Leaders in all healthcare arenas know the words nursing shortage. Some may feel better calling the shortage a staffing challenge but certainly we are in the midst of a human capital crisis. Most hospitals, nursing homes as well as home care agencies are experiencing the staffing challenges [1]. A survey from the American Association of Critical Care Nurses found that 92% believe the pandemic has depleted nurses and will cut their careers short and 66% have considered leaving nursing after their experience in the pandemic [2]. The global shortage of nurses, estimated to be 6.6 million in 2016, has decreased slightly to 5.9 million nurses in 2018. An estimated 5.3 million (89%) of that shortage is concentrated in low- and lower middle-income countries, where the growth in the number of nurses is barely keeping pace with population growth, improving only marginally the nurse-to-population density levels [3]. Improving the shortage by 2030 in all countries, of nurses completing programs and passing their examinations for licensure would need to increase by 8% per year on average. Additionally, how the nurses are retained in their positions alongside an improved capacity to employ them should be considered (p. 5). Nursing homes in every state, along with Washington, DC, are informing CMS in parallel that they have a shortage of valuable nurse resources. According to the latest release of CMS’s COVID-19 Nursing Home Data set, 15.7% of all nursing homes nationwide reported a nurse staff shortage. The percentage of state-level nurse staff shortages ranged from 29.7% in Alabama to 1% in California. Fourteen states reported that between 20.1%-29.7% of their nursing home facilities were suffering from nursing staff shortages, potentially negatively impacting their ability to contend with a still unfolding pandemic sequelae. Furthermore, 234 nursing homes across 40 states in the nation reported a staff shortage across all available categories (nursing, clinical, aides, and other). Of those states, Texas has the greatest number of nursing homes reporting across the board staff shortages (41 facilities), while Ohio came in second with 21 facilities. The American Health Care Association and National Center for Assisted Living released a report showing long term care facilities are suffering from the worst labor crisis and job loss than any other health sector demonstrating a loss of 221,000 jobs [4]. Only 1% of 1,100 nursing home and assisted living operators said they are have sufficiently staffed [5]. Turnover rates globally place the United States second and a significant proportion of turnover costs are attributed to temporary replacement, highlighting the importance of nurse retention [6].

The United States needs more than 550,000 new grads to enter the workplace to ensure adequate nursing coverage. and supply a needed 1.1 million RNs in 2022 Buerhaus et al. [7]. Shortages are due to a number of factors, burnout, retiring nurses, and pandemic caused attrition of seasoned nursing staff. In addition to nurses leaving, there is a significant skills deficit left by losing experienced nurses with potential for jeopardizing patient care and safety [8, 9]. Skilled nurses leaving may not have mentored younger replacements creating opportunities for performance gaps, lost skills, loss of knowledge of processes and procedures that experience can support. The knowledge and lack of mentor support can cause holes in organizational systems creating opportunities for patient safety deficits, and working condition challenges. According to the American Nurses Association [10] the health care system is strained by an aging population and the care requirements of a diverse population. New technology requirements and challenges, breaches in technological security systems, the multitude of requirements for regulatory compliance, including changes related to COVID-19 and requirements to provide safe and effective care may culminate in nurses feeling the weight of patient safety, and care responsibility on their shoulders in a chaotic climate of practice. Changing operational system demands loom large and create workplace stresses that may be felt by staff in the workplace. By 2022, there will be far more registered nurse jobs available than any other profession, at more than 100,000 per year. The health care system strain is impacted seriously with more than 500,000 seasoned RNs anticipated to retire, the U.S. Bureau of Labor Statistics projects the need for 1.1 million new RNs to replace nurses retiring, and avoid a nursing shortage [11]. Complicated by the world pandemic with new variants emerging and a potential for nurses both vaccinated and unvaccinated to contract the COVID-19 illness with a risk of disability and death, there is further need to recognize additional nefarious factors that cause shortages in the nursing workforce.

During the first year of the Pandemic more than 3600 healthcare workers died [12]. Lower paid workers, nurses, nursing home and support staff were more likely to die than physicians. Additionally noted was the racial inequity as 2/3 of the healthcare workers who died were identified as people of color. This is a finding that needs immediate analysis and preventative strategies. Healthcare workers that are a part of the team also impact the successful ability of the nurse to perform optimally. Critically important is recognizing that other healthcare shortages impact the nursing experiences, unit care, as well as the tendency to leave. Estimates of physician shortage may reach approximately 104,900 physicians by 2030 driven by decreasing working hours, retirement, and increasing demand, particularly from aging baby boomers [13]. The nursing population is also aging. In 2000, only 9% of nurses were younger than 30 years old, and more than 330,000 registered nurses were projected to retire between 1998 and 2008. Shortages are due to a number of factors, burnout, retiring nurses and even pandemic deaths. Nurses as an occupation in health care achieved the highest death rate at 32 percent [14].

