The American Nursing Shortage

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Nursing workforce: Then and now

A nurse’s role is extremely important in healthcare in order to deliver safe, positive and successful patient outcomes. In fact, nurses are the fastest growing and have the largest numbers in the profession, with approximately 3.9 million registered nurses in the United States alone, 29 million worldwide (Haddad & Toney-Butler, 2018). However, even with this substantial number, there is still a shortage of one million nurses (Haddad & Toney-Butler, 2018). Nursing shortages have been a discussion for many years, yet it remains an epidemic.

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According to the American Nurses Association (ANA), registered nursing jobs will have the highest needs through 2020, which is more than any other profession in the United States (Haddad & Toney-Butler, 2018).

The start of a nursing shortage began around 1936 when hospitals started to realize they did not have enough nurses to care for patients. (Penn Nursing, n.d.). With reports of a nursing shortage, healthcare workers began to reevaluate where changes could be made for improvements. Specific changes that took place were allowing an increased number of students to be accepted into nursing programs, as well as, decrease the timeframe in which students attended school, to expand the number of nurses in the workforce at a quicker rate (Penn Nursing, n.d.). It was also decided to increase the number of less-educated employees to work under registered nurses, such as certified nursing assistants. (Penn Nursing, n.d.). All these efforts have proven to be successful, however, it did not stop the nursing shortage from reoccurring (Penn Nursing, n.d.).

Today, the nursing profession faces different dilemmas, for example, nurses who are near retirement. Currently, there are approximately one million nurses over the age of 50 and within the next 10 to 15 years, there is an anticipated number of 500,000 who will be at the age to qualify for retirement, that will need to be replaced. (Haddad & Toney-Butler, 2018). Currently, the United States has 71 million people over the age of 65, which is the highest number in history (Haddad & Toney-Butler, 2018). As the population continues living longer, there is a greater need for additional healthcare services due to multifaceted health issues (Haddad & Toney-Butler, 2018). Another aspect of the nursing shortage today includes a decrease in nursing instructors, which could potentially lead to negative impacts on nursing programs. If there are not enough instructors to properly conduct a nursing program, this would impact the number of students that could be accepted into a program, as well as, the quality of information that is taught (Haddad & Toney-Butler, 2018). In return, this would result in students not receiving the full potential aspects of nursing school, leading to fewer graduates, contributing to the ongoing nursing shortage (Haddad & Toney-Butler, 2018).

Impact on patient safety:

Patient care is and always will be the most important factor to consider when discussing nursing shortages. There are many risk factors that can occur when patients are in medical facilities that have an inadequate number of nurses working. Promising evidence has been shown that nurses who experience fatigue from working overtime or double shifts (more than 40 hours a week), due to understaffing, results in a potential for increased patient harm, specifically medication errors (Olds & Clarke, 2010). There has also been a link shown between nurse to patient ratios and patient safety, proving that an increased number of morbidities, failure-to-rescue, and mortality occur. (Haddad & Toney-Butler, 2018). In fact, for every extra patient that is added to a nurse’s assignment, the mortality risk increases by seven percent and at an increased risk of death by two percent (DPE, 2016). Furthermore, when facilities work with less than the required nursing staff, they are at an increased risk to be “among the worst 10 percent of facilities for heart failure, electrolyte imbalances, sepsis, respiratory infection, and urinary tract infections.” (“Safe Staffing Ratios: Benefiting Nurses and Patients,” 2016).

Impact on nursing safety:

Not only are patient’s health and safety at risk due to the nursing shortage, but nurses themselves are at an increased risk. As mentioned above, when a nurse must work over 40 hours a week, due to understaffing, fatigue ensues, which leads to increased harm for the nurse, just as much as the patient. Data has shown when nurses work over sixty hours per week a risk of injury rate increases by 23% and working beyond sixty hours increases the risk of injuries by 61%, specifically musculoskeletal injuries (Olds & Clarke, 2010). Fatigue also places nurses at a heightened risk of needlestick injuries when working longer than twelve-hour shifts. For every additional ten hours worked, the risk goes up by 16%. (Olds & Clarke, 2010). As research continues to provide evidence of extended work hours causing errors and adverse events, it becomes increasingly significant for healthcare facilities to determine specific practices and policies that will protect both the patients and nurses (Olds & Clarke, 2010).

Impact on job satisfaction:

In order for any healthcare facility to operate, they must be able to recruit and maintain nurses as employees. However, job satisfaction has proven to be the main contributing factor that causes the recruitment and retainment of employees to be difficult (Halcomb, Smyth, & McInnes, 2018). Burnout is known to cause stress, emotional exhaustion, physical tiredness, decreased job performance and ultimately, decreased job satisfaction (Halcomb et al., 2018). When a nurse personally experiences burnout, research has shown this tends to be the cause of employees leaving their positions (Halcomb et al., 2018). As mentioned, burnout can cause stress, which has shown to be detrimental to a persons mental and physical wellbeing. (Roberts & Grubb, 2014). For the last ten years, nurses have consistently been the most reported profession in healthcare to experience job-related stress (Roberts & Grubb, 2014). Due to work-related stress and burnout being the highest reported causes related to decreased job satisfaction, healthcare workers must determine specific interventions that will improve these factors in order to retain nurses and maintain their safety, as well as patients, despite nursing shortages. (Roberts & Grubb, 2014).

The future:

Facilities must start meeting the needs of nurses to help empower and support them to ensure safe care to all patients. The high demand, along with the growth of healthcare is now beyond what the nursing profession is able to meet (Penn Nursing, n.d.). Solutions to the nursing shortage have continued to be on-going, with areas of concern that outweigh the benefit. However, since 2004, states have begun adapting to the idea of enforcing state legislation pertaining to safe nurse to staff-patient ratios assignments and as of 2015, fourteen states are participating (DPE, 2016). It has been proven that when nurses are working with safe ratios, it helps decrease nurse burnout, overtime, job dissatisfaction, stress, medication errors, mortality rates and stress (Haddad & Toney-Butler, 2018). Unfortunately, when a facility simply does not have enough staff, the legislation for the nurse to patient ratios do not apply because all patients still need to receive care.


  1. Department for Professional Employees. (2016). Safe-Staffing Ratios: Benefiting Nurses and Patients. [Fact sheet]. Retrieved from:
  2. Halcomb, E., & Smyth, E., & McInnes, S., (2018, August 7). Job Satisfaction and Career Intentions of Registered Nurses in Primary Health Care: An Integrative Review. National Center for Biotechnology Information, (19)(1), 136-152. doi: 10.1186/s12875-018-0819-1
  3. Haddad, L., & Toney-Butler, T., (2018). Nursing Shortage. Retrieved from:
  4. Olds, D., & Clarke, S., (2010, March 12). The Effect of Work Hours on Adverse Events and Errors in Health Care. National Center for Biotechnology Information. (41)(2), 153-162. doi: 10.1016/j.jsr.2010.02.002
  5. Roberts, R., & Grubb, P., (2014, May 21). The Consequences of Nursing Stress and Need for Integrated Solutions. National Center for Biotechnology Information. (39)(2), 62-69. doi: 10.1002/rnj.97
  6. Where Did All the Nurses Go? (n.d.). Retrieved February 15, 2019, from Penn Nursing website,
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The American Nursing Shortage. (2021, Oct 16). Retrieved from