NCSL Podcasts

The Growing Nursing Shortage | OAS Episode 188

Episode Summary

Even before the pandemic, there was a growing shortage of registered nurses in the majority of states. From 2020 to 2021, during the height of the pandemic, more than 100,000 registered nurses left the workforce, the largest exodus in at least 40 years. Adding to the problem, in 2019, nursing schools turned away about 80,000 qualified applicants because of too few faculty, clinical sites and preceptors, and the problem persists. Our first guest is Dr. Cynthia McCurren, a dean and professor at the School of Nursing of the University of Michigan in Flint. McCurren, who also serves as the board chair of the American Association of Colleges of Nursing, discussed the role of nurses in the health care system, a variety of initiatives aimed at increasing the number of qualified faculty, and state and federal efforts to help address the problem. Our other guest is Sarah Jaromin from NCSL, who drilled down into a variety of state efforts aimed at increasing the supply of nursing faculty and also where legislators can learn more about different approaches being tried around the country.

Episode Notes

Even before the pandemic, there was a growing shortage of registered nurses in the majority of states. From 2020 to 2021, during the height of the pandemic, more than 100,000 registered nurses left the workforce, the largest exodus in at least 40 years. Adding to the problem, in 2019, nursing schools turned away about 80,000 qualified applicants because of too few faculty, clinical sites and preceptors, and the problem persists.  

Our first guest is Dr. Cynthia McCurren, a dean and professor at the School of Nursing of the University of Michigan in Flint. McCurren, who also serves as the board chair of the American Association of Colleges of Nursing, discussed the role of nurses in the health care system, a variety of initiatives aimed at increasing the number of qualified faculty, and state and federal efforts to help address the problem. 

Our other guest is Sarah Jaromin from NCSL, who drilled down into a variety of state efforts aimed at increasing the supply of nursing faculty and also where legislators can learn more about different approaches being tried around the country. 


Episode Transcription

Ed:      Hello and welcome to “Our American States,” a podcast from the National Conference of State Legislatures. This podcast is all about legislatures, the people in them, the policies, process, and politics that shape them. I’m your host, Ed Smith. 


CM:    Nurses are the backbone of the health care system with more than 4.2 million registered nurses in the United States workforce of which approximately 84% are employed. 


Ed:      That was Dr. Cynthia McCurren, a dean and professor at the School of Nursing at the University of Michigan in Flint. Dr. McCurren, who also serves as the board chair of the American Association of Colleges of Nursing, sat down with me to discuss the growing shortage of nurses in the U.S. Even before the pandemic, there was a growing shortage of registered nurses in the majority of states. From 2020 till 2021 during the height of the pandemic, more than 100,000 registered nurses left the workforce, the largest exodus in at least 40 years. Adding to the problem, in 2019 nursing schools turned away about 80,000 qualified applicants because of too few faculty clinical sites and preceptors and the problem persists.


            Dr. McCurren discussed the role of nurses in the health care system. A variety of initiatives aimed at increasing the number of qualified faculty and state and federal efforts to help address the problem. 


            My second guest is Sarah Jaromin from NCSL, who drilled down into a variety of state efforts aimed at increasing the supply of nursing faculty and also where legislators can learn more about different approaches being tried around the country. Here is our discussion starting with Dr. McCurren.


            Dr. McCurren, thanks for coming on the podcast.


CM:    Well, thank you for the invitation and the opportunity to participate in this important discussion.


Ed:      So, we are talking to you today about what I understand is quite a severe shortage of nurses. Shortage that existed before the pandemic and was exacerbated by it. But why don’t we start with the big picture and could you just talk a little bit about the role nurses play in our health care system.


CM:    No one would disagree that nurses are the backbone of the health care system. With more than 4.2 million registered nurses in the United States workforce, of which approximately 84% are employed in a part-time or a full-time nursing position. Nurses comprise the largest component of the health care workforce. They are needed in all settings where care is delivered to provide an extensive array of health care services. They are the primary providers of hospital patient care and deliver most of the nation’s senior care services and long-term care. They provide an increasing amount of urgent care, primary care and preventive services. They are the most prevalent health care provider in community-based care settings to include our schools. And they are often the only provider available in rural settings. They are the health care provider who spends the most time with patients and play critical roles in patient education and recovery. So, for example, if you are admitted to a hospital in this day and age, it is likely because you need nursing care and surveillance. The bottom line is nurses stand watch over the nation’s health care system 24 hours a day 7 days a week. 


