The nursing shortage: Why it isn’t a good time to become a nurse

For years we’ve read that the US faces a looming shortage of nurses. Shortfalls in the hundreds of thousands of nurses are routinely predicted. These predictions have been good for nursing schools, which have used the promise of ample employment opportunities to more than double the number of nursing students over the last 10 years, according to CNN.

Yet somehow 43 percent of newly-licensed RNs can’t find jobs within 18 months. Some hospitals and other employers openly discourage new RNs from applying for jobs. That doesn’t sound like a huge shortage, then does it?

But the purveyors of the nursing shortage message have an answer for that. Actually two answers: one for the short term and another for the long term. The near term explanation is that nurses come back into the workforce when the economy is down. Nurses are female and tend to be married to blue collar men who lose their jobs or see their hours reduced when the economy sours, we’re told. Nurses bolster the family finances by going back to work — or they stay working when they were planning on quitting. There’s something to that argument even if it’s a bit simplistic.

The longer term argument is that many nurses are old and will retire soon, just when the wave of baby boomers hits retirement age themselves and needs more nursing care. Don’t worry, the story goes, there will be tons of jobs for nurses in the not-too-distant future. This logic comes through again in CNN’s story:

Demand for health care services is expected to climb as more baby boomers retire and health care reform makes medical care accessible to more people. As older nurses start retiring, economists predict a massive nursing shortage will reemerge in the United States.

“We’ve been really worried about the future workforce because we’ve got almost 900,000 nurses over the age of 50 who will probably retire this decade, and we’ll have to replace them,” [economist and nurse Peter] Buerhaus said.

I don’t buy this logic. And I stand by what I wrote almost a year ago in Nursing shortage cheerleaders: There you go again.

My issue with the workforce projections is that they don’t take into account long-term technological change, but simply assume that nurses will be used as they are today. I’ve taken heat for writing that robots will replace a lot of nurse functions over time. People seem to be offended by that notion and have accused me of not having sufficient appreciation for the skills nurses bring.

So let me try a different tack. Think about some of the job categories where demand is being tempered by the availability of substitutes. Here are a few I have in mind that have similar levels of education to nurses:

  • Flight engineers. Remember when commercial jets, like the Boeing 727 used to fly with two pilots and a flight engineer? Those planes were replaced by 737s and 757s that use two member flight crews instead.
  • Junior lawyers and paralegals. Legal discovery used to take up many billable hours for large cases. Now much of it is being automated
  • Actuaries. Insurance companies used to hire tons of them, but their work can be done much more efficiently with computers

I don’t know exactly how the nursing profession is going to evolve but I do notice that the advocates for training more nurses are typically those who run nursing schools rather than prospective employers of nurses, such as hospitals.

If you want to be a nurse, go for it. But if you’re choosing nursing because you think it’s a path to guaranteed employment, think again.

David E. Williams is co-founder of MedPharma Partners and blogs at the Health Business Blog.

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  • NeuronMD

    Hospitals won’t hire nurses because a third of all US hospitals are financially in the red. Look at the workload of nurses who actually have a job; it’s not a pretty picture.

    So yeah! We can wait for 500,000 nurses to retire en masse and see how well robots will replace them. I can’t wait to see how pleased the families of patients will be to witness the care of their loved ones put under more machine supervision.

  • ninguem

    Same with the doctors.

    There is no physician shortage. The medical schools are being expanded to where we will soon have “musical chairs” with more graduates than postgraduate training positions. It may well be the case already, if not, very soon.

    • Don’t lie

      I agree, you guys are next. It’s in the works. At least some of you are awake. Try to stop this scam before it gets you guys too.

    • Suzi Q 38

      It is getting competitive already.

  • http://www.facebook.com/jackie.schneider.1426 Jackie Schneider

    My husband is doing this, he is a surg tech, lpn and he had to get a different job in management, due to the positions were hourly. The hours fluctuate from week to week, with no guarantees. So many nurses are prn, on call, as needed, only working 3 days a week, used as floats, it’s a shame, we need stable employment. Another thing that is happening, doctors are not even employing nurses, they use CMA’s Certified Medical Assistants, but when you call up and ask to speak to the nurse, they get on the line, I feel this is fraud, they are not nurses, yet we are led to believe they are. Some who graduated with my husband in the LPN program, are only working 3 days a week and can’t find full time employment, despite the fact the school had the local hospitals come in and talk about what great benefits they offer. Once out, the hospitals don’t hire LPN’s. Like you said, it’s great for the schools that profit from all the students who are told they will have great employment after graduation. Many nurses are not leaving due to the economy.

