Shortage In Nursing: The Problem and the Solution

Shortage In Nursing: The Problem and the Solution


Most States mandate a workable nurse-to-patient ratio for effective delivery of nursing care. A ratio of 1:1 or 1:2 may be considered good in intensive care settings; in the same settings, a ratio of 1:3 or 1:5 should raise an alarm. For the patients, it implies low-quality care, divided medical attention, and high risk of complications. For the nurses, it means burnout, low efficiency, low job satisfaction, and high stress levels. The nurse-to-patient ratios have been greatly impacted by the recent nursing shortage, leading to the extended working hours of the existing nurses, resulting in their burnout and low motivation to work. Due to this, many nurses quit their jobs, looking for non-clinical options, thus, worsening the shortage. This vicious cycle needs to be broken at some point, to help improve the patient care and cutting down healthcare costs.

Traditional portrayal of nursing is quite contrasting to the contemporary trends observed. Modern nurses work in a dynamic environment. The changing demands of healthcare services, implementation of Patient Protection Act, a rise in the baby boomer generation, diverse career opportunities for nurses have boosted the demand for nurses in the present day. Nonetheless, nursing industry is not witnessing the parallel step-up in the students choosing nursing as a career, creating a shortfall in supply. In this disparity, emerged a stage of radical nursing shortage, cautioning the world to catch up in resolving the issue. Nursing, as an occupation, is obviously impelling prosperity, handing out the vast potential for the entrepreneurs to embrace the nursing industry. This article is an attempt to provide useful information on different aspects of shortage in the nursing industry. This information in return can help an entrepreneur to hustle up the last minute preparation before starting a business in the nursing industry.


Patient Protection Affordable Care Act; International migration; Nurse Entrepreneur; Medical Tourism; Home care agency

At a Glance

  1. Introduction
  2. Nursing Shortage: How did it start?
  3. Mapping: Which places have the most shortage?
  4. Projected Score: How much shortage?
  5. Ingredients – Factors causing shortage
  6. Conquering: Steps to Overcome Shortage
  7. Career prospects in nursing
  8. Nurse Entrepreneurs: A New Trend in Nursing
  9. Every Cloud Has a Silver Lining


What is nursing? The first thought that comes to our mind is- a woman in a clean white skirt, wearing a passive smile, holding a tray full of bottles and medicine and walking behind a physician. Cut to the present era…nursing is now no longer limited to the patient’s bedside. The industry experienced a breakthrough from a traditional practice of bedside care to the nurse being a clinical researcher, information analyst, designer of medical equipment or a nurse entrepreneur.

Nursing is the largest workforce in health care profession and is one among the highest paying occupation in U.S.A. The nursing industry is estimated to experience the highest job growth in coming years. Ironically, there is a global shortage of nurses, in terms of, both the quantity and quality. It is mandatory to address the issue and bridge the shortage before the situation could worsen to a point affecting the patient care.

Nursing Shortage: How did it start?

Shortage in the nursing industry was rampant, since World War-II. The profession was meant for females, with few men interested to pursue it as a career. Later, with women moving on to other professional options, there was a deficit created in the nursing industry.

The number of students enrolling for nursing courses have gown down, largely due to lack of nursing staff for education. As a result, the number of graduating nurses has also decreased. In addition, many nurses choose non-clinical occupations, leaving a few trained professionals for bed-side nursing.

Implementation of the Affordable Care Act has extended the health care to underprivileged people, adding up to the numbers who must receive care, with no increase in the numbers of nurses who must provide care. Also, the large number baby boomers are now in the health state, where they need long-term and end-of-life care. All these factors together, have created a huge demand for trained professionals and are exerting pressure on the already over-worked nursing fraternity.

Mapping: Which places have the most shortage?

Shortage of nurses is turning out to be a global embarrassment. Nonetheless, it is significant in U.S., Canada, Australia, Western Europe and  the Philippines.

Figure 1: Geographical distribution of shortage in nursing over the states of U.S.

