The Implications of Modern Nursing Shortages in Healthcare
Madison Conti, Fairleigh Dickinson University
Abstract: This thesis provides a detailed analysis of the substantial impact nursing shortages have had in both the United States and abroad. The additional countries highlighted in this review include the United Kingdom, Ghana, and South Africa. Various studies pertaining to the measures implemented to combat nursing shortages are referenced. Interviews from nursing supervisors and employees are also featured to reflect individuals’ perspectives on the matter and how their work environment has been affected by a depletion in nursing staff. Several comparisons to current healthcare policies and those of the Crimean War era, when Florence Nightingale founded modern nursing, are addressed. Despite the turmoil from the decline in working nurses, the review concludes by proposing interventions relating to increased wages, more refresher courses, employing more educators and mentors, and hiring more diverse staff to exemplify inclusivity and versatility.
Receiving quality medical care from trustworthy professionals is a priority worldwide. Technological advancements, biological discoveries, and the effectiveness of vaccines have evolved to promote optimal health. These developments may seem insignificant; however, they can potentiate an array of issues if there are not enough healthcare employees. This is especially evident in the nursing profession. When the supply of nurses does not meet the demand, the healthcare delivery system is impaired. Despite having nearly 4.7 million nurses nationwide (Smiley et al., 2023), 62% of hospitals in the United States report a nursing vacancy rate of 7.5% or higher (Harnois-Church et al., 2024). One can trace the emergence of nursing shortages back to the 1850s and their progression through the early 1900s to the 2020 coronavirus pandemic. Throughout each era, there has been a consistent quantitative depletion of nurses. The factors contributing to nursing shortages must be considered to help alleviate this pertinent issue. As a result of modern nursing shortages, the burnout among nurses has increased, patient mortality rates have increased, and rudimentary education systems have been implemented.
Historical Considerations
Florence Nightingale, the founder of modern nursing, is celebrated for her efforts in response to nursing shortages during the Crimean War of 1854. Initially, only a small number of nurses practiced during the Crimean War in England, and this trend was mirrored overseas, particularly during the Great Depression in the United States. From the beginning, nursing shortages have been a persistent issue in society, significantly reducing the quality of patient care. During the Crimean War in 1854, the British army “lacked any kind of nurse” until the efforts of Florence Nightingale, who efforts led to a 41% decrease in mortalities (Egenes, 2009, p. 6). Nightingale's motivation to hire more nurses was crucial, as she and many other women defied tradition in pursuit of this career. Her pioneering efforts pioneered made nursing one of the most valuable and desired professions. According to Egenes (2009), a limitation of Nightingale's philosophy, evident during the Great Depression, was educating aspiring nurses through experience rather than formal training. Due to limited education, nurses did not always possess the necessary knowledge to practice. During the Great Depression, there was also a shortage of registered nurses to teach new nurses. Individuals could practice nursing without a license, leading to competition between licensed nurses and those who did not maintain a license. Mandatory licensure laws were eventually implemented, but not until ten years later (Egenes, 2009, p. 13). It is interesting to compare nursing fundamentals in England and the United States. Although it is valid that both eras had more medical staff, they did not prioritize proper care as they neglected to educate nurses. Enforced certifications for aspiring nurses could have fostered a pro-education mindset, leading to the employment of more qualified nurses and fewer fatalities in the United States during the 1930s.
Current Measures to Combat Nursing Shortages
In the United States, the coronavirus pandemic has significantly contributed to the decreased number of employed nurses and heightened patient mortality rates. Nationwide, hospitals cannot meet staffing standards; which is very alarming given that the average daily number of people hospitalized with COVID-19 now exceeds 39,000 a day, “the highest it has been since the waning days of the first Omicron surge” (Chung, 2022). The rapid increase in the number of deaths reported at the beginning of the pandemic, and how they escalated daily, can be easily recalled. The mortality rates were expected to increase, and the solution to this issue would be to hire more nurses. Upon examining the current numbers of patients hospitalized with COVID-19, although declining, they are still elevated to a concerning degree, peaking at 30,000 between January and March of 2023. The fixed number of nurses contributes to such devastating circumstances, as dividing the workload is as challenging as ever. According to Isath (2023), the overall reports indicate a patient mortality rate of 13.2%, with projections ranging from 13.6% to 23.5%. This potential increase is quite startling, and despite being under 50%, an increase in mortalities is significant. It is important to consider how shortages impact working nurses. Without enough nurses to dedicate enough time to each patient, it becomes difficult to identify high-risk patients with COVID-19, leading to more fatalities (Isath, 2023). Failure to allocate sufficient time during evaluations and assessments could cause a nurse to overlook something crucial to a patient’s diagnosis. Therefore, the increased patient mortality rate from nursing shortages must be addressed by hiring more nurses.