    • John Henry

      How exactly is having a CMA answer your call “fraud?” Why is it that you think yourself entitled to have a nurse answer your telephone call in the first place? Just because you call and ask for a “nurse” does not mean one is required to be provided to you at your request. Fraud would imply you were paying for a specific service that was offered but intentionally not provided; are you paying for professional time when you make your phone call? Didn’t think so.

      • Don’t lie

        Sure is fraud. You know it is because you’d like your patients to believe they are speaking to someone with a clinical license to practice. I know you don’t want them to know the kid you have working for you doesn’t have even a GED. Ha ha ha, time to fess up. I encourage every patient to ask for names. You can look up MDs and RNs on your state licensing website. See if this person giving you medical advice, and authorizing your medications and “interpreting” your lab results is really licensed. You can also file a complaint for fraud at these very websites. Your MD figures you don’t know better, now you do.

    • Suzi Q 38

      What state are you living in?
      In the state of California, the LPN’s have to have their B.S. in nursing by 2015/2016 or not work as a nurse. I know several LPN’s studying to complete their BSN’s now.
      The new health care structure will bring changes, too.
      I think more nurses will lose their jobs. They will not be alone.
      Many older nurse and hanging in there because the economy is so bad.

  • http://twitter.com/DiNovia DiNovia

    You are spot on. Here in Northern California, the shortage is in nursing jobs open to new grads, not in nurses themselves. There are several issues:

    Private practices, clinics, and ambulatory care centers that once hired RNs have instead transitioned that portion of their workforce to CMAs who don’t have the scope of RNs nor the price tag. That leaves new RNs the option of hospitals or long-term care facilities without on-site physician presence.

    Hospitals, financially overburdened, have expanded the scope of the RN in two ways: by increasing patient load per nurse and by eliminating CNAs (or drastically reducing their numbers). They want experienced nurses to fill open slots in their ranks because the resident nursing staff has no time to train new nurses. They often don’t have time to eat lunch! How can they train a new grad?

    I see the first issue (CMAs) as analogous to your robot theory. It is regrettable but inevitable. RNs in a clinic setting often let 3/4 of their training go underutilized because it isn’t necessary in an outpatient setting. No one will change their minds on hiring less expensive CMAs to replace RNs in that sector.

    The second issue is a genuine problem that requires myriad approaches. With acute care and long-term care needs rising and RNs expected to facilitate medical care as well as the work of the CNA (bathing, feeding, taking vitals, toileting), patients will die due directly to the overwork of hospital nursing staff. A single nurse patient load in a hospital averages 6 now and continues to rise. With expanded scope of care and expanded expected duties, how is one nurse expected to adequately care for six acute care patients in one shift? The answer, most of the time, is shoddily, unfortunately.

    Until nurses are respected for their participation in the healing of every patient and are treated as a vital care component rather than interchangeable workhorses who detract from the bottom line financially, the second issue will continue to get worse.

    Right up until patients begin dying and those deaths are directly related to their nursing care, that is. It is unfortunate that it will take people dying of preventable hospital-acquired ailments (pressure ulcers, sepsis, MRSA, even accidental choking) in increasing numbers to get the industry’s attention. I, myself, would prefer a more forward-thinking, proactive approach to the problem.

    • http://twitter.com/ssnbn1 Susan Borden

      I see haven’t missed anything these last four years. Thanks for the reminder, and the thankless job you do!

    • w_km

      Great response, thanks! But I don’t think it’s true to say nurses aren’t “respected for their participation in the healing of every patient.” The transitioning roles of everyone in the team (MD/DOs, PAs, NPs, RNs, CMAs, CNAs, etc) is continuing to change and will continue even more in the future. As you say, SO many outpatient settings and clinics are better off hiring CMAs. They can do that sorta work very well, and for half the price (think twice as efficiently from the number-cruncher’s point-of-view), but potentially at the replacement of a nursing position. No I’m not saying a CMA is twice as efficient as an RN at the low-skill tasks (much to contrary!), but healthcare organizations seeking to curtail spending find the nursing role in an odd position (in terms of price and current role in the healthcare team), which is not to say they aren’t respected, only that we’re finding different, and yes, sometimes worse, ways to run things. The fact is that we’re all overpaid and underappreciated at times (think about it…), and the intrinsic nature of the healthcare system and ‘marketplace’ is poorly set up to accommodate necessary change in such a massive field..

