During the recession that began in December 2007, many retirement aged nurses were forced to unretire or to delay retirement due to lost savings or lose of family income due to a spouse being laid off. Because healthcare demands continued to rise during the eighteen-month recession, many hospitals prioritized hiring these experienced nurses, resulting in a nursing workforce of almost 900,000 nurses over the age of 50 (Keyes). As the economy began to recover, many healthcare leaders feared that this may lead to many of these nurses retiring for good, leaving a leadership and experience void in the workforce that we are not ready to easily replace. This fear is even greater among the rural and low-income population, especially here in Memphis. Many of the hospitals here in Memphis are already struggling to fill nursing positions, and a mass retirement of nurses could exacerbate this problem even more. This paper will examine the potential nursing shortage and determine its effect on Memphis, where a significant portion of the city is designated a Medically Underserved Area/Population (HRSA Data Warehouse).
Nursing Workforce & Forecast
One important fact to take note of when discuss shortages of nurses is that the nursing workforce tends to ebb and flow. For example, the U.S. had a nursing shortage in the early 2000s (Goodin). After a 2004 report from the HRSA, in which they recommend increasing the number of new nurse graduates from about 68,000 to 130,000, many institutions began increasing their enrollment and capacity for their nursing programs (National Center for Health Workforce Analysis). This contributed to the number of new graduates more than doubling from 2002 to 2010 (Auerbach, Staiger and Muench). In their most recent report in 2017, the HRSA are now forecasting a surplus of about 293,800 registered nurses (RNs) by 2030 (National Center for Health Workforce Analysis). However, the HRSA is not the only organization or researchers that project the nursing workforce. Joanne Spetz, a professor at the Phillip R. Lee Institute for Health Policy Studies and Associate Director for Research in the University of California-San Francisco’s Center for Health Professions, analyzed three separate forecast models that projected ranges from a shortage of almost one million RNs by 2030, to a surplus of 340,000 RNs, each of which were reviewed and released by reputable institutions (Spetz). This has caused confusion among nursing leaders, employers, policy makers, and nursing/pre-nursing students who may worry about future job opportunities upon graduating (Spetz). These reports, among other factors, are affecting the current workforce and education pipeline in a way that could potentially have significant effect in the future.
During the eighteen-month recession that officially began in December 2007, the healthcare industry added 428,000 jobs while the rest of the economy lost 7.5 million jobs (Staiger, Auerbach and Buerhaus). While the industry proved to be recession-proof, the recession did have some negative consequences on the nursing field. Many older nurses either delayed retirement or unretired to rebuild lost savings or to supplement lost income of a spouse (Keyes). Combine this with the fact that many employers are looking for RNs with a bachelor’s degree and at least two years of experience (especially if you have at least one year of critical care experience) and you are left with many newly graduating nurses without much prospect to get the experience these employers seek (Keyes). This has resulted in an experience gap which will be felt once the older nurses do start to finally leave the workforce.
Another factor that must be consider regarding the workforce is the lack of nursing professors to not only train the next generations of nurses, but to also train new nursing professors. Many prefer to work in a clinical setting as opposed to working as an educator because of the salary gap. The average salary of a nurse practitioner is approximately $20,000 higher than a master’s prepared Assistant Professor (Rosseter). However, there is also a salary gap between nursing professors and other professors. Nachole Johnson, a Family Nurse Practitioner, noted that professors in the nursing field on average makes about 45% less than their counterparts in non-nursing fields (Johnson). In additional, many qualified nurses who wish to obtain an advanced degree are rejected simply because there are not enough faculty members or clinical sites to educate them (Rosseter).
Whenever a location, whether it’s a hospital or clinic, city, state, or nation, are suffering from a shortage of nurses, patient care declines and adverse patient outcomes increases. While most location do not have a set-in-stone nurse-patient ratio, many studies have proven the detrimental effect of a higher nurse-patient ratio (Martin). Medical mistakes are more likely to happen, patients feel more neglected and less hopeful, and nurses are more likely to suffer from burnout. Nurses who work in critical care units are especially likely to suffer from burnout during a shortage of nurses.
What is being Done?
Efforts are currently underway to lessen or eliminate the effects of a nursing shorts across the U.S. Many hospitals around the country have adopted the Nurse Residency Program for new graduate nurses. These programs have been adopted to fill the gap between nursing school and nursing practice (Hendren). These programs usually consist of classroom coursework, a preceptor and/or a mentor, and monthly sessions with their peers to help process what they are learning (Wood). Some programs also offer residents the opportunity to select specialties that they may be interested in for a more focused training experience. Michael R. Bleich, who was previously recognized a Dr. Carol A. Lindeman Distinguished Professor for the School of Nursing at Oregon Health & Science University in Portland, OR, noted that this programs typically last six months to a year (Bleich). Some hospitals use the residency period to decide who they will retain at the end of the residency, while other will hire new nurse into the program to train under a mentor before staffing them in different units after residency (Bleich). The largest residency program in the nation is run by the American Association of Colleges of Nursing (AACN), which is also the parent company of the Commission on Collegiate Nursing Education, the nation leading accreditation agency for nursing schools (AACN). Forty states have hospitals participating in the AACN residency program, with three of them (Hawaii, Maryland, and Pennsylvania) adopting it as a statewide model.
