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DOI: 10.1055/s-0043-1775724
Understanding the Gap Between Nursing Workforce in the United States and Population Needs—A Policy Brief
Abstract
Purpose This report is intended to analyze the root causes for the current gap between the nursing workforce and population needs in the United States. It aims to consolidate what is known about these contributing reasons and provide evidence-based recommendations for action.
Methods The report utilized the Sample, Phenomenon of Interest, Design, Evaluation, Research type framework to develop the research question and the 5 Whys methodology for the root cause analysis.
Results This report highlighted six major causative problems, including workforce market mismatch, poor financing design, inadequate governance, flawed technologies, insufficient research, and suboptimal service delivery. A detailed evaluation of root causes with supported evidence is presented.
Conclusion The report provided seven actionable recommendations based on the analysis: (1) strengthening the nursing role in advancing equity, (2) investing in nursing well-being, (3) changing policies and payment structure, (4) including nursing in technology design, (5) strengthening nursing education, (6) developing a robust public health emergencies preparedness plan, and (7) investing in relevant research.
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Introduction
Nursing is a crucial part of the U.S. health workforce, and without it, achieving the health system outcomes, such as accessibility, quality, and efficiency,[1] would not be possible. This was echoed in the World Health Organization (WHO) report titled: “A Universal Truth: No Health Without A Workforce”[2]. Although the current staffing of 102.6 FTE/10,000 population exceeds the WHO target benchmark of 59.4 (2), there exists a considerable and worsening shortage of over 1 million nurses[3] due to an unexpected shift of market forces from equilibrium.[4] In addition to nursing availability, other domains of the workforce, including accessibility, acceptability, and quality[5] [6] [7] are affected ([Fig. 1]).
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There are several contextual factors[8] that can explain the gap between the nursing workforce in the U.S. and population needs. These include structural factors (aging population, geography[9] [[Fig. 2]], social determinants of health (SDOH), health inequity, and nursing student loans), situational (coronavirus disease 2019 [COVID-19] and opioid crisis) and cultural factors (traditional view of nursing as a women's job), and international factors (global nursing shortage).[10]
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This report outlines a root cause analysis (RCA) to analyze the causes of the aforementioned gap. Then, it will present policy recommendations based on the result of this RCA.
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Methodology
The 5 Whys methodology[11] was selected for the RCA as it provided an extensive analysis of factors associated with the nursing gap. The Sample, Phenomenon of Interest, Design, Evaluation, Research type format ([Table 1]) was utilized for evidence synthesis,[12] leading to the following research question: “Using the Five Whys framework (D) of qualitative research (R), what were the root causes (E) of the inability of nursing workforce (PI) to meet population need in the United States (S)?”.
Component |
Description |
---|---|
Sample (S) |
Population in the United States |
Phenomenon of interest (PI) |
Nursing unable to meet population demand |
Design (D) |
5 Whys |
Evaluation (E) |
Problem and root causes |
Research type (R) |
Qualitative |
Note: Data adapted from[12]
Note: SPIDER format for evidence synthesis.
A literature review of peer-reviewed studies and gray literature was carried out. Three databases were included Medline, EMBASE, and Web of Science, in addition to gray literature sources encompassing governmental and nongovernmental organization reports.
A keyword strategy was applied, which comprised the following: (“nurs*” OR “healthcare*” OR “hospital?” OR “workforce”) AND (“shortage?” OR “suppl*” OR “demand*”).
Inclusion criteria comprised articles that addressed nursing shortages in the United States and explored their causes. Full-text sources published in English between 2010 and 2021 were assessed, including observational and experimental studies, policy briefs, and commentaries. Studies were excluded if they were abstract, if addressed nursing shortages outside the United States, or if focused on other health care workers.
The selected articles were extracted using a standard form detailing the study design, location, and findings. The author (M.A.) assessed the studies for inclusion. Quality assessment was not performed. The WHO building blocks[13] framework was used for grouping causative factors and evidence synthesis.