      • http://www.facebook.com/shirie.leng Shirie Leng

        My head got taken off for saying the same thing about physician extenders. The change is coming. We have to figure out how to make it work for our respective fields.

        • w_km

          So do you think the future physicians’ role will inevitably become more specialized/sub-specialized? As a future med student I don’t see the incentive to become a PCP when ‘physician extenders’ such as PAs and NPs can accomplish similar results on the primary care front. Insurance reform doesn’t seem to be helping the ‘looming’ PCP shortage, or is that a common misconception?

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            W_km, the PAs and NPs may be helpful to those without chronic health problems but it is going to be a big problem for those that do have chronic health problems. These are the ones that are going to be in need of a Primary Care Physician to help them manage, and if there are not enough of these doctors to help take care of them even bigger problems are to come.

          • buzzkillerjsmith

            I’ve been a family doc for 23 years. Don’t make my mistake. Subspecialize. America talks about how important PCPs are, but it is all empty rhetoric. They’d replace us all with midlevels to save a few bucks on the front end. Go into primary care and some day your supervisor might be a midlevel!

          • disqus_En6rJ88A7A

            As a “midlevel” in primary care I blame the primary problem on weak doctors probably like “killer” above. We powerless midlevels in prim care are forced to see excessive patients because other weak PCP doctors don’t have the backbone to tell management NO, or the PCP docs who own the clinic want to pad their pockets by pushing volume. Blame yourself not the NPs and PAs.

  • http://www.facebook.com/profile.php?id=1138076670 Lori Selby Devine

    Nurses replaced with machines? So what you are saying is that we need to go back to college and learn the skills to build robots that will wipe bottoms, change dressings, start IV’s, recognize (without fail) PEA and begin chest compressions, call the docs and ask to switch from Dopamine to Neosynepherine (because the hear rate is 140), give baths, tie restraints, retape ET tubes, insert NG tubes, administer NG feed and check residuals…….wait. You get the idea.

    • bears24

      the author is not saying that nurses will be replaced by machines…he is saying that SOME tasks/duties may be helped by machines. meaning that a single nurse will be able to more in a given time, meaning less nurses will be needed at a time.

      • Suzi Q 38

        I can see this.
        Years ago, no one thought a machine could replace the bank teller.
        I am sure that robots or diagnostic machines will decrease the need for nurses.
        The time is already here.

      • http://www.facebook.com/profile.php?id=1138076670 Lori Selby Devine

        The increase in technology has only increased the need for more staff–at least in the ICU setting. The problem is, due to staffing shortages, mandatory overtime, and general fatigue, experienced nurses are leaving the ICU for greener pastures. That leaves us with a new crop of untrained and inexperienced nurses. That is very dangerous. I have seen technology evolve over my 17 years of acute care experience, and never once has it TRULY decreased the need for nurses.

    • meohmyohmeoh

      Absolutely right!! AND don’t forget that the restriants have to be untied and the circulation checked at certain time intrevals and ROM done and the patient allowed to eliminate. or Can a robot watch a pt for a blood transfusion reaction? Sure you can hook the pt up to the vital sign machine but will it tell you if the pt is having symptoms of a reaction if you are not checking on the pt? and sure the monitors tell us what arrythmia the patient is having but does it tell you what medicine to give and how much? Does it access the pt’s symptoms, history, labs, ekgs, xrays etc and meds the pt is on, that may interact with what you may consider giving. No, that takes an educated person to do. I have seen doctors get out their books to read up on things before they give an order to start certain meds. Some things can’t be left up to a computer. Every treatment is not one size fits all. Nurses and doctors are not robots treating other robots.

  • http://www.facebook.com/kelley.hughesreep Kelley Hughes Reep

    Technology (CPOE, EMRs) has not lessened the burden on nurses in my hospital–it has increased the “chores” we must do in addition to patient care. Patients are sicker and increasingly complex…many of the misses and near-misses that make up horror stories on TV can be traced back to overworked nurses.

  • Becky

    I understand where you are coming from, but I have to disagree, or at least challenge, your robot theory. As a disclaimer, I can only speak for inpatient nursing as that is where my experience lies. I honestly cannot think of ways that a computer can replace the important aspects of my job. Computers already take vital signs for me, no loss there, I am happy to use my time in more productive ways. Medication administration involves a degree of clinical judgement. Should I give this patient his metoprolol right now? Sure, his blood pressure is 95/60, and his heart rate is 65. But in my sign out I was told that he spontaneously converts to rapid AF, and his blood pressure certainly can’t tolerate a heart rate sustained in the 140′s. Is the dose appropriate? Has his BP/HR been this low the last couple days? How has he responded to it in the past? That isn’t even a quarter of what I do. Dressing changes, ambulating/PT, teaching (all day every day), assessing the current treatment plan and suggesting changes. These are not tasks that can be done more efficiently by a computer.

