There aren’t enough nurses. Anywhere. It’s not a new problem and it’s one that received heightened scrutiny during and since the COVID pandemic.
There’s no quick fix because the problem is multifaceted beginning with the big experience gap between older, more-seasoned nurses retiring versus newly graduated nurses arriving to replace them.
Second, there’s a yawning gap between patient numbers and available nurses to care for them.
The number of registered nurses in the workforce dropped by more than 100,000 from 2020 to 2021, the most substantial decline in the last 40 years, a report from the U.S. Chamber of Commerce (“Data Deep Dive: A National Nursing Crisis”) reveals.
A troubling statistic lurks beneath that alarming top line number. A big chunk of those departing were not retirees but were nurses younger than 35. As of December 2023, the national nursing unemployment rate was 1.6%, compared to the 4% rate reported in May 2024 by the U.S. Department of Labor.
There are nine nurses on average for every 1,000 people in the U.S. In Tennessee, that ratio is somewhere between 9 and 10, the U.S. Chamber reports.
Those numbers are all too high, say educators and health care providers alike, leading to burnout and early career exits.
Solutions include new coursework for students, field mentoring for new grads, recruiting new nurses, training them more comprehensively and, most importantly, keeping them on the job during those crucial early years when burnout is highly likely.
Rebuilding the talent pipeline
Dean Pamela Jeffries has pushed several initiatives since arriving at Vanderbilt University’s School of Nursing in July 2021. Among those are a new degree program for generalist nurses, two specialized academies for diverse nursing leaders and faculty, a professional-development initiative for health systems to help with staff retention and starting the process of being able to offer a certified registered nurse anesthetist program.
“We continually work on new-student outreach to recruit more highly qualified students to our nursing profession,” Jeffries says. “A nursing career is rewarding; we inform our students about the types of nursing programs, the various career opportunities that are offered in nursing and how the nursing career will serve them well and be rewarding now and in the future.”
That’s accomplished through an ongoing admissions marketing plan that seeks to create awareness of VUSN and attract students, she says. Components of that plan include a bigger spend on digital marketing and a nationwide reach.
“Prospective students meet with our faculty while being recruited; they hear authentic voices and experience,” she says. “We also have created selected student affinity groups where students with a particular interest, such as geriatric nursing and healthy aging, can be part of this affinity group working with faculty to learn more about this special population and be immersed in more activities while in school.”
The struggle to find new nurses is eased somewhat by continuing interest in the profession. At the University of Chattanooga School of Nursing, there are more applicants now than the school can handle in both the traditional and accelerated BSN programs, says Dr. Christine Benz Smith, the school’s director as well as a UC Foundation professor and the university’s Chief Health Affairs Officer. The goal now is to give those students the education they need to succeed in a rapidly evolving health care landscape.
“The applicant pool is pretty robust, which tells me that a lot of students want to come to UTC for those programs,” Smith says. “But the things we are focusing on are different. We are bound to teach to what is set forth by our accrediting body, the essentials, and those are changing. We are moving the focus out of the hospital and more into population health, more out into the community. We are looking more at palliative care, at interprofessional education opportunities.
“We are exploring the social determinants of health, which means knowing that someone who shows up at the hospital is a product of their environment,” Smith continues. “We need to learn how they live, what their neighborhood is like, what their access to care looks like. When we do this, we can move away from our more traditional ‘see the disease, treat the disease’ methodology and be more preventive.”
Classroom-workforce partnership
At Vanderbilt, Jeffries has worked closely with Marilyn Dubree, executive chief nursing officer at Vanderbilt University Medical Center, and who also serves on the school’s faculty, on many new initiatives. She says that continued collaboration between educators and providers, be they hospitals, clinics or other sites, is essential.
“At VUSN, we work with our health care partners to ensure we are preparing new graduates to have a successful transition to practice,” she says. “We understand the need for new graduates to be prepared to join the workforce and be part of the health care team upon hiring. Through various teaching strategies and focused curricula, particularly in our pre-licensure program, we teach clinical reasoning/clinical judgment to prepare the student in the clinical environment.”
“Daily, new graduate nurses, just like experienced nurses, make decisions regarding patient care, nursing interventions and on various other types of care and holistic patient decisions,” Jeffries adds. “When students come to VUSN, we want them to know we are preparing them to transition to practice and appropriately to provide safe, high-quality care.”