In addition to helping to developing new graduate nurses, hospitals with nurse residency programs have also reported other benefits. Hospitals with AACN residency programs report a new graduate nurse turnover rate of five percent within their first year, below the nation rate of thirty percent (Wood). Because of this, they are able to save thousands, as much as $400,000 depending on the size of the hospital, by reducing the number of new nurses they need to hire year to year (Hendren). For new nurse graduate, who typically have limited experience in the healthcare field, by rotating through different units, they are able to see the cohesiveness of each unit and how each piece complement each other to make the hospital whole (Quinn-Szcesuil).
Effects on Memphis
Anyone who has worked in a hospital field or have made frequent trips to the ER will know that from about 1:00pm to about 2:00am is typically when the ER is at its busiest. Although a typical ER shift is either from 7am-7pm and 7pm-7am, hospital will also staff swing shifts position from 11am-11pm and 3pm-3am. Not surprisingly, the swing shifts are usually the hardest to keep staff consistently. If anyone has ever visited the ER during its peak hours, they’ve likely been frustrated with how long it takes for them to be placed in a room. Even then, a longer wait before a nurse or a doctor becomes available is likely. Now imagine if the nurses who unretired or delayed their retirement decide to retire in short succession. Imagine that many nursing professors also decide to retire. We could be facing a scenario where almost forty-percent of the workforce has retired, and there are fewer recent nursing graduates to replace them due to an even worse shortage of professors to train them.
Like many hospitals across the nation, Memphis area hospitals are feeling the growing demand for nurses and have respond with various recruitment and retention strategies (Memphis Medical News). Earlier in 2017, Saint Francis Hospital began offering $10,000 signing bonuses for hard to fill position like surgical and Emergency Room (ER) nurses, while Methodist Le Bonheur Healthcare offer a referral bonus for surgical nurses (Memphis Medical News). In addition, every hospital in the Memphis area offer some form of tuition reimbursement or loan repayment program to incentivize nurses to continue their education while offering a residency-type program for new nurses to learn and gain experience (Memphis Medical News). Despite this, demands locally are still outpacing supply (Memphis Medical News). While nursing student enrollment has increased in Tennessee, lack of faculty has forced nursing programs to reject qualified students to meet teacher-student ratios (Memphis Medical News).
Institutions of higher learning in West Tennessee have also taken steps to increase the graduation rate of nurses. Many universities offer an accelerated Bachelor of Science in Nursing (BSN) program for applicants who already have a four-year degree. They also offer an online RN-BSN degree for RNs who have an Associate Nursing degree. In 2016, West Tennessee Healthcare funded a $2.5 million endowment to provide scholarships to students enrolled in the Loewenberg College of Nursing at the University of Memphis-Lambuth campus (West Tennessee Medical News). Recently, the University of Tennessee Health Science Center (UTHSC) College of Nursing recently announced that it had formed a partnership with LeMoyne-Owen College and Rhode College (UTHSC already had the same agreement with Southwest Tennessee Community College and Dyersburg State Community College) (Perry). Students who complete a baccalaureate degree with a GPA of 3.0, with a 2.6 science prerequisites GPA, will receive guaranteed full admissions into UTHSC’s accelerated BSN program (Perry). In addition, students who meet other requirements can bridge into either a Doctor of Nursing program or a Nursing Ph.D. program (Perry).
With the numerous factors that affect forecast models for the nursing field, it is difficult to know exactly what the workforce will look like in a few years. If the worst-case scenario happens and a significant portion of the workforce retires before there are new nurses ready to step in, the U.S. could experience a significant decline in the quality of patient care and an increase in negative patient outcomes. This could lead to nurses experiencing burnout at a much higher rate, causing many of them to leave the field temporarily or even permanently. With many professors also retiring and not many qualified educators able to replace them, colleges and universities could be forced to reject a high number of qualified applicants, which could lead to a decline in the graduation rate of new nurses. By 2025 or 2030, we may be facing a situation where nurses are leaving the field quicker than we can replace them. Some location will be likely be hurting more than others.
In the above scenario, I believe Memphis will likely be one of the cities most affected by the nursing shortage. Hospitals, to attract and maintain nurses, will likely began trying to poach nurses from other hospitals with bigger salaries, more benefits, and bigger bonuses. This may lead to bigger, more prestigious hospitals (like Johns Hopkins or the Mayo Clinic) outbidding many communities, effectively drying up the talent pool. St. Jude’s may be able to compete somewhat, but many of the other local hospital may have difficulty staffing nurses for each unit, likely forcing them to shut some units to save others. With a metro area population of over 1.3 million people, the quality of healthcare would decline significant in this scenario, with the people who can afford to deciding to move somewhere with better quality of care, leaving the poor and destitute behind.
However, I do not believe that the above scenario is the most likely. The steps that hospitals and institutions have taken will likely mitigate the worst-case scenario. With the HRSA updating their forecast models every couple of years, hospitals, nursing leaders, policy makers, and institutions will have a chance to minimize, if not stave off, the nursing shortage. Memphis may still have a nursing shortage by 2020, however I do believe that the workforce will still be strong enough and attractive enough to produce a talent pool from the local colleges and universities. The city of Grit and Grind will get by how it always does, by relying on the people who call it home.