Addressing the Nursing Shortage in the United States: An Interview with Dr. Peter Buerhaus

The nursing shortage in the United States has reached a crisis point. Hospitals that have been overwhelmed by patients with COVID-19 face an additional challenge because nurses have decided to no longer work in hospital care, have gone to work in temporary positions, or have left the workforce altogether. To understand this problem better, Dr. David Baker, Editor-in-Chief for The Joint Commission Journal on Quality and Patient Safety, interviewed Dr. Peter Buerhaus on January 27, 2022. Dr. Buerhaus is a professor in the College of Nursing at Montana State University and director of the Center for Interdisciplinary Health Workforce Studies. He's one of the leading authorities in the country on the nursing and physician workforces in the United States. Dr. Buerhaus is both a nurse and a health care economist, so he brings a unique perspective and experience to his work in this area.

Dr. David Baker: The COVID-19 pandemic has been devastating in so many ways, but one of the most profound negative consequences has been the strain that it's placed on nurses. How is the pandemic affecting the current nursing supply?

Dr. Peter Buerhaus: Let me just begin by noting that as of today, there have been about 72 million reported cases COVID in the United States, and 872,000 people have died from the disease. Nurses have tried to care for these patients, they've done their best to try to save them, and they have to live with the emotion of having lost a patient. At the same time, nurses have helped save tens of thousands of lives. So I'm just glad we are having this conversation.

I'd like to start with a 40,000-foot-level look at this. The nursing workforce is composed of about 3.5 million registered nurses who are working on a full-time basis and then another roughly 400,000 who are working on a part-time basis. So there's a lot of nurses in the country. About a million RNs are working in inpatient care units, and about a third of those are working in ICUs and emergency departments. We were all shocked at how rapidly that demand for care increased for nurses with the education, the skills, and clinical experience needed to take care of so many very critically ill patients.

Now if we get down closer to ground level, I think the pandemic has decreased the supply of nurses, and it's come about in several different ways. Some nurses have become ill with COVID-19 themselves, and they aren't in the workforce while they're waiting to get cleared, or they've left permanently as a result of having COVID. Others are not in the workforce because they don't want to increase their risk of exposure to the disease and give it to their families. Others aren't in the workforce due to vaccination requirement policies and their beliefs about vaccination. Some nurses are not in the workforce because they are taking care of parents or in-laws, they're raising children and providing home schooling. And some RNs have retired sooner than they had planned. For the first time in 10 years, we saw an overall drop in employment among RNs, LPNs, and nursing assistants about five or seven months into the COVID pandemic.

Dr. David Baker: So, do you think that this is going to have a lasting effect? What do you see coming in the next decade for the nursing supply?

Dr. Peter Buerhaus: Just recently, our team, using data through 2019 just before the COVID pandemic began, we estimated the RN workforce would grow by about one million, reaching 4.5 million in 2030. So this is really good news because these projections take into account the retirement of an estimated 640,000 baby boom RNs who are expected to retire by the end of the decade. We'll be able to replace those RNs and add another million. Now that's the good news. But what concerns me are, are factors that affect entry into the workforce and exit out of the workforce.

We don't know this, but the pandemic could speed up and condense the time for RNs who were planning to retire over the decade and maybe move that up closer. So we could have an accelerated rate of retirement in the next couple of years. We could also see the pandemic leading to younger and middle-aged RNs withdrawing from the labor market for the reasons that I just described.

And depending on the magnitude and timing of these sort of reactions, the exit from the workforce in coming years could disrupt labor markets and have real consequences for employment. They could aggravate shortages or even create new shortages—that's the exit side. The entrance into the labor market is also something I'm concerned about. If the pandemic decreases people's interest in becoming a nurse, this would lead to decreased enrollment in the nursing education programs, and decreased graduations, and ultimately less entry into the nursing workforce.