#
Results
Based on the literature review,[3] [4] [6] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] a total of 5,043 studies were identified. After excluding duplicates and studies that do not address the nursing shortages in the United States, a total of 245 studies were included. We grouped the causes of the gap between nursing and population needs into the following categories ([Table 2]).
Abbreviations: ACA, Affordable Care Act; APRN, advanced practice registered nurse; CNM, certified nurse midwife, COVID-19, coronavirus disease 2019; CPT, current procedure terminology; ECMO, extracorporeal membrane oxygenation; EHR, electronic health record; ICU, intensive care unit; NP, nurse practitioner; PCP, primary care physicians; PPE, personal protective equipment; SDOH, social determinants of health.
Source: Data adapted from[3] [4] [6] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26]
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Workforce market mismatch: The two major causes are increased demand and reduced supply.[26] The high demand stems from structural factors such as growing population needs (aging, substance use, and inadequate access) and situational factors (ICU shortage during the COVID-19 pandemic). The reduced supply resulted from gender and racial underrepresentation (cultural), low rates of graduating nurses, and high retirement rates (structural), which was augmented by the COVID-19 pandemic (situational) due to staff burnout.[17] [19] [Fig. 3] shows labor market forces before and after the pandemic and how COVID-19 worsened the existing nursing shortage.
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Poor financing design: The current finance system limits nurses' involvement in patient care by not crediting them for work coordinating services, diagnosis, or management. In addition, cuts in federal funding augmented the public health nursing shortage.[6]
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Inadequate leadership/governance: Existing policies do not support building nursing skills to advance equity, providing telehealth, treating substance abuse, delivering babies, or preparing for pandemics, and they restrict nurses' ability to diagnose and manage patients.[3] [18]
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Flawed medical products/technologies: There are several reasons why technology contributed to the nursing gap. Nurses were not included in the design of many projects. This poor design resulted in them spending significant time with electronic health records rather than clinical duties. This was further compounded by the fact that they deal with excessive alarms leading to burnout and stress. In addition, a lack of safety culture and training led to increased medication errors.[22]
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Insufficient information and research: Inadequate funding of nursing research due to lack of prioritizations from funders has led to fragmented and uncoordinated care, which lacked the focus on evidence-based medicine.[23]
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Not optimized service delivery: Service delivery has suffered from reduced quality, equities, and accessibilities. This is caused by not including nurses in service delivery design, not prioritizing cultural competencies in nursing schools, structural racism, absence of safety culture, financial payment models, limited resources, and state restrictions on nursing scope.[24-25]
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Discussion
In order to overcome the nursing gap, the following policy recommendations for health system reform were developed ([Table 3]) based on the RCA above, the Future of Nursing 2020-2030 report[6] and other gray literature publications.[20] [27] [28]
Abbreviations: CMS, Centers for Medicare and Medicaid Services; COVID-19, coronavirus disease 2019; CPT, current procedure terminology, EHR, electronic health records; SDOH, social determinants of health.
Source: Data adapted from[6] [20] [27] [28]
Short-Term Recommendations (by 2024)
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(1) Investing in the health and well-being of nurses: Focusing on nursing health and well-being should be part of nursing schools and health organizations. Employers should provide an environment that is both physically and physiologically safe (e.g., available personal protective equipment [PPE] and no retaliation), support diversity, and include nurses in key organizational decisions.
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(2) Empowering nurses by changing policies and payment mechanisms: All temporary COVID-19 nursing scope expansions should be made permanent, including telehealth and insurance coverage policies. Payment models should be restructured to allow reimbursement of nurses for care coordination, case management, telehealth, and school nursing.
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(3) Improving the quality and accessibility of nursing education: Programs should provide students with knowledge and skills to address equities, provide distance learning opportunities, promote a diverse faculty with experience in SDOH, and encourage civic engagement.
