Address the nursing shortage with realistic staffing and fair contracts

America’s persistent nursing shortage reached a dramatic new inflection point earlier this year when 7,000 New York City nurses went on strike, alleging that their hospitals are so short staffed they’re unsafe. New York’s strike comes on the heels of 714 strikes or labor actions from healthcare personnel over the past two years, many centered around inadequate staffing and pay. In a 2022 survey, more than 90 percent of nurses reported staffing shortages at their organizations.

Policymakers at all levels of government have taken steps to increase the number of nurses entering the profession through investments in nursing education. However, new programs will be of limited effectiveness if they are not paired with reforms that prevent nurses from leaving the floor altogether, starting with staffing policies that limit the number of patients per nurse and banning all types of health care employers from requiring workers to sign noncompete agreements.

Concerns about healthcare and nursing shortages are nearly as old as the nursing profession itself. During the Crimean War, Florence Nightingale trained a group of women to provide standardized sanitary interventions because insufficient physician staffing led to high rates of patient mortality. Yet the health care system has long struggled to train and retain enough nurses to keep patients safe, which can increase worker injuries, diminish patient safety and leave staff vulnerable to violence, burnout and mental and physical strain. 

A 2021 study of New York state hospitals — where nurses were assigned an average of 6.3 patients each — found that each patient added to a nurse’s load was associated with higher rates of in-hospital mortality, longer lengths of stay and higher rates of readmission. Staffing ratios of 4:1 saved an estimated 4,370 lives and $720 million over two years. 

Three main factors contribute to the current nursing shortage: demographics, educational pipelines and working conditions. Stereotypes of nursing as a woman’s profession — an example of occupational segregation — mean men are less likely to pursue nursing, while the expansion of professional opportunities for women throughout the 20th century further lessened the pool of available workers. Today, the aging of the Baby Boomer generation and innovations in medical science to extend lives also mean that the nation requires more care. The nursing workforce itself is increasingly nearing retirement, while not enough new nurses are entering the workforce. In 1978, 45 percent of nurses were between the ages of 18 and 34; in 2021, that number was only 29 percent.

And educational institutions lack adequate capacity to train aspiring nursing students. In 2021, nursing colleges turned away more than 90,000 qualified applicants, largely due to a lack of clinical placements, faculty and facilities.

The federal government, states and localities have sought to alleviate the nursing shortage by addressing educational pipelines. Becker’s Hospital Review counts at least 135 new or expanded nursing programs in 2022. Last fall, the U.S. Department of Labor announced an $80 million investment to support career pathways from direct care roles into nursing and increase the number of nursing instructors. The approved federal fiscal year 2023 budget includes nearly two dozen earmarks for nursing education.

And yet, once trained, nurses are increasingly leaving the profession. In 2021 alone, more than 100,000 registered nurses exited the profession, the greatest decline in the last 40 years, and in June 19 percent of nurses surveyed considered leaving direct patient care in the next 6 months. Many nurses report poor workplace conditions resulting from being overburdened.

Some states have enacted laws and regulations to address a common request from nurses: set and enforce patient-staff ratios. Several states including New York require nurse-driven hospital committees to set ratios and/or require hospitals to publish their ratios. Only California has implemented explicit nurse-to-patient ratios across settings, while Massachusetts has ratios for intensive care units. A 2006 survey of California nurses found that the ratios made them more likely to stay at their jobs and improved patient safety. On the federal level, policy proposals such as the Nurse Staffing Standards for Patient Safety and Quality Care Act of 2021, would require hospitals to be more transparent about their staffing levels. 

Another step forward is the Federal Trade Commission’s proposed ban on noncompete agreements, employment contract terms that prohibit employees from working for a competitor in their next job. Besides trapping workers in low-paying or poor-quality jobs, noncompete clauses can also force those who do want to quit to leave the profession. The ban would advance worker power, but its effectiveness in health care may be limited by the FTC’s lack of enforcement authority over nonprofit hospitals.

While the New York City strike resolved, the national nursing crisis is far from over. Investing in nursing education expands access to good jobs for many more people and expands the size of a workforce critical to American health care. But policymakers must also support nurses by addressing the factors that are causing nurses, newly trained and experienced alike, to leave.

Marina Zhavoronkova is a senior fellow for workforce development at the Center for American Progress and Nicole Rapfogel is a policy analyst for Health and Emily R. Gee is the senior vice president for Inclusive Growth at the Center.