            The significance of nurses in our health care system has been recognized. For more than 20 years, the public has ranked nurses as the most trusted and ethical of professionals across all the professions and disciplines according to the national gallop poll. Nurses not only provide direct patient care in a variety of settings. They also conduct research. They teach. They can shape public policy. Lead health systems. Consult with corporations and implement evidence-based solutions that can revolutionize health care. So, you can see the breath of what nurses do is quite extensive. 


Ed:      I worked on a website at NCSL about scope of practice and I was surprised at the as you say the many, many things that nurses are involved in so. Thanks for that background. But let’s now talk about this nursing shortage. How bad is it and what are the key reasons behind it?


CM:    The cumulative number of nurses that are needed now in the workforce is somewhat elusive depending on what you read, who you talk to, where individuals are located because it’s not only availability of nurses, it’s distribution of nurses. But we continue to hear from our practice partners across the nation that they are having trouble finding registered nurses to fill their open positions. Anecdotally, we hear that rural states are having more trouble finding well qualified nurses to fill their available positions than more populated areas. But we don’t have exact data. Employment of registered nurses is expected to grow by 6% each year through 2031. This growth and demand for nursing services continues to expand for a number of reasons including an increased emphasis on preventive care, growing rates of chronic conditions and demand for health care services from the aging baby boomer population as they are living longer and have more active lives. 


            It’s also affected by nursing retirements and an increase in new opportunities for nurses. In total there is an imbalance in nursing supply and demand. So, talking about data specifically, the Bureau of Labor statistics projects 203,200 openings for registered nurses each year through 2031. In addition, more than 30,000 new advanced practice nurses which would be your nurse practitioners or nurse anesthetic, will be needed each year through 2031 to meet a rising demand for care. Historical reasons for the shortage of nurses have persisted for quite some time and they include insufficient onboarding or transitioning of new graduates into practice. Nurse incivility toward each other. Inadequate nurse/patient ratios and lack of schedule flexibility. 


            But since the pandemic, the shortage has been intensified and we feel like we are dealing with a different situation. We are seeing more reports about nurse dissatisfaction. And, of course, it is common to hear the word burnout associated with that. But we have the burnout is due to insufficient staffing. We have experienced what we call an increased amount of moral distress and workplace violence which is happening for all providers but is very real for nurses. And this could lead to more nurses leaving the profession. 


            We have new data from the National Council of State Boards of Nursing that shows that more than 100,000 nurses left the profession during the pandemic due to these variables that we just talked about and also retirement. The National Council of State Boards of Nursing has also found that about one-fifth of those currently practicing nurses have expressed an intent to leave the profession. If these nurses would leave, the shortage would intensify and the quality of patient care would likely suffer. One of the big areas where we are worried about with the shortage of nursing is patient safety. And that is an area that we’ve been working on since 2000 in the United States to improve safety and quality for our patients and to take a step backwards is very troubling. 


            Efforts to address the nursing shortage must focus on addressing the nurse faculty shortage as a priority. So, we know faculty shortages at nursing schools limits the capacity at a time when we most need to educate more nurses in order to grow the supply. Budget constraints at schools of nursing, an aging faculty, increasing job competition from clinical sites have all contributed to our crisis about faculty. So, these are some of the overall talking points I guess I would say about the nursing shortage that I think are really relevant. 




Ed:      Well, I think all of us during COVID, those of us who are not in your world, were very aware of the degree to which nurses were both the heroes and also in many ways the victims of an incredibly difficult situation in a lot of communities. So, the notion of a couple 100,000 openings a year seems a little daunting. And I want to drill into that some more, but first I want to ask you this question. There are workforce shortages across the economy and health care is certainly the case. But education, law enforcement, construction, so many different things, and I wonder to what degree the shortage of nurses is related to this overall phenomenon in the economy and to what degree it is really a thing in and of itself.


