Nursing Shortage: What Research Shows About the Crisis and Long-Term Solutions

The nursing shortage in the United States is a chronic and worsening problem that researchers, healthcare systems, and policymakers have grappled with across multiple cycles of shortage, recovery, and renewed shortage. The COVID-19 pandemic dramatically accelerated existing trends by accelerating retirements, burning out active nurses, and disrupting nursing school education, producing shortfall projections that are the most severe in recent history. Understanding what research shows about the causes of the shortage, its effects on patient outcomes, and the interventions with the strongest evidence for addressing it is essential for policy that can produce durable improvement. Nursing is the largest healthcare occupation in the United States, with approximately four million registered nurses and a substantial additional workforce of licensed practical nurses and nursing assistants. Despite this large workforce, demand for nursing services regularly exceeds supply, driven by an aging population that requires more healthcare, an aging nursing workforce that is approaching retirement in large numbers, and educational capacity constraints that limit how quickly new nurses can be trained. Research projecting future workforce dynamics finds that the imbalance between supply and demand will persist and likely worsen through the 2030s if current trends continue. The pandemic effect on nursing was severe and documented. Research on nursing workforce trends during and after COVID-19 finds elevated rates of burnout, intent to leave nursing, and actual departure from the profession among nurses who experienced the pandemic at the bedside. Studies using validated burnout measures found rates of emotional exhaustion and depersonalization far exceeding pre-pandemic levels, particularly among nurses in intensive care units and emergency departments. Surveys of nursing intent to leave found that substantial proportions of nurses planned to leave their positions within one to three years, driven by workload, staffing inadequacy, and trauma from pandemic losses. Nurse-to-patient ratios are a central issue in both working conditions and patient safety research. Research on the relationship between nurse staffing levels and patient outcomes consistently finds that higher nurse-to-patient ratios are associated with worse outcomes including higher mortality, more preventable complications, and longer hospital stays. California mandates minimum nurse-to-patient ratios for different hospital units, and research comparing California outcomes to other states finds better patient outcomes in California, providing evidence that minimum staffing standards improve care quality. Efforts to enact similar mandates in other states have faced resistance from hospital industry groups citing cost and workforce availability concerns. Nurse education capacity is a significant bottleneck in addressing the shortage. Nursing schools turn away large numbers of qualified applicants each year, not because of insufficient student demand but because of shortages of clinical training sites, faculty, and classroom space. Research on nursing education capacity finds that faculty shortages are a primary constraint, driven by faculty salaries that are substantially lower than what nurses with equivalent clinical expertise can earn in practice settings. Increasing faculty compensation and expanding clinical training partnerships with healthcare systems are strategies that some states have implemented to expand education capacity. The nursing workforce is aging alongside the patient population, with a significant share of registered nurses approaching retirement age over the next decade. Research on nursing workforce demographics finds that retirement of baby boomer nurses will remove experienced nurses from the workforce at a rate that new graduates cannot replace without both expanding graduation numbers and reducing attrition among active nurses. Succession planning, knowledge transfer from experienced to newer nurses, and phased retirement options that allow older nurses to remain engaged in mentorship roles are strategies that research supports. International nurse recruitment is a significant and controversial component of the US nursing workforce strategy. Large numbers of nurses are recruited from the Philippines, India, Nigeria, and other countries to fill domestic shortfalls. Research on international nurse migration finds that it provides short-term supply relief but raises ethical concerns about brain drain from countries that also face nursing shortages and have invested public resources in nursing education. Healthcare systems that rely heavily on international recruitment may also face disruptions when immigration policy changes affect visa availability and processing. Working conditions are a primary driver of nursing turnover and attrition. Research on factors associated with nurse retention finds that workplace violence, which research documents as disturbingly common in healthcare settings, is a significant driver of departure. Nurse-identified factors most associated with intent to leave include insufficient staffing, inadequate support from management, exposure to violence, moral distress from being unable to provide care they believe patients need, and excessive administrative burden. Interventions that address these working conditions, including safe staffing policies, zero-tolerance violence protocols, and leadership development for nurse managers, are associated with improved retention in research.