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(4) Developing a robust public health emergency preparedness response plan: A national nursing hub[6] should be developed to build nursing education and staffing plans during emergencies. School curriculum and licensing exams should emphasize pandemic preparedness. Health care systems should include nursing in their local emergency planning design and implementation.
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(5) Including nursing expertise in technology design and implementation: A technology infrastructure should be created to capture the community knowledge and SDOH visualization. Nurses should be incorporated into innovation, optimizing person-centered care, care coordination, and improving equities.
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Long-Term Recommendations (by 2026)
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(6) Strengthening the nursing role in advancing equity: Substantial actions should be taken to increase the number of nurses with a special focus on health equity expertise and specialties with marked shortages (e.g., mental health, geriatrics, maternal health, and school health). This will require investing in nursing education, collaborating with historically Black and Hispanic-serving universities, supporting student loans and scholarships, enabling students from disadvantaged backgrounds, and integrating nursing expertise during health reform planning.
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(7) Investing in relevant research: Government funding should increase to strengthen evidence-based nursing research as a significant focus. Research priorities should include the nursing workforce, public health collaboration, improving equities, performance and outcome measures, improving diversity, nursing well-being, eliminating structural racism, restructuring payment models, disaster preparedness, and advancing technologies.
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#
Conclusions
In conclusion, there are several root causes for the gap between the nursing workforce and population needs. Addressing these causes requires better responding to the market demand and supply forces, understanding the population's needs, preparing a competent nursing workforce, optimizing services, technological innovation, funding research, and leadership transformation.
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Conflict of Interest
None declared.
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References
- 1 Tello J, Barbazza E. Health Services Delivery: A Concept Note. Copenhagen:: WHO Regional Office for Europe;; 2015
- 2 Truth AU. No Health Without a Workforce. World Health Organisation (WHO) Report.; 2013: 1-04
- 3 Zhang X, Tai D, Pforsich H, Lin VW. United States Registered Nurse Workforce Report Card and Shortage Forecast: a revisit. Am J Med Qual 2018; 33 (03) 229-236
- 4 Snavely TM. A brief economic analysis of the looming nursing shortage in the United States. Nurs Econ 2016; 34 (02) 98-100
- 5 World Health Organization. Global Strategy on Human Resources for Health: Workforce 2030;. 2016
- 6 Wakefield M, Williams DR, Le Menestrel S. The Future of Nursing 2020–2030: Charting A Path to Achieve Health Equity. National Academy of Sciences; 2021
- 7 America's Health Rankings. Premature death racial disparity. Accessed April 22, 2022 at: https://www.americashealthrankings.org/explore/annual/measure/YPLL_Disparity/state/ALL
- 8 Langlois ÉV, Daniels K, Akl EA. World Health Organization. Evidence synthesis for health policy and systems: a methods guide. World Health Organization; 2018
- 9 USAHS. . The 2021 American Nursing Shortage: a data study. Accessed April 22, 2022: https://www.usa.edu/blog/nursing-shortage/
- 10 Statista. Distribution of registered nurses in the United States from 2014 to 2019, by gender. Accessed April 22, 2022 at: https://www.statista.com/statistics/1227142/distribution-of-registered-nurses-in-the-us-by-gender/
