Yes, America has a nursing shortage. (But it isn't what you think.)

Topics: Providers, Nurses

By Danielle Poindexter, staff writer

For years, industry analysts have warned about looming nursing shortages in the United States. In fact, these concerns are repeated so often that it feels like we're always on the verge of shortage.

But current workforce projections tell us a different story. Data from HHS' Health Resource and Services Administration (HRSA) shows a growing nursing workforce, with a nationwide supply of nurses will outpace demand resulting in an excess of nearly 300,000 nurses by 2030.

That's not to say there won't be shortages in certain areas. Nationally, HRSA projects that seven states will have nursing shortages by 2030, driven in part by population density, local nursing school capacity, and competition. And it's possible that other markets will also experience regional shortages, particularly those in rural areas. However, at a national level, the nursing workforce is not facing a shortage.

The new nursing shortage

This constant focus on an overall shortage has masked the real nursing shortage: an experience shortage. Anne Herleth, a senior researcher with the Advisory Board, explained that an increase in the number of new nurses entering the workforce coupled with the annual retirement of thousands of experienced nurses has led to a far more novice nursing workforce. American Health Line is published by Advisory Board, a division of Optum, which is a wholly owned subsidiary of UnitedHealth Group.

In 2000, the age distribution of the nursing workforce closely mimicked a bell-shaped curve.

Most nurses employed in the United States were in the middle of their careers, with about 750,000 employed nurses between ages 35 and 44. The number of experienced nurses still outnumbered the novice nurses, with about 650,000 nurses ages 45 to 54, and 450,000 ages 25 to 34.

But since 2000, experienced nurses have been retiring at rapid rates—and taking their decades of hands-on nursing experience with them. At the same time, the nursing workforce grew bringing a flood of new nurses into practice—which helped avoid a true shortage but is also changing the demographic makeup in the workforce. Advisory Board research found the number of employed, mid-career nurses (ages 35 to 44) dropped to just under 700,000 in 2017, while the number of younger nurses (ages 23 to 35) exceeded 800,000—a 45% increase from 2000.

This shift in the nursing workforce is also simultaneous with rapid changes in care delivery. The average patient is complex and older, with more chronic conditions. Care teams are larger, there is more technology, and standards are rapidly changing. Which makes entering practice for a new nurse even harder because there are very few "easy" patients in the hospital.

As the collective experience of the workforce declines and care complexity rises, a new challenge is emerging, which the Advisory Board deemed, the "experience-complexity gap."

The experience-complexity gap poses risk to patients, experienced nurses 

If left unaddressed, the experience-complexity gap will continue to grow, posing a threat to care quality and safety, Herleth said.

Without more experienced nurses to guide them, novice nurses must care for patients that require higher complexity care alone. This can result in adverse quality outcomes. For instance, 40% of new-graduate nurses report making medication errors, while 50% report missing signs of life-threatening conditions.

The experience-complexity gap can also contribute to the burnout of more experienced nurses, who have to train, onboard, and oversee the new graduates, along with their other responsibilities.

How to close the experience-complexity gap

Advisory Board identified two key ways to close nursing's experience-complexity gap: accelerate nurses' transition from novice to competent and better leverage experienced nurses.

But how do you achieve those two goals? Advisory Board recommends three pathways for hospitals and health systems:

  1. Teach novice nurses more effectively by streamlining the list of skills and competencies they are expected to learn in the first 12 weeks of practice, and standardizing preceptor work, including training and materials;
  2. Redistribute experienced nurses across the health system by developing career pathways to specific units or care sites in need of more experience; and
  3. Differentiate practice for experienced nurses by positioning more experienced nurses "at-the-hip" of novice nurses or scaling their impact with expert-led staffing models.