Decreased entry would have a significant impact on the future, and more so than the retirements. Now if both of these occur, both the exit from retirements and withdrawal of existing nurses and decreasing entrants due to loss of interest in becoming a nurse, then we're setting up the potential for very large and persistent shortages. We would be in big trouble. We would see hospital operations and health care systems being deeply affected, and this would harm patients and harm those nurses who remain in the workforce.

Dr. David Baker: So how can we put the nursing supply on a more stable footing going forward? You've talked about these different factors increasing the supply as well as the exodus of nurses. How do we address those two factors?

Dr. Peter Buerhaus: In the first place, I would suggest that we start to get control of the messaging of nurses and of hospitals. And by that, I mean that I believe that way too much of the current imagery, the tweeting media coverage, the social messaging about nurses and about hospitals is, frankly, just dreadful. It emphasizes unprecedented shortages, their negative effects, and that hospitals are to blame. And I think if we don't counterbalance these negative messages with positive portrayals of nurses, we risk decreasing entry into nursing education programs and not growing the nursing workforce over the decade.

I want to take us back to the 1990s, because there's history that has relevance here. Back in the 1990s, nurses protested vigorously and persistently throughout the country over how hospitals were coping with the growth of HMOs and managed care. The media reported on this extensively, and the imagery that the public saw was very negative. And not surprisingly, interest in nursing as a career dropped over the next six years, and the number of RNs graduating from nursing education programs decreased substantially.

In 1995, we graduated 97,000 RNs each year. But by 2000, we were graduating 30,000 fewer RNs. So this effect of decreasing interest showed up quickly and by the late '90s and early 2000s, we were having a large national shortage of registered nurses. The American Hospital Association reported about 125,000 vacant positions for nurses in 2001. Now that was the last large national shortage of RNs in this country. Now, we need to learn from that experience and start controlling the message about nurses and hospitals. We need to rebalance and put forth more positive portrayals of nurses, or else we could risk repeating the 1990s drop in interest in nursing and in enrollment and graduations.

And I think this is a shared responsibility. Nurses have to take ownership on this, our leadership has to, professional associations, educators, certainly the media, social media, and unions. We need to grow the workforce, so we've got to rebalance current messages.

The second area is to come to a deeper awareness of the implications of the withdrawal from the workforce of our retiring baby boom generation. We've retired about half of the 1.2 million RNs born in the baby boom generation, and over this next decade were going to see the remainder of that generation leave the workforce. And when they do leave, these nurses take with them decades’ worth of knowledge, experience, leadership, and mentorship of younger nurses.

I think our hospitals and other institutions really need to ascertain how many RNs are expected to retire and identify the nursing units, the departments, the patient populations that could be most affected by this retirement. Share that information with hospital leaders, with physicians and other clinicians who could be affected, and seek their involvement in helping to mitigate some of the potential harmful consequences with this.

I think there will be some baby boomers who we want to remain in the workforce longer. Is there something that can be done to engage them, to keep them in so that they would delay their retirement? I think we also want to focus in on bringing the older, soon-to-be-retiring nurses together with younger nurses to impart the knowledge and skills, particularly for taking care of patients with COVID or working in specialty units.

Dr. David Baker: Thanks Peter. You talked about the importance of messaging and controlling the messaging. Is that possible? Last week the New York Times published a video editorial by Lucy Ken and Jonah Kessel about the nursing shortage in hospitals that had nurses talking about these really horrible experiences that they had. It claimed that the most important root cause is chronic under-staffing leading to nurse burnout. So how do we control the messaging in this environment where social media is going to fan the flames of these concerns?

Dr. Peter Buerhaus: I think that there could be discussion among the major health care associations, provider associations, delivery of care associations, payer associations, educators, nurses themselves, about how resources could be pulled together to finance a campaign that brings forward positive images of nurses.

Dr. David Baker: So if part of the solution is increasing salaries for nurses, who should pay? How should those payments flow? I think it will be very difficult for hospitals to increase the salary for nurses without increased pay from payers. How should that be dealt with yet?