                                                               Source: www.RNtoBSN.org

Projected Score: How much shortage?

  • Based on the figures furnished by Bureau of Labor Statistics, the employment opportunities for a registered nurse during 2012-2022 would raise from 2.71 million 3.24 million, along with additional 525,000 nurses for replacement, a total of 1.05 million nurse placements would be available.
  • American Medical Association had published an article written by Dr. Peter Buerhaus, an analyst in the workforce. The article highlights the fact that within the next 20 years, the American workforce would reach a plateau as a result of the retirement of currently practicing nurses. The result would be a long-term shortage of nurses in the latter half of the next decade.
  • A joint statement given on Registered Nurse Supply and Demand Projections, by Tri-council for Nursing in 2010, raised concerns about the temporary easing of shortage due to decline in the economy.

Figure 2: Supply vs. Demand estimate graph of nurses FTE (Full time equivalent) in U.S. for the next decade

                                             Source: Bureau of Health Professions (2002)

Ingredients – Factors causing shortage

1. Demographics

It is estimated that one out of five Americans will be above 65 years by 2030. The American Medical Students Association estimates, the Baby Boomer generation of U.S. to would reach up to 73% in a span of 2010-2030. It poses a challenge to the healthcare system to deliver services particularly for chronic illness, palliative, and end-of-life care services especially when most of the nurses experienced in geriatrics themselves are a part of the boomer generation.

The Nursing Institute at the University Of Illinois College Of Nursing, prepared a report titled, “Who Will Care for Each of Us?” in May 2001, which revealed that the ratio between the healthcare professionals and elderly population who need healthcare will decrease by 40% in 2010-2030. A survey conducted by National Council of State Board of Nursing and The Forum of State Nursing Workforce Centers, in 2013, concluded that 55% of registered nurses working in U.S. are above 50 years.

2. Nursing program enrollments

According to the information released by American Association of Colleges of Nursing, the number of students enrolling in the nursing schools is growing. However, many applications are turned away due to vacancies in faculty positions, budget constraints, classroom space, and lack clinical preceptors. The nursing schools are advised to expand their classroom spaces to accommodate more number of students without compromising on the quality of the nursing education.

                                          Figure 3: AACN survey of nursing schools, 2014

Source: http://www.aacn.nche.edu/faculty/news/2015/enrollment

3. Nurses drop out

The nursing workforce, in the present day, have to face the challenges of delivering quality healthcare, increased number of patients to be taken care of and increased working hours. All these circumstances further lead to building up stress, work dissatisfaction, a decline in performance and insufficient salary, which resulted in many nurses quitting the profession and taking up other professions.

Dr. Peter Buerhaus et.al conducted a survey in 2005 and found that more than 75% of RNs believe that nursing shortage is a result of drop out from the profession. Nurses do realize that shortage led to increased stress on nurses (98%), lowered the quality of patient care (93%) and caused the nurses to leave the profession (93%).

An article published in American Journal of Infection Control, reveals the results of a study conducted by Dr. Jeannie Cimiotti et.al in Pennsylvania hospitals. The researchers recognized a proportional relationship between the patient-to-nurse ratio and nurses’ burnout. A high nurse-to-patient ratio resulted in an escalation of nurse burnout resulting in increased incidence of infections related to urinary tract and surgical sites.

Conquering: Steps to Overcome Shortage

1. Automation of non-valued tasks

A nurse spends nearly a quarter-fourth time of the work shift performing non-valued tasks such as communicating and charting the patient information or waiting for critical patient information.

A research conducted by American Academy of Nursing in 2002, reveals that 40% of registered nurses engage most of the time in non-valued tasks.

Automation of non-valued tasks would enhance the time spent on the patient and the number of patients receiving the actual direct nursing care. Many hospitals have started to work towards automating the non-essential tasks involved in nursing. Automation is progressing rapidly in specific areas such as pneumatic tube system implemented in laboratories, computer-based charting of patient’s progress and acquiring drugs from the pharmacy.