    Because medical professionals deal with people, not planes or law books, you simply can’t develop a computer program that will replace clinical judgement. An MD of all people should recognize that. Every patient responds to a treatment differently. A nurses job is to assess both subjective and objective data, and I don’t care how good technology gets, it will never be a replacement for human critical thinking.

  • http://www.facebook.com/shirie.leng Shirie Leng

    I got a whole bunch of heat a few weeks back for posting about loving your nurse practitioner, and, having been both a nurse and a doctor, am a huge advocate for nursing. I think nursing’s future is fantastic, as long as the nursing leadership acknowledges like everyone else that the practice is changing. Nurses will always, always be needed, but so will “nurse extenders” who do some of the basic stuff for us. I also know from experience that nursing has a cyclical employment picture. It tends to go up and down over a roughly 10 year period. I think it’s still a rock-solid choice for long-term employment.

    • Suzi Q 38

      Yay. My daughter is working on her N.P.

    • N N

      Your hypocrisy is that you wouldn’t allow the same for your field. CRNAs can easily do the jobs that anesthesiologists do. So WHY would I hire and pay for you, an anesthesiologist when I can hire a much cheaper version of you in a CRNA instead?

      • nomidazolam

        CRNA’s aren’t cheaper for the patient, and in this case, since both the nurse and the doctor cost the same, I choose the doctor. I will happily pay more for a doctor. On that page, AA’s can do the same job as the CRNA and are (allegedly) cheaper than a CRNA. My personal experience has been that CRNA’s are insufferably arrogant and are harder to deal with than a doctor.

  • LeoHolmMD

    “Shortage mongering” uses about the same pattern each time. There is an erroneous assumption using fantasy figures from a future that hasn’t happened yet. This could be easily resolved by looking at a very real world indicator: How many help wanted signs are hanging right now for nursing positions? How many nurses were hired last year? This is not a demand side industry. It is irrelevant how many patients there are that may need nursing care.

  • DavidBehar

    What
    is short is not the need for nurses, but the funding for nurses.
    Hospitals and nursing homes are being defunded and plundered by the
    lawyer in total control of health care from all sides. Example, there
    are almost no obstetrics wards in Philadelphia. The couple that remain
    are overflowing into the hallways, yet are hanging on by a thread. Where
    did the money go for the other much needed, but closed up OB wards? The
    big law firms are filthy rich from false claims for birth injuries. The
    HMO executives are filthy rich from bonuses for defunding and closing
    many local hospitals. Organized medicine has stood by and caved or
    collaborated with this massacre. That is where the needed nursing jobs
    went.

    • drgg

      You know the thing I have learned recently in medicine is that it really matters what part of the country you practice in. A lot of us assume it is the same everywhere when it is not. That is despicable what you describe yet I heard another doc i ran into from Philly with a similar complaint who was in a different specialty. But same story. did not matter what the need was for patient care. What mattered is what specialty was the money maker that took over the unit. It made more money for the hospital. I guess that’s capitalism for you. Not a fan.

  • S Yellen

    There is still a nursing shortage. We work short staffed every day in many units in my hospital. Instead of hiring regular staff my facility uses travelers, short term hires, from registries. They charge nursing students forty thousand a year for their education in the nursing school affiliated with our hospitals and then don’t hire them upon graduation.

    • Suzi Q 38

      Yes, it happens all of the time.
      I was on the receiving end of it in January.
      I was hospitalized for C spine surgery. I am so fussy, I will admit that.
      I had great care from the preparation before my surgery, to post op, with two nurses or CNA’s were holding ice and feeding it to me, begging me and cheering me on to get up and stay awake after my surgery. I was pretty impressed with that.
      I then was taken to a regular hospital room, with a roommate.
      The nurse was a visiting nurse and she rarely came when I called for help. My family had to do everything.
      My point is that I could tell the difference between a visiting and regular nurse. The visiting nurse didn’t even know where the supplies were. They disappeared for hours. Never checked on you unless you held that buzzer down repeatedly, LOL.

      I left within 30 hours of my surgery because I realized that I could care for myself better than these visiting nurses could.
      The surgeon said that he stopped by a couple of hours after I left, but I had already gone home, LOL. I didn’t tell him why.

