Nursing Economic$ Editorial Board member Karlene Kerfoot, PhD, RN, FAAN, interviewed Peter Buerhaus, PhD, RN, FAAN, FAANP(h). A long-time supporter of the journal and its mission, Buerhaus said, "Early in my career, I published my first article in the journal, and now, at the end of my career, I am once again working with Nursing Economic$. Thank you [Publisher] Anthony J. Jannetti, [Editor] Dr. Donna Nickitas, [Former Managing Editor] Kenneth Thomas, past editors, and many others at Nursing Economic$ who have supported my career, and a heart-felt congratulations on the journal's 40th anniversary!"
Karlene Kerfoot (KK): Are there any lessons from the past that we should consider when thinking about how the nursing workforce can emerge stronger from the COVID-19 pandemic shock?
Peter Buerhaus (PB): The last national shock to the nursing workforce occurred in the early 2000s, when there was a national shortage estimated at 126,000 vacant hospital registered nurse (RN) positions. This was not the largest shortage hospitals have experienced, but it was certainly a bad one – a "category 4" shortage that affected hospitals around the country. Many hospitals had to close inpatient care units and limit operations in outpatient facilities, resulting in decreases in quality of care, safety, and access to care. The shortage developed largely because the number of RNs entering the workforce shrank dramatically during the mid to late 1990s. At that time, hospitals were cutting their costs to become price-competitive and win contracts with health maintenance organizations and managed care organizations, which were being used to infuse market competition in health care. Indeed, the annual growth of hospital-employed RNs decreased to 1% from its usual yearly growth of 2% to 3%, and hospitals also reduced the number of clinical and administrative staff supporting nurses. RNs responded by taking to the streets, literally, protesting and marching in cities throughout the country, particularly in Washington, D.C., which the media covered extensively. For several years, the public viewed images of unhappy and angry nurses who often denigrated the nursing profession and hospitals. Unfortunately, the media's extensive coverage influenced the public's perception of nursing, and interest in becoming a nurse among college freshman decreased each year from 1994–2001. Enrollment into nursing education programs decreased, and graduations decreased from 97,000 in 1995 to 67,000 in 1999. RN shortages began to develop and reached levels in 2000 that severely impacted hospitals.
KK: I remember the turbulent '90s and the long and harsh shortage all too well. What happened to resolve the shortage?
PB: The American Hospital Association and The Joint Commission both published white papers on how to address nurses' concerns, developed high-level committees made up of nursing leaders, sponsored meetings and conferences, and made resolving the shortage their top priority. In 2000, my economics team published an article in The Journal of the American Medical Association forecasting the longer-term decreases in the growth of the RN workforce if the then current trends persisted. Jack Needleman, PhD, FAAN, a member of the Nursing Economic$ Editorial Board, and I published an article in The New England Journal of Medicine which provided evidence of an association of hospital nurse staffing with six or seven inpatient complications. These articles played a major role in the establishment of the Johnson & Johnson (J&J) National Campaign for Nurses Future, which reversed the negative imagery of nurses, and the passage of the Nurse Reinvestment Act of 2002 that provided nursing education programs with resources to increase enrollment. The Magnet® Recognition Program was gaining traction, foundations provided additional support of nurses, particularly the Robert Wood Johnson Foundation (RWJF), and hospitals paid attention to high-profile articles by Linda Aiken, Sean Clarke, and others about the quality of workplace environments and the association of higher proportions of BSN graduates with decreased mortality among surgical patients.
Together, these developments seemed to have positive impacts as, over the decade, national biennial surveys of RNs led by Karen Donelan reported increases in job and career satisfaction, improvements in the quality of the workplace environments, increasing quality and safety of care, and much greater willingness of RNs to recommend nursing to high school and college students. The national RN shortage soon ended. The lesson from the last great shock to the nursing workforce, I believe, is that guided by leadership, data, and high-quality evidence, positive changes in the nursing workforce can occur. Today we need strong leadership and much better data and evidence to help guide nurses, educators, and organizational leaders to help the workforce and health systems find ways to overcome the longer-term implications of the COVID-19 pandemic.
KK: This brings us to today's workforce. I am curious about what you think are the strengths of the nursing workforce.