2. Upgradation of nurses

A nurse with skill and expertise in specific areas would improve the quality and quantity of care delivered to the patients. Public health organization should work towards providing

training and up gradation of already existing nurses, say for example, CNA to LPN to PNalong with encouragement for students to take up nursing as a career.

The US Department of Labor granted more than $12 million in June 2005 through the President’s High Growth Job Training Initiative, of which $3 million is granted to address the nurse faculty shortage. The funds put together for health care workforce through the High-Growth program is more than $43 million.

3. International migration

Nearly 25% of overseas nurses are from the Philippines, projecting it to be the largest exporter of nurses in the world and also to the U.S. This enormous migration of Filipino nurses is a consequence of “push-pull” strategy driven by economic condition of both the countries.

Overproduction of RNs coupled with unemployment, low wage rates and lack of benefits, pushed the Filipino nurses to migrate. Meanwhile, the government of U.S. has implemented immigration legislation to pull nurses from other countries by providing access to a work permit in one step.

4. Continuous recruitment and marketing

Healthcare industry has fallen back in attracting young nurses into the services, resulting in nurses taking up employment in other organizations such as pharmaceutical companies and marketing healthcare products.

The recruitment of young population into the nursing industry can be improved by encouraging them to participate in teaching and learning sessions, conferences and providing financial assistance wherever required. Recruitment of nurses should not be limited to times of shortage only; continuous recruitment should be encouraged to ensure that the nursing work force remain skilled, trained, and motivated.

5. Legislation to improve recruitment and retention

The Nurse Reinvestment Act passed in 2002, is intended to grant scholarships for continuing nursing education, loan repayment programs, nursing faculty programs and also geriatric education. The nursing shortage can be addressed on a long term basis by improving recruitment and retention in the healthcare sector.

6. Bank Nurses

Bank Nurses are nurses registered with a local organization or a hospital nurse bank, willing to work for additional hours when required to patch up the shortage. This concept could be effectively applied in operating rooms and intensive care units where a nurse with skill and expertise can deliver the services with ease.

7. Contract services

Float pool and agency nurses are the two kinds of contract based services that can be utilized for addressing the shortage of nurses immediately in the short run. In both types, the nurses need to have a license to work within the scope of the permit provided to each of them.

  1. Float pool nurses are appointed by the management of the hospital. Their services can be utilized in any unit, as long as the nurse is working within the organization.
  2. Agency nurses are appointed by the staffing organization independently, working on daily, weekly or contractual basis of payment.
  3. Travel nurses are appointed by recruitment agencies to travel and work in temporary positions at hospitals. This concept of employment is spreading rapidly because of high pay, professional development, and personal adventure involvement.

Employment and Wages

The wages of a nurse varies depending on many factors for say location, industry, education and experience along with other benefits such as travel benefits, health insurance, life insurance, dental and vision insurance, paid time-off and many more to go.

Figure 4:  Hourly wages of nurses

                                              Source: Bureau of Labor Statistics May 2014

Career prospects in nursing

There is a good deal of opportunities in the field of nursing, directly associated with patient care and also in the range of operation involving other industries.

Nurse Entrepreneurs: A New Trend in Nursing

Entrepreneurship in nursing can be tracked down to early 1900’s with a shift from traditional nursing towards private duty nursing, earning respect and satisfaction in the profession. Karen Gibson, a nurse, was the pioneer to start a nursing agency in the name of American Nurse.

Nurse entrepreneurs are nurses possessing knowledge in nursing and a passion for self-employment. They provide services themselves or utilize the skills of their employees to deliver direct care, health promotion, education, advocacy, research, administration, and consultation. These nurses believe that services are best delivered independently. The reimbursement for services is secured directly from the client or through a private insurance company.

