CC BY 4.0 · Avicenna J Med 2023; 13(04): 206-214
DOI: 10.1055/s-0043-1775724
Original Article

Understanding the Gap Between Nursing Workforce in the United States and Population Needs—A Policy Brief

1   Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
› Author Affiliations
 

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]).

Zoom Image
Fig. 1 This figure shows different aspects of nursing human resources for health including availability, accessibility, acceptability, and quality. Data adapted from Wakefield et al and America's Health Rankings. [6] [7] FTE: full-time equivalent; RN: registered nurse.

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]

Zoom Image
Fig. 2 This figure shows the states with highest estimated nursing shortage. Data adapted from USAHS.[9]

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)?”.

Table 1

SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) format for evidence synthesis[12]

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.


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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]).

Table 2

Root cause analysis (5 WHYs) for the inability of nursing workforce to meet population needs across the United States

1st Why (causative problem)

2nd Why

3rd Why

4th Why

5th Why (root causes)

Workforce market shift (mismatch between demand and supply)

Increased demand for nursing

Growing population needs nationwide

Increased medical comorbidities

Aging population, obesity, racial inequality, geographic trends, poverty

Increased mental and behavioral illnesses

substance use, gun violence, anxiety, depression

Inadequate access to PCP

Low uptake of Medicaid expansion, insurance not mandatory, out-of-pocket fees, NPs scope restriction

High maternal mortality

Racial inequities, low numbers of hospital providing maternity care

Worsening PCP shortages

Decreasing hours, retirements, increasing demand, NP scope restriction

Clinical specialty needs

Geriatric nursing shortage

Geriatric physician shortage (due to low salaries)

ICU nursing shortage

COVID-19, aging population, increased medical comorbidities, and ECMO

Psychiatric nursing shortage

Increased in mental health (COVID-19, anxiety, depression, and suicide attempts)

Dialysis nursing shortage

Aging population, increased hypertension

Anesthesia nursing shortage

Aging population, increased comorbidities

Uneven distribution of patient needs

Higher need in rural areas

Lack of transportation, education, and poverty

Larger physician shortage in rural areas

Insurance status

No universal coverage, out-of-pocket payments

Reduced supply of nurses

Increased retirement rates

Large proportion of nurses are Baby Boomers

Shifting U.S. demographics

Early retirement or changing jobs

Long-term impact of COVID-19

Staff burnout, lack of safety culture, reduced PPE supply

Shifting roles and responsibilities

Providing end-of-life care

Impact of human-caused disasters

Insufficient pandemic preparedness knowledge or skills

No decision-making authority

Lack of trust with nursing and healthcare administration

Scarce resources and staffing shortages

Feeling unsafe due to gun violence, active shooters in hospitals and terrorism

Cultural and political factors

Social unrest due to political climate

Systemic racism

Underrepresentation and low diversity (gender, race, and ethnicity)

Insufficient number of graduating nurses

Low recruitment and admissions to nursing schools

Increased tuition and diminished financial support

Absence of short pathways for graduation

Absence of distance learning opportunities

Poverty

Low retention rates in nursing schools

Insufficient nursing training slots

lack of social, emotional, academic, and economic support

Lack of transparency (passing rate)

Shortage in nursing faculty (low salaries, lack of diversity, and burnout)

Inability to adapt to changes in demand (e.g. COVID-19)

Cost of training

Absence of distance learning

Inflexible curricula

Poor financing design

Fee-for-service system not advancing equity

Nurses not incentivized for cognitive activities and/or coordination

No CPT codes exist for these services

Technology not incorporated

Financing systems heavily rely on fee-for-service

APRN are not credited for diagnoses and treatment

Advanced practitioners can only bill under “incident-to” billing

Medicare reimburses supervising providers rather than actual providers

Most schools do not have full time nurses

Limitation on billing ability of school nurses

Varying state, school, and local policies

Complexity and scarcity of funding sources and not taking advantage of currently available ones

Nursing shortage in public health

Inability to hire vacant nursing positions, offer job security or promotion opportunities

Cut in federal funding by 10% (2010–2019)

