The Nursing Workforce Challenge
Public Policy for a Dynamic and Complex Market
Document date: August 31, 2009
Released online: August 31, 2009
The text below is an excerpt from the complete document. Read the full report in PDF format.
Nurses are health care's backbone, spending the most time with patients and adding value within institutional teams of caregivers and in providing ambulatory primary care. Short-term shortages wax and wane as employers seek to hire at accustomed prices. More seriously, the next decade may see more older nurses retiring than new ones entering the workforce, so education needs to be augmented and improved. But no precise estimation method can show how many nurses society "should" produce. Policy should focus more on nurses' scopes of practice and aligning how they are treated and paid with the value they add to patient care.
This report reviews major policy issues related to the nursing workforce, drawing
upon prior Urban Institute work, new literature review, assessment of federal survey
data, and key informant interviews.
- Nurses constitute the backbone of health services, spending the most time with
patients and playing a key role in promoting quality and medical safety.
- Nursing has faced recurrent short-term labor market shortages as shown by vacancy
rates reported by employers. Intermittent shortages vary by state and are
normal, as the market is not static but responds to shifting supply and demand.
Unpredictable shifts in both supply and demand can also occur, as seen in the
current economic downturn.
- However, there are now long-term structural issues as well. The aging of the
population of Americans will increase demand for nursing care while retirements
will reduce the nursing workforce available to care for them. The large generational
bulge of nurses who were educated in the long expansionary period of the
late 1960s and 1970s are now nearing retirement age, and the succeeding age cohorts
of nurses are smaller.
- Nursing wages serve as a signal both to would-be nurses and to nurse employers
and thus affect both supply and demand.
- Lower wages reduce the attractiveness of nursing as a profession and so
reduce supply. At the same time, they increase demand for nurses by
lowering employers' total wage bill.
- Wages that do not accurately reflect the value of nurses' contributions
allow employers to use them at less than their full capabilities. Conversely,
higher wages draw more people into nursing and drive employers
to use the more costly input more efficiently.
- Some efforts to combat shortages, such as importation of foreign-trained
nurses, offer temporary relief but may exacerbate the problem by depressing
wages in the short run.
- The frequently cited projections of future large shortages of nurses are based
mainly on demographic trends and past patterns in supply and demand. The different
projections produce a broad range of shortage estimates and should not be
relied upon to provide policymakers with a precise number of nurses that will be
needed at any particular future time.
- Moreover, the overall projections do not address the qualifications of nurses needed to respond
to shifting demands for various levels of care. Therefore, good data need to be filtered through
informed judgment to support workforce planning.
- Projections of nursing supply relative to demand vary across states and across regions within
states, particularly between rural and urban settings. Medical personnel, including nurses, tend
to work near where they were trained, so the distribution of support for nursing education matters.
- Men and racial, ethnic, and language minorities are not well represented in the nursing workforce.
Language skills are essential for high quality care, and the availability of culturally appropriate
care has been shown to improve patient outcomes. In addition, encouraging a broader
range of people to go into nursing will expand the labor pool.
- The evidence that nurses contribute greatly to producing high quality care is strong, and nurses'
unique contributions to care teams for expanded access to primary care, coordination across modalities
of care, and continuity of care merit greater attention as health care reform discussions
- Educational institutions have shown substantial responsiveness to demand for new paths to licensure
and for mid-career advancement from one nursing status to another or into nursing from
another career. Nonetheless, educational bottlenecks and rigidities still impede smooth increases
in nursing supply in response to increased demand.
- The educational pipeline is long (5 to 10 years from application to productive entry to
the workplace), and some evidence suggests that demand for nursing degrees exceeds
available student slots.
- Schools report difficulties in maintaining sufficient faculty. Nurses today tend to obtain
their doctorates later in life than during earlier eras and thus will likely have shorter
faculty careers. It is hard for schools to staff for fluctuating demand using lifetimetenured
positions, and it can be hard to pay differential salaries in times of tight faculty
- Schools face shortages of teaching space and clinical training placements.
Current and Recommended Responses and Interventions
- The market has responded to the recent shortage as it did in previous shortages. Enrollment in
nursing programs has risen over the past several years in response to increases in wages and improvements
in working conditions. Diverse private initiatives seem helpful but are often limited
in scope. Many are also institution-specific and lack a clear way to bring them to scale.
- Public funding has historically been a mainstay of nursing education with a focus on increasing
the number of nurses trained. Going forward, it could be tailored to help address the structural
aspects of the current shortage.
- Key federal Title VIII support for nursing education has declined markedly as a share of health
spending and on a per-student basis since the 1970s era of expansion.
- Graduate medical education funding supports hospitals and would have to be retooled
to support clinical training for nurses in new roles in a redesigned system.
- Further support of educational bridge programs could facilitate access to nursing
careers for a broader population.
- Public funding of health coverage through Medicare and Medicaid accounts for over a third
of total health expenditures. Payment reforms to these two programs, such as those that focus
on outcomes rather than on procedures, could serve to recognize the contributions of
nurses. They may be easier to achieve today than before as high level policymakers, both
public and private, are focusing on reform of health financing and delivery.
- Regulatory reform to address evolving scopes of practice could allow appropriately qualified
nurses to contribute at more advanced levels of practice and ancillary personnel to assume
some tasks traditionally assigned to nurses. Scope of practice change should be coordinated
with educational policy and supported by payment reform.
- Today's health care system stands on the brink of great change. Decisions taken under public
reform—and in the private sector's push for better value—will massively influence the future
of nursing. Policies under discussion include how to expand health coverage, the scope of
benefits to be covered, what providers should participate on what basis, and how services are
priced in various delivery modes and for various levels of patient acuity. It is imperative that
nurses be constructively involved in policy discussions on the future shape of health care.
- A nursing workforce agenda going forward should expand its focus beyond professional aspirations
and advocate more strongly for policy relevance. It may be helpful for nursing advocates
to emphasize nurses' positive contributions, such as promoting safety, relative to
messages that may seem negative, such as complaints about working conditions.
- Specific advocacy goals could include the following:
- Setting clear and measurable objectives and prioritizing among them. Public and
private policymakers need realistic actionable proposals rather than restatement of
the dimensions of the problem and the need for action.
- Promoting greater investment in nurse workforce data. Information should be
available about developing shortages and surpluses by geographic area. A particular
emphasis is needed on timeliness and consistency across reporting formats.
- Documenting further the business case for nurses. A greater understanding of
nurses' contributions to improving access and promoting quality of care is critical
as the health system is redesigned. Such information can help promote payment
and other reforms that encourage institutions to enhance nursing capabilities in the
interest of better and more cost-effective patient care.
- Broadening the focus of policy emphasis. Focusing simply on the number of
nurses trained or in the educational pipeline without paying attention to how they
are paid and used once in practice does not serve the long-term interests of either
nurses or nurses' employers. Policies that better match nurses' wages to their contribution
to care will both encourage an adequate supply of nurses and promote
their efficient use.
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