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Dealing with reality: Confronting the global nursing shortage

Nursing shortage update: A conversation with Peter Buerhaus

Peter I. Buerhaus

In 2000, Peter I. Buerhaus, RN, PhD, FAAN, together with economists David Auerbach and Douglas Staiger, published in the Journal of the American Medical Association the results of their seminal research about a looming nursing shortage, then in its infancy. A follow-up article on the shortage by Buerhaus was published in Reflections on Nursing Leadership (RNL) in early 2001. Now, seven years later, in a conversation with editor James Mattson, Buerhaus brings RNL readers up to date on the current and future state of the shortage.

Mattson: Seven years ago, in an article published in the First Qtr. 2001 issue of Reflections on Nursing Leadership, you reported that between 1983 and 1998, the number of RNs age 30 and under had decreased by 41 percent, while the total number of people in the U.S. workforce under age 30 had declined only 1 percent. That was a striking statistic, with obvious negative implications for the future of health care in the United States. Has there been any change in the trend?

Buerhaus: I’m going to throw you a curveball. The data I’ve been looking at more recently tracks RNs ages 21 to 34, rather than 30 and below. Twenty-five years ago, about 500,000 RNs in the workforce were between the ages of 21 and 34. They were by far the largest group, four to one compared to RNs over age 50. In the past 25 years, there has been a steady decline in the number of RNs in the 21 to 34 age group, except for a couple of years when that number increased. Today, there are fewer than 400,000 in that age group.

In the same period that RNs age 21 to 34 have decreased in number by more than 100,000, RNs in the middle age group, age 35 to 49, have risen from about 250,000 to 600,000. Also, RNs age 50 and older who, 25 years ago, numbered 100,000, today number just a shade below 400,000. So we’ve really seen a change in the professional nursing workforce with steady growth in older-age RNs and reduction in the number of younger RNs. We expect that trend to continue indefinitely.

So the average age of nurses in the United States continues to climb?

Right. Today the average age of RNs in the workforce is about 43.5. In the federal government’s national sample survey data, the average age of RNs is reported to be around 47, but that includes approximately 350,000 to 400,000 RNs who are retired but still registered to practice nursing, though are not in the workforce.

In 2000, you and your colleagues, David Auerbach and Douglas Staiger, reported that by the year 2020, the number of RNs would fall 20 percent below requirements. How do we stand on that score today? Do the numbers still indicate that we are going to end up short? What is your projection?

In 2000, when we initially published our work in the Journal of the American Medical Association (JAMA), we were using the forecast of demand published by the government at that time, and we projected a shortage by the year 2020 of approximately 400,000 RNs. In 2002, the government’s Health Resources and Services Administration updated its forecast of supply and demand. When we compared the supply forecast we had published in JAMA to the government’s new demand forecast, the shortage doubled to about 760,000, according to our estimates.

The government’s estimate was for a shortage of around 800,000, so this became quite alarming, unprecedented. That would be like a Category 5 hurricane on steroids. We have not seen anything like that. In our most recent work, published in the January 2007 issue of the health policy journal Health Affairs, we revised our model to reflect the trend we were observing of people coming into the profession at a later age, specifically the 20-somethings and those in their early 30s. Our previous model wasn’t sensitive to that and didn’t capture that data very well. We also provided updated workforce data and population projections. When we ran our model using data through 2005, there were significant changes.

One of those changes was that the average age of the workforce is no longer going to increase as dramatically as projected. RNs are still getting older, but we have knocked about one year off their average age over time. Second, we projected that the size of the workforce was growing—not fast but slowly—and that this growth would occur for a few years further out in the future than earlier projected. The source of this growth was the 20-somethings and a large number of people in their early 30s. We believe these individuals are largely in accelerated nursing programs—that many have completed other postsecondary education goals, but are now coming into nursing. They are probably choosing nursing for three reasons:

First, 9/11 may have caused a good number of people to think about what they are doing with their life, with their career. Some may even have concluded that they should pursue something that has more social meaning, or perhaps they had always wanted to be a nurse and 9/11 motivated them to pursue that goal.