Reduction in local and state funding

Inadequate leadership/ governance response

Government policies not advancing equity

Shortage of staff providing delivery

CNM do not have autonomy for providing birth

State law restriction on providing selected services

Reduced production capacities of RNs and NPs

State requirement for physician oversight (24 states)

Physicians and public concerns about nursing and NPs abilities to diagnose patients and prescribe medications

Shortage of mental health providers in rural areas

APRN not empowered to provide treatment for substance use

Federal and state laws prohibiting nonphysicians from prescribing treatment (e.g., buprenorphine)

Nurses not participating in telehealth

Few opportunities exist to provide telehealth

Unclear if waivers to provide telehealth during the COVID-19 pandemic will continue to exist

Education system not advancing equity

Insufficient integration of SDOH in nursing education

No expanded opportunities to build competencies

SDOH not prioritized by nursing schools

Public health policies insufficient for emergency preparedness

Lack of robust national, state and local action plans to address nursing workforce response to disasters

ACA focused on medical and healthcare readiness but ignored nursing preparedness

Nursing preparedness was not a key policy priority

Lack of metrics to measure facilities preparedness

Local, state and national policies did not delineate how to equip nurses with skills needed

Nursing education was not prioritized

Flawed medical products/ technologies

Challenges with adaption to new technologies

Stress from charting and reviewing EHR

Significant time spent with EHR

Nursing not included in EHR selection and implementation

Suboptimal nursing training on EHR and investment in user interface

Alarm fatigue and missed alarms

Excessive electronic alarms

Nursing not included in alert design

Poorly designed health informatic policies

Errors in medication dispensation

Soundalike medications and insufficient time

Lack of safety culture

Insufficient technology training programs for nursing

New technologies not person-centered

Population health innovative projects not integrated with nurse practice

Nurses with technology expertise are not included in project design

Nurses are not part of priority setting

Insufficient information and research

Research gaps in the field of nursing

Uncoordinated and fragmented efforts without evidence-based recommendations

Inadequate funding of nursing research

Lack of alignment between funders' priorities and needed research infrastructure

Not optimized service delivery

Reduced health quality

Inability to deliver person-centered care

No emphasis on codesigning interventions and services with the population

Nurses are often not included in developing and optimizing services

Lack of care coordination

Health system parts are not incentivized to collaborate

Financial healthcare payments are often not bundled

Ineffective and unsafe nursing care

Limited nursing education and time

Absence of safety culture

Gaps to achieve cultural humility

Structural racism

Cultural competence not incorporated in nursing schools

Nursing care not comprehensive

Several services not fully covered (private nursing, some nursing home and home care)

Limited resources and deficient federal and state policies

Reduced health equities and accessibility

Nurses not empowered to address SDOH

Nurses not provided with sufficient skills, training, and education

Lack of resources and prioritization for SDOH

COVID-19 related inequities

Limited ability of nurses to aid in linking health to social and economic needs

State restrictions for nursing scope

Insufficient nursing time, knowledge and skills

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]


  1. 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.

  2. 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]

  3. 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]

  4. 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]

  5. 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]

  6. 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]

Zoom Image
Fig. 3 This diagram shows the labor market for nurses before the coronavirus 2019 (COVID-19) pandemic given the parameters (demand D1, supply S1, need N1, and wage W1) leading to a shortage of C1 to B1 to meet the prepandemic demand and E1 to B1 to meet the prepandemic need. During the COVID-19 pandemic, the demand increased to D2, the supply decreased to S2, the need increased to N2, and the wage to W2, leading to a larger shortage of C2 to B2 to the meet the pandemic demand and E2 to B2 to meet the pandemic need. Data adapted from Scheffler et al. [26]

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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]

Table 3

Tasks required for policy recommendations

Recommendations

Specific tasks

Data collection

Indicators

Goals

Short term (by 2024)

Investing in health and well-being of nurses

Nursing programs should incorporate materials on nursing well-being in their curricula

Online surveys of nursing programs

Proportion of programs offering well-being training

Percentage offered >90%

Employers should provide resilience and well-being programs to nurses

Online surveys of healthcare facilities

Proportion of healthcare facilities offering well-being training

Percentage offered >75%

Employees should provide a safe environment

Online assessment of nursing perception of work environment

Need to develop a Likert-score questionaries to measure cultural safety

Percentage staff feeling safe > 75%

Empowering nurses by changing policies and payment mechanisms

Change CPT codes to reimburse nurses for care coordination, team-based care, school nursing and teleservices

