A Crisis for Health Care: How the Nursing Shortage Impacts Patient Care, Education and Burnout
The United States is experiencing a nursing shortage that is expected to expand over the next 10 years.
After 30 years as a nurse in the 8 East Medical Oncology unit at UF Health Shands Hospital, Eyrone Bush has seen it all.
Gone are the days, for instance, of the iconic white uniforms and paper charting systems. There have been tremendous advances in technology and pharmaceuticals. There are more men in the field, bringing greater diversity. Most importantly, she said, nurses now are seen as colleagues in interdisciplinary health care teams.
Still, there are days when she wonders whether she can keep going. At times like this, she reaches for her stash of inspiration.
“I have a file at home and it’s labeled, ‘Why I do what I do,’ ‘’ Bush said. “In those moments when I may feel burnt out or discouraged about something, I flip open my folder. I have hundreds of notes from my patients, and they say: ‘You really made a difference; thanks for making cancer bearable; you really helped my family cope during a difficult time.
UF Health oncology nurse Eyrone Bush speaks with a physician on the unit.
“You can’t describe or replace those things,’’ she said. “Those are things people may not see when they look at a career, but they’re the things that make nurses stay in the profession because those are the rewarding parts of what we do.”
Despite the moments of quiet satisfaction that bring joy to those who answered the call to care for others, it is becoming harder to fill nursing vacancies. Even with nearly 4 million nurses nationwide — the largest segment of health care workers — the United States is experiencing a nursing shortage that is expected to expand over the next 10 years.
More than half of the current nursing workforce is age 50 or older, according to the National Council of State Boards of Nursing, and a July 2017 issue of the Journal of Nursing Regulation reported that nearly 1 million nurses will be retiring in the next 10 years, leading to a significant deficit in the health care landscape.
Ample research has shown that the number of nurses available to provide care has a direct correlation with mortality rates. With a shortage of nurses to provide this unique blend of health and healing, many are concerned for the future of the health care industry. What is contributing to the nursing shortage? How is it impacting the profession and patients? And what’s next for nursing?
“As nurses, we are the coordinators of all,” Bush said. “Between multiple phone calls and multiple alarms, trying to meet patient needs, help our peers, answer questions, participate in interdisciplinary rounds — it’s nonstop. We’ve become the ultimate multitaskers, but the constant demands can also lead to burnout. There’s not enough of us to go around.”
The Root of the Shortage
A common misconception is that the shortage is because too few individuals are interested in becoming nurses. In fact, the opposite is true. The real shortage is in the number of faculty needed to educate and prepare the new nurses, which can be attributed to the fact that most faculty positions require a doctoral degree and often nurses can earn a higher salary in the clinical setting.
“Last year, over 75,000 qualified applicants to nursing programs across the United States were turned away,” said Anna M. McDaniel, PhD, RN, FAAN, UF College of Nursing dean and the Linda Harman Aiken Professor. “One major factor in the lack of ability to educate these people who want to be nurses is that there are no faculty to teach them. It can really have an impact on the nursing shortage when we are not able to educate the next generation.”
According to the American Association of Colleges of Nursing, the national nurse faculty vacancy rate is nearly 8%. In addition, one-third of the current nursing faculty nationwide are expected to retire in the next five years.
There are also not enough faculty positions in many nursing programs. However, at UF, the College of Nursing has taken steps to increase the number of faculty positions, which, in turn, reduces the student-to-faculty ratio so that students are receiving proper instruction in smaller groups. In addition, the smaller student-to-faculty ratio positively impacts the overall university ranking. Last year, nine new faculty were hired, and in 2019, 13 new positions were created at the College of Nursing.
“In 2013, the College of Nursing increased the number of students accepted in the undergraduate program without increasing the number of faculty,” McDaniel said. “These new faculty positions allow the college to evenly distribute the teaching load among more faculty members. It is vital to have quality instructors because every year, there are more and more jobs for nurses. As the general public is aging and dealing with more complex health care issues and more chronic conditions there are more needs for nurses to care for people.”