PB: Another great question. To me, the COVID-19 pandemic has been so oppressive that many nurses and leaders in organizations have become focused largely on just getting through the day, let alone plan for tomorrow. But pandemic conditions have changed, and today, more nurses are thinking about the future. This is a good time for us to pause and consider the strengths of the RN workforce.
I can easily think of many strengths that we should build off of as we strategize to create a post-pandemic nursing workforce that is better able to meet the needs of society and address health-care delivery organizations needs to provide health care. For example, one strength of the RN workforce is that it is more highly educated. Since 2011, more RNs graduate each year with a BSN than an associate degree and today, roughly 50,000 RNs graduate each year with a masters or doctoral degree compared to less than 10,000 per year 15 or so years ago. Nationally, these educational gains have extended to RNs of color who have achieved or exceeded the educational attainment of White RNs. That is, the proportion of RNs of color who have earned a baccalaureate, masters, or doctoral degrees is at or exceeds the proportion of White RNs who have earned the same degrees. This is a wonderful accomplishment!
The RN workforce has become much more diverse – more diverse than many people realize – but we still have a long way to go to increase the proportion of Hispanic RNs so that they are proportional to the percentage of Hispanics in the population. To me, we are creating a diverse and educated workforce that once financed, can make meaningful improvements in decreasing the impact of social determinants of health (SDOH) that harm health and health inequities.
Another strength of the RN workforce is the persistent positive public perceptions of nurses, marked by 20 years of annual Gallup polls that have consistently reported the public ranks nurses highest in honesty and ethical standards of professions and occupations surveyed – 20 percentage points higher than physicians. Another large national survey conducted in 2019 found the public trusts nurses more than any other profession or group to improve the healthcare system – 30 percentage points higher than physicians. And Karlene, you and I know how foundations have contributed to support nurses in recent years, particularly the RWJF, the Gordon & Betty Moore Foundation, the Jonas Family, and J&J. I estimate these and other foundations have provided easily more than a billion dollars to support nurses over the past 15 years.
Adding to these strengths, is the rapid growth of the NP workforce since 2010, and projections the nurse practitioner (NP) workforce will more than double in size by 2030, reaching almost 400,000. Today, NPs are employed throughout the healthcare system, particularly in physician offices and hospitals, and a good 40,000 work in all types of community-based settings. There has been a tremendous growth in the literature providing evidence of how NPs contribute to quality of care, types of services provided, and lowering costs. And evidence shows how NPs contribute in other areas, such as reducing emergency department admissions, decreasing the number of physician malpractice payments, decreasing cesarian sections, increasing access to care for vulnerable populations, increasing access to behavioral and mental health care, and decreasing mortality associated with serious mental health conditions, including suicide. Pretty impressive.
Other strengths involve expanding graduations from nursing education programs each year since the early 2000s, steady growth in the number of Magnet® hospitals, hospitals' preference for hiring RNs with a bachelor's degree, very limited use of staffing ratios, and nurses contributions to inpatient quality and safety have become firmly engrained in quality improvement initiatives and even linked to hospital payment. And we have had two national reports from the National Academy of Medicine, one in 2010 and another in 2021, both providing recommendations on advancing the nursing workforce and strengthening nurses' capacity to address the health needs of society.
When we start to think strategically on how to create a better nursing workforce, we begin by identifying our strengths and incorporate ways to leverage them moving forward.
KK: Yes, one of the first elements of good strategic planning – know your strengths and leverage them. Before we get to the future of nursing, can you describe the major results of your research on the impacts of the COVID pandemic on nurses?
PB: This is a recently concluded project funded by the RWJF, J&J Foundation, the John A. Hartford Foundation, and UnitedHealth Group in which we determined the immediate economic impacts of the pandemic on RNs, licensed practical nurses (LPNs), and nursing assistants (NAs). We also have forecasted the pandemic's impact on the growth of the RN workforce through 2030. We gathered monthly workforce data on unemployment, earnings, and employment before the pandemic and during the pandemic through September 2022. Briefly, we found unemployment spiked early in the pandemic for RNs, LPNs, and NAs, but quickly dropped to pre-pandemic levels. We also found that unemployment rose more in 2020–2021 among nurses of color, especially LPNs and assistants, not by a lot, but enough to be statistically significant. Regarding earnings, the monthly data showed that wages, after rising to meet increases in inflation, increased another two percent for RNs, by nine percent for LPNs, and six percent for NAs. These are strong earnings increases and more than likely reflect organizations trying to cope with shortages of nurses.
