The COVID-19 pandemic worsened a national shortage of registered nurses, making it increasingly urgent that policymakers invest in higher education, coordinate strategies to alleviate the pressures on the nursing workforce, and make the entire health care system more equitable and stable.
Since the COVID-19 pandemic began more than two years ago, no region of the United States has been spared an acute shortage of registered nurses. In January, governors across the country, some for the second time, called in the National Guard to assist health care providers, and 1,118 hospitals—more than 1 in 6 hospitals in America1—reported critical nursing shortages.2 As of March 2022, almost every state had taken executive actions to address the shortage,3 such as issuing temporary licenses to put nursing students to work.4
Registered nurses are among the professionals most sought after today. They provide care in every possible health care setting, including hospitals, physicians’ offices, outpatient care centers, and skilled nursing facilities, as well as in behavioral health settings, the home, schools, universities, prisons, and private employer settings. Nurses are not only critical providers of patient care, but they also have an important role in addressing inequities within health outcomes and improving the health of the population as a whole.
At the same time, nursing is a bedrock profession of the middle class and is particularly important for the economic security of women, especially women of color. Last year, there were approximately 3 million nurses working in the United States—the single largest category of health care professionals and the fifth-largest profession nationally, after retail salespeople, home health and personal care aides, cashiers, and fast food workers.5
And yet the United States still needs more registered nurses. Tens of thousands of qualified students are turned away every year from the university degree programs that train students to become registered nurses,6 while nurses are considering leaving the profession in large numbers after bearing too much of the burden of the country’s response to the pandemic.7
These problems have not received the attention they deserve, especially the lack of capacity within institutions of higher education to educate enough nurses. This report examines factors behind the current nursing shortage and discusses why nursing is a crucial occupation for improving health, economic security, and racial equity in this country. It also explores the problems inhibiting higher education from educating more nurses and inhibiting more cohesive management of nursing shortages.
Central to building a strong nursing workforce is a higher education system that has the capacity to supply enough nursing graduates to meet the demands of the health care system. This report recommends that Congress pass legislation that would invest in nursing faculty, clinical placements, and nursing program facilities so that colleges and universities have the resources to enroll and graduate more students. Policymakers should also invest in programs to help nurses who have associate degrees obtain bachelor’s degrees, which would boost the training level, wages, and career trajectories of many nurses of color.
In addition, to create a more organized strategy to address the nursing shortage, this report makes recommendations to establish or designate federal and state-level entities to monitor nursing shortages and advise policymakers and the health care and education sectors.
While this report’s recommendations are focused on the pipeline into the nursing profession, it is just as important for health care employers, policymakers, and others to address the conditions in the workplace affecting retention of nurses. This problem, and approaches that other organizations have proposed to address it, is discussed at the end of this report. (see Appendix)
COVID-19 has strained the health care system to its seams, and nurses have borne much of that pressure. Remarkably, amid a vast increase in the number of patients, employment levels for registered nurses declined by 3 percent between 2020 and 2021, the largest decline in at least 20 years.8 Chief nursing officers have consistently reported staffing as their greatest challenge throughout the pandemic, with vacancy rates as high as 30 percent.9 The American Nurses Association has urged the U.S. Department of Health and Human Services to declare the nursing shortage a national crisis.10
An acute symptom of the shortage is the rise of travel nurses—registered nurses who are contracted to work short stints at understaffed hospitals across the country for double, triple, or quadruple their usual pay. Travel nursing grew by 35 percent in 2020 and was estimated to grow an additional 40 percent by the end of 2021.11 While health care employers have historically brought in travel nurses during full-time staff members’ parental and medical leaves or in other moments of short-term need, current conditions drive a vicious cycle: Lucrative pay draws nurses away from their usual institutions, increasing those same institutions’ demand for contracted relief.
Low morale and traumatic experiences during the pandemic are also driving some nurses to leave the profession altogether.12 This is compounded by the fact that there are now more opportunities for nurses to leave the bedside, as work is available in other industries such as pharmaceuticals, retail health, and consulting.
Nurses of color have experienced even more adversity: Throughout the coronavirus pandemic, Asian American and Pacific Islander (AAPI) nurses reported that patients had refused their care—and even that they had been physically attacked.13 Although discrimination against AAPI people is not new, racist perceptions of COVID-19’s origins have contributed to an increased number of attacks on AAPI communities at large.14 A 2020 study found that overall, nurses of color were more likely to care for coronavirus patients than white nurses and less likely to have access to adequate personal protective equipment.15