Educated Nurses to Meet Complex Needs
In 2010, the Institute of Medicine (now known as the National Academy of Medicine) published a revolutionary report called “The Future of Nursing” that called for 80% of nurses to hold a Bachelor of Science in Nursing degree, or BSN, by the year 2020. With only a few months remaining, the current number of BSN nurses nationally is only about 56%, according to the Campaign for Action, which was established to support the Future of Nursing report.
Evidence has found that entry-level nurses should be baccalaureate-prepared to meet the ever-demanding needs of complex patients. According to the American Association of Colleges of Nursing, nurses who hold a BSN degree are prepared with skills that include critical thinking, leadership and health promotion.
In a 2014 issue of the Lancet, University of Florida College of Nursing alumna Linda Aiken, PhD, RN, FAAN, FRCN, published an international study that found every 10% increase in BSN-prepared nurses is associated with a 7% decrease in patient mortality. In addition, by increasing a nurse’s workload by just one patient increases the likelihood by 7% of patients dying within 30 days of admission.
At the UF College of Nursing, there are a variety of nursing programs to help supply the ever-increasing shortage. The BSN degree is considered the gold standard for a nursing education, and there are three pathways to receiving this degree: the traditional track, the accelerated track for those who have a previous degree in another field and the RN-to-BSN track for those with a two-year associate’s degree in nursing. The graduate programs include the Doctor of Nursing Practice, or DNP, program for advanced practice nurses and the PhD program for those interested in a career in research.
McDaniel said that UF is poised to meet the challenges in health care because of its comprehensive academic health center, commitment to the community and the abundant interdisciplinary opportunities across campus.
“One of the most important aspects of my job as dean is building a partnership with practice,” McDaniel said. “With UF Health, we are systematically building our shared mission in working together. This not only helps to alleviate the nursing shortage but it increases the quality of care that is being delivered and it increases the nurses’ job satisfaction.”
The Backbone of Health Care
In terms of cost effectiveness, nurse practitioners save consumers on multiple levels. According to the American Association of Nurse Practitioners, nurse practitioners provide equivalent or improved medical care at about one-third of the cost of physicians. These savings are due, in part, to the lower cost of education for nurse practitioners and lower salary compared to physicians.
Archer Family Health Care patient Joy Kubotsuka (left) consults with a DNP student Noreen Haq (right) and practice director Denise Schentrup, APRN, DNP (center).
When it comes to health care providers, Joy Kubotsuka prefers the nurse-managed experience at UF Health Archer Family Health Care, or AFHC, the UF College of Nursing’s primary care practice. The practice is a federally designated Rural Health Clinic in the small town of Archer, just west of Gainesville, that provides care to vulnerable, underrepresented populations. Approximately 60% of the patients there have incomes less than twice the federal poverty level and about half have no health insurance.
Kubotsuka had no health insurance when she became a patient at AFHC 12 years ago, and despite living 45 minutes away and having other options, she is a loyal patient of AFHC because of the way she is treated there. Her first visit was based on the recommendation of a friend, who received care there. Kubotsuka was experiencing depression and lethargy, which she said is unlike her. When she made an appointment at AFHC, the nurse practitioner ran tests and discovered she had an issue with her thyroid, which has since been managed through medication.
“I feel very comfortable with the nurses at Archer Family Health Care,” Kubotsuka said. “I feel like they really listen to my health care problems and care about me and are respectful of me.”
Several years ago, Kubotsuka obtained health insurance and briefly had to find another provider through a medical practice in Gainesville. She said it was not the same intimate, caring atmosphere that she is used to, and she was happy when she was able to return to the nurse practitioners at AFHC. She said especially as she and the rest of the population ages and she begins to experience more health problems, she is wary of the nursing shortage and what it may mean to health care.
“It’s a little scary because I’m a baby boomer, and I have noticed as I get I older, I need more care,” she said. “I know I may not get as much or as good care if there are not enough nurses that we need.”