At the University of Tennessee in Knoxville, a partnership with the University of Tennessee Medical Center is the latest effort to tackle the nursing shortage with a new program called the BSN Scholar Program. Victoria Niederhauser, dean of the College of Nursing, and Dr. Sandy Leake, senior vice president and chief nursing officer at the hospital, say they see the program as beneficial for both the school and the hospital.
The BSN Scholars Program includes 102 students who will have their tuition paid and are guaranteed a job at UTMC after graduation. Immediate benefits? Little to no student debt and a job in a hospital they’re already familiar with.
A similar program – the nurse Scholars Program – has been offered at Vanderbilt. It pays for up to four semesters of nursing school tuition at VUSN or Cumberland University in return for a work commitment to VUMC.
Evolving the classroom
“One of the methods we use to prepare students for the workplace is immersing them in clinical simulation scenarios where clinical decision-making and (simulated) real-life events take place,” Jeffries says. “This allows for a student to practice in a safe, nonthreatening environment before graduating and becoming a licensed RN or certified APRN.”
This also can help prepare students for what they’ll face, especially high-stress periods that can lead to quick burnout and career exits.
“Our students learn the knowledge, skills and competencies needed to be a nurse or advanced practice nurse and be ready for the workforce,” she says. “Often students take extra electives or courses to add onto their foundational knowledge to be an RN or nurse practitioner. Our students at VUSN are high achievers; many are earning post-master’s certificates in nursing education, in psychiatric/mental health, or in another area on top of their existing MSN or DNP degree.
“Our students, and eventually our graduates, want to be prepared to provide safe, high-quality care to all patients, families and communities,” she continues. “Within our nursing curriculum and post-graduation, our students and graduates seek learning through professional development opportunities about self-care, resiliency and more on how to navigate our complex health care systems. We have events, activities and opportunities for students to practice self-care or to avail themselves of resources here at the School of Nursing or at the university level. Our graduates want to be prepared and ready for the workforce now and long term.”
Six months into her tenure as dean of the Gordon E. Inman College of Nursing at Belmont University, Julie Honey says she too is focused on all the ways nurses can be recruited, trained and set up for success.
“I wanted to innovate, to do things differently in terms of new partnerships and rethinking nursing education,” Honey says. “We need to address a lot of needs, not just the shortage of nurses, but also of nursing faculty, clinical placement opportunities, areas like that. There are shortages across the field.”
She crafted a strategic plan that covers several key areas, including growth opportunities and career-pathway development, looking not just at high school students but moving downward through middle and even elementary schools, to get students engaged and interested in nursing.
“We want to build community partnerships with Metro Nashville Public Schools and others, schools where there already may be health academies, to reach younger students,” she says, “then we can work with them as they move into and through the upper grades.”
Another strategic growth area is better capturing people who return to college for a second degree and want to pursue nursing. More than 65,000 qualified applications were not accepted at schools of nursing nationwide, the American Association of Colleges of Nursing reports, ranging across levels from entry-level baccalaureate programs on up through RN-to-BSN, master’s degree and doctoral nursing programs. That’s a stat that has to be corrected now, Honey says.
“We want to innovate our program but do it in a way that makes nursing education more accessible,” she says. “We want people who are interested in nursing to be able to pursue it, and we also want those who are in nursing, such as those working in a rural community, to be stopped by issues of affordability or logistics to make it work.”
To that end, Belmont University soon will offer an accelerated, hybrid-style program that “leans into the idea of getting students into early rotations, into community and hospital settings,” Honey says.
“We want to put students, whatever their experience level, in places that nurses don’t always get exposed to,” she says. “That might be a homeless shelter or an addiction-care center. There are a lot of different kinds of nursing.
“Last semester, we had students spending the whole time with one clinical agency, getting really comfortable in that space. That can lead to someone matriculating into a position there. We’re growing our community partnerships, because without them, this won’t work. We have to fix this problem together.”
That also includes normalizing the notion of a treatment team in which everyone from the attending physician to nurses, nursing assistants, various therapists, dietitians and others play a role in a patient’s recovery.
“It takes a village,” Smith adds. “We must have those interprofessional relationships and teams managing patients. If I’m a family nurse practitioner and have a patient who’s struggling with diabetes, and nothing I’m doing is working, I need to be able to send them to a nutritionist, for example. This is why we are teaching and showing how community care works now. This is why we have students doing foot care in homeless shelters, going into schools, prison behavioral health facilities.”