Examples successful nurse entrepreneurs

  1. Clara Barton, the founder of American Red Cross in 1881, was the first nurse entrepreneur.
  2. Barbara Bartlein, owner of The People Pro, is a well known high content speaker who educates, and motivates professionals to improve workplace performance. Previously, she was the president of the National Speakers Association and further earned the (CSP) designation, the highest honor given by the National Speakers Association.
  3. Anthony Battaglia had worked previously as medical ICU nurse at Allegheny General hospital, proceeded to be board president at Keystone Stimulation Education Centre before taking up President designation at Pocket Nurse.
  4. Ellen Reilley Farrell, owner, Gericalls LLC is a coordinator for Palliative Care Nurse Practitioner Program at George Washington University.
  5. Cyndie Colarusso, founder, and president, Pathways Consulting involved in tissue banking to spread awareness on tissue and organ donations.
  6. Mary Doherty, along with Meghan Stoia founded Jean Angles LLC to help people obtain credible information about health and wellness, especially after the implementation of Obama care.
  7. Janet Celli and Susan Whitney, co-owners, CPR Associates of America are spreading awareness in life-saving techniques among the general public with a vision to develop Public Access Defibrillation Programs in association with American Heart Association.

Entrepreneurial Opportunities During Nursing Shortage

The nursing has opened a wide range of opportunities to start up health care businesses. A few trending businesses in nursing industry have been listed as follows:

1. Healthcare staffing agency

 According to Medical and Nursing guide, a healthcare contractor can earn $12,000-18,000 for recruiting a nurse or imaging technician. The current scenario in the nursing and the demand for healthcare professionals, particularly the nurses, provide a good option for an entrepreneur to set up a healthcare staffing agency.

An agency is required to fulfill specific staffing requirements like nursing agency registry business, supplemental staffing agency, permanent placement medical recruiter, and homecare and staffing pool business. An agency should address the staffing needs of hospitals, nursing facilities, assisted living residences, schools, physician practices, and camps for health care provider. A franchise for this kind of business would require an investment of $50,000 to $59,999.

Agency should ensure that a nurse is provided with benefits such as facilities for work, shifts and days reported to work, vacation pay, health insurance, retirement schemes and bonuses based on the number of hours they work.

2. Home care agency

A home care business can be started on your own or in a franchise. Starting business independently has low start-up costs without franchise fees and autonomy to deal with business strategies. The requirements of a license vary widely from state to state for non-medical home care agencies. An entrepreneur possessing strong communication and organization skills with a well-planned business strategy can achieve progress quickly.

3. Medical tourism travel agency

Based ona story published in 2006 by CNN, nearly half a million medical tourists seek procedures abroad, and the figures are expected to increase in the near future. Based on the details furnished in the Surgeon Abroad website, certain places are considered famous for certain medical-surgical procedures.

COUNTRYIndiaPhilippines and HungaryTurkeyCosta Rica
PROCEDUREHeart and orthopedic surgeryAdvanced DentistryEye surgerycosmetics

It is interesting and challenging, yet highly profitable for an entrepreneur to set up a medical tourism travel agency. You need to conduct research for the best practitioners and hot spots in the destiny country, and get the permits, visas and licenses cleared before setting up an agency. The business should cater to the needs of the patient efficiently, as patient satisfaction is the prime criteria for success in this business. 

4. Online nursing program

Kaplan University, South University and The University of Phoenix have already started high-quality online nursing program to overcome the lack of infrastructure and teaching faculty. These programs are flexible, and can be accessed anytime and from anywhere.

Every Cloud Has a Silver Lining

This holds true for the problem of nursing shortage as well! Every problem has a solution, and this problem of nursing shortage has many solutions. Addressing the problem of nursing shortage needs the collaboration between nursing education institutes, healthcare facilities, the federal government, and the nursing professionals themselves. With nursing being projected as a lucrative and progressive career option, more number of aspirants, irrespective of their gender, are likely to choose nursing as a career. In the long run, the nurse-to-patient ratio would improve and the nursing shortage would become a thing of the past.


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