1. Sofer, Dalia


Can this shifting workforce circumvent a nursing shortage?


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The aging of the baby boom generation will soon lead to the retirement of a sizable number of U.S. nurses-as well as to an increase in the number of older adults needing care. By 2030, the number of people in the United States ages 65 and older is projected to be about 70 million, meaning that a large proportion of the population will be living with chronic conditions that may require complex health care. According to a study in Forum for Health Economics and Policy, the rate of all major chronic conditions-high blood pressure, heart disease, diabetes, cancer, stroke, and lung disease-is expected to rise among the elderly, driven by higher rates of obesity and by greater life expectancy. It's estimated, for example, that the prevalence of diabetes will increase from about one in four older adults in 2010 to nearly four in 10 in 2030.

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At the same time, the nursing workforce is growing older: between 2001 and 2015, the percentage of full-time RNs ages 50 and older increased by 11% (from 26% to 37%). While a severe nursing shortage has until now been averted thanks in part to the Great Recession, which prompted many nurses to postpone retirement, it's estimated that by 2030 approximately 1 million RNs will have retired.



This grim picture, according to a recent study in Health Affairs, has one bright spot: millennials. Unlike their predecessors-Generation Xers who turned away from nursing in favor of professions previously unwelcoming to women, such as law, business, and medicine-millennials, born between 1982 and 2000, have been embracing the nursing profession as the baby boomers did in the late 1970s and '80s. And they've been doing so in even greater numbers: those born in the late '80s were 65% more likely to become an RN than those born in 1955.


Even among millennials, nursing remains dominated by women. "The number of men among the millennials entering nursing is increasing slightly, [but there are] no major increases," says Peter Buerhaus, PhD, RN, FAAN, coauthor of the Health Affairs study and director of the Center for Interdisciplinary Health Workforce Studies at Montana State University. In a 2017 study in Nursing Economics, Buerhaus and colleagues found that the percentage of full-time-equivalent (FTE) male RNs increased from 9% in 2001 to 12% in 2015.


Despite the recent popularity of nursing as a career choice, the influx of millennials into nursing has plateaued in recent years. While the number of RNs taking licensure exams doubled between 2003 and 2013, it remained constant between 2013 and 2016. Given the acceleration of nurses' retirement and the stabilization of the number of millennials entering nursing, the authors of the Health Affairs study predict that between 2015 and 2030, the RN workforce will expand by 36%-a rate of 1.3% annual per capita growth-to a total of just over 4 million (it is currently about 3 million). "Whether a growth rate of 1.3% per year will be adequate to prevent large national shortages, particularly in light of the aging population," the researchers write, "is difficult to gauge."



The possibility of experiencing a nursing shortage may depend on where you live. A 2012 report in the American Journal of Medical Quality predicted that a shortage would most likely occur across the country, but that western and southern states would be particularly affected. Florida, which has the fastest-growing demand for RNs of any state, is expected to be hit hardest. Only two states-Massachusetts and South Dakota-are forecast to have a nursing surplus in 2030.


But the potential nursing shortage isn't just about numbers of nurses; experience and education also play a part. The exodus of the 1 million RNs who will retire over the next 12 years will be accompanied by a vast loss of accumulated nursing experience. Buerhaus estimates that by 2030 the number of years of experience lost (the product of the number of RNs leaving the workforce and the average years of experience for each) will be about 2 million-a dramatic forfeiture of nursing knowledge and expertise, which, he predicts, could affect the quality of care.


As if in response to this loss of experience, more U.S. nurses are seeking higher education. In 2015, nurses with a bachelor of science in nursing or a graduate degree made up 62% of all FTE RNs, up from 55% in 2001. Yet here, too, obstacles persist. While enrollment in nursing programs is on the rise, a shortage of nursing school faculty is slowing the rate. According to the American Association of Colleges of Nursing (AACN), nursing schools turned away 64,067 qualified applicants from baccalaureate and graduate nursing programs in 2016 because of factors such as an insufficient number of faculty, shortages of clinical sites and classroom space, and budget constraints. Furthermore, of 821 schools of nursing surveyed regarding vacancies in the 2016-2017 academic year, 56.2% reported having vacant full-time positions, while 16.2% said they needed additional faculty even though they didn't have vacant budgeted full-time positions. Most vacancies (90.8%) were for positions requiring or preferring a doctoral degree.


To help alleviate the faculty shortage, many programs are under way. The Jonas Nurse Leaders Scholar Program, for example, sponsored by the Jonas Center for Nursing and Veterans Healthcare, has offered grants and support to over 1,000 scholars at 140 schools nationally since it was established in 2008. The Minority Nurse Faculty Scholarship, launched in 2008 by Johnson and Johnson and the AACN, offers financial support to graduate nursing students from minority backgrounds who agree to teach in a school of nursing after graduation. Much also depends on the fate of the Title VIII Nursing Workforce Reauthorization Act of 2017, which would extend through fiscal year 2022 such nursing initiatives as education grants, training opportunities, diversity promotion, and faculty loan repayment programs.


With so many factors at play, the future of the nursing workforce remains uncertain. One unlikely and controversial helper may come in the form of robots-which are already assisting at hospitals worldwide. "TUG," an American-made "mobile delivery robot," transports food, medications, and linen; Belgium's "WellPoint" enables patients to monitor their vital signs and delivers the results to the clinician; "Robear," manufactured in Japan and still a prototype, lifts patients in and out of beds and wheelchairs. Time will tell if patients will take to robotic assistance and whether questions of ethics regarding the use of artificial intelligence in health care will be adequately addressed. But for now, one thing remains fairly certain: most Americans will likely feel the absence of nurses at some point in their future health care.-Dalia Sofer