Politics, Economics, and Nursing Shortages: A Critical Look at United States Government Policies

Rob Elgie, BSN, RN, BC


Nurs Econ. 2007;25(5):285-292. 

In This Article

History of the Nursing Shortage

What is often represented as a recent shortage of nurses is not a new problem, and dates at least as far back as 1964 when the Nursing Student Loan program under Title VIII of the Public Health Service Act first began as an attempt to entice students into nursing to solve the same problem at that time. A series of significant events have occurred over the years that shaped the modern nursing profession into what it is today and contributed to the shortages we seem to perpetually face.

In 1965 the ANA wrote its first position paper on education for nurses. At that time, up to 85% of nurses in the United States were educated in hospital-based diploma programs (Donley & Flaherty, 2002). The 1965 ANA document promoted change in entry level nursing practice educational re quirements.

At that time, according to Donley and Flaherty (2002), hospital-based nursing education programs provided a cheap supply of student nurses to staff hospital wards. Student nurse programs were focused almost exclusively on meeting the staffing needs of hospitals. Nursing students were required to spend 24 to 30 hours a week meeting heavy demands on hospital wards instead of studying. Student nurses staffed the wards for free in exchange for their diplomas after about 3 years of service. The 13 authors of the 1965 ANA document envisioned all nursing education based in colleges or universities, and the effect of this document over time was to wrest control of nursing education away from hospitals and physicians (Donley & Flaherty, 2002). With hospitals no longer controlling a free nurse supply in the form of student nurses to manage ward staffing needs, national demand for graduate nurses increased.

In 1983 government policy applied additional pressure to the demand side of nursing when legislation changed the Medicare reimbursement formula from a fee for service system to a system based on diagnostic categories. Although patient length of stay decreased and beds were closed, the intensity of nursing care, technology, and paperwork increased as did demand for nurses. Simul taneously, the supply of nurses decreased as all nursing programs showed declines in enrollment because "nursing was judged to be too demanding, too undervalued, and too unrewarding" (Donley & Flaherty, 2002, p. 9).

Cycles of nursing shortage have continued to this day with only a few brief periods of exception; in the mid-1980s supply and demand for nurses were relatively balanced, and from 1990-1992 there was a slight surplus of nurses (Buerhaus, Staiger, & Auerbach, 2003). Buerhaus and colleagues (2003) warn that the current shortage is likely to continue for the long term due to the demand-side pressures of population growth, the rising proportion of people over age 65, and economic growth. "Moreover," state the authors, "the RN workforce will continue to age, as nearly half of RNs are projected to be over age fifty by 2010 and the average age rises to above forty-five years" (p. 196).

Regardless of how the nursing workforce is evaluated or who does the evaluating, there is no debate as to whether there is a serious nurse supply problem. The lack of qualified nurses to meet health care needs in the United States "promises to grow to alarming proportions in the next 15 years" (Miller, 2004, p. 1). The national shortage is expected to double to 12% by 2010 and then quadruple to a projected 20% in 2015 and a shortage of 800,000 by 2020 (Andrews, 2004).


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