More Support Needed to Shore Up Nurse Pipeline, Experts Say

While interest in nursing as a career hasn’t diminished, faculty shortages and other institutional factors have prevented some from entering the field, experts explained during an online panel discussion on Tuesday, which was hosted by the Bipartisan Policy Center and sponsored by the American Hospital Association.

Recent data have shown that the number of nurses in the U.S. fell precipitously for the first time in four decades, with the sharpest decline among nurses younger than 35. The total nursing workforce dropped by 100,000 registered nurses from 2019 to 2021, according to an analysis published in Health Affairs Forefront.

“If we want to think about policy solutions that are going to really stop the leakage … we really need to make sure that we understand the major drivers” of nurses leaving the profession, said Patricia “Polly” Pittman, PhD, of the Milken Institute School of Public Health at George Washington University in Washington, D.C.

Approximately 185,000 registered nurses graduate nursing programs every year, Pittman said, which is not too far from the 195,000 nurses that the Bureau of Labor Statistics projects are needed. But a shortage of faculty, preceptors, and clinical sites have prevented many of those interested in nursing from entering the field, she explained.

In 2021, over 90,000 qualified nurse applicants were turned away from nursing schools due to a lack of space, said Maria Zangardi, MS, of Universal Health Services in King of Prussia, Pennsylvania, citing the American Association of Colleges of Nursing.

As Linda McCauley, RN, PhD, dean of Emory University’s Nell Hodgson Woodruff School of Nursing in Atlanta, pointed out, the number of PhD-prepared nurses has “completely flat-lined” — a trend she characterized as “alarming,” given the need for highly educated nurses to help lead health systems in the future.

Even a 10% increase would help get the field on the right track, she noted.

The other big challenge, according to Pittman, is “leakage” — nurses moving from “job to job” within the profession or leaving it entirely.

One factor affecting the decline in the nurse workforce is the predictably counter-cyclical nature of the market, she said. Nurses tend to enter the workforce during times of recession — when a husband or a child may have lost a job — while in periods of full employment, nurses may cut back their hours or even leave the profession, she explained.

Hospitals do have a “toolkit” for addressing these expected downturns, she said, such as bonuses, wage increases, tuition reimbursement, transition-to-practice programs, flexible scheduling, daycare, awards, and even international recruitment.

However, the COVID-19 pandemic and the working conditions that resulted from it has added a new layer of harder-to-treat problems.

In Pittman’s work as a grantee for the Human Resources & Services Administration (HRSA), interviewing nurses about working conditions, she discovered that an important precursor to burnout in the field has been “moral injury” — a term derived from soldiers returning from war with “a form of post-traumatic stress disorder.”

“What people say is that they are feeling betrayed,” not only by employers, but also by colleagues and by society, she explained. And, as a result, they feel unable to do their jobs because “something is in direct conflict with their professional code of ethics.”

Nurses are torn between speaking up and keeping quiet, and if they say nothing they often experience “a sense of guilt, shame, and helplessness,” she added.

“There are other drivers of burnout too, but this may be the superhighway,” Pittman said, noting that it’s something that’s important to bear in mind when trying to identify solutions to the workforce problem.

Solutions to the Nurse Shortage

One classic approach to addressing workforce shortages at the federal level is loan repayment programs, Pittman said. For example, HRSA’s Nurses Corps pays 85% of unpaid education debt if the nurse pledges to work in critical shortage facilities or at certain nursing schools.

Programs that focus on transitioning to practice for both RNs and nurse practitioners have also been shown to be effective, she added.

Zangardi noted that her health system offers a nurse “externship” program that incentivizes students to stay with the system and receive tuition reimbursement and loan repayment. It also has invested in a “post-hire survey,” which requests periodic feedback from nurses about their experiences on the job.

McCauley said that a number of Graduate Nurse Education Demonstration Projects have proven very effective at the federal level, such as CMS-funded nurse practitioner training programs and initiatives incentivizing hospitals to provide preceptors, though “getting the federal government to adopt [these programs] is very difficult.”

The Robert Wood Johnson Foundation also launched a program to financially support and mentor “nurse scholars” pursuing a 3-year PhD, McCauley said, which had “phenomenal outcomes.”

However, “no one’s adopting those models,” she said.

Zangardi argued that the increased burden on hospitals that implement these strategies is one reason they are asking payers for greater reimbursement, “because we want to be subsidizing these types of programs that we know are effective in keeping nurses engaged and retained.”

McCauley took a different tack. “I believe deeply that nursing is a public good, and the production of a sufficient number of nurses to care for our population is a public good,” she said.

“I think for the production of nurses right now to really get our country where it needs to be, there needs to be investment at the national and state level,” she added, noting that differences in licensure and scope-of-practice laws “do nothing but hurt us in today’s world.”

To see any significant change in hospital culture, there have to be more nurses in health system governance “at the highest levels,” she continued. “If there’s one nurse on the board, that’s viewed as a huge achievement, when really, when you consider the size of the workforce … nursing is very underrepresented.”