Why everyone should care about the U.S. nursing shortage
Why Everyone Should Worry About the United States Nursing Shortage

Mendel Zilberberg, Esq.

Published By One World United Inc.

If you have ever been hospitalized, you may know what it is like to call for a nurse and have your call go unanswered for longer than you might expect. This scenario directly relates to the critical nursing shortage, which if not promptly addressed, could have devastating effects on the provision of healthcare in the United States.

The Shortage

By now, we are all familiar with the fact that there is a critical nursing shortage in the United States, as well as many other countries which raises the issue and its related ramification from the national level to a global issue. A U.S. Department of Health and Human Services report titled Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020 1 projects that the U.S. nursing shortage will grow to over 800,000 by the year 2020. A significant amount of information and various workforce reports relating to both the reasons for the shortage and the actual extent of the shortage exists. However, in order to gain a meaningful understanding of the problem, we must first identify the moving parts.

The first two basic categories are supply and demand. It is rather obvious that if the supply of nurses remains constant, and the demand for nurses increases, there will be an ever widening gap between supply and demand with an ever growing shortage of nurses.

If demand continues to grow and supply decreases the disparity and shortage of nurses becomes even more critical. The Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020 report reveals that while the supply of nurses may marginally increase until approximately 2011; it will begin to decline thereafter.

The nursing shortage will increase in severity because of a decrease in the supply of nurses as well as an increased demand. This shortage of nurses will (unless properly addressed) lead to a severe degradation in the quality of U.S. health care.

At an intuitive level, I am alarmed at the ramifications of an ever-worsening nurse shortage. I will use many reports and statistics to develop the facts, however, I think that it is evident that an ever-increasing nurse shortage will adversely affect American healthcare. It is important for us to focus on the effects of the looming crisis and to develop ways through which we increase the number of practicing nurses in the United States.

The Supply Side

The U.S. Department of Health and Human Services report also details a number of causes for the decline in the supply of nurses. Among the significant factors are decreased enrollment in Baccalaureate, Associate and Diploma nursing programs resulting in a decline of nursing school graduates, the higher average age of recent nursing school graduates, the aging of the existing pool of licensed nurses, and nurses? salaries. The study further projects that the number of new licenses in nursing is expected to be 17 percent lower in 2020 than in 2002.

Accordingly, if you have less people entering the profession, the supply decreases. The aging of the workforce will also have a significant impact in one of three ways. Older nurses are more likely to retire, seek nursing management jobs or seek nursing jobs that are less physically taxing than the work they perform in a hospital setting. Other less physically taxing areas include nursing home care and home health care. The growth patterns for these two areas support increased migration of nurses from hospital based employment.

Almost two-thirds of U.S. nurses are employed in hospitals. This percentage is forecasted to remain fairly constant between 2000 and 2020. During this period, nursing homes have a projected increase of approximately 23%. That?s an increase from slightly more than 8% of the total nursing population in 2000 to more than 10% by 2020. As such, American healthcare providers may face the declining supply of nurses while hospitals may face the additional problem of nurses leaving for employment in nursing homes or home health care.

The New England Public Policy Center and The Massachusetts Health Policy Forum, a series of research studies over the last several years, shows that many nurses are likely to quit due to their dissatisfaction with their work conditions. The report cites a Health Affairs article by Julie Sochalski, an associate professor of the University of Pennsylvania who found that ?in the early 1990?s, 41% of hospital nurses expressed job dissatisfaction ? three times the rate of all professional workers nationwide? and 43% reported high levels of job burn out.?

One would think that since nurses are central to the administration of hospital operations and health care maintenance significant measures would be taken to increase job satisfaction resulting in higher nurse retention rates. In a Bernard Hodes Group 2006 survey of almost 1,000 nurses dealing primarily with the future shortages expected as a result of the aging workforce and impeding retirement of current nurse population, the opposite is shown. The results revealed that hospitals apparently were not, in any meaningful way, seeking to alleviate the physical toll placed on nurses in many areas.

