By Diane Koyasu Heine, DNP, RN, CEN, ADN, BSN, MSN

According to the US Bureau of Labor Statistics, more than 200,000 registered nurse (RN) positions are projected to be vacant annually over the next decade. This prediction was made prior to the pandemic, which saw a multitude of nurses transition out of bedside care through retirement or just leave the field. The need for staff nurses is a topic of great concern, but what is the solution?

The pandemic brought fear to the healthcare provider as we battled against a foe we could not see and had to watch some of our peers die or suffer with long COVID. In addition, the dramatic increased need for clinical nurses drove a price war with the travel companies that provided nurses for those hospitals willing and able to pay the high costs.

As the demand rose, the supply, which was already short, shifted from location to location. Staff nurses left hospitals for the lucrative pay offered by the travel companies. This did not increase the nurse workforce nor did it help improve the care delivery for patients.

The problem with the lack of nurses remains. The 2022 study, the shortage of nurses was attributed to:

-Inadequate staffing

-Pay discrepancy related to equal pay for equal experience

-Lack of hazard pay for staff nurses during the pandemic

-Lack of adequate support

-Lack of competent mental health services

-The inability to take a break, sick time, or a day off

Staffing Ratios

The aging baby boomers and their retirement from the profession has left a gap in staffing. Already short on staff for the units, the acuity and volume of COVID patients drove up the need for nurses. Maintaining standard nurse-to-patient ratios was nearly impossible. Closing inpatient beds due to lack of caregivers led to a backup in emergency departments (EDs), which were holding patients until a bed was available. The lack of ED beds affected the timeliness for patients to be seen. And nurses leaving to join travel companies made this gap worse.

A big push in the past few years has been to offer residency programs for new nurses. A nurse residency program is designed to help recent nursing graduates transition into clinical practice. Through facilitation of an educator and an assigned veteran RN, new nurses gain the knowledge and direct experience they need to provide thoughtful, high-quality care to their patients. New nurses can do residencies in the ED and ICUs, which was not a common practice in the past.

Nursing schools have wait-lists for entry because there are not enough nursing instructors to accommodate those wishing to enter the field. In addition, nursing instructors make significantly less money than do bedside nurses. Plus, hiring experienced educators to teach at the university level is a challenge.

Pay Limits

Pay has been an issue since I entered the field in 1982. Granted, nurses make up the greatest number of employees in a hospital. The reality is the patients are admitted to the hospital because they need the care and skills of a RN. The hesitation to increase pay is related to the overall cost, but also, some limitations were placed by the unions. The step-raises established in multiyear contracts limited the ability of the hospital to increase pay for the staff.

Travel nurses received hazard pay if they worked COVID units. The high dollars paid to the travel nurses was not lost on the staff. It had a negative impact on staff morale.

Lack of Support

Nurses are struggling with more work than can be completed within their shift. In addition, many units are unable to safely cover patients for a nurse to take a 15-minute rest period let alone a 30-minute meal break. Nonclinical nurses (educators, quality improvement, managers, etc.) have been required to cover holes in schedules, making them unavailable to the staff in their needed roles. Bed closures due to staff shortages ultimately limits access to care.

Mental Health Needs

Personally, I can attest to the need for competent and appropriate mental health services for the staff. The pandemic brought out so much fear of dying and of the unknown in the staff. I remember walking into the ED every morning and being bombarded with questions, many of which I could not answer. My manager and I worked long hours, both shifts, to provide our team with what they needed to get beyond the fear and provide safe and efficient care for their shift.

As a result of the pandemic, many nurses suffer from posttraumatic stress. An article describes the need for nurse leaders to advocate for their staff and collaborate with others to provide mental health support. This is a collaborative effort with the executive team and human resources to serve the entire staff.

Continuous Cycle

Hospitals need patients to make the money to run operations. Hospital funding is driven by quality metrics. Lack of nurses has a negative impact on these metrics. Poor outcomes decrease the reimbursement received by the hospital. The hospital lacks the funds to increase the pay of the staff or fund new programs, which affects the ability to attract more experienced nurses. Layoff of support staff can increase the workload of the clinical nurse and the nurse leaders. And nurses' competencies caring for the higher acuity patients decline.

Close the Gap

According to the American Association of Colleges of Nurses. over 80,000 applicants for nursing schools across the country were turned away during the 2019-2020 school year owing to lack of faculty, clinical sites, classroom space, preceptors, and budget. Priority in bolstering the baccalaureate and graduate nursing schools is needed to have an increase and continuous flow of new nurses.

Residency programs need to increase their interviews and onboarding of new nurses to two to three times per year. This continuous flow of nurses will help revitalize and stabilize staffing on units.

Recruitment should be phased. Short-term use of travelers will be necessary only while orientation and nurse residency programs are completed. Nurse leaders also need ongoing training and competency assessment to be able to develop with the organization and to build their units.

Long-term plans could be developed for communities to "grow their own" nurses. The interaction with healthcare providers should start at the elementary level with local scholarships to assist finance nursing education.

Hospitals need to review their nurse satisfaction surveys and work with the profession to make improvements in the workplace. Pay and retirement are a big deal. The dollars spent on travel nurses has been exorbitant, but it did not improve the nursing shortage.

There isn't a quick solution for the shortage of nurses. The solution will take time and a greater effort than a single hospital developing an innovative recruitment and retention program. Together we must work to escape this catch-22 so that quality healthcare can continue to be provided to those in need.