She said her hope lies in the next generation of nurses being able to provide the same kindness and care that she has received, which has really made a difference.
“You can’t function without nurses,” she said. “They’re the backbone, I think, of the health care system. I think it’d crumble if you didn’t have nurses.”
The Changing Role of Nurses
Nurses are considered the heart of health care, and serve in myriad roles that range from diagnosing and treating in primary care, delivering babies, prescribing and administering medication, performing and assisting in medical procedures and — perhaps the most humbling and rewarding role — supporting and serving as advocates for patients and families.
But nursing has changed over the decades and many are asking what will the workforce lose as veteran nurses prepare to retire?
Eyrone Bush, MSN, RN, makes adjustments to a patient’s chemotherapy treatment at UF Health Shands Hospital.
Bush, a veteran nurse herself, earned her BSN degree from the UF College of Nursing in 1990. Her now-husband, Robert Bush, was in the same class and also works at UF Health. She said an aging baby boomer population with multiple comorbidities and critical needs, in addition to the demands placed on nurses, can also lead to burnout and contribute to the nursing shortage. After 30 years in bedside nursing, she is planning a new path to make a difference in nursing.
In December, Bush earned her Master of Science in Nursing degree and became a licensed advanced practice registered nurse because she said as she gets older, the physical and emotional demands of bedside nursing is starting to take a toll. As a nurse practitioner, she plans to retire from 8 East and practice nursing in the community, which will still allow her to make a difference but be a little less taxing physically and emotionally.
As for the next generation of nurses, she said there is power in the support nurses can receive from one another.
“I think one of the things we can do, because we don’t always take good care of ourselves as nurses, is be supportive and take care of each other,” Bush said. “It is a hard job and it’s very stressful. In the heat of the moment, anybody can be critical or heated or stressed. We have to step back and remember we are in this together and we can’t do it alone. It does take a village.”
The Future of Nursing
BSN student Marianna Colon in the College of Nursing’s Nursing Resource Center.
There may be a dire need for more nurses, but nursing is not for everyone. And certain specialties of nursing are more suited for some than others.
UF College of Nursing BSN senior Marianna Colon is a first-generation college student who grew up in a military family. She initially thought she wanted to be a doctor until volunteering at a hospital showed that nurses are the ones who interact the most with patients.
“Seeing the love and compassion and empathy that nurses have in everything that they do is what I wanted,” Colon said.
But it was not until she participated in a College of Nursing international study abroad trip to Grenada in the spring that she solidified her decision to pursue a nursing career. Specifically, Colon learned of opportunities in public health and the community that align with her own values after watching the Grenadian nurses, who are vastly outnumbered but still care for their patients like family and support one another.
“A lot of people have different definitions of what nursing is, and I was still trying to form my own,” Colon said. “But going to Grenada and seeing how these Grenadian nurses welcomed all of us in with open arms and took us under their wing, it just showed that nursing is also a family-oriented career.”
During her summer break, Colon worked as a night-shift certified nursing assistant three days a week. She said she has witnessed the nursing shortage, which leads to nursing burnout and high turnover in the profession. She knows an overworked nurse who skips lunches or bathroom breaks to care for patients can actually backfire and be a danger to patients.
BSN student Marianna Colon during an international study abroad trip to Grenada.
“I’m one that I like challenges, but this actually seems frightening in a sense because I already know with the shortage there is going to be a higher patient-to-nurse ratio, and with more patients to fewer nurses, it’s not going to be as safe,” she said.
But Colon is not daunted by the challenges that lie ahead for nursing. As she prepares to enter her last year in the BSN program, she knows she still has a lot to learn, and also a lot to contribute.
“Personally, I feel like with me becoming a nurse in general, I’m adding to the number and I can help any way possible. Since I do want to go further in my education, I can also come back and teach. Teaching will also rise up a new generation and encourage more nurses.”