The number of boomer RNs peaked at 1.26 million in 2008. Subsequently, the baby boomer RN cohort began retiring in large numbers [15]. The anticipation of baby boomers exiting the workforce is paramount to planning for healthcare services and providing quality patient care. Developing a strategic plan for replacement of nurses who anticipate retiring should be inclusive of both analysis of numbers of retiring nurses as well as the speed of replacements required to maintain staff and prevent decline in care processes and quality services. The plan that is formulated must include a region specific analysis of both nurse retirement anticipated patterns as well as replacement speed to support quality care [7]. Nurses form the backbone of the healthcare system in every organization and are integral to interprofessional team performance and leading the provision of quality care. Gallup places nurses as one of the most trusted professionals for 20 years in a row [16]. The need for every organization to honor, retain, develop and promote nurses is paramount.

Education is of utmost importance as students require an educational pathway to licensure and teaching and precepting faculty shortages are representative of a supply and demand crisis. According to the American Association of Colleges of Nursing [17] the nursing schools across the United States turned away 80,407 qualified applications from baccalaureate and graduate nursing programs in 2019. Although salaries are not always listed as a prominent reason, there is justifying concern and discriminating evidence of higher compensation in clinical and private-sector settings, and travel nursing. Salaries are not comparable according to the American Association of Nurse Practitioners, [18] as the median base salary of a nurse practitioner, across settings and specialties, is $110,000. By contrast, [19] reported in March 2020 that the average salary for a master’s-prepared Assistant Professor in schools of nursing was $79,444.

This monetary advantage is luring potential and current nurse educators away from teaching at the college level. Until we compensate equitably the positions vacant in university and associate degree schools may remain empty causing student admissions to be impacted negatively. The current demand for master and doctorally prepared nurses for advanced practice, clinical practices in hospitals and homecare, teaching, and research far outweigh the supply [19].

Actions to support nurses and those who choose nursing as their profession must be blasted to social media, news outlets, and employers. Opportunities to improve knowledge of this crisis include media notifications, professional association newsletters and published employer based strategic outcomes proactively anticipating and addressing the retention needs and potential retirements of human capital. Management should be transformative, improvise, use team creativity, and recognize the importance of nursing human capital with efforts to maintain staffing stability through retention and hiring practices. Examples of processes to improve retention and staff stability are as follows:

1. Leadership should establish a culture of humanity. Transformational leaders know their staff, talk to their staff and assist the staff to do their best to achieve a workable schedule for work life balance. Supporting staff when sudden illness occurs in the family and emergent situations occur without making the nurses feel bad is critically important.

2. Use internal pools of staff to supplement staff challenges. Pay well upfront and use financial incentives for extra shifts. Analyze travel staff costs and support current staff financially. Creative analyses of overtime, supporting available shifts with appropriate shift exchange to improve flexibility to satisfy human life schedules. Special events and school conference days are critical to proactive staffing. An on-sight day care is helpful to mothers and grandmothers.

3. Recognizing staff through competitive pay and benefits that requires a frequent review of community compensation packages ensuring fair market wages. Educators need to be compensated and attracted with benefits equal to clinical nurses for all the positions at levels of student nurse education, from Associate to Bachelor’s degrees and Master’s and Doctoral degrees.

4. Recognition of employees who do a good job and go above and beyond frequently with a monetary thank you and a certificate of recognition is important.

5. Close monitoring of the civility of the work environment through employee satisfaction surveys and regular rounding is a healthy environment maintenance function.

6. Careful analysis and conversations with those staff who are turning over is valuable for lessons to learn and identification of retention issues.

7. Creative problem solving with the health care team members from all departments helps ensure all employees are aware of department struggles which may impact performance within their own niche. Transparency is important.

8. Train leaders to be transformative so that workers are inspired and are actively engaged in self-improvement endeavors. Reward publicly steps toward a degree or other self-improvement plan you have sanctioned. An article in the local paper is helpful and demonstrates creative recognition.

9. Anticipate changes and updates from regulators, best practices, and policy adoptions. Implement at a pace to support staff, as performance improvements are integrated into the regular daily practices. Remember to discuss the why of change and the role of each team member.

10. Value loyalty and longevity and creativity. Recognize nurses for years of service, and creative problem solving. Train staff to be comfortable with conflict. Different ideas encourage creativity.

11. Talk to staff. Regular dialogue opportunities encourage conversations where opinions can be verbalized demonstrating the employees are valued. Foster resilience and prevent moral distress.

12. Shared governance implemented on the nursing units to encourage active participation and engagement of leadership and decisions.

13. Be strategic and transparent in planning for the future nurse retirements and other positions such that mentorship can support a logical and organized succession planning.

Waiting to take action to support, retain and consider the health of the work environment for nurses may result in terrible costs and negative outcomes to patients and nurses now and in the future. The time is now to sound the alarm using all the available resources.

Competing Interests

The author declares that she has no competing interest.