CM:    Well, I think that’s a really good point and a valid issue to raise. I would say overall we know there is a decline in college enrollment and so that is indeed going to affect the labor shortages. And economists speculate, but I think some of the major reasons that we have a decline in college enrollment is that there are simply generational differences in what is valued. What they feel like they need to have or prepare themselves for to have quality of life. The pandemic also contributed to a declining faith in the value of a college degree. We found other ways to make ends meet and found out that we really didn’t need as much of those extra benefits that we thought we needed.


            There is the burden of student debt that is very real for individuals. And of course, in general, there’s the what we call the demographic cliff if you will in that we just have a drop in the number of college age individuals in the United States. So, I think all of those also contribute to the shortage in that we are just not bringing as many students in. 


Ed:      One of the most surprising things I discovered preparing for this podcast has to do with exactly what you are talking about and these statistics that the number of students enrolled in entry level baccalaureate nursing programs decreased by 1.4% in 2022 ending a 20-year period of enrollment growth. This is according to data from the American Association of Colleges of Nursing. I believe you are the chair of the board of that organization. This decline is consistent across masters and PhD level nursing programs as well. Of course, the people who would be the educators for the nurses of tomorrow. And nursing programs reported turning away thousands of qualified applicants due in large part to this shortage. So, if people want to go into nursing in many instances but aren’t able to get into school and you talked about this a little bit, but could you dive in a little more into the faculty issue and the scope of the faculty shortage.


CM:    To start you know the role of the nursing faculty member is to combine their clinical expertise as well as their passion for teaching. And you put this together and many individuals find that to be a very rich and rewarding career. So those of us who dedicate ourselves to nursing education as professionals, we are working in the classrooms. We are working online. We are working in the practice settings. So, we have to keep ourselves at the top of the game and with the most current knowledge and knowledge about what the realities of practice are. So, we have to keep our finger on the pulse ahm on that as well. 


            We are responsible for preparing and mentoring future nurses. We need to be role models for them and the best kind of role models. We play a pivotal role in strengthening the workforce and providing the leadership that is needed to be innovators and determine better ways to deliver patient care. So, the AACN’s latest data did show the national faculty vacancy rate in baccalaureate and higher degree nursing programs to be at almost 9% now. And this is higher by a percentage point than a year ago. It’s the highest vacancy rate that AACN has recorded since we first began doing our annual survey and data collection in 2008. So, the nursing schools identify the shortage of faculty and preceptors as you said. The top reason why we are not able to take in all the qualified applicants that apply to our schools of nursing. We use that datapoint of 78,000 qualified applications turned away from nursing programs in the last year. I do want to stress that that’s not 78,000 unique individuals necessarily because some individuals apply to multiple programs and so I think it is always important to recognize that. The ability to expand our capacity in accommodating all of the applicants though must be addressed and is essential if we are going to have enough nurses in the workforce. 


            Included in the 78,000 applications that I mentioned that were not accepted, over 10,000 were applications to master and doctoral programs. So, turning students away from graduate programs could actually further limit the pool of potential nurse educators because we do require graduate education to be in those roles. So, some of the factors that contribute to the shortage in 2017, AACN had published a study in nursing outlook revealing that 1/3 of the nursing faculty workforce in our baccalaureate and higher degree nursing programs would retire by 2025. So, this is just setting us on edge for what’s ahead of us if we think we have a shortage now. Where are we going to be and that underscores the urgency for the nursing education community to address this impending exodus of senior faculty and to develop younger faculty for succession. And this is something that we are taking very seriously in our work in AACN really encouraging individuals to find participating as a nurse educator to be a rewarding part of the nursing profession.


            Ed:As you look around the country and I’m sure you talk to nursing educators across the nation, what do you think are the most promising strategies to try to improve the situation?


CM:    Well, AACN is constantly working from an advocacy perspective and trying to influence the ability to have more federal support to ensure the pipeline of students into the nursing profession. So, we are always asking for support for our nursing workforce development programs. We advocate for the reintroduction of the future advancement of academic nursing FAAN act which would provide significant support in areas of great need including support to hire more faculty. We are also helping to address the issue through our work with the Jonas Philanthropies that help support doctoral nursing students and host an annual faculty development conference that helps us a great deal.


