Is nursing crisis health system’s perfect storm?

Improved workplace, respect for profession needed

The worsening nursing shortage is a crisis that can completely sink the struggling U.S. health care system if hospitals and other institutions don’t do more to address the root causes of the shortage, health executives told government leaders last month.

The current shortage is more than just a recurrence of the supply-and-demand problems that periodically have occurred in the past, they claim, and multifaceted solutions are needed — fast.

"Nurses experience high stress and low job satisfaction, leading to burnout, high turnover rates, and an exodus from the profession itself," says Barbara Blakeney, MS, RN, CS, ANP, president of the American Nurses Association (ANA) and director of health services for the homeless at the Boston Public Health Commission.

"These conditions discourage young people from considering nursing as a career choice, thereby further reducing the number of people in the pipeline who will be available to replace the very large number of nurses who will soon be of retirement age. This situation has been dubbed the perfect storm’ of the American health care system."

According to estimates by the U.S. Health Resource and Services Administration’s (HRSA) Bureau of Health Professions, there could be a nationwide shortage as high as 808,000 nurses by the year 2020 — a number greater than the number of existing physicians practicing today. And there is growing evidence that nurse understaffing and high patient-to-nurse ratios result in poorer patient outcomes, higher rates of medical errors, and high levels of nurse burnout and job frustration.

A recent study by Linda Aiken, MD, and colleagues in the Journal of the American Medical Association, analyzing data from more than 10,000 nurse surveys and the discharge information of more than 200,000 patients at 168 Pennsylvania hospitals, found that high patient-to-nurse ratios were independently associated with increased patient mortality and more episodes of failure to rescue.1

An August report by the Joint Commission on Accreditation of Healthcare Organizations found that insufficient nurse staffing was a contributing factor in almost 25% of unanticipated problems resulting in injury or death to hospitalized patients.2 Among patients dependent on ventilators, the percentage was almost 50%.

"If the nurse wasn’t there to pick up on subtle problems before it became a major problem, the situation got out of control," Blakeney explained.

Blakeney and other experts participated in a forum discussing possible solutions to the nursing shortage on Oct. 17 in Washington, DC, and sponsored by the Alliance for Health Reform.

Recruitment measures not enough

Hospitals must move beyond just stepping up recruitment efforts and perks and do more to improve their working environments and the practice of nursing in general, Edward H. O’Neil, PhD, MPA, director of the Center of Health Professions at the University of California-San Francisco, told participants.

"We have to increase overall supply," he emphasized. "The strategies offered up by the profession, by industry, by labor, by education, have essentially focused on increased supply by recruitment — stealing from St. Mary’s to staff St. Paul’s. But it doesn’t add one new nurse; it just makes you feel better."

Surveys of nurses have reported serious dissatisfaction with the work environment — lack of respect, hostile attitudes, mandatory overtime, and lack of training and resources — that must be addressed, he says.

"Right now, we think of nursing as a commodity. We need to think of them as a strategic asset that the hospital or health system deploys."

Throughout the managed care crunch of the early 1990s, hospitals sought to cut costs by reducing nurse staffing — laying off nurses, cutting nurse salaries, and replacing RNs with less skilled assistive personnel, notes Blakeney. That’s part of the reason the situation is so critical.

"In the mid-1990s, the average wage of RNs employed in hospitals actually dropped by roughly $1 an hour," she adds. "And the staff reductions occurred at a time when patient acuity was increasing, sophisticated technology was increasing, and the length of stay of hospital patients was decreasing."

The overall impact of these changes was to drastically increase the pressure on remaining staff nurses who were required to oversee unlicensed assistants while caring for a larger and sicker patient population.

A 2001 ANA survey found that nurses across the country reported experiencing increased patient loads, more floating between departments, decreased support services, and increased demands for mandatory overtime.

"Disturbingly, more than 40% of those nurses reporting in that survey reported that patient care had suffered to a point that they would feel uncomfortable recommending anyone close to them using that hospital facility for their own care," she said.

Hospitals addicted to mandatory overtime

The continued dependence of many health care facilities on mandatory overtime is something that must be addressed, Blakeney said. Hospitals continue to rely on overtime to staff their facilities. "We know that the use of mandatory overtime is not an isolated incident. In fact, nearly 5,000 nurses across the country have revealed that two-thirds of them are required to work overtime — unplanned overtime — on a monthly, if not weekly, schedule."