- 11 Institute for Health Improvement. 5 Whys: finding the root cause. Accessed April 22, 2022 at: http://www.ihi.org/resources/Pages/Tools/5-Whys-Finding-the-Root-Cause.aspx
- 12 Foley Library Gonzaga University. SPIDER: mixed methods qualitative research questions. Accessed April 22, 2022 at: https://researchguides.gonzaga.edu/c.php?g=957005&p=6908049
- 13 World Health Organization. Everybody's Business–Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. 2007
- 14 Feke T. When medicare won't pay for nursing home care. Accessed April 22, 2022 at: https://www.verywellhealth.com/when-medicare-won-t-pay-for-nursing-home-care-4140074
- 15 Yang YT, Mason DJ. COVID-19's impact on nursing shortages, the rise of travel nurses, and price gouging. Accessed April 22, 2022 at: https://www.healthaffairs.org/do/10.1377/forefront.20220125.695159/
- 16 Bradley University. The nursing shortage and how it will impact patient care. Accessed April 22, 2022 at:: https://onlinedegrees.bradley.edu/blog/the-nursing-shortage-and-how-it-will-impact-patient-care/
- 17 American Association of Colleges of Nursing. Nursing Shortage. Accessed April 22, 2022 at: https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage
- 18 Health Leaders. Tipping point: As Kansas grants full practice authority to nurse practitioners, most states have now adopted it. Accessed April 22, 2022 at: https://www.healthleadersmedia.com/nursing/tipping-point-kansas-grants-full-practice-authority-nurse-practitioners-most-states-have-now
- 19 US Department of Health and Human Services. Supply And Demand Projections of The Nursing Workforce: 2014–2030. Health Resources and Services Administration. 2017
- 20 Spurlock Jr D. The nursing shortage and the future of nursing education is in our hands. J Nurs Educ 2020; 59 (06) 303-304
- 21 InTouch Health. How Telehealth Can Ease the Nationwide Nursing Shortage. Accessed April 22, 2022 at: https://intouchhealth.com/nationwide-nursing-shortage-eased-with-telehealth-services/
- 22 Yen PY, Pearl N, Jethro C. et al. Nurses' stress associated with nursing activities and electronic health records: data triangulation from continuous stress monitoring, perceived workload, and a time motion study. In AMIA Annual Symposium Proceedings 2019 (Vol. 2019952). . American Medical Informatics Association; 2019: 952
- 23 Davis DA, Napier MD. Strategically addressing the nurse shortage: a closer look at the nurse funders collaborative. Health Aff (Millwood) 2008; 27 (03) 876-881
- 24 25ABC. In-depth: rural hospital labor & delivery units close as staffing shortages grow. Accessed April 22, 2022 at: https://www.kxxv.com/hometown/mclennan-county/in-depth-rural-hospital-labor-and-delivery-units-close-as-staffing-shortages-grow
- 25 Smith Z. How the nursing shortage affects patient care and healthcare services. Accessed April 22, 2022 at: https://nursegrid.com/blog/how-the-nursing-shortage-affects-patient-care-and-healthcare-services/
- 26 Scheffler R, Bruckner T, Spetz J. The Labour Market for Human Resources for Health in low-and middle-income countries. Human Resources for Health Observer; 2012: 11
- 27 World Health Organisation. State of the World's Nursing 2020. 2020
- 28 World Health Organisation. Strengthening Nursing in Primary Care in Poland. 2016
Address for correspondence
Publication History
Article published online:
27 September 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
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References
- 1 Tello J, Barbazza E. Health Services Delivery: A Concept Note. Copenhagen:: WHO Regional Office for Europe;; 2015
- 2 Truth AU. No Health Without a Workforce. World Health Organisation (WHO) Report.; 2013: 1-04
- 3 Zhang X, Tai D, Pforsich H, Lin VW. United States Registered Nurse Workforce Report Card and Shortage Forecast: a revisit. Am J Med Qual 2018; 33 (03) 229-236
- 4 Snavely TM. A brief economic analysis of the looming nursing shortage in the United States. Nurs Econ 2016; 34 (02) 98-100
- 5 World Health Organization. Global Strategy on Human Resources for Health: Workforce 2030;. 2016
- 6 Wakefield M, Williams DR, Le Menestrel S. The Future of Nursing 2020–2030: Charting A Path to Achieve Health Equity. National Academy of Sciences; 2021