            Collecting data to quantify the scope of the shortage is another way that AACN contributes to this work. We promote faculty careers through our graduate nursing student academy in which many of our graduate students that are in their academic programs across the nation are active in. And we collaborate with national nursing organizations and practice partners to help identify solutions. One of our biggest initiatives that we have been engaging in in the last two to three years is really creating a shared vision with our academic and practice partnerships so that we work together to solve what the challenges are in nursing. Another way that we can try to address the shortage is to advocate for more federal funding around the nurse faculty loan program and the faculty loan repayment program. And that has been in place for quite some time and helped to advance faculty careers and reduce the financial burden that comes from advancing your education to the doctoral level. 


            And many nursing school and practice partners as I said working together are beginning to find creative ways to bridge the faculty gap. So, in some schools, we partner with our clinical agencies and hospitals to share graduate prepared nurses who are working at the bedside but also serve in clinical educator roles and that helps us a great deal. We also encourage retired faculty to teach part-time and find ways to supplement salaries to strengthen recruitment and retention which is really important. And finally, we want our current faculty. We want nurses who are practicing in the profession to do all that we can to help recruit students of color into the profession because we are very committed to diversifying our cohorts of nursing students and our graduates because of the appeal for addressing the disparities in health care and ensuring equity. 



Ed:      I plan to talk with an expert from NCSL and I’m sure she is going to layout the specific legislative things that are going on, but I think this has been a real service. I think an awful lot of people in our audience are probably not aware of how extreme the shortage is for nursing. 


CM:    There is one more thing Ed. There is a National Advisory Council on Nurse Education and Practice and they are available and actually do provide advisement to congress on the nursing workforce and they are very informed. They are looking at what the public private response needs to be and we need to identify ways to support and fund a lot of different kinds of initiatives that can address the shortage. So, we need to get out of our sort of traditional way of looking at the shortage, but what are those incentives that we need to have in place. And we think about that 90% of the nursing profession is still made up of females and we know that women have lots of obligations in society because of the roles that women play. And so, when you think about how do we encourage those individuals to stay active and actively working, but also help them to be able to have that work life balance and be able to sustain the many roles that we are dependent on in our society as well. So, I think that is just one way of thinking about being creative, but we need to work together to think about how we address what the real barriers are.


Ed:      Well, that is a great point and a great point to wrap up on. I want to thank you so much for taking the time and going through this for us. Take care. 


CM:    It’s been my pleasure. Thank you for the opportunity.


Ed:      I’ll be right back after this short break with Sarah Jaromin from NCSL. 




            Sarah welcome to the podcast.


SJ:       Thank you so much for having me on. It’s a pleasure to be here. 


Ed:      So, let’s talk a little about what sort of actions states can take to address the nursing shortage the issue I just discussed earlier with Dr. McCurren. As in a lot of policy areas what the federal government does can often affect what states can do. Can you talk about what initiatives there are at the federal level to address the nursing educator shortage.


SJ:       There have been a variety of actions taken by the federal government to address nursing shortages over the past couple of years. However, these actions do tend to focus on nursing shortages more broadly and less so on the nursing educator shortages that we are going to talk about today. The reason federal action in that area specifically includes the creation of grant programs and the allocation of funding to existing programs that are addressing this issue. So, for example in 2021, the Covid Relief Package included $200 million to expand Nurse Corps which was a 44% increase in funding from prior years. Nurse Corps is a program that provides scholarships and repays student loans for RN’s and APRN’s who are working in primary or mental health professional shortage areas or as a nursing faculty in schools of nursing. So, another example is the Build Back Better Act of 2021 which included $500 million for personal grants to enhance and modernize nursing education programs as well as increasing the number of faculty and students enrolled in these schools. And so just to give a few other ones first there’s Nurse Faculty Loan Program which I’m sure many people have heard of and the Nurse Education Practice Quality and Retention Clinical Faculty and Preceptor Academies. It’s a mouthful. So, it’s NEPQRCFPA. And so, the Nurse Faculty Loan Program provides low interest loans for individuals studying to be nurse faculty and loan cancellation for those who go on to work as faculty. And so accredited schools of nursing with advanced education programs are encouraged to apply. And then the NEPQRCFPA supports the creation of academies that develop and implement formal nurse education training curriculum which is then used to train clinical nursing faculty and preceptors. And so HRSA has distributed over $8 million to 10 different organizations during 2022 through this program. It plans to continue. And then lastly in recent years, Congress has earmarked in their budget at the request of state senators some congressional funding to local nursing workforce programs so that’s another avenue for states to leverage congressional funding.


