Policy Strategies for Addressing Current Threats to the U.S. Nurse Workforce

The Covid-19 pandemic has exposed a dangerous weakness in the U.S. health care system: without enough registered nurses, physicians, respiratory therapists, pharmacists, and other clinicians, the system cannot function. This weakness is particularly concerning when it comes to the registered nurse workforce, which could well see a mass exodus as the Covid-19 pandemic eases in the United States and the economy recovers. Over the past two years, multiple surveys suggest that a substantial proportion of nurses have considered leaving the profession, far higher than prior reports. Unsafe work environments — which predated the pandemic — are a key contributor to intentions to leave. Clinicians, health system executives, and policymakers have issued calls to address this crisis, but there has been little in the way of tangible federal or state policy action to prevent workforce losses or build capacity.

Although it may comfort hospital executives to imagine a post-Covid future in which nurses are again willing to accept positions at local pay scales, such a scenario is unlikely to occur anytime soon. Historically, nurses have reduced their working hours or left the workforce during economic growth periods and returned during recessions, when family incomes fall.¹ Nurses may again choose reduced employment as Covid-19 pressures ease and economic conditions improve. Moreover, nurses reported pervasive unsafe working conditions before the pandemic and have cited a range of stressors and traumatic experiences during it, including furloughs, a lack of adequate protective equipment, increased violence, excessive workloads, and reduced support services. Nursing workforce pressures may therefore only worsen as Covid-19 subsides.

State and federal policy solutions could prevent workforce losses and increase the supply of nurses (see table). Although there are nursing-workforce challenges and opportunities throughout health care settings, hospitals are a particularly important area of focus.

Federal and State Policy Approaches to Supporting Nurse Staffing in the United States.^*

Preventing Losses
Federal Approaches	State Approaches
CMS rules to establish hospital safe-staffing ratios	Implementation of mandatory maximum patient-to-nurse ratios
Financial penalties for exceeding safe workloads	Prohibition of mandatory overtime
Funding for AHRQ to test health care delivery-system innovations	Loan-repayment programs
Funding for NIOSH to test interventions that improve health care worker safety	Incentives for hospitals to provide child care, on-site graduate school, and other programs to retain experienced nurses
Rulemaking to reduce or eliminate onerous regulatory standards and expectations from accrediting bodies	Innovation grants for hospitals to develop programs establishing safer, more supportive work environments
Increasing Supply
Federal Approaches	State Approaches
Appropriation of funds for the National Healthcare Workforce Commission	Legislation to eliminate restrictive scope-of-practice regulations and increase access to care
Investment in nursing education and nurse educators by means of loan-forgiveness programs, a nurse faculty corps program, or expansion of the CMS Graduate Nurse Education Demonstration project	Investment in schools to increase the supply of nurses and nurse educators (e.g., by implementing targeted scholarships or tuition support for nursing students or nurse educators)

^*CMS denotes the Centers for Medicare and Medicaid Services; AHRQ the Agency for Healthcare Research and Quality, and NIOSH the National Institute for Occupational Safety and Health.

Preventing the loss of current nurses is an essential component of shoring up the hospital nursing workforce. We contend that there isn’t a shortage of nurses, but a shortage of hospitals that provide nurses with safe work environments and adequate pay and benefits. At the federal level, the Centers for Medicare and Medicaid Services (CMS) could publish regulations, similar to recently announced policies governing skilled nursing facilities, that specify standards, including maximum patient-to-nurse ratios, to ensure safe nursing care and could establish financial penalties for hospitals that violate these regulations. Data supporting such ratios have been available for decades.²

Another federal strategy centers on investing in reimagined, safer health care systems. Congress could appropriate funds to the Agency for Healthcare Research and Quality to support investigator-initiated grants focused on developing new, scalable care-delivery models that are designed to improve outcomes for patients and clinicians. The National Institute for Occupational Safety and Health could expand testing of protective equipment and strategies for improving health care workers’ well-being. Data are needed on care-delivery models that keep patients safe and on strategies for promoting joy and safety in clinical work.

Regulatory bodies, including CMS and CMS-approved accreditors, such as the Joint Commission, could scale back regulations and standards that add to nursing workloads. Although some regulations were temporarily eased during the pandemic, new rulemaking could eliminate especially burdensome provisions that are not essential to patient safety. For example, clinical documentation burden is a frequently cited source of job dissatisfaction and burnout. Documentation requirements, which are interpreted in various ways by different hospitals, could be minimized to reduce burnout and attrition.