Furthermore, several countries have hired inexperienced nurses to address staffing shortages which has sparked controversy among patients’ families. Mitigating this crisis by employing new hires seems very fair, and, in fact, preferable, however, nurses lacking the necessary experience can be detrimental to the well-being of their patients. Without an adequate number of nurses in hospitals, the workload increases for the current staff. This can lead to hesitation when receiving medical care, as patients may doubt the effectiveness of their treatment. Increased instances of clinical monitoring in Scotland have been prompted by “concerns about shortages of trained nurses” (Entwistle, 2004, p. 2). Patients should feel comfortable confiding in their healthcare professionals. As nurses spend a considerable amount of time with patients during their shifts, patients questioning nurses’ abilities could suggest a lack of trust in their healthcare provider. Hiring nurses with limited experience implies that the nursing shortage crisis can be solved by merely recruiting individuals for the sake of filling positions. Generally speaking, family intervention can “precipitate a loss of confidence or trust in hospital services” (Entwistle, 2004). Furthermore, in England, the unprecedented demand for nurses “does not look like it is going away” (Scammell, 2019). If there are not enough experienced nurses in the profession, patients’ conditions could deteriorate, causing more issues, such as fatalities. Entwistle (2004) also found that U.K. shortages in nursing staff correlated with increased skepticism about the quality of care.
The effects of burnout preceding the COVID-19 pandemic, coupled with nursing shortages, have led many professionals to leave the field, exacerbating the issue of limited staff in Africa. A cross-sectional study of nurses in Kumasi, Ghana, (Opoku et al., 2022) found that 49.3% of participants considered abandoning their profession due to burnout. If nurses are experiencing burnout at such high rates, it may be because they are performing additional work, typically handled by other professionals. The same study reported that 56% of nurses experienced high levels of depersonalization (Opoku et al., 2022). One can only imagine the impact this could have on their patients. This parallels the issue in the U.K., where patients feel uncomfortable confiding in their healthcare providers. Perhaps the disconnect experienced by the nurses translates to the patient. Finally, Opoku et al. (2022) found that 42% of the nurses felt that their levels of personal accomplishment were low, and it is evident that high levels of burnout were a contributing factor. This supports the findings of Moyo et al. (2021), who discovered that nurse administrators in South Africa experienced an “increased workload due to the overflow of admissions.” This likely contributed to nurses experiencing burnout due to the rapid influx of patients and the limited number of nurses available. The practice of “keeping nurses on duty regardless of whether they have been tested for COVID-19” is not surprising as it has resulted in “a major challenge affecting healthcare systems” (Moyo et al., 2021). The shortages became so extreme that the nursing supervisors had to assume additional responsibilities. Since their new roles are not typical of their daily duties, one can anticipate that administrators will leave, further reducing the number of nurses. Therefore, the effects of burnout from a limited number of working nurses have significantly contributed to the decrease in nurses in many African hospitals.
Nursing Education & Hiring Standards
Furthermore, nursing shortages have a major impact on the educational systems in the United States and abroad because of the limited faculty available to teach the programs. Education in the medical field is crucial for understanding treatments and assessing patients. The limited number of instructors and programs expose the dangers of employing nurses solely to fill gaps instead of determining their qualifications. Following the Brexit period, England has experienced its highest nurse turnover rate at 14.1% (Scammell, 2019). Additionally, a third of the nurses in London have quit the profession within that same year. Since hospital nurses may switch to teaching clinical programs, the failure to meet employment rates impedes access to education for aspiring nurses.