Second, shortly after 9/11, the Johnson & Johnson “Dare to Care” campaign was launched, which coincided with the initiative that Sigma Theta Tau International had been developing. For the sake of open disclosure, I need to mention that some of my research is funded by Johnson & Johnson. Nevertheless, it was a national campaign that created substantial visibility in national prime-time media, with lots of publicity about nursing that was positive and undoubtedly helped induce others to enter the field of nursing.

The third reason people began entering nursing occurred in 2002 and 2003, when hospitals raised earnings of nurses quite significantly. RNs’ pay had not increased for roughly seven to eight years during the 1990s and the early part of the 2000s. I think hospitals finally recognized that the shortage wasn’t going away, so they raised wages substantially, which caught a lot of people by surprise. Some people decided that, with earnings going up, it was a good time to enter nursing so, given these three developments, we’ve had a big wave of people wanting to enter nursing in recent years.

Our models are reflecting these changes, and they are very positive. That Category 5 “hurricane” has been knocked down to something like a Category 3, and we’ve gone from a shortage of about 800,000 to one we are estimating to be roughly 340,000, which, importantly, is based on comparing our projections to the government’s published demand forecasts through 2020. That’s still a very, very large shortage and more than large enough to significantly damage the health care delivery system, but it’s a smaller number and we have a better chance of getting this down to something like a Category 2 if we stay the course and keep working to increase the future supply of RNs.

So the current estimated shortfall is around 340,000 by 2020. Your original forecast was that by 2020, we would fall about 20 percent short. What is your current estimate, percentage-wise?

Our research team—Doug Staiger, who’s an economist at Dartmouth University, and David Auerbach, an economist in the Congressional Budget Office, and me—is in the process of developing a book on the future of the nursing workforce that will include a top-to-bottom, complete analysis of the workforce, the labor market, the quality of care, etc., and we will be publishing some new projections. There is some good news and some worrisome news, which I’m not yet able to reveal. That information should be coming out in May 2008.

I’ve read numerous reports about boomers choosing to retire later in life than earlier generations. Is that also true of registered nurses?

That’s a great question, and I don’t know the answer to it with precision. None of the evidence we’ve looked at recently would substantiate that, although I’m not precluding it. What we do see is that when nurses approach age 53 to 54, we begin to see a clear indication in employment data that reveals RNs begin to participate less in the workforce. From that point on, there is a steady downhill decline in RNs’ participation in the labor market. In the Health Affairs article, we project that in 2020, there will be approximately 300,000 RNs over the age of 60 still working. It’s vital that we keep older nurses in the workforce for longer periods of time by finding ways to induce them to stay.

I assume one reason nurses retire earlier than those in some professions is that nursing is physically demanding.

Absolutely! And that’s a major concern with the nursing shortage. The people who retire are very experienced. They’ve been around. They have terrific clinical and communication abilities. They are the kind of nurse who can walk into a patient’s room and sometimes by just looking at the patient’s family—at the eyes of family members—know that there is something wrong with the patient. They recognize early complications and often prevent them from developing, worsening or even causing death.

This is a huge issue. Several years ago, Jack Needleman and I and our quality research team published a study in The New England Journal of Medicine. We analyzed about 6 million patient discharges in 11 states and found that, of hospital patients who experienced one of five complications, 20 percent died. The complications analyzed are all sensitive to nurse staffing. So the good news is that, for the foreseeable future, we’re going to have very experienced RNs who can pick up on the signs of complications and intervene as appropriate, or get help. But the bad news is that these older RNs are going to be trapped in their bodies—older, slower and falling apart. So hospitals need to overcome ergonomic deficiencies that keep these great nurses from practicing for as many years as they can. Fortunately, hospitals are making significant improvements to improve the ergonomic environment.

Over the last three years, particularly, this issue has come alive and now you see ergonomics really being taken seriously by many hospitals—in physical design, equipment, in getting the need to emphasize the quality of the ergonomic environment higher on the CEOs’ and CNOs’ agendas. So we’re making great progress.

Lack of educational resources—both faculty members and facilities—is contributing to the nursing shortage, creating a bottleneck. Are we making progress on that front?

You have put your finger on the toughest part of the whole issue—the collapse, if you will, of the nurse education market. Demand for nursing education, as you know, has been increasing as a result of some of the forces we’ve been talking about. The problem has been the ability of the education market to respond to that demand.

