Beyond the obvious and most discussed risks of prematurely ending social distancing restrictions, such as a second and third wave of infections, more illness and deaths, and more long-term damage to the economy, an equally important risk to public health has not received the media attention it deserves: an acute and perhaps dramatic escalation of the national nursing shortage due primarily to the interruption of prelicensure nursing education. Much of what I note in this editorial is applicable to nursing education programs and nursing roles at all levels—and even to other health professions such as medicine, physical, occupational, speech therapy, and so on. However, because of the central role RNs play in the U.S. health care system, I focus here on prelicensure nursing education, delivered primarily in associate- and baccalaureate-level degree programs in colleges and universities across the United States.
The World Health Organization (WHO, 2020a) recently reported there are 28 million nurses across the globe, with nurses comprising 59% of the total number of global health professionals and 56% of the total number of health professionals in the United States. The National Council of State Boards of Nursing (NCSBN, 2020) reports there are more than 4 million RNs in the United States.
Perhaps a timely but unwelcome coincidence due to the COVID-19 pandemic, the WHO (2020b) has deemed 2020 as “The International Year of the Nurse and Midwife.” As the largest single health profession in the world, nurses form the backbone of health systems across the globe. Nurses greet us at birth and comfort us at death. They work when there is a foot of fresh snow on the ground, during hurricanes, and yes, most assuredly, they work during pandemics. (On a related note, no health care worker should ever be asked to care for patients without adequate protective equipment.)
As many of us have now experienced, throughout March and April of this year, colleges and universities closed across the nation, and traditional clinical learning sites for health professions students, especially hospitals, began to disappear overnight, often restricting students from clinical sites due to a lack of personal protective equipment (PPE) at those sites. With little to sometimes no time to prepare for the transition, college and university faculty in most states across the country and across all academic disciplines were asked to convert their courses into an online format.
Luckily for nursing education, we have long embraced new learning technologies such as distance learning and simulation. Nursing education leaders and researchers have provided global leadership on how both in-person and virtual simulation can be used in health professions education. I am happy to say that the rapid transition of prelicensure nursing education from a predominantly face-to-face experience to a predominantly online experience in the United States, although not without various and sometimes significant challenges, has gone as well as it could have—so far.
According to aggregate counts from NCSBN (2019), 252,311 new RNs entered the U.S. nursing workforce by taking the NCLEX-RN in 2019. Recent estimates by Buerhaus et al. (2017) suggest the country needs more than double that number, approximately 550,000, new RNs to enter the workforce in 2020 and 2021 to address a projected shortage of 1.1 million RNs in 2022, thought to be fueled in large part by a wave of RNs starting to age out of the nursing workforce.
With the risks and impacts of COVID-19 on RNs already in the workforce becoming clearer each day, especially for older nurses (Buerhaus et al., 2020), the extent to which nurses leaving the workforce—and perhaps the profession—earlier than planned due to psychological trauma and even physical disability will only exacerbate the nursing shortage further. Although nursing faculty across the country have done an astonishing job in providing continuity in their students' educational programs that were, like almost everything else in the country, brought to a halt by COVID-19, it is still unclear what portion of the prelicensure nursing student population graduated on time in May and June because of regulatory and program requirements that are challenging or impossible to fulfill in a completely online environment. It is equally unclear, and equally disconcerting on a personal level for many, as to what will happen to the jobs of nursing faculty members whose programs cannot provide sufficient clinical education for its prelicensure students, if only for a year.
As states such as Georgia, Texas, and South Carolina became the first to relax social distancing restrictions in late April (Iati et al., 2020), ahead even of federal guidelines for doing so, the nation began to closely observe trends in COVID-19 infection rates in these areas. According to nursing workforce projections through 2030 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (2017), the state of Georgia—pre-pandemic—is already projected to have a shortage of 2,200 RNs by 2030. For Texas, the shortage is projected to be 15,900 RNs. South Carolina has the second highest projected shortage (behind Alaska) in the United States, with a stunning projected shortage of 10,400 RNs—a shortfall of 16.6%—by 2030.
Continuing spikes in COVID-19 infections due to premature ending of social distancing will continue to stress and overwhelm hospitals and health systems, locally and regionally, as outbreaks move from place to place within the country until effective treatments or vaccines become available. Hospital-based clinical learning sites desperately needed by nursing and other health professions education programs will continue restrictions on student learning as they focus scarce resources instead on their patients and staff. U.S. society has had a strong and long-standing compact with the nursing profession, built on trust and mutual advocacy. This compact is evident in the Gallup organization's annual public perception poll (Brenan, 2018) about the honesty and ethics of various professions, where nurses have been rated as the most trustworthy profession by the public for 18 years in a row.
Nursing has demonstrated its commitment to society and to the populations it serves, time and again. Now, society has a chance to demonstrate this mutual respect and commitment, and can do so by strictly observing social distancing guidelines to prevent inflicting enduring and significant damage to our existing nursing workforce and the workforce pipeline that nursing programs around the country are struggling to fill in these uncertain times. Now is the time for nursing faculty—and even nursing students—to raise their voices on this issue, in every venue where they can be heard. There is no doubt that a functioning and productive national economy is essential, but it is no more essential than the other basic building blocks of a modern society, including a capable, sufficiently large, and well-educated nursing workforce that can skillfully and effectively meet the needs of the populations it serves.
A stark choice is largely up to our federal and local elected leaders and to individuals resisting or ignoring social distancing and stay-at-home orders: follow the evidence-based social distancing guidelines strongly endorsed by public health experts or, conversely, compound the burden of COVID-19 that all of us have borne, that nurses have borne in particular, and that vulnerable populations have borne perhaps most significantly. Let us not waste the progress we have made.
Darrell Spurlock, Jr., PhD, RN, NEA-BC,
- Brenan, M. (2018, December20). Nurses again outpace other professions for honesty, ethics. https://news.gallup.com/poll/245597/nurses-again-outpace-professions-honesty-ethics.aspx
- Buerhaus, P.I., Auerbach, D.I. & Staiger, D.O. (2020). Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA, 323(18), 1777–1778 doi:10/ggqsn7 [CrossRef]
- Buerhaus, P.I., Skinner, L.E., Auerbach, D.I. & Staiger, D.O. (2017). Four challenges facing the nursing workforce in the United States. Journal of Nursing Regulation, 8(2), 40–46 doi:10/ggcht5 [CrossRef]
- Iati, M., Beachum, L., Pell, S., Goff, S., Kornfield, M., Armus, T., Farzan, A.N., Sonmez, F., O'Grady, S. & Mettler, K. (2020, April20). Georgia, South Carolina and Tennessee governors announce plans to ease coronavirus restrictions. Washington Post. https://www.washingtonpost.com/world/2020/04/20/coronavirus-latest-news/
- National Council of State Boards of Nursing. (2019). 2019 NCLEX pass rates. https://www.ncsbn.org/13495.htm
- National Council of State Boards of Nursing. (2020, April). Active RN licenses: A profile of nursing licensure in the U.S. https://www.ncsbn.org/6161.htm
- U.S. Department of Health and Human Services, Health Resources and Services Administration. (2017). Supply and demand projections of the nursing workforce: 2014–2030. U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_Nursing_Report.pdf
- World Health Organization. (2020a). State of the world's nursing report—2020: Investing in education, jobs, and leadership. https://www.who.int/publications-detail/nursing-report-2020
- World Health Organization. (2020b). Year of the nurse and the midwife 2020. https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020