women.40 In the broader labor market, discrepancies in wage attainment by race and gender are well-documented, and women across all occupations make 73 cents for every $1 men make.41 Women of color typically experience much larger wage gaps, reflecting intersecting racial, ethnic, and gender biases. In nursing, significant wage disparities persist between women and men across every racial and ethnic group. (see Figure 4) However, on average, nursing pays competitive wages to Hispanic, Black and AAPI women, although it should be noted that looking at all AAPI workers together—the only data available here—often masks wage gaps between specific AAPI communities,42 and American Indian and Alaska Native women earn less than all other ethnicities.
There are a variety of potential explanations for this unusual pattern, including the fact that nurses of color report working more hours of overtime43 and that standardization of roles and higher rates of unionization can lead to greater wage equity within occupations.44 While additional research and action is required to address the striking gender pay gap between male and female nurses, increasing access to the nursing profession is still a vital strategy to build economic mobility and financial sustainability for workers and families of color across the country.
Community colleges and universities train most of the workforce’s registered nurses through programs offering an associate degree in nursing (ADN) or a bachelor of science in nursing (BSN). A smaller pathway to the nursing profession is through a registered nurse diploma, a vestige of early American nurse training programs operated by hospitals. Graduates of all three types of programs must pass the same national exam to practice in all U.S. jurisdictions.
In addition to the students who enroll directly in a BSN program, many ADN graduates go on to earn a BSN. Another path into registered nursing is through an accelerated or “second degree” BSN.45 These programs, which have grown during the past two decades, allow people with bachelor’s degrees in other disciplines to complete a BSN in one to two years.46
Students today also increasingly have opportunities to pursue a BSN at community colleges; across 25 states, there are at least 64 community college BSN programs, and more are added every year.47
ADN and BSN programs prepare nurses with technical skills to work at the bedside, but BSN nurses have more opportunities for advancing into management roles, pursuing graduate education, and developing a nursing specialty. As such, there is a wage disparity: In 2021, the average wage of a registered nurse with an ADN was about $60,000, while the average wage of an RN with a BSN was approximately $73,000.48
There is also evidence that BSN preparation improves patient outcomes,49 and hiring trends and interviews with experts suggest health facilities increasingly prefer to hire registered nurses with BSNs.50 Despite this, the ADN pipeline—with a more affordable degree and a more diverse student population—is an indispensable lever to increase the size and expand the diversity of the nursing pipeline.51 In 2020, ADN and BSN programs graduated about equal numbers of nursing students. ADN students graduating from community colleges are slightly more racially and ethnically diverse than BSN graduates. (see Figure 5)
The nursing shortage cannot be solved unless higher education institutions train more nurses. Research and interviews with experts present ample evidence that capacity within higher education is significantly lower than what is needed.52 In the 2020-21 academic year, program constraints prevented universities from enrolling more than 66,000 qualified applicants to BSN programs,53 and community colleges turned away thousands of qualified applicants too.54
Evidence points to three main constraints that prevent higher education institutions from graduating more nurses: a shortage of nurse educators, a lack of clinical placements for student nurses, and inadequate campus facilities and equipment.
An undergraduate nursing education consists of general education courses, didactic core nursing courses (in-classroom learning), simulation, and clinical experiences, each requiring a qualified nurse educator. Nurse educators include college and university faculty, clinical instructors, and preceptors.
Nursing faculty, including adjunct and clinical instructors, are employed by higher education institutions to teach courses and supervise simulation and clinical experiences.
