Introduction
Nurses make up the largest section of the healthcare profession and spend more time with patients than any other care team member. During the COVID-19 pandemic, many people learned the incredible impact hospital nurses have on patient care. After at least three pandemic surges across the country, we, as a society, learned that one of the main rate-limiting factors to expanding access to care during COVID surges was not access to beds or sufficient supplies. A major issue was having enough specially-trained nursing professionals to take care of patients, particularly as COVID led to absences due to provider illness and burnout. The typical nurse-to-patient ratios are 1:4 in the non-critical care setting and 1:1 or 1:2 in critical care, but during COVID, nurses were providing care to as many as six critical care patients at a time. As a result, the nursing profession became overworked and burned out. Nearly 30% of nurses left the profession within two years of the pandemic as part of the Great Resignation. This occurred during a time when workplace violence against nurses was common. Although the pandemic has since subsided, and nurses are happier and more satisfied with their work in 2024 than in any year since the pandemic, hospitals and other healthcare entities are still struggling with having sufficient nursing staff. In fact, The International Council of Nurses has identified the shortage of nurses as a global health emergency.
Causes of the Nursing Shortage
The causes of the nursing shortage are multifactorial. A systematic review identified that some of the main factors leading to the shortage are ineffective policies, poor human resource planning, inadequate workforce recruitment, and lack of leadership management. The main barriers affecting new entrants to the profession include cost of education, decreasing nurse enrollment, and lack of available training, including insufficient clinical sites for new nurses. Meanwhile, the main causes of nursing staff turnover are lack of social support, work overload and low‐level job satisfaction as well as poor salaries and poor working conditions. When nurses have to work long hours, it leads to increased stress, burnout and psychosomatic disorders such as back and shoulder pain, anger and worry that impacts nurses as well as their families and social relationships.
Impact of the Nursing Shortage
The impact of the nursing shortage has been extensively researched. According to several studies, the nursing shortage has a direct effect on patient health outcomes due to delayed detection of patient complications and insufficient care. In one study, poor staffing and resource adequacy resulted in a 39% increase in missed care, including failure to provide comfort measures, failure to provide skin care, failure to update the nursing care plan, and failure to document what care was done. The same study showed a significant association between missed care and patient adverse events, including medication error, infection, falls, patient complaints, and verbal abuse towards nurses.
Pennsylvania as a Case Study
The State of Pennsylvania has fifth largest elderly population in the United States. More than 20% of its population is over the age of 65 years. Due to the stress of the pandemic, retirement, an aging workforce, a lack of nurse educators, and an increased need for acute care, projections are that Pennsylvania will have a shortage of 20,000 Registered Nurses by 2026, with an average job vacancy rate of 14%.
A survey by the Hospital and Healthsystem of Pennsylvania recently concluded that nearly 70% of hospital administrators reported longer wait times in emergency departments and long waits for medical appointments and medical procedures. Due to staffing issues, about 30% of Pennsylvania hospitals have ceased offering certain medical services or have reduced availability of medical services.
Just as the causes of the nursing workforce shortage is multifactorial, so are the solutions. Pennsylvania has taken a multifactorial approach to address the shortage, as follows:
- Tuition Reimbursement. In March 2025, Pennsylvania Governor Josh Shapiro announced a $5 million proposal to fund hospitals partnering with nursing schools and to reimburse tuition for nurses who commit to a three-year placement in Pennsylvania hospitals. This Nurse Shortage Assistance Program will be the first time the state has stepped in to mitigate the shortage. South Carolina initiated a similar program in 2024, and new data evidences that the plan is working.
- Addressing Workplace Violence. In 2020, Pennsylvania made it a felony to assault a healthcare worker and established laws to protect healthcare worker identities allowing workers to omit their last names from photo ID tags.
- New Training Hubs. Western Pennsylvania has a new training hub for nurses' aides. The hub is funded by a PA Industry Partnership grant and is intended to combat Pennsylvania's healthcare staffing crisis.
- Independent Scope of Practice. Pennsylvania Governor Shapiro has expressed support for legislative expansion of Nurse Practitioner scope of practice. Nurse Practitioners more commonly provided care to rural and critical access areas and will expand patient access to care.
- Hospital Collaboration. Pennsylvania hospitals are collaborating with technical schools, colleges and universities, and nursing schools to increase entrants to the profession. Examples of hospital–educational partnership include: WellSpan and Jersey College; Penn Highlands Healthcare and Central Pennsylvania Institute of Science and Technology; Pennsylvania College of Health Sciences and LG Health/Penn Medicine; and Reading Hospital School of Health Sciences and Alvernia University.
In combination, these strategies represent thoughtful efforts to address the main barriers identified above and to improve Pennsylvania's nursing workforce position.
Focused Strategies to Impact the Nursing Shortage
In addition to strategies like those being implemented in Pennsylvania, healthcare entities may look internally to provide any of the following approaches:
- Access to Care Programs. Support on-going education and training efforts in the community the hospital serves, including through application for grant programs and other pilot programs to improve access to care.
- Improve Compensation Packages and Retention Bonuses. According to the 2024 State of Nursing Report, nurse pay still falls short of expectations. Twenty-nine percent of nurses are supplementing their income with a secondary source. Of the nearly 2,500 nurses surveyed, most felt that improved staffing ratios and better pay would help retain seasoned nurses and recruit new ones. When it comes to attracting new talent, sign-on bonuses are commonplace. With the rise of AI, data analytics could be used to pinpoint high-need zones and tailor nursing recruitment to those areas of need.
- Address working conditions and provide more support staff. Some hospitals are contracting with third party entities to provide nursing staff with free mental health services on an as needed basis. Data shows that when staff are happy at their job, it positively impacts work environment, employee retention, patient satisfaction, patient outcomes, and professional liability. Improving the everyday experience is achievable through organizational empowerment and implementation of technological advances – with proper training to avoid technological resistance.
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