The Real History of U.S. Nursing Shortages

Thousands of U.S. businesses are struggling to deal with staffing shortages. In restaurants and retail, being short-staffed might mean longer waits for diners and shoppers. In extreme cases, it may even mean businesses have to close down because they don’t have anyone available to work. 

But when nursing shortages hit healthcare facilities, the impact can literally be deadly.

Insufficient nursing staff can lead healthcare facilities to turn away some patients or provide less-than-optimal care. Trying to do more with less not only raises the potential for poor patient care, but also for increased mistakes with serious consequences.

While individual facilities may take some comfort in the knowledge that the nursing shortage is an industry-wide problem (and a challenge they face alone), the widespread nature of the problem means that there isn’t an easy playbook or set of best practices to guarantee easier recruitment and retention. 

Instead, providers need to push themselves beyond the ranks of average healthcare employers and stand out if they hope to compete for a limited pool of these critical healthcare professionals.

In this white paper, we’ll discuss the historical context of the current nursing shortage, because it reveals economic and behavioral patterns over time. We’ll look at how the current shortage differs. And finally, we’ll investigate the similarities that the current shortage shares with previous shortages. 

Historical Nursing Shortages

The current nursing shortage may seem unprecedented from the perspective of the patients, providers, and healthcare professionals experiencing the shortage firsthand. Observers outside the industry may interpret it in the context of the COVID-19 pandemic. 

But nursing shortages have persisted over most of the past century. Some shortages have had healthcare-specific causes, while others have followed more general trends in the labor market and the economy. In other words, while nursing shortages may have more significant consequences than labor shortages in other industries, their causes aren’t necessarily unique or healthcare-specific.

The 1930s

One of the earliest major nursing shortages occurred in the 1930s when other industries in the United States were gripped by historic unemployment during the Great Depression. An article for the University of Pennsylvania’s Penn Nursing program explains that, like most 20th-century nursing shortages, this shortage was largely demand-driven; i.e. the shortage was due more to increasing usage of healthcare than to a reduction in the supply of nurses. 

“During the 1930s, increased hospital use, changes in hospital construction, more technologically complex patient care requirements, and a reduction in the working hours for nurses all necessitated an increased number of nurses to deliver bedside care,” the article explains.

Nursing shortages were a novel problem in the 1930s, and hospital administrators struggled to cope with these shortages or find constructive solutions to the problem. “Unaccustomed to dealing with nurse shortages, hospital administrators reacted slowly to the situation,” according to the Penn Nursing article. “Some blamed nurses themselves for creating the shortage by failing to live up to the ideals of their profession and refusing to work.”

World War II

As America mobilized for war in the early 1940s, its ongoing nursing shortage became even more pressing. To make matters worse, supply-side challenges emerged to compound the existing demand-side struggles. While the U.S. military was able to pull in sufficient resources for the war effort – 77,000 nurses who joined the military services by the end of the war – by and large, these nurses were not newly trained additions to the workforce. They were drawn from the civilian sector, which lost roughly a quarter of its pre-war nurses.

Even the pool of potential replacement nurses – those who didn’t necessarily have any nursing training or experience but who fit the typical nursing demographic – faced plenty of competition from other sectors. Not only were these other sources of employment aggressively recruiting, but they were also superior in many ways to the opportunities nursing offered. “The traditional population of nursing students: young, white females with a secondary school education, was exactly the same group heavily recruited by war-related industries,” says Penn Nursing. “For those eager to help the war effort immediately, the three years required before a young woman graduated from nursing school was a disincentive. Further, discrepancies between working conditions for nurses, such as low salaries, long hours, and requirements that nurses live within hospital grounds, and working conditions for other occupations made nursing a less attractive field for young people to consider.”

In response to the shortage, the U.S. government took aggressive steps to shore up the nursing labor force. While earlier efforts by the federal government had provided small amounts of money to help fund some nursing education programs, it wasn’t until the passage of the 1943 Bolton Act and the creation of the U.S. Cadet Nurse Corps that the government put serious weight behind its efforts.

“The act provided $160 million for nurse education funding and financial support for nursing students, a much larger amount of federal money for both students and hospitals than had previously been allocated,” says Penn Nursing. “Students enrolled in the program received a free education as well as a monthly stipend and uniforms.”

At the same time, efforts were made to address the supply-side nursing challenge by creating new categories of nurses with reduced training and educational requirements. The movement to train and recruit licensed practical nurses (LPNs) began in the late 1930s and picked up in the next decade. LPN training was typically about one year, as opposed to the three years it took to graduate from nursing school. Both LPNs and nurses’ aides performed work geared more towards providing supervised assistance to support more highly trained nurses, helping to bridge the labor gap quickly and at substantially less cost.

Post-World War II

Some optimistic observers expected the United States to benefit from an abundance of skilled nursing professionals in the labor force as civilian wartime nurses stayed on the job and tens of thousands of military nurses returned home. But many nurses who had served in the military did not return to that line of work after the war, and with the evaporation of federal money for the U.S. Cadet Nurse Corps in the late 1940s, the influx of new entrants into the nursing profession began to slow.