Dr. Peter Buerhaus: It strikes me that this is in society's interest that government and payers step up. And I don't think hospitals have the resources or all the resources needed to economically recognize nurses, so I do believe there is a role for government to provide resources specifically earmarked for nurses.

I'm reminded that when the government passed Medicare in 1965, Medicare paid hospitals extra to cover the cost of hiring more nurses needed to care for the influx of older patients. So I think there is a precedent for a step-up by the federal and state governments.

Dr. David Baker: Peter, you've been studying the nursing workforce for a long time. How does the current situation compare to these past crises that you've seen? Is this crisis unique? Are there basic forces that led to the shortages in the past that are being repeated now? Or is this something really fundamentally different today?

Dr. Peter Buerhaus: I think the first thing I would say is, in the years leading up to the pandemic from, say, 2010 to 2020, we were seeing about 70,000 baby boom RNs retiring each year from the workforce. Well, some of these baby boom RNs worked in ICUs, in emergency departments, in critical care units, and in other units that were later transformed to care for COVID patients. Now in some hospitals, this retirement was already causing shortages of nurses in the very units that would then suddenly become under siege by the rapid admission and very ill COVID patients.

Second, I think a unique aspect of the current situation concerns the rapid growth in the number of RNs becoming nurse practitioners, and this has really accelerated over the past 10 years. We've done some research on this and it turns out that the numbers of nurses who have left the workforce to become nurse practitioners led to a withdrawal of about 80,000 fewer RNs between 2010 and 2017. I expect that during 2018 and '19 there were continued losses from the nursing workforce as RNs continued to become NPs

Dr. David Baker: Peter, while we're working on long-term solutions, health care organizations and the staff that work in them have to get through today, and tomorrow, and the months to come. What's your advice on how leaders can help get through the challenges that they face today?

Dr. Peter Buerhaus: I think that in the short run as we are hopefully seeing the current variant, Omicron, spiking and hopefully receding over the next several months. We just have to get through it. We've just got to come to work each day, and we need to help one another, support each other, understand each other, and be kind to ourselves and to others. We're all in it together, and we just have to persevere. But I also think that it would be helpful to anticipate that there will be a time when COVID becomes more in our rearview mirror, we can get back on our feet, we can take some deep breaths.

And at that time, I would hope that hospitals and other care delivery organizations and nurses could come together in a very meaningful way and reflect on what's happened over the past couple of years, discuss what things really worked well, what was the process that led to good decisions, what didn't work, what have we learned about ourselves clinically and personally and organizationally, what are our strengths and weaknesses, an honest assessment. I believe that nurses and hospital leaders all want to get back to some sort of normal. But I don't think we want to go back to a normal that also included things that weren't working. We want to go forward forging a new normal.

I think we really need to reset that relationship, and do it in a way that's mutually beneficial and aimed at a better future for both nurses and hospitals, and of course that benefits the patients that we together serve. If we're going to purposely take the time to reset this relationship, it can be helpful, if organizations could survey their nursing staff and others and ask both questions that were negative and positive, get the full understanding, assess what nurses know, what their knowledge is—there may be some inaccuracies or misperception. What are their attitudes? Take the temperature on both nurses’ and leadership's willingness to change, their willingness to engage, and in listening to each other, and in building a new path forward, to jointly grasp the fuller situation and learn from it.

Dr. David Baker: Great. Well, thank you so much for taking the time to talk with me today. It's really been a pleasure. I really value the comments that you've given us today.

Dr. Peter Buerhaus: Well, thank you, David. I am so thrilled and glad that you took the time, and hopefully there'll be some benefit for nurses and hospitals as a consequence.

This interview transcript has been edited for length. The video interview is available at https://player.vimeo.com/progressive_redirect/playback/678918045/rendition/1080p?loc=external&signature=b5091feabb76a9d59d7c536fbb4b9ab064299f2165d8032aaff22b89fba3e536.