There is a shortage of faculty members, classroom space and clinical arrangements, not necessarily in every program, but those are the three big areas that survey results suggest are the reasons for schools not being able to meet the demand. There are reports of many thousands of students being turned away in each of the past four years, many who eventually may have gotten tired of waiting and moved into other careers. These are the very people we need to replace the aging, baby-boomer generation of nurses, and we’re not doing it.

The private sector is helping. Hospitals are trying to work in unique ways with schools of nursing. Some state governments have been active in passing legislation, developing resources to help schools. The federal government, i.e., Congress, has done nothing other than talk about this issue for more than five years. They simply have not delivered on any legislation with meaningful dollars that could help this issue. If we wait for private sector forces to develop, we will be waiting many, many years. We need government infusion of specifically targeted resources to help resolve this issue, or we’re going to have this same conversation in another five years.

The lead-time to develop those educational resources has to be significant.

Oh, this should have begun five years ago, and we’re missing it! We are burning time that we don’t have, and it’s eventually going to cost us a heck of a lot more in dollars, and in needless suffering for our profession and totally avoidable pain and suffering experienced by the patients that we’re going to be asked to take care of downstream, when we are looking at a major nursing shortage. It’s a cruel situation we are stuck in that doesn’t have to be this way. We really need to get this education market resolved quickly, or we are all going to be in a world of hurt.

We’ve made some progress on the shortage. The forecast is not as pessimistic as it was. As you look forward, what is your biggest concern?

My biggest concern is that, as a nation, we are still facing a predictable increase in demand as the baby-boom generation ages. We know boomers are going to have a lot more money to spend on health care—private money, in addition to their benefits through Medicare—and they are going to spend it on health care. They are going to demand more health care than generations before them. At the same time, RNs who were born in the baby-boom generation will be retiring out of the workforce. Because of the education problem, there won’t be enough nurses to replace those who are retiring. Unless we increase the supply of RNs over the longer term, hospitals and other health care delivery organizations will have little choice but to go to the global market and try to get as many foreign-educated nurses as possible into the United States, and they will increasingly be motivated to develop some sort of substitute for nurses, and who knows what that could be.

In your 2007 article in the journal Health Affairs, you and your colleagues note that one result of the more optimistic, updated forecast is decreased pressure on other countries facing their own nursing shortages. Do you foresee less dependence in the United States on nurse migration?

We’re into a new world now. A global nurse labor market is developing and will develop and evolve over the next decade. We have a global shortage today. The price of getting foreign-educated nurses will be higher than employers are used to paying. There will be more competition for these nurses in the future as the shortage in the United States grows, so I really fear that employers and others will gather the support needed to create some sort of substitute for nurses, and I worry about the quality and safety of patient care that could be an outcome.

We really need to quickly grow the supply of RNs now, while we have such interest in nursing, while we have such a great talent pool of really smart people wanting to become nurses, as well as experienced, more sophisticated people coming into the profession. This is a great opportunity we are wasting, and “we” is broader than the profession. It is “we” as a society. We’re not going to get this opportunity very often in our future to get ahold of such a great supply of prospective RNs.

We are facing, I think, a very significant point where it is you and me who are going to bear personal cost, where we’re waiting and waiting and waiting for surgery or some sort of treatment, but we can’t get it because there aren’t enough nurses. Our own safety will be at risk, and that of our families, our loved ones. That’s where we’re heading. There are improvements that show we can make important changes. We’ve got to sustain those changes and realize we can actually get ahead of this looming disaster. RNL

Peter I. Buerhaus, RN, PhD, FAAN, past director at large on the board of the Honor Society of Nursing, Sigma Theta Tau International, is Valere Potter Distinguished Professor of Nursing at Vanderbilt University School of Nursing in Nashville, Tennesee, USA, and director of the Center for Interdisciplinary Health Workforce Studies, based in the Institute for Medicine and Public Health at Vanderbilt University Medical Center. In the latter role, he conducts research and develops initiatives aimed at facilitating interdisciplinary research, practice, education and policy among physicians, nurses, researchers and others.