Turning to employment trends during the pandemic, RN employment has decreased the least (-1%) compared to LPNs (-20%) and NAs (-10%). These declines persisted through 2022 for LPNs and NAs, and were largest for those under age 50. In 2021, we observed a sharp decrease in the RN workforce of almost 50,000 full-time equivalent RNs that was concentrated among hospitals. While we aren't sure why the size of the hospital workforce dropped so suddenly, it could be driven by several factors, including RNs being sick with COVID-19, needing to stay home to provide in-home schooling, taking care of parents or in-laws, and some RNs encountering quarantine and vaccination policies that kept them from working.
From a forecasting perspective, we want to know if the 2021 reduction in the number of employed RNs was a temporary phenomenon or perhaps signaled a permanent change. To make forecasting future growth of RNs more complicated, our analysis of monthly employment data through September shows a very large increase in RN employment that has more than made up for the 2021 reduction! Although we have not yet finished our work, I am feeling optimistic the RN workforce will growth substantially over the decade – more to come on that, soon.
KK: Speaking of the future, what do you see are the challenges the nursing workforce needs to be overcome in the years ahead?
PB: There are several challenges that need to be handled successfully, and I'll try to be concise. Let me begin by noting there does not appear to be a strategy that is commonly agreed upon by nursing and healthcare leaders on how to create the post-pandemic nursing workforce needed by society, employers, and nurses themselves. Rather, I hear people say we must regulate traveler nurses, must impose mandatory minimum patient to nurse staffing ratios, must separate nurses from hospital inpatient room charges, must pay nurses directly, must… you name it. To me, these suggestions mostly reflect long-held interests and strongly held passions and beliefs that are not well thought out – particularly in how they could be implemented successfully – and what specific outcomes they intend to achieve. It is unclear to me how any of these ideas, if implemented somehow, will benefit nurses or patients. I think they distract many nurses who have little time to read and think through all the implications of these ideas. I would rather like to see nurses at all levels take ownership of the workforce's future and create a strategy that identifies the problems that most need addressing and setting forth specific actions that will address them successfully, using the least amount of time, energy, and cost. Now that I have irritated some readers, let me get back to your question about the challenges facing the nursing workforce.
The immediate challenge is that we all must pay careful attention to the messaging about nurses and hospitals so that we can assure a growing workforce for the future. Starting in 2021, too much of the imagery, tweeting, media coverage, and social messaging about nurses and hospitals has been dreadful! Karlene, I fear if these negative messages are not counter balanced with positive portrayals of nurses, we risk decreasing entry into nursing education programs and growing the nursing workforce. This is on all of us – nurses, leaders, educators, professional associations, the media, social media, and unions. If we don't address this problem, then we risk repeating the 1990s drop in interest in nursing, enrollment, and graduations that fueled the last major national RN shortage I talked about earlier.
I think healthcare delivery organizations and the nurses they employ should reset their relationships. This is a confusing and uncertain time and calls for communication and rebuilding trusting relationships. Organizational leaders, particularly those in hospitals where nurses have been most directly impacted by the pandemic, should engage discussions with nurses to identify what worked well during the pandemic, where and how the organization's culture supported nurses, identify the innovations that nurses developed, talk about examples of nursing clinical and organizational leadership, and about the numbers of people who nurses tested for COVID-19, vaccinated, and whose lives were saved. There is much to be proud of. Similarly, these discussions should also identify where the organization got in the way, the aspects of the organization's culture that needs to be changed or discarded, what was done or said by nurse and leaders that was not helpful, and what needs to be improved.
Nursing students who experienced difficulty obtaining clinical hours during the pandemic need to hear from organizations that they are important, they are needed, and that organizations are prepared to provide enhanced on-boarding for new graduates to improve their skills and confidence. Nursing educators and deans, I believe, should develop relationships with organizational leaders and nurses so that everyone is, together, working to support each other. What I am thinking goes beyond practice education partnerships but is a deeply felt relationship in which everyone is committed to each other's success.