Preceptors are registered or advanced practice nurses who supervise one or two student nurses at the health care facility where they work. They may also mentor newly hired nursing school graduates to help with their transition to professional practice.55 Most often, preceptors are volunteers; they are not paid extra and are expected to maintain the same levels of productivity, even with the added workload of supervising students.56 Instead of pay, preceptors are commonly given incentives, such as “access to university resources, adjunct faculty status, free courses, credit toward recertification, reference letters, and [public] recognition.”57
There is wide variation in state laws and nursing board standards for educator qualifications. For example, the National Council of State Boards of Nursing (NCSBN) recommends that faculty in all RN preparation programs “have either a master’s degree or a doctoral degree in nursing,”58 but only half of states require nursing faculty to have at least a master’s degree in nursing.59 Other states allow nurses with only BSNs to teach under certain conditions, such as if they are pursuing a graduate degree in nursing or if they have a graduate degree in another discipline. The NCSBN recommends preceptors “be educated at or above the level for which the student is preparing.”60
Like the nurse shortage, the shortage of nurse educators—including college and university faculty, clinical instructors, and preceptors—is not new. Researchers and nursing leaders have lamented the educator shortage as a cause of the nurse shortage since at least the 1960s,61 and the COVID-19 pandemic may have made things worse. Challenging teaching conditions, such as the sudden shift to online and hybrid learning, and challenging financial conditions—for example, if a spouse lost their job amid the volatility in the economy—are driving nurse educators back into higher-paying bedside nursing positions.62
According to a 2021 survey of 935 university nursing programs by the American Association of Colleges of Nursing, 576 programs (62 percent) had at least one vacancy for a full-time faculty member.63 In total, the full-time university faculty vacancy rate stands at 8 percent, up from 6.5 percent in 2020.64 Half of all vacant positions require a doctorate, and 72 percent require both classroom and clinical teaching responsibilities. Community colleges experience similar faculty shortages.65
More than any other factor, the nurse educators whom the report authors interviewed identified low salaries as the chief cause of the educator shortage,66 which recent surveys corroborate.67 Nurses with advanced degrees can earn much more as clinicians than as educators. For example, in 2021, nurse practitioners and nurse midwives—who have at least a master’s degree—made a median annual wage of approximately $113,000 and $121,000, respectively,68 whereas the median wage for a college nursing instructor with equivalent credentials was about $77,000.69 When also considering the high cost of graduate education, the burden of student loans, and the forgone income while attending graduate school, it becomes understandable why advanced nurses choose clinical practice, even though teaching can offer benefits to quality of life in terms of factors such as more flexible work hours and fewer physical demands.70
Other conditions also affect the pipeline into teaching.71 There are not enough nurses with doctoral degrees to meet the demand for faculty, and even within doctoral programs, students may not get adequate preparation for faculty careers. More nurses are pursuing practice-focused doctor of nursing practice programs rather than teaching- and research-focused programs that offer a doctor of philosophy in nursing.72 Similarly, there are more career options for nurses today due to the growth in nurse specialties and opportunities in the private sector,73 which may draw away some of the nurses who in the past may have considered teaching.74
Retaining nursing faculty is also challenging.75 Because nursing faculty typically work in the field before starting teaching careers, they are older when they become faculty and thus tend to have shorter teaching careers; waves of retirements exacerbate the educator shortage. In addition, nursing faculty report low satisfaction with their jobs, citing not just low pay but also the heavy workloads that come with teaching, research, publishing, maintaining clinical licensure, and earning tenure and promotion.76
Despite longtime awareness of the educator shortage and its causes, the National Advisory Council on Nurse Education and Practice concluded in 2020 that “efforts to increase the supply of nurse faculty have largely failed, while the number of clinical preceptors to supervise nursing students in patient care is inadequate to meet the current need.”77
In addition to the number of nursing educators, their demographics matter. As of 2016, 16 percent of full-time university nursing faculty members were nonwhite, up from 11 percent in 2007, and just 7 percent were men, up from nearly 5 percent in 2006.78 These figures show slow progress in diversifying the faculty—and the stakes are high for making better headway.
Educators are often students’ most visible role models, and having nonwhite, nonfemale instructors is important for the success of underrepresented students. Research demonstrates that as faculty diversity increases, so too do the graduation rates of underrepresented students.79
A diverse faculty, therefore, is critical for the recruitment, retention, and graduation of underrepresented students. Because higher education institutions are the entry point for most of the nursing workforce, they must accept responsibility for producing a sufficiently diverse workforce that will be equipped to serve the complex health care needs of America’s patients.
Higher education institutions are dependent on health care partners to provide their students with hands-on learning experiences, but there are not enough of these clinical placements.80
The shortage of nurse educators drives the shortage of clinical placements. Many of the challenges described above about nurse educators apply to preceptors, including inadequate training for precepting, heavy workloads, and noncompetitive pay.81
There is a vigorous debate within the nursing community about whether to pay preceptors extra for their service.82 On the one hand, precepting is traditionally a volunteer position that allows nurses to give back to the profession; paying preceptors could also increase competition for clinical placements and shut out underfunded nursing programs.83 On the other hand, because there is a cost to precepting—most notably the potential loss of productivity—some colleges find it necessary to pay health care facilities for preceptors or for clinical placement slots.84 More pay from both academic institutions and preceptors’ employers may be needed to encourage more registered nurses to serve as preceptors.