From this survey we learn that 58% of the surveyed nurses worked for 26 years or more in nursing. The average nurse leader?s age was over 50 and the average age of nurses was over forty.2 In addition, nurses retire more quickly than nurse leaders. While one obvious conclusion is that as nurse leaders age they will retire quicker, the other inescapable conclusion is that the job of a hospital nurse walking the floors and tending patients is physically more taxing than the work of a nurse that may be working in management or administration.

Furthermore, from the survey?s questions relating to job satisfaction, we know that something as simple as the implementation of lift teams (a system by which the ease of lifting patients is enhanced) falls short, ranging from 30% at hospitals applying for Magnet status, 29% for hospitals with Magnet status and 20% for non-Magnet hospitals. 3

An additional area of the survey related to mandatory overtime. Aside from nurses being wholly dissatisfied with the practice of overtime, the overtime itself is extremely costly. While some facilities may be forced to use overtime, it is all too easy to fall into the trap of using overtime as a way to address the nursing shortage. While using overtime as the solution to the shortage may work in the very short term; in the long term it raises operating costs, causes burnout, and is an impetus for nurses leaving the professional sooner than they might otherwise.

The Demand Side

In the face of the graying of America, the baby boomer generation reaching retirement age, and an aging nurse workforce, we need to have more registered nurses in all healthcare disciplines to handle an influx of more patients into hospitals and healthcare facilities.

When considering the changes in demographics and population levels, however, we do not necessarily think in terms of the implications of the nursing shortage. In The Global Shortage of Registered Nurses: An Overview of Issues and Actions developed by James Buchan and Lynn Calman for the International Council of Nurses, certain conclusions based on the World Health Organization?s statistical information of 2004 becomes readily apparent. North America has approximately 1,000 nurses, per 100,000 people, which means that nurses comprise approximately 1% of our population. At this rate, everything else being equal, we will need a 33% increase in the number of nurses, or one million nurses by the time our population reaches 400 million people. As set forth in USA Today4, a U.S. population of 400 million will be reached by 2040.

More than 36 million Americans are now over the age of 65, with more than 4.6 million in the 85+ age group. By 2020, the U.S. population of people over 65 is projected to grow to 55 million while those over 85 will increase 300% to over 13 million. When we factor in how medical advances will require more nurses in addition to an increasing population and the overall aging of our population, the projected shortage of over 800,000 nurses by 2020 becomes quite believable.

The Result

So what is the U.S. population facing in the coming years, if our nursing workforce does not increase? The introduction helps address that question. If you are a patient in a hospital, you may not receive the hands-on care you would have received if the nursing shortage did not exist, or was not at critical levels.

Of course, the issues relating to the shortage of nurses can be further analyzed looking at the number of medical and medication errors. The 2003 May/June issue of American Nurse reported that as many as 98,000 Americans die every year as a result of preventable medical errors, and more than 700,070 people are injured by medication errors alone, according to the Food and Drug Administration (FDA).

Dr. Linda H. Aiken, PhD, FAAN, FRCN, RN of the University of Pennsylvania5 has done extensive research on the mortality rates of patients based on nurse to patient ratios. Her research has determined that patients undergoing common surgeries in hospitals with the worst staffing levels have up to a 31% increased chance of dying. This research is further broken down to indicate that mortality rates increase with the decrease of nurse to patient ratios. For example, going from a nurse-patient ratio of 1:4 to 1:5 increases the odds of dying by 7%.

Dr. Aiken?s research in an article published in Health Affairs May/June 2001 issue found that more that 30% of nurses working in hospitals reported being dissatisfied with their jobs.

In an article published in the September/October 2005 issue of Nursing Economic$, Dr. Peter Buerhaus and associates found that the majority of RN?s (79%) and Chief Nursing Officers (68%) believe the nursing shortage is affecting the overall quality of patient care in hospitals and other settings, including long-term care facilities, ambulatory care settings, and student health centers. Most hospital RN?s (93%) report major problems with having enough time to maintain patient safety, detect complications early, and collaborate with other team members.