Another challenge involves resetting the economic relationship between nurses and hospitals. I don't believe hospitals and nurses want to ever go through another year like 2021 and a good part of 2022, when many nurses traveled across town to work in a hospital that offered higher earnings.
I think there are two ways to reset the economic relationship. First, I believe nurses should embrace hospitals' transition to value-based payment. At its core, value is about two things: the outcomes produced and how much it costs to produce the outcome(s). Value-based payment reimburses hospitals more for achieving better outcomes at lower costs and pays hospitals less for achieving lower outcomes/higher costs. Consequently, nurses who find ways to improve outcomes and lower costs will not only improve patient care, but contribute to the economic stability of the organization, empower themselves, and shift the focus on nurses away from costly labor and more toward 'revenue generators.' The pandemic slowed the momentum to value-based payment systems, but this will change in the years ahead, and I believe current nurses and future nurses need to practice what is termed value-informed nursing practice.
To speed up nursing's ability to contribute to value, hospital chief financial officers must recognize their economic interests are increasingly tied to a well-prepared and value-informed nursing workforce. They and their staff need to spend time working with and supporting value-informed nursing practice among nursing leaders and clinical staff in their organization. It is also important to find ways to educate and work through value creation with nursing faculty so that they can teach value informed nursing practice. Faculty can work with hospitals to co-design value improvement ideas, implement them, evaluate, refine, and scale improvements. Sounds a lot like quality improvement. How about adopting 'value-informed nursing practice improvement.' For value-informed nursing practice to succeed, it is critical to ensure nurses who contribute to higher value care are rewarded in ways that are most meaningful to them and to their patient care units. My colleagues Olga Yakusheva and Betty Ramber and I have published a series of short articles that more fully explain value-based payment and the implications for nurses.
The second way to reset the economic relationship between hospitals and nurses is to prevent the imposition of mandatory minimum patient to nurse staffing ratios. In my view, some unions and nurses appear to be taking advantage of the instability created by the pandemic to demand staffing ratios. I could not think of a worse policy! I have written about ratios (see the reference list at end of this article) and the harm they will cause, so I will only say here that imposing ratios will poison the relationship between organizations and their nursing staff. Briefly, ratios will: disrupt the dynamic relationship between an organization's use of capital and labor that is needed to constantly find ways to improve quality and lower costs, and inevitability leads to inefficiency providing patient care, increased costs, and do little if anything to improve quality; impact hospitals inequitably as some hospitals, particularly those with tight financial margins or who are located in areas without nursing education programs; add additional costs connected to compliance; decrease the quality of patient care in certain circumstance; devalue the positive public image of nursing; decrease the economic value of nurses at the very time policy is embracing value-based care that aims to increase quality and decrease costs; and ratios are an endlessly and enormously costly regulatory imposition that, when they inevitably don't work, advocates will say that all we need is more regulations to get the desired effects (see references).
Further, ratios will do nothing to solve the issues which affect nurses' workplace environment that have to do with managing unwieldy electronic medical record systems, poorly functioning technology and equipment, difficult physicians and poor nurse-physician relations, poor unit management/leadership, burdensome and excessive regulatory compliance, uncooperative and unproductive support staff and co-workers, lack of nurse competence, skills, teamwork, communications, and poor attitudes. These are examples of some of the problems that nurses and hospitals, together, should address. Imposing ratios will only add more problems for nurses and hospitals at a time when we need to be fixing problems, not creating new ones.
To create the nursing workforce we need, we should anticipate helping educate younger nursing students who are academically or psychologically under-prepared for nursing education because of pandemic-induced disruptions in their education. ATI Testing [assesses a student's preparedness to enter the health sciences fields] has examined this problem and is sounding the alarm. Such students will also likely need additional clinical preparation when they graduate and enter the clinical workforce. Similarly, we should prepare for the retirement of an estimated 500,000 RNs (70,000 each year) who will leave the workforce by the end of the decade. Note, the retirements are less likely to impact the inpatient acute care clinical workforce, but rather will impact occupational health, rehabilitation, home health, and long-term care settings. Additionally, large numbers of hospital chief nursing officers and nursing faculty are currently in their 50s and 60s, and can be expected to retire. A few years ago, my team published strategies on how to prepare for retirement of the baby boom generation of RNs (see references).