- 7 America's Health Rankings. Premature death racial disparity. Accessed April 22, 2022 at: https://www.americashealthrankings.org/explore/annual/measure/YPLL_Disparity/state/ALL
- 8 Langlois ÉV, Daniels K, Akl EA. World Health Organization. Evidence synthesis for health policy and systems: a methods guide. World Health Organization; 2018
- 9 USAHS. . The 2021 American Nursing Shortage: a data study. Accessed April 22, 2022: https://www.usa.edu/blog/nursing-shortage/
- 10 Statista. Distribution of registered nurses in the United States from 2014 to 2019, by gender. Accessed April 22, 2022 at: https://www.statista.com/statistics/1227142/distribution-of-registered-nurses-in-the-us-by-gender/
- 11 Institute for Health Improvement. 5 Whys: finding the root cause. Accessed April 22, 2022 at: http://www.ihi.org/resources/Pages/Tools/5-Whys-Finding-the-Root-Cause.aspx
- 12 Foley Library Gonzaga University. SPIDER: mixed methods qualitative research questions. Accessed April 22, 2022 at: https://researchguides.gonzaga.edu/c.php?g=957005&p=6908049
- 13 World Health Organization. Everybody's Business–Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. 2007
- 14 Feke T. When medicare won't pay for nursing home care. Accessed April 22, 2022 at: https://www.verywellhealth.com/when-medicare-won-t-pay-for-nursing-home-care-4140074
- 15 Yang YT, Mason DJ. COVID-19's impact on nursing shortages, the rise of travel nurses, and price gouging. Accessed April 22, 2022 at: https://www.healthaffairs.org/do/10.1377/forefront.20220125.695159/
- 16 Bradley University. The nursing shortage and how it will impact patient care. Accessed April 22, 2022 at:: https://onlinedegrees.bradley.edu/blog/the-nursing-shortage-and-how-it-will-impact-patient-care/
- 17 American Association of Colleges of Nursing. Nursing Shortage. Accessed April 22, 2022 at: https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage
- 18 Health Leaders. Tipping point: As Kansas grants full practice authority to nurse practitioners, most states have now adopted it. Accessed April 22, 2022 at: https://www.healthleadersmedia.com/nursing/tipping-point-kansas-grants-full-practice-authority-nurse-practitioners-most-states-have-now
- 19 US Department of Health and Human Services. Supply And Demand Projections of The Nursing Workforce: 2014–2030. Health Resources and Services Administration. 2017
- 20 Spurlock Jr D. The nursing shortage and the future of nursing education is in our hands. J Nurs Educ 2020; 59 (06) 303-304
- 21 InTouch Health. How Telehealth Can Ease the Nationwide Nursing Shortage. Accessed April 22, 2022 at: https://intouchhealth.com/nationwide-nursing-shortage-eased-with-telehealth-services/
- 22 Yen PY, Pearl N, Jethro C. et al. Nurses' stress associated with nursing activities and electronic health records: data triangulation from continuous stress monitoring, perceived workload, and a time motion study. In AMIA Annual Symposium Proceedings 2019 (Vol. 2019952). . American Medical Informatics Association; 2019: 952
- 23 Davis DA, Napier MD. Strategically addressing the nurse shortage: a closer look at the nurse funders collaborative. Health Aff (Millwood) 2008; 27 (03) 876-881
- 24 25ABC. In-depth: rural hospital labor & delivery units close as staffing shortages grow. Accessed April 22, 2022 at: https://www.kxxv.com/hometown/mclennan-county/in-depth-rural-hospital-labor-and-delivery-units-close-as-staffing-shortages-grow
- 25 Smith Z. How the nursing shortage affects patient care and healthcare services. Accessed April 22, 2022 at: https://nursegrid.com/blog/how-the-nursing-shortage-affects-patient-care-and-healthcare-services/
- 26 Scheffler R, Bruckner T, Spetz J. The Labour Market for Human Resources for Health in low-and middle-income countries. Human Resources for Health Observer; 2012: 11
- 27 World Health Organisation. State of the World's Nursing 2020. 2020
- 28 World Health Organisation. Strengthening Nursing in Primary Care in Poland. 2016
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