CPT codes are publicly available by CMS

Utilization of specific CPT codes

Increased utilization by > 100% from baseline

Make permanent all COVID-19 nursing scope expansions

Assessment of state regulations for nursing practice

Number of states with permanent expansion of nursing scope

Increase the number of states to 45 (90%)

Improving the quality and accessibility of nursing education

Nursing programs should add SDOH competencies to their curricula

Online survey of nursing schools

Percentage of schools with SDOH competencies incorporated

Percentage offered >75%

Nursing schools should provide distance learning opportunities

Percentage of schools offering distance learning

Percentage offered >50%

Nursing programs should increase diversity among their faculty

Number of minority staff in faculty

Increase by 50% from baseline

Nursing schools should encourage student civic engagement

Percentage of schools with policies promoting civic engagement

Percentage offered >50%

Developing a robust public health emergencies preparedness response plan

CDC to develop a nursing hub for nursing disaster preparedness response

CDC external communication

Development of the nursing hub

Hub established

Nursing schools should incorporate emergency preparedness in curricula

Online surveys of nursing programs

Percentage of schools offering emergency preparedness skills

Percentage offered >75%

Nursing boards should incorporate emergency preparedness in their licensing exams

Online surveys of nursing boards

Percentage of nursing boards requiring emergency preparedness as part of their licensing exams

Percentage offered >75%

Healthcare systems should include nurses in their emergency preparedness plans

Online surveys of healthcare facilities

Percentage of healthcare facilities with nursing representation in their emergency plans

Percentage with representation > 90%

Including nursing expertise in technology design and implementation

Employers should include nurses with technology expertise in their EHR deployment teams

Online surveys of healthcare facilities

Percentage of healthcare facilities with nurses included in their EHR teams

Percentage > 75%

EHR should capture SDOH data

Percentage of healthcare facilities with EHR features capturing SDOH

Percentage > 50%

Long term (by 2026)

Strengthening the nursing role in advancing equity

Increase the number of nurses with health equity expertise

Online surveys of healthcare facilities

Number of nurses with specific health equity training

Increase from baseline by 100%

Increase the number of nurses in shortage areas

Online surveys of healthcare facilities

Number of specialized nurses in specific areas

Increase from baseline by 100%

Develop state programs to advance students from disadvantaged socioeconomic status

Online surveys of nursing schools

Percentage of schools with established policies promoting advancement

Percentage > 75%

Include nursing expertise during state health reforms

Assessment of state regulations

Percentage of states requiring nursing presence in health reforms

Percentage > 50%

Investing in relevant research

Develop nursing grants to fund priority nursing research

Online surveys of nursing schools

Amount of funding for nursing research

Increase by > 50% from baseline

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)

  • (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.

  • (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.

  • (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.

  • (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.

  • (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)

  • (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.

  • (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.


Address for correspondence

Mayar Al Mohajer, MD, MBA
6720 Bertner Avenue, Room P508E, MC-166, Infection Prevention, Baylor St. Luke's Medical Center
Houston, TX 77030
United States   

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.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India


Zoom Image
Fig. 1 This figure shows different aspects of nursing human resources for health including availability, accessibility, acceptability, and quality. Data adapted from Wakefield et al and America's Health Rankings. [6] [7] FTE: full-time equivalent; RN: registered nurse.
Zoom Image
Fig. 2 This figure shows the states with highest estimated nursing shortage. Data adapted from USAHS.[9]
Zoom Image
Fig. 3 This diagram shows the labor market for nurses before the coronavirus 2019 (COVID-19) pandemic given the parameters (demand D1, supply S1, need N1, and wage W1) leading to a shortage of C1 to B1 to meet the prepandemic demand and E1 to B1 to meet the prepandemic need. During the COVID-19 pandemic, the demand increased to D2, the supply decreased to S2, the need increased to N2, and the wage to W2, leading to a larger shortage of C2 to B2 to the meet the pandemic demand and E2 to B2 to meet the pandemic need. Data adapted from Scheffler et al. [26]