Tired, overworked nurses are not only unhappy, they also have a direct impact on patient care, she added.

Even proactive hospitals that strive to provide a good working environment and opportunities for advancement for their nurses have a hard time getting away from the use of mandatory overtime, says Maureen White, RN, MBA, senior vice president and chief nursing executive for North Shore-Long Island Jewish Health System in New York City, which employs 7,000 registered nurses.

Their system is able to offer tuition reimbursement programs and on-site nursing education classes to their staff, and even provide perks such as on-site dry cleaning and on-line grocery shopping at deep discounts to personnel.

Two of the system’s hospitals, North Shore University Hospital and Long Island Jewish Medical Center, have both been named magnet hospitals by the American Nurse Credentialing Center’s Magnet Recognition Program. The program identifies health care facilities that have fostered an environment that attracts and retains nurses. But even they have not been able to totally eliminate mandatory overtime, White says.

"We have looked at the issue of mandatory overtime. Sadly, I think it is used too much," she said. "Earlier this year, in January, we initiated a policy in the health care system. The first statement in the policy states that we, the members of North Shore Long Island Jewish Health System, are adamantly opposed to mandatory overtime."

At this point, the system has been able to reduce mandatory overtime usage by 80%, with a goal of eliminating it by the end of the year, she says.

"People need to know that if they are scheduled to work an 8-to-4 shift, they can expect to go home at 4," she says. "They have things outside of work that they need to prepare for."

Help with education

Nursing programs also can do more to encourage and support people who might be talented health care providers or want to be nurses, say O’Neil and White.

In California, two-year training programs have a 44% washout rate, O’Neil says. "We could probably improve on that."

Hospitals need to encourage their nurses to continue their education, obtaining advanced degrees and certifications, says White. And they should make it easier for nonlicensed personnel to pursue nursing education if they are interested.

"To some degree, the nurses of tomorrow are in our hospitals today. Those nonlicensed personnel within our facilities who for whatever reason could not or chose not to pursue a nursing license earlier in their career," she says.

North Shore-Long Island Jewish started a pilot program to recruit employees interested in pursuing a nursing career but who felt unable to return to school. Many people lacked the financial resources earlier in life to attend college, she notes.

The system partnered with a local community college to offer classes at the hospital, and the hospital assumed payment of the tuition for a select number of applicants and provided mentors to the students to help ease the transition, she says.

They also made the commitment without asking that the employees commit to work for the system after graduation.

"The last thing we told our employees is that we would not require them to sign a service contract," she said. "Because of the size of our organization, we have an accountability and responsibility to the communities that we serve. As long as we can grow one nurse, then we are serving our community at large."

So far, 400 employees are participating in the program, which will see its first 10 graduates next year.

Recruit beyond traditional population

One factor often cited as contributing to the nursing shortage is the expansion of opportunities for women in the workplace.

Whereas women once were steered toward teaching and nursing as career options, they now have a wider variety of opportunities.

The problem, says O’Neil, is that, now, leaders in the profession have not asked themselves why nursing has not attracted nontraditional nurses.

"We need to not focus so much on why women have left the profession," he says. "One of the interesting things is why so many women have stayed in nursing. The more interesting question is why is it still 94%-95% female?"

The vast majority of these women also are still non-Hispanic Caucasians, he added. Why is the profession not attracting more men and racial and ethnic diversity?

"Another big driver that makes this more interesting than previous shortages is the shift in orientation towards work," O’Neil continues. "Workers want a more service-oriented, anti-institutional, non-hierarchical system. They value diversity, technology, and new skills."

Contrast those values with the environment at most hospitals where nurses are employed and it goes a long way in explaining the journey that institutions may have to make to attract a work force in the next generation, he said.

His biggest fear? That hospitals and health systems will scramble around to recruit new nurses, then because the system has institutional "attention deficit disorder," they will move on to the next crisis du jour without solving the key problems.

"It’s very important that we think about this transition," he said. "We’ll scramble around, we’ll do ad campaigns. We’ll do signing bonuses. We’ll put a few more dollars into the pay rate — and, it is necessary to do that. But it won’t solve the problem until we change the work environment."


  1. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 16:1,987-1,993.
  2. Joint Commission on Accreditation of Healthcare Organizations. Healthcare at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Available on-line at