At the same time the supply of available nurses was reduced, demand again increased sharply. “In the four-year period between 1946 and 1952, hospital admission rates rose 26 percent,” according to Penn Nursing.

Multiple mid-twentieth-century studies suggested that a key to improving interest in the nursing profession was to increase wages. Unsurprisingly, hospital administrators were less than enthusiastic about this approach and instead shifted their focus to encouraging greater participation in nursing education and an increasingly heavy reliance on less-trained nursing assistants like LPNs and nurses’ aides.

The 1960s

Post-war efforts to fix the nursing shortage did little to address the problem, and in 1964 the federal government again stepped in to correct it. The 1964 Nurse Training Act, which authorized $283 million into building new nursing schools, sought to expand nurse training and provide loans for nursing students.

While this injection of funds into the infrastructure of nursing education was perhaps the most visible attempt to address the nursing shortage, Penn Nursing argues that other private and public sector market forces had a larger role in the rebound of the supply of nurses. 

“Several analysts have attributed the increase in working nurses not to an increase in the number of nurses, but rather to rising wage rates for nurses,” they write. “In the late 1960s, hospitals, reaping the financial benefits of the passage of the Medicare and Medicaid legislation, began offering nurses better salaries. Taking advantage of this chance to improve their economic situation, more nurses joined or rejoined the workforce.”

Historical Recap

Throughout the middle of the 20th century, supply and demand both played a role in what can be considered as much a decades-long shortage with brief periods of relief. 

A couple of key factors can explain many of the shifts in supply and demand. First, demographic changes from the early 20th century meant that more Americans were living longer, thereby experiencing more age-related healthcare needs. They were also wealthier on average, increasing their ability to pay for medical services and allowing the demands of their old age to increase relatively unchecked. 

Second, the attractiveness of the field of nursing varied throughout the same time period. As World War II came and went, demand for the same young women who made up the bulk of the nursing profession ebbed and flowed in competing industries. At the same time, the many efforts aimed at making the nursing profession more attractive, compared to non-nursing options, had uneven success. The appeal of nursing, both in terms of ease-of-entry and demand, was constantly in flux.  

Today’s Nursing Shortage

For those who haven’t had direct exposure to the current nursing shortage, a few data points may help illustrate the problem the industry is facing. 

In October 2010, the Institute of Medicine released its landmark report on The Future of Nursing. Initiated by the Robert Wood Johnson Foundation, the report called for increasing the number of baccalaureate-prepared nurses in the workforce to 80% and doubling the population of nurses with doctoral degrees. The current nursing workforce falls far short of these recommendations with only 64.2% of registered nurses prepared at the baccalaureate or graduate degree level according to the latest workforce survey conducted by the National Council of State Boards of Nursing.

That situation is only expected to worsen.

According to the United States Registered Nurse Workforce Report Card and Shortage Forecast: A Revisit published in the May/June 2018 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to persist across the country between 2016 and 2030. In this state-by-state analysis, the authors forecast the RN shortage to be most intense in the South and the West.

Contributing Factors to the Current Shortage

The global COVID-19 pandemic is a predictable target for those seeking to assign blame for the problems of U.S. healthcare. But even granting the pandemic’s heavy repercussions, it’s not the sole factor at play in the current nursing shortage, which is more complex than it might seem.

First, demographic changes in the United States are contributing to the problem. An aging population simultaneously reduces supply and increases demand for healthcare services. “The population surge from the baby boomer generation has led not only to a greater number of aging patients but also means that a large portion of the nursing workforce is heading toward retirement,” according to the University of St. Augustine for Health Sciences. “Between 2000 and 2018, the average age of employed registered nurses increased from 42.7 to 47.9 years old. And nearly half (47.5%) of all RNs are now over the age of 50.”

Second, the labor market phenomenon known as the “Great Resignation” continues to pose challenges for employers across many industries, as both scheduled and early retirements strip the labor force of experienced professionals at a faster rate than they can be replaced by new entrants. Part of this trend could have been predicted decades ago by simply considering birth rates. It was always apparent that Baby Boomers would start to retire in their 60s, and that subsequent generations weren’t as large. But many retirements during the great resignation have accelerated that schedule, making shortfalls more intense than birth rates indicated. That is, more people are retiring sooner than expected.

Many older professionals, already close to retirement and exhausted by long-term policies requiring masks, vaccines, social distancing, and remote work, have decided they’ve had enough, even if they haven’t yet reached the traditional retirement age. As older professionals with seniority leave the labor force, younger professionals are taking advantage and climbing into better paying and more fulfilling jobs, leaving a cascade of vacancies behind them. In the healthcare industry, this means fewer nurses and fewer support staff, which adds to the workload of the personnel that remain and drives further burnout and attrition.

While it may be small comfort for healthcare providers to know that the current nursing shortage is not a historic first, they should study their history, nonetheless. Over the last 100 years, the United States has experienced multiple nursing shortages, offering examples both good and bad of how to address the current shortage.