Overworked and Underpaid: An Impending Nursing Crisis

Abstract

The nursing shortage has existed for a long time, well before the COVID-19 pandemic. During the pandemic, our health care system came close to collapsing, in part because of a shortage of health care workers, and the nursing shortage will get worse because of nurses retiring, nurses experiencing high levels of burnout, nurse recruitment challenges, widening wage gaps among nurse positions, and hospital profit margins.In the United States, 40% of nurses are older than 50 years and more than 1 million nurses are estimated to retire by 2030.1 There were approximately 3 million registered nurses in May 2021,2 so the health care industry could lose nearly one-third of registered nurses to retirement over the next 7 years. Furthermore, baby boomers are reaching retirement age, a phenomenon referred to as the “Silver Tsunami.”3 The elderly population (>65 years) will total an estimated 78 million people and will outnumber children for the first time in history by 2035,4 resulting in an increased burden on a shrinking health care workforce.In a 2021 survey,5 half of the nurses reported having considered leaving the profession, citing staffing shortages, feeling underpaid and underappreciated, mental health reasons, and a lack of work-life balance. In a 2021 study, Lasater et al6 found that more than half of nurses experienced burnout. According to a survey conducted by the American Association of Critical-Care Nurses, 92% of nurses believe their careers as nurses will be “shorter than intended,” and 66% are considering leaving nursing because of their experiences during the pandemic.7According to the US Bureau of Labor Statistics, the United States will have to add 203 700 nurses annually for the next decade in order to meet the market need.8 A limiting factor to nurse recruitment is the number of new nurse graduates—a lack of faculty with clinical experience, clinical sites for hands-on experience, classroom space, and clinical preceptors caused more than 75 000 nursing school applicants to be turned away in 2018.9 After nurse graduates enter the workforce, many quickly move to nursing professions in less stressful environments such as administration.10In 2021, the national average salary of full-time registered nurses was $77 600 per year, or about $38 per hour.2 In 2023, the national average salary for travel nurses is $88 320, or about $51 per hour.11 Travel nurses are typically eligible for sign-on bonuses, travel stipends, and housing allowances; some also receive benefit packages.11 Staffing agencies usually bill the hospital from $65 to $85 per hour for travel nurses.12 The difference between the bill rate (what the agency pays the hospital) and the pay rate (what the employee is paid) ranges from 32% to 65%.13 Kansas, Ohio, Oregon, Illinois, and Pennsylvania are pursuing legislation to set maximum rates for travel nurses, which has been done in Minnesota.14 Despite the high cost of travel nurses, the demand keeps increasing,15 widening the wage gap between full-time nurses and travel nurses further.According to the Centers for Medicare & Medicaid Services, the national health expenditure grew to $4.3 trillion, or $12 914 per person, in 2021, amounting to 18.3% of the gross domestic product.16 The hospital industry is responsible for 5.8% of the gross domestic product, or nearly one-third of annual health care revenue.17 Despite being among the most profitable sectors in the US economy, hospital systems estimated a revenue loss between $53 billion and $122 billion in 2021.18 Conversely, some reports have suggested that the US hospital market size increased between 2017 and 2022, despite setbacks related to the pandemic.17Current recruitment practices are not up to the task of filling the applicant pool required to meet the future demand. The wage gap incentivizes nurses to “job hop” rather than remain in their current position. Many talented and experienced nurses are burned out and either take early retirement or switch their clinical role to a nonclinical role. The nurses who leave the profession are taking with them the expertise and skills learned during their clinical tenure; most are not sharing their expertise among peers, colleagues, graduates, trainees, and students. We need to advocate for structural solutions and consider ways nurses can pass along their knowledge. Many nurses who leave the profession may not realize that they are qualified to teach in the laboratory or clinical setting. Moreover, an educator’s role may be a flexible option for nurse retirees as part-time positions are often available. Lastly, retired nurses have opportunities to serve as guest faculty in nursing schools; be keynote speakers and session speakers at various state, national, and international conferences; and participate in community-based educational settings.We must act and we must act soon! Let us save our nursing workforce and advocate for them so that they have an environment in which to thrive, succeed, and mentor.