Additionally, in the United States, the availability of nursing staff to deliver is crucial in addressing nursing shortages. A sample of enrolled nursing students from Sam Houston State University was obtained from 2014 to 2018, revealing 85% identified as female and 15% identified as male (Xie, 2020). This highlights how a significant portion of the nursing shortages in the United States can be attributed to the lack of male nurses. Similar to London schools, the United States endures challenges of hiring more faculty due to shortages of practicing nurses. Therefore, an inadequate number of nurses available to instruct programs can discourage students from entering the profession, compounding the already prevalent nursing shortages in the United States and globally.
Although some argue that the nursing shortages that predated the coronavirus pandemic were equally as impactful as those today, their effects are not as drastic as the current ones. During the Crimean War, the Spanish Flu pandemic, and the Great Depression, there were instances when “several individuals with different levels of nursing expertise volunteered to provide assistance” (Kolawole, 2010). Therefore, the opposite can be instantly observed today: due to the decreased number of employed nurses in the present-day U.S., “the availability of individuals to assist in the medical field is more restricted compared to previous eras” (Mariani, 2022). Nursing education requirements are significantly different from those in the past. Hospitals did not require mandatory nursing licensure, and any person could legally work as a nurse for pay (Egenes, 2009, p. 16). Without a doubt, no healthcare facility should employ individuals without the necessary credentials. However, during the Crimean War, Spanish Flu, and Great Depression, this was the only plausible solution to mitigate nursing shortages. During the Spanish Flu, nurses provided “tender loving care while the disease took its course,” maintaining the ability to offer reassurance to the community and serve as psychological support to civilians (Kolawole, 2010). The strength exhibited by these nurses demonstrates that despite millions of deaths, they remained resilient, providing the utmost support to others. In nursing today, increased levels of mental health issues such as stress and burnout have been reported to drive the development of technology to address these effects (Berlin, 2022), a concern that was not present during the Spanish Flu pandemic. This highlights why recruiting unlicensed civilians was a better approach to addressing nursing shortages compared to ignoring the consequences, as is evident today. Despite the devastation caused by nursing shortages in the 19th century, their impact never quite amounted to that of today.
Conclusions & Recommendations
Finally, integrating travel nurses into the realm of medical professionals exemplifies a long-term solution to relieving the issue of nursing shortages and, thus, improving the quality of patient care. If U.S. hospitals are not experiencing the rates of nursing turnover reflected in other countries, hiring more nurses overseas could alleviate this issue. A nurse administrator from Namibia commented, “Staff shortage continues to be a challenge in our hospital; we do not have enough nurses” (Moyo et al., 2021). The word “still” implies that these shortages exist during the post-pandemic era. Namibia is one of the 30 countries facing a significant depletion of nurses. Creating more opportunities for nurses to work abroad can substantiate a worldwide impact. For other countries to achieve “the necessary 46% increase in travel nurses,” they can hire nurses from other countries (Alston, 2019). It is a mutually beneficial profession, as traveling provides nurses the opportunity to expand their knowledge and enhance their training (Morris, 2023). There are several incentives to address the challenges of working overseas, such as higher salaries, improved living arrangements, and short-term assignments. International hospital executives are extremely grateful for the services of nurses from other countries. One travel nurse recalls, “The level of respect is far greater than [she has] ever seen” (Alston, 2019). Providing care to underserved populations makes this area of nursing especially fulfilling, reflecting how essential nurses truly are to healthcare. Therefore, travel nursing is a rewarding profession that can provide mutualistic benefits to patients and healthcare professionals.
Ultimately, the nursing shortage crisis must be remedied, and hospital executives should take the necessary actions to recruit nurses from overseas. Although nursing shortages are not surging as rapidly as during the beginning of the COVID-19 pandemic, they can still be improved. Recovering from such a traumatic event in history certainly has lingering effects on individuals’ mental health; however, “authoritative officials must make accommodations to prevent any repeat of such circumstances” (Mariani, 2022). Rectifying these shortages by sacrificing financial losses to increase wages, implementing advanced training opportunities, hiring more educators and mentors, and employing more individuals from underrepresented backgrounds would incentivize more to pursue the profession. Thus, the number of patient mortalities would be curtailed significantly. This will impact healthcare in a multitude of ways because, at the end of the day, we depend on nurses, who are patient advocates and healthcare heroes.
“Apprehension, uncertainty, waiting, expectation, and fear of surprise do a patient more harm than any exertion. Remember, he is face-to-face with his enemy all the time.”
--Florence Nightingale
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