States have more flexibility than the federal government when it comes to enacting legislative and regulatory changes to improve work environments and prevent nursing workforce losses. In the absence of federal action in this area, state legislation promoting safer nurse-staffing practices — such as laws establishing mandatory patient-to-nurse ratios — is an evidence-based intervention to support patient safety and reduce the likelihood of nurse departures. Studies have reported improved nurse staffing, improved job satisfaction among nurses, and improved patient outcomes after California enacted legislation prohibiting mandatory overtime for nurses and establishing maximum patient-to-nurse ratios.³ Many U.S. hospitals continue to require nurses to work overtime hours, however, and few have mandated staffing ratios. Legislatures in some states have introduced bipartisan bills similar to California’s law that would restrict mandated overtime and implement maximum staffing ratios. When considered at a national scale, mandated staffing ratios face implementation hurdles, since coordination would be required to distribute the nursing workforce equitably throughout the country. But such policies would likely prevent workforce losses and boost the number of entrants into the profession.

Policies could also support career development among nurses. Studies have documented the negative effects of Covid-19 on the careers of women in particular. Approximately 90% of U.S. nurses are women, and many of them have faced family-care pressures during the pandemic, amid school and child-care facility closures. To ease nurses’ household burdens, states could offer loan-repayment programs and offset nursing-school tuition debt. They could also provide grants or tax benefits to hospitals offering on-site child care, after-school care, or comprehensive dependent-care programs. Finally, states could offer innovation grants to hospitals to develop safer, more supportive workplaces or fund new initiatives to support on-site graduate-school and professional-development programs designed to retain experienced nurses.

Preventing loss is important, but another way to address threats to the workforce involves increasing the supply of nurses. The United States lacks access to real-time workforce data and expert guidance for evaluating those data and advising policymakers on workforce shortages. The National Healthcare Workforce Commission was authorized as part of the Affordable Care Act, but Congress never funded it. Appropriating funds for this commission would strengthen the country’s ability to respond to the current nurse staffing threat and prepare for future ones.

A key factor constraining the supply of nurses derives from structural barriers within nursing education. Being hired as a nursing school faculty member requires having an advanced degree, but expert nurses rarely accept faculty positions because salaries are higher for practice roles. Faculty shortages, among other factors, limit nursing school enrollments; over the past decade, schools turned away between 47,000 and 67,000 qualified applicants annually.⁴ Federal policies could loosen the nursing bottleneck. For example, policymakers could increase financial incentives to recruit nurse educators, expand nursing school loan-forgiveness programs, fund grants for hospitals and nursing schools to share expert nurses as clinician-educators, and develop a nurse faculty corps program to raise salaries in regions with nurse shortages. Creative financial incentives, such as tuition-remission programs or programs that provide low-interest-rate loans, could encourage prospective students to choose nursing careers. Pipeline programs and partnerships among high schools, technical schools, and universities could permit emergency medical technicians, certified nursing assistants, and armed forces corpsmen or medics to apply clinical work hours toward nursing degrees and qualify for targeted scholarships supported by state or federal funds. Expansion of the CMS Graduate Nurse Education Demonstration project could substantially increase the number of qualified nurse practitioners, who could also serve as clinical nursing faculty.

State legislation that eliminates onerous scope-of-practice regulations for advanced practice providers would enable nurse practitioners, including midwives, to practice independently and could increase access to health care. In Michigan, S.B. 680 would implement these reforms, thereby allowing nurse practitioners to prescribe tests, medications, and services. This bill could increase the state’s supply of clinicians and potentially attract nurses planning to pursue advanced degrees.

Threats to the nursing workforce aren’t new, and neither are proposals to address them.⁵ Although policies aimed at individual components of this problem could be helpful, a comprehensive package of federal, state, and local efforts would likely be the most effective approach for averting health care system dysfunction and adverse outcomes. We believe federal and state policies should both prevent the loss of current nurses and increase the supply of nurses. Without timely investments in the nursing workforce, the United States may have enough hospital beds for seriously ill patients, but not enough nurses to deliver the essential, safe care that patients deserve.