  • Doug Capra

    Do you see nurses being replaced with more cna’s and patient techs? Fewer nurses who oversee more nursing assistants — and the scope of practice being expanded for those assistants. I don’t agree with that, but I see that happening, too. How about the move in some hospitals to move the profession to BSN’s and pretty much eliminate LPN’s, replacing them with assistants? Any comments on those trends?

    • Suzi Q 38

      My daughter has seen this at her hospital in California.
      By 2016, the LVN’s are not going to be utilized as much.
      I don’t know if it is a state mandate for higher level hospitals (however they are rated), or what.
      The LVN’s at her hospital are signing up for additional classes to obtain their BSN by that date.
      My daughter has her MSN, yet she is taking additional courses in order to complete her NP.
      At least the state has given everyone notice so that they have time to complete the coursework and possibly hang on to their jobs.

  • Dorothygreen

    Seems very confusing now. The job destinctions are overlapping and there are a number of other health professionals, assitants. Each want higher pay as education increases. How is it in other countries?

    The greatest issue that affects the future of nursing as well as heath care costs in our fragmented health care – not yet a system – is the state of Americans Health. Heavier and more malnourished folks (due to the Standard American Diet) make for more patients with multiple conditions and medications to know, harder physical work, for all at the bedside in health care.

    You would think by watching American TV ads that you can eat all the low nutrition, high calorie food you want and then just ask your physician or purchase a pill OTC to take care of the consequences of repeated gourging. Even many health care professionals do not practice the level of primary preventive care that is understood now to be necessary to prevent disease.

    We really must try to think ahead 10 -20 or more years. The goal is to be a healthy population. Then we wouldn’t need so many sickness care professionalsI. Jobs would be in wellness – recreation, exercise, nutrition assistants, researching the use of robots to help wherever, growing and preparing the most nutritious food, addiction counseling for all addictive products. We don’t have to be as sick a country as we are.

    Sickness care would then be needed primarily for those that develop genetic, undetermined etiolgy, accidental, addictive, autoimmune, infectious diseases not yet known how to prevent or cure.

    Robots are increasingly being used as assistants to humans in both sickness and in wellness. There is no going back. What we need to purge is a model used as a name for a book by Rosemary Stevens in the 1980s – “In Sickness and in Wealth”. No democracy should have those two words linked.

  • Molly_Rn

    BS! But I think
    Mr. Williams writing could have been performed by a computer with access to
    Google. But a computer cannot make the types of observations and decisions that
    ICU/CCU nurses make every day. I work in the medical software business and I
    know just how flawed computers are (the software is built by humans and there
    is always a bug) that is why the Star Wars idiocy of Ronald Reagan was not
    real. Of course computers can compute quickly but making observations and
    interacting with a live patient and having real life experience is not something computers excel at. The issue is money and you get what you pay for. The increase in infections of central lines, the overall increase in infections and the many other issues in healthcare probably relate to too few nurses per patient load. Nursing is a curious profession. We are absolutely essential for
    good patient care and patient survival, but (I am speculating here….) as an historically female dominated profession we are not valued sufficiently to either pay us what we are worth or to provide sufficient staffing to provide good patient care. As I said, you get what you pay for.

  • LastoftheZucchiniFlowers

    Mr. Williiams, I read Buerhaus’ comments in the CNN piece and found him to be a dullard of the highest order when he commented that senior (older) nurses were remaining in the workforce and clogging up the employment ‘pipeline’. My husband was a flight engineer (2nd officer) who transitioned to 1st officer then CAPT because the airplanes which required a flight engineer (B727) were scuttled. Since we are using aviation as a template, let’s recall the very senior CAPT Sullivan whose decades of flying experience SAVED the LIVES of passengers who landed in the icy Hudson River. Senior personnel are experienced and nurses are no different. There ARE always good jobs for nurses but as you likely know – it’s VERY hard work, the hours are often terrible AND unlike our friends in aviation, nurses do NOT have an organization like the FAA which put a limit on pilots’ flight hours, lest their fatigue endanger the flying public’s safety. A good nurse is tough to find and worth her/his weight in gold but the work is not for the faint of heart. If you are looking only for ‘guaranteed employment’ – there are safer, cleaner, easier careers. Accountant? Politician? Librarian?

  • Sh

    I am literally bombarded with nursing job positions, either by e-mail or by telephone. I obviously disagree with you., and by the way I happen to be 61.

    • Molly_Rn

      Me too. I don’t go a day without job offers.

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