“A decade ago, we were ignoring the community and focusing on those big, tall buildings with lots of beds in them,” Smith says. “Now so much of what patients went in for is now done in an outpatient setting. The focus is moving to patient care in their environment, not ours. When we go where they live, be it rural or urban, we do better. And it’s not just nursing; colleges of medicine are moving this way as well.”
Support stems early-career exits
Much as nursing schools are exploring ways to reach potential nurses earlier, they also are diving into making sure those they’ve trained stay in the profession. The adage about medical professionals being bad patients holds true here in terms of the profession’s history of not taking care of itself mentally, educators say.
“We need to do a better job supporting them once they are out,” Belmont’s Honey says. “Hospitals are strapped; they are struggling to support new graduates, to keep them happy and healthy and mentally well. Stress and burnout are very real.
“We need to get into the setting and stand up alumni mentoring programs, for example. We have some retired faculty who are leaning into that, especially for nurses in their first couple of years. We want to have a comprehensive wellness program not just for current students, but also our alumni and our clinical partners.”
The profession doesn’t have a lot of experience offering in-house programs to take care of its own, either on campuses or in treatment settings. Honey says Belmont is trying to change that by infusing wellness, mentoring and partnerships into students’ lives before the first semester kicks off.
“The focus has always been getting them through nursing school,” she says. “There is so much to learn and it’s overwhelming. It’s not like other college programs because those students aren’t being asked to get up at 6 a.m. to go on a clinic shift. We have to become partners of the priority – talk about wellness and talk about it in different ways.
“It can’t just be ‘go use this app.’ It needs to involve mentoring, people who have been there and know what this feels like. Research tells us people who have our experiences to share, and to help process, is really helpful.”
In the past year, VUSN started a professional development office. Among its early programs are one for micro-credential courses which connect nursing-school faculty with working nurses who want to grow in their careers, but don’t have time to pursue a new degree. Topics are broken down into manageable portions and courses are created for online delivery. People take as many or as few as they want and when finished, they earn a micro-credential alongside continuing education units, or CEUs. If they earn several in a series, they might earn a badge when they can then list these on their CVs.
Faculty are working currently on courses on healthy aging, nursing informatics, faculty development and more. There also are ongoing talks with major Middle Tennessee health care organizations about creating custom educational content for them.
Prepping for different future
Everyone involved in health care can discuss how the landscape has evolved and how quickly. Everything from new treatment modalities to the proposed (and often battled) introduction of artificial intelligence, upends care settings practically daily. What that means for those who are working with nurse now, and preparing to work with them tomorrow, is a willingness to see trends, react to them, and most of all not stay stuck in “the way it’s always been.”
“Nursing is not the same as it was in 1960, but all too often we teach it the same,” Honey says. “Last year, accreditation standards changed for the first time since I’ve been in nursing, for the first time in at least 30 years. The standards have been focused on a competency-based education. We rotate them through all the sites and specialties the same way we always did and that won’t work anymore.
“We have to upend our curriculum and start with some very new and different approaches. We must teach them to think critically, to reason critically. They do not have to memorize the minute details sometimes; they can look that information up. Training now needs to be about how to think and reason, now how to memorize a dose.”
Mentoring also can help nurses avoid burnout by providing real-world advice on how and when to explore new opportunities with the profession.
“When nurses get older, they don’t want to be in an emergency department or trauma ICU,” Benz Smith says. “They want a slower pace, and that’s there for them. You can find something totally different, using your same license, in your same state.
“I was a nurse practitioner in an inner-city clinic, and when that shut down I came to UTC to teach. I’ve gone from a hospital career to being a family nurse practitioner and working in an outpatient setting to now teaching and administration. I’ve gone 360º and the nice thing about nursing is that most anyone can do that.”
“You look at all your options and you set your course,” she adds. “When we talk to brand-new students we ask them what they want to be. Much of the time they want to be in obstetrics or pediatrics, but when we check in with them further down the road the honestly don’t know. They have seen and experienced many other situations.
“If we are working with students right away, or even before they get here, to see that nursing has so many options, it’s going to benefit everyone.
“One of my faculty members said we are preparing nurses to be generalists, not specialists,” she adds, “and so the more exposure we give them to different opportunities, the better.”