Possible Solutions

We have identified at least some of the causes and effects of the nursing shortage, but where does the industry go from here?

Many hospitals are using travel nurses to help fill severe shortage gaps. This is a helpful, but temporary solution that can become costly. Furthermore, it is always better to develop a permanent staff of nurses to grow and change with the hospital, as continuity of care enhances the quality of healthcare. Likewise, overtime is at best a temporary measure, which, if abused, increases the cost of healthcare, reduces nurse morale, and may contribute to nurses leaving the profession earlier than they might have otherwise left.

Other hospitals are working with their local high schools, colleges and nursing schools to develop curriculum and begin to grow their own workforce by offering internships, scholarships and work-study options for students. Again, this is a viable option, but it may take many years to develop these candidates, the shortage is critical now.

The most practical option is international recruitment. Many American hospitals have been very successful in recruiting nurses from the Philippines. However, the Philippines can not reasonably bridge the gap. Typically, nurses who are recruited internationally are experienced and offer hospitals a diverse workforce with second language skills.

India with a population 13 times as large as the Philippines and to date a very limited source of nurses for U.S. healthcare (1/30 the number of nurses emigrate from India as from the Philippines) is an area where significant focus and resources should be devoted to properly prepare nurses to become long term valued members of American healthcare teams.

However the healthcare industry chooses to handle the nursing shortage, it is clear that large scale solutions need to be discovered sooner rather than later for the good health of the country.

Mendel Zilberberg is President and CEO of One World United Inc. (OWU), an international firm which harnesses global efficiencies in the provision of healthcare. OWU?s subsidiaries in India include GS3 India and BestMed Journeys. GS3 India specializes in recruiting nurses from India to work in hospitals and healthcare facilities in the United States. GS3 India provides these nurses with the necessary clinical, language, and cultural training to help them become long-term additions to U.S. medical teams. Soon after founding GS3 India, Zilberberg realized the opportunity to help many Americans receive quality health care resided in the formation of BestMed Journeys, a medical travel company which helps patients find and reach locations abroad where world-class health care is available, affordable and offered in a timely manner.

Mendel Zilberberg is an entrepreneur and attorney with more than 25 years of experience in the areas of law, business, banking, insurance, real estate and healthcare. He initially created One World United and its subsidiary GS3 India because of India?s vast resource of registered nurses and the potential for them to alleviate the critical nursing shortage in the U.S. With the founding of BestMed Journeys, however, Zilberberg?s vision evolved from providing the U.S. healthcare industry with highly qualified nurses to harnessing global efficiencies in the provision of healthcare.

Contact Information

Mendel Zilberberg, Esq.

President & CEO

One World United, Inc.

6619 Thirteenth Ave

Brooklyn, NY 11219

[email protected]



1 The Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis is the primary federal agency responsible for providing information and analysis relating the supply and demand for health professionals.



2 There is additional research that the median age of nurses is approximately 10 years older than the median age of the American population.



3 The magnet recognition program was developed by The American Nurses Credentialing Center (ANCC) to recognize health care organizations that provide nursing excellence. The program also provides a vehicle for disseminating successful nursing practices and strategies. It is considered to be the gold standard of nursing care.



4 http://www.usatoday.com/news/nation/2006-07-04-us-population_x.htm?POE=click-refer



5 Dr. Aiken is the Claire M. Fagin Leadership Professor of Nursing, a Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, and a Senior Fellow at the Leonard Davis Institute for Health Economics and Research Associate in the Population Studies Center. Prior to joining the faculty of the University of Pennsylvania in 1988, she was Vice President of the Robert Wood Johnson Foundation. Dr. Aiken received her bachelors and masters degrees in nursing from the University of Florida, Gainesville, and her Ph.D. in sociology and demography from the University of Texas at Austin. She was a postdoctoral research fellow in medical sociology at the University of Wisconsin, Madison.