The nursing shortage is as old as the dawn of modern nursing itself. Of the 38 nurses under the supervision of Florence Nightingale and who arrived with her in Scutari on November 4, 1854, three were gone by January 1855. One was dismissed for drunkenness, another for ill health, and the third for incompetence—these reasons for leaving or being asked to leave nursing resonate in modern times. The 2022 National Nursing Workforce Study conducted by the National Council of State Boards of Nursing (NCSBN) reported that an estimated 100,000 (to as many as 200,000) RNs and 34,000 licensed practical (LPNs) and vocational nurses left the workforce over the past 2 years. The reason? The pandemic. Quite understandably, the pandemic and its aftermath have become the default explanation of life’s many convoluted twists and turns since March 2020. For nursing attrition, it would be too simple to singularly assign blame to the stressful working environments of the pandemic. And numbers are poor storytellers.
Where have all the nurses gone?
What the NCSBN and other nursing workforce studies don’t report is what became of the ex-nurses. If they didn’t retire, what careers did they transition into? What are they doing now? Did they leave the profession entirely? Or, did they simply move away from the toxic bedside and take on less stressful jobs? Gone are the days when one entered the profession as a bedside nurse and existed as one at retirement. Although acute care hospitals employ 73.5% of newly licensed RNs, these cohorts of new nurses don’t stay very long at the bedside; similar patterns have been noted worldwide. It’s not uncommon for great bedside nurses to quickly lose steam from burnout, though not their zest to make a difference in healthcare. As a result, they take on less taxing and more satisfying roles in academia, research, quality improvement, telehealth, outpatient services, concierge medicine, and many others. Another development of concern is that for the first time in 20 years, enrollment in entry-level baccalaureate nursing programs decreased by 1.4% in 2022. Not auspicious data next to the ever-increasing nursing shortage.
Overeducated and underprepared?
In the last 50 years, great upheavals have occurred in nursing education across all levels. The shift from the apprenticeship model of the 1950s to university-based education in the 1970s has produced a generation of highly educated nurses who may not be practice-ready to tackle multiple complex patients upon graduation. This challenge is multifactorial. One notable disconnect is that although the complexity of patients has increased exponentially, the length of nurse education has decreased. Some accelerated nursing programs are as short as 11 months! Can you imagine? In most pre-licensure clinical education, the student takes care of one stable patient, but when they become an RN, they’re assigned at least four or five “sick” patients in better hospitals. One of healthcare’s biggest challenges is getting new RNs practice ready and also solving the nursing shortage.
Do they know what they’re getting into?
Staffing issues and all its attendant adverse effects are given lip service in undergraduate nursing curriculum. The topic typically is embedded in courses with names like Leadership and Management or Professional Nursing. Incidentally or accidentally, students might see the issue first-hand during their hospital clinical practicum when they witness a nurse assignment conundrum. This usually is played out at the nurses’ station, sadly at times within earshot of patients and visitors. The eager nursing students might sometimes see sparks fly from burnt out staff members and wonder to themselves: “What am I getting into?”
Bewitched, bothered, bewildered, and benevolent
Every nurse has heard of Patricia Benner’s skills acquisition novice to expert model—still a serious and salient nursing document. Here, I offer more aspirational stages of development for a nursing novitiate. Ask any nursing student why they want to be a nurse, and almost always they extol nursing as a virtuous choice. They’ve been temporally and contextually bewitched by a personal or a family healthcare experience involving a caring nurse. They imagined: “Yes, I want to make a difference just like the nurse who took care of me.”
So, off they go to nursing school and to their first staff nurse role. The good, the ideal, and the evidence-based practice they learned from their air conditioned classrooms comes crashing down. Now, the well-meaning new nurse is hot and bothered. Thoughts such as, “This is not what I signed up for” or “I’m not prepared for this” cross their minds as they encounter adverse scenarios resulting from understaffing that leaves them depleted and deflated. This is a stage when the new nurse might quit nursing; they’re bruised and disillusioned.
If they rise to the challenge and stay on, the next stage gives them a bewildered feeling of possibilities; to be part of the solution and not just be the squeaky wheel in the sclerotic health system. The bewildered nurse will know how to seek help and act courageously to do good by the patient and society—against all odds.
Experience and expertise usher the nurse into the benevolent phase, which is one of reckoning and kindness—offering grace for blunders made and lessons learned. The benevolent nurse doesn’t bite, chew, and spit their young. Instead, they coach, mentor, prod, back-up, and stand by them. Benevolent nurses haven’t only mastered the art and science of caring, but also themselves. Ultimately, a benevolent nurse completes the great mandala of nursing.
How might we, as educators, preceptors, nurse managers, researchers, policy experts, and family members make a difference in the life of a new nurse as they navigate from being bewitched to practicing benevolence? Now, that’s the call to action.
Fidelindo Lim, DNP, CCRN, FAAN is a Clinical Associate Professor at New York University Meyers College of Nursing.
Bostridge M. Florence Nightingale: The Making of an Icon. New York City, NY: Farrar, Straus and Giroux; 2008.
National Council of State Boards of Nursing. 2022 National nursing workforce study highlights. 2023. ncsbn.org/research/recent-research/workforce.page#1657179108341