Beyond these challenges, we must prioritize the elimination of state- and organizational-level, and payer restrictions placed on nurse practitioner scope of practice. Numerous studies provide evidence of how such restrictions decrease access to care especially to the roughly more than 80 million Americans have inadequate access to primary care. I am unaware of quality-of-care lapses in states that lifted regulatory restrictions on nurse practitioners on an emergency basis during acute phases of COVID-19. These states should not re-impose these restrictions.
As described in chapter three of the National Academy of Medicine's The Future of Nursing 2020–2030 report, there are major gaps between society's growing healthcare needs: aging population, inadequate access to primary care, mental and behavioral health, maternal mortality, and inadequately sized, prepared, and distributed RN and advanced-practice registered nurse workforce. These gaps need to be narrowed as soon as possible, and I believe we have reached the point that nursing education programs need to be held accountable for producing the types of nurses needed to narrow these gaps.
There are two more challenges that come to mind. First, as I noted earlier, we have come a long way in growing a more diverse and educated workforce especially among RNs of color. We have The Future of Nursing 2020–2030 report that provides many ideas and recommendations for how nurses can address SDOH that negatively impact health and decrease health inequities. But what we don't have is the financial means to enable RNs to practice in these areas. Fortunately, the Centers for Medicare & Medicaid Services (CMS) has started to include outcome measures to enable organizations to be reimbursed for addressing SDOH and health inequities. As explained in the financing chapter in the 2020–2030 report, we need nurse-sensitive indicators to be included in reimbursable outcomes so that hospitals will be incentivized to use its nursing workforce to address these problems. If hospitals are not paid for using its nursing workforce to improve SDOH and reducing health inequities in their communities, it is difficult to see how nurses will have the means to make meaningful impacts. Once again, incorporating nurse-sensitive SDOH and health equity outcomes into emerging value-based payment systems creates the financial means for nurses and hospitals to address this challenge. Nursing's policy leaders and professional organizations need to work closely with CMS officials to make decisive changes in payment. If not, then I fear we'll spend years producing more articles and reports describing well known problems and bemoaning the lack of achievement until eventually something else comes along and attracts our attention away.
The final challenge on my mind is addressing shortfalls in the nursing workforce in taking care of the growing number of older people. If we continue to have nursing homes and other long-term care facilities providing care to older and frail adults, then we must overcome chronic understaffing, and I suggest doing this by seriously considering doubling or even tripling salaries. Sometimes economics are the best tool to evoke change quickly, and I suspect that significant salary increases would quickly improve staffing. But I don't think that long-term care organizations have the capacity to provide the needed salary increases and, therefore, I wonder if the time has come for federal and state governments to provide the means to increase care giver earnings. Millions of people and many organizations throughout the country received sizeable economic benefits from federal COVID-19 relief measures during 2020 and 2021, so I don't see why increasing worker pay for providing needed geriatric care should be excluded from public subsidies. It seems to be a matter of what society values and what it wants to pay for. Let's use economic means to get the workforce needed to address the needs of older people immediately, and then make long overdue changes in care delivery models for the aged.
This is a formidable list of challenges facing the nursing workforce. But we have managed through prior shocks that affected healthcare delivery organizations and nurses. Strong leaders emerged, and researchers provided high quality data and evidence to help guide public and private policy decisions in the early 2000s. Subsequently, the nursing workforce developed many strengths that today, if recognized and leveraged, enable nurses to overcome challenges in creating the nursing workforce needed for the future.
KK: Peter, there is no way we can thank you for your career of contributing to the sophistication of nursing and healthcare economics, and to the professional growth of the profession. Without your influence, we would not be as strong. Thank you for your commitment to nurses and patients by always pushing for better outcomes for nursing and patients. And thank you, Peter, for your commitment to publishing your results and the 'bookends' you have contributed to Nursing Economic$ from the beginning of your career to now. You are such a wonderful role model for all of us!
PB: As always, Karlene, it was wonderful to talk with you. Thank you! And to Nursing Economic$, thank you for making an important difference in elevating knowledge to help nurses
Nurs Econ. 2022;40(6):270-277, 311. © 2022 Jannetti Publications, Inc.