Other conditions also contribute to the shortage of clinical placements. As new nursing degree programs are created, and as nursing student enrollment grows, competition for clinical sites intensifies. In addition, where health care happens is changing. Traditionally, students get most of their clinical training in hospitals, but as hospitals close across the United States—especially in rural areas85—health care services are shifting to other sites, such as community and behavioral health centers, health departments, primary care offices, nursing homes, schools, and even people’s homes. In these community-based sites, health care is being redesigned to be more patient-focused, which could provide valuable learning experiences for student nurses. New clinical placements in these settings may be a good opportunity for meeting the demand from nursing schools.86
Transportation and its costs, however, are among the barriers to moving more students into clinical sites “located in rural, remote, or frontier settings or areas with limited access.”87 Preceptors in remote or under-resourced locations may also face even more productivity pressures, reducing their capacity for—and interest in—supervising student nurses.
It is also important to look at clinical sites as an aspect of equity in training nurses, to ensure that students from under-resourced institutions, such as community colleges, have access to the clinical sites that will prepare them best for their future work with diverse patient populations.
Although less frequently discussed, a third constraint on higher education institutions is inadequate facilities and equipment. Some programs are already constrained by these factors, and if colleges are to add faculty and enroll more nursing students, there would be additional need for more classroom space, simulation technology, laboratories, and equipment.88
The heightened nursing shortage during the pandemic spurred a wave of nursing program expansions, and to take on more students, colleges and universities have had to construct new buildings for nursing and other health sciences programs. Recent capital projects have been funded by voter-approved bonds,89 state legislatures,90 private donations,91 and partnerships with health systems.92 The variety in funding strategies among these examples alone warrants attention for identifying the most effective models through which to fund and scale improvements to college nursing facilities.
Within campus nursing buildings, simulation labs are key investments. Simulation in nurse education involves the use of sophisticated manikins that can replicate a wide variety of medical complications, role-playing, and computer-based critical thinking simulations.93
During the pandemic, simulation took on new importance. When overwhelmed health care facilities closed their doors to student nurses, state regulatory authorities granted flexibility to nursing programs to replace clinical hours with more in-person and virtual simulation.94 The national standard holds that up to 50 percent of clinical experience in an undergraduate nursing program can be replaced with simulation;95 however, simulation requirements set by state boards of nursing vary widely.96 For example, California typically allows students to spend no more than 25 percent of their clinical hours in simulation but temporarily increased the limit to 50 percent during the pandemic.97
Simulation requires expensive equipment, software, and training for faculty.98 Even after the pandemic, college nursing programs will need to continue to invest in state-of-the-art simulation-based education.
Federal policymakers must devise sustainable, long-term solutions to today’s nursing shortage and ensure that the education and health care systems are better prepared to mitigate and address any future shortages. The recommendations in this report are designed to reach the goals of increasing the number and diversity of nurses entering the profession and creating a standing structure to address current and future changes to supply and demand in the nursing workforce.
Given how significant nurses are to the lives of millions of Americans, factors affecting the likelihood that individuals will enter, stay in, or leave the nursing profession require constant monitoring and response. A permanent body must be authorized to document the state of the nursing workforce and advise on policy solutions to address challenges. This body should be able to connect and respond to both pipeline and education issues, as well as matters of workplace conditions.
Nursing shortages have been a facet of American life for decades, and the COVID-19 pandemic will not be the last time that the United States struggles to maintain an adequate nursing workforce. Major investments of federal funding and sustained coordination are needed to mitigate the impact of nursing shortages and improve the nation’s ability to respond.
If policymakers at all levels think more ambitiously about solving the nursing shortage and improving racial equity, more workers will have equitable access to a high-quality, well-paid profession; more patients will have equitable access to high-quality nursing services; and a healthier population will have better educational and life outcomes and be able to build stronger communities.
The authors thank the many experts interviewed whose perspective, research, and experiences shaped this report. The authors also thank Osub Ahmed, Jared C. Bass, Marquisha Johns, David Madland, Lily Roberts, Jesse O’Connell, Jill Rosenthal, Madeline Shepherd, and Lola Oduyeru for their review and input, and Rose Khattar and Kyle Ross for their review and fact-checking.
While the emphasis of this report’s recommendations is on how to expand equitable access to the nursing profession through education and training, other research and policy efforts must focus on the equally critical issue of improving working conditions for nurses. Simply put, efforts to train more nurses are futile if those nurses leave the workplace. Examples of strategies to improve working conditions include:
For more reading on this topic, please see reports issued by the National Academies of Sciences, Engineering, and Medicine;120 American Nurses Association;121 and World Health Organization.122
Prelicensure Nursing Programs,” Clinical Simulation in Nursing 33 (2019): 17–25, available at https://epublications.marquette.edu/cgi/viewcontent.cgi?article=1647&context=nursing_fac.
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