Ed:      In my previous conversation with Dr. McCurren, she mentioned faculty and preceptors, who supervise nursing students during their clinical training. Have these initiatives that we just talked about really moved the needle in terms of increasing the number of faculty or preceptors?



SJ:       That is a great question, but I think it’s unfortunately just a little bit too premature. There hasn’t been a lot of data or outcomes on it just because it’s been a new focus. I will say that the whole nursing educator shortage movement kind of came out of them doing data on nursing shortages and realizing that there weren’t faculty who could support these nursing students so this little bit of data was used to kind of talk about this issue. We will be keeping an eye on it. I do expect that there is going to be some outcomes data on what these initiatives are doing. 


Ed:      Well sure that makes sense. Let me ask you. We are of course interested in state actions, state policymakers on this podcast. And I wonder how state policymakers are responding to the nursing educator shortages in their states. Are there actions states can take or are taking to strengthen the nurse faculty and preceptor workforce shortage?


SJ:       So, we’ve seen a lot of state interest in action in addressing these nurse educator shortages during the 2023 session. So, in addition to leveraging the federal funding and grant programs that I talked about earlier, states have quite a few options available to them to address these educator shortages and we’ve really seen quite a few different takes on this. So, some of the trends we are seeing include tax deductions or tax credits. Loan forgiveness programs. Establishing fellowships. Investing in simulation equipment and technology. Establishing their own grant programs. Changing requirements necessary in order to teach and/or recruiting part-time faculty from clinical practice sites. Of these options the most common strategy being utilized by states is tax incentives and loan forgiveness programs, but it really is a very wide breath of what states can really do. 


            I’ll just unpack some of these a little bit further, what they are, how states are doing it in practice. So, tax deductions and tax credits in most cases preceptors are not compensated for the hours that they spend supervising clinical rotations. To offset this some state programs, make tax credits available to reduce the amount of taxes a preceptor will owe to the state. Other states have used tax deductions so lowering the taxable income of eligible preceptors. We have these loan forgiveness programs so states may choose to forgive loans of students who are currently serving as a nursing faculty or students who will commit to becoming a nurse educator. Forgiveness requirements often have stipulations about how long the student will have to serve as a faculty in order to qualify. So, for example committing to serving at an accredited institution in that state for at least 3 years and those numbers can vary, but that’s just one example. 


            Another option is establishing fellowships so nursing educator fellowship programs provide supplemental salaries in the form of financial awards or scholarships in an effort to retain existing or new nursing faculty. So, a little bit more on that retention side rather than recruitment. States can also invest in equipment or technology for simulation-based teaching. This one is a little bit newer so simulation-based teaching uses modernized and technology driven simulation to provide a variety of opportunities for nurse educators to train students without the risk associated with using their warm patients or if you don’t have someone directly there to supervise. So, the research on this has been pretty positive. It’s been found to improve nursing knowledge, critical thinking skills, self-advocacy and leadership skills. And this can really be used to reduce the reliance on educators and clinical placements for clinical hours. 


            And then a few more. So, states also have the option to establish grant programs. So, distributing funding to nursing institutions to create their own innovative programs that are addressing this area of need. Or the last one is really just creating those relationships with clinical partners so you can recruit already graduately prepared nurses to serve as part-time faculty as well as continuing to practice in a clinical setting.


Ed:      Let me ask you this and maybe this is similar to the situation at the federal level but is there evidence out there on what things seem to work best. Have any particular states had success in one area or another that you can highlight?


SJ:       Yeah absolutely. I have a lot of state examples I think very similar to the federal program though there is not a lot of outcomes data on what exactly is working thus far and so I think it will be really interesting because I will show some examples. They are very wide. So, when they start doing the data collection about which ones are working better than others and maybe that impacts what direction states go in in the future, but as for now, they are doing a wide breath of things. And so, this list will not be exhausted, but there’s a few examples of some recent state actions. So, the Wisconsin Legislatures just approved $5 million in funds for a grow your own initiative which is called the Wisconsin Nurse Educator Program for the 2022-2023 school year. And so eligible students are enrolled full-time in a PhD program, a Doctor of Nursing program or a Master of Science in nursing, nurse educator program. And so eligible students will receive up to $50,000 in financial support to cover the cost of tuition as well as school related expenses so they can spend it on books, travel, childcare, etc. And then in return, these students will commit to teaching in an approved Wisconsin based school for at least 3 years post-graduation. 


            Colorado actually just created a very similar program as well, but they have included part-time faculty who meet these requirements who will be eligible for up to $25,000 in loan repayment as well. 


            Next, we have Illinois and Maryland who have taken a slightly different approach and created the New Nursing Faculty Fellowships. Maryland institutions with nursing programs may nominate an unlimited number of newly hired full-time faculty who will receive $50,000 over 5 years as a salary supplement. So, these awards can be used on professional development, loan repayment, research, conference fees, really anything that they deem a reasonable expense that will further a nursing faculties career. They most recently gave out around $1.3 million dollars in awards and again are focused on that retaining of faculty rather than recruitment.


            Next, we have Texas, who currently has a bill in committee that would establish a grant program through the Texas Higher Education Coordinating Board for programs that are supporting nursing education and training through innovation solutions, but with a particular emphasis on addressing the nursing faculty shortage. So, I think to your earlier point, they really found that they had been putting in a lot of money towards these nursing shortages and then they found that they don’t actually have the educators to support it. So, this bill is a little bit of a response to that data that they’ve seen. 


            And then lastly, the Washington State Legislature took a technological approach and made a significant investment in simulation laboratory equipment so $15.2 million was included in their 2022-2023 budget for nursing programs to build on or supplement existing simulation labs. And so, as you can see there really is quite a bit of variety across states in terms of what actions they are taking and honestly there are a plethora of other examples that we will leave out for the sake of time. But states are very involved in combating this and they are getting creative about what they think is best for their state’s population. 


Ed:      Well clearly, it’s something to keep an eye on in the next couple of years to see what seems to be among the most effective tools. And I think a lot of our listeners who are not particularly attentive to this area of policy will probably be surprised by this podcast and where the shortage problem occurs because this isn’t the workforce shortage we are seeing in a lot of other areas in the economy. So, some very interesting stuff. As legislators, legislative staff think about how they address this in their state, can you talk about some resources that are available either through NCSL or other sources where people can kind of educate themselves about how to address this?


SJ:       Yeah absolutely. So, the American Association of Colleges of Nursing which is where Dr. McCurren is from does a lot of work on this issue. So, they have released fact sheets providing the scope of best shortage. Factors that could attribute to the shortage. Strategies that are being used to address it as well as keeping a tab on those most recent articles and research as it comes out as well as conducting their own research in the area. So, I always send people over there because they are really on top of this issue. I believe Dr. McCurren brought this up as well, but the National Advisory Council on Nurse Education and Practice so they annually prepare reports on findings and recommendations in this area. And it is tailored to the federal government, but I think often there are takeaways for states and also, they are frequently impacted by what the federal government decides to do on these issues. And then lastly NCSL always available to help states with the policy research and questions if there are specific questions for states. But also, we recently released an article on this last summer, but we really are always open as that resource for states who are having questions on what other states are doing, what the policy options are. We are always here to help.


Ed:      Well, thank you Sarah and we will include links to these resources in the show notes on this podcast. This has been very illuminating and educational for me so I appreciate your time and Dr. McCurren’s time. Take care.


SJ:       Thank you so much.


Ed:      I’ve been talking with Dr. Cynthia McCurren from the University of Michigan and Sarah Jaromin from NCSL about the nursing shortage in the U.S. Thanks for listening. 



You can check out all the podcasts from the National Conference of State Legislatures by searching for NCSL podcasts wherever you get your podcasts. Tim Storey, NCSL’s CEO, hosts “Legislatures:  The Inside Storey” where he focuses on leadership and legislatures. The “Our American States” podcast dives into some of the most challenging public policy issues facing legislators. On “Across the Aisle” host Kelley Griffin tells stories of bipartisanship. Also check out our special series “Building Democracy” on the history of legislatures.