Understanding the Gap Between Nursing Workforce in the United States and Population Needs—A Policy Brief

Purpose  This report is intended to analyze the root causes for the current gap between the nursing workforce and population needs in the United States. It aims to consolidate what is known about these contributing reasons and provide evidence-based recommendations for action. Methods  The report utilized the Sample, Phenomenon of Interest, Design, Evaluation, Research type framework to develop the research question and the 5 Whys methodology for the root cause analysis. Results  This report highlighted six major causative problems, including workforce market mismatch, poor financing design, inadequate governance, flawed technologies, insufficient research, and suboptimal service delivery. A detailed evaluation of root causes with supported evidence is presented. Conclusion  The report provided seven actionable recommendations based on the analysis: (1) strengthening the nursing role in advancing equity, (2) investing in nursing well-being, (3) changing policies and payment structure, (4) including nursing in technology design, (5) strengthening nursing education, (6) developing a robust public health emergencies preparedness plan, and (7) investing in relevant research.


Introduction
Nursing is a crucial part of the U.S. health workforce, and without it, achieving the health system outcomes, such as accessibility, quality, and efficiency, 1 would not be possible.This was echoed in the World Health Organization (WHO) report titled: "A Universal Truth: No Health Without A Workforce" 2 .Although the current staffing of 102.6 FTE/ 10,000 population exceeds the WHO target benchmark of 59.4 (2), there exists a considerable and worsening shortage of over 1 million nurses 3 due to an unexpected shift of market forces from equilibrium. 4In addition to nursing availability, other domains of the workforce, including accessibility, acceptability, and quality [5][6][7] are affected (►Fig.1).
There are several contextual factors 8 that can explain the gap between the nursing workforce in the U.S. and population needs.These include structural factors (aging population, geography 9 [►Fig.2], social determinants of health (SDOH), health inequity, and nursing student loans), situational (coronavirus disease 2019 [COVID-19] and opioid crisis) and cultural factors (traditional view of nursing as a women's job), and international factors (global nursing shortage). 10his report outlines a root cause analysis (RCA) to analyze the causes of the aforementioned gap.Then, it will present policy recommendations based on the result of this RCA.

Methodology
The 5 Whys methodology 11 was selected for the RCA as it provided an extensive analysis of factors associated with the nursing gap.The Sample, Phenomenon of Interest, Design, Evaluation, Research type format (►Table 1) was utilized for evidence synthesis, 12 leading to the following research question: "Using the Five Whys framework (D) of qualitative research (R), what were the root causes (E) of the inability of nursing workforce (PI) to meet population need in the United States (S)?".
A literature review of peer-reviewed studies and gray literature was carried out.Three databases were included Medline, EMBASE, and Web of Science, in addition to gray literature sources encompassing governmental and nongovernmental organization reports.
Inclusion criteria comprised articles that addressed nursing shortages in the United States and explored their causes.Fulltext sources published in English between 2010 and 2021 were assessed, including observational and experimental studies, policy briefs, and commentaries.Studies were excluded if they were abstract, if addressed nursing shortages outside the United States, or if focused on other health care workers.Improving the Nursing Shortage in the US Al Mohajer 207 The selected articles were extracted using a standard form detailing the study design, location, and findings.The author (M.A.) assessed the studies for inclusion.Quality assessment was not performed.The WHO building blocks 13 framework was used for grouping causative factors and evidence synthesis.

Results
Based on the literature review, 3,4,6,14-26 a total of 5,043 studies were identified.After excluding duplicates and studies that do not address the nursing shortages in the United States, a total of 245 studies were included.We grouped the causes of the gap between nursing and population needs into the following categories (►Table 2).
(1) Workforce market mismatch: The two major causes are increased demand and reduced supply. 26The high demand stems from structural factors such as growing population needs (aging, substance use, and inadequate access) and situational factors (ICU shortage during the COVID-19 pandemic).The reduced supply resulted from gender and racial underrepresentation (cultural), low rates of graduating nurses, and high retirement rates (structural), which was augmented by the COVID-19 pandemic (situational) due to staff burnout.Nurses were not included in the design of many projects.This poor design resulted in them spending significant time with electronic health records rather than clinical duties.This was further compounded by the fact that they deal with excessive alarms leading to burnout and stress.In addition, a lack of safety culture and training led to increased medication errors.Improving the Nursing Shortage in the US Al Mohajer This is caused by not including nurses in service delivery design, not prioritizing cultural competencies in nursing schools, structural racism, absence of safety culture, financial payment models, limited resources, and state restrictions on nursing scope. 24

Discussion
In order to overcome the nursing gap, the following policy recommendations for health system reform were developed (►Table 3) based on the RCA above, the Future of Nursing 2020-2030 report 6 and other gray literature publications. 20,27,28ort-Term Recommendations (by 2024) (1) Investing in the health and well-being of nurses: Focusing on nursing health and well-being should be part of nursing schools and health organizations.Employers should provide an environment that is both physically and physiologically safe (e.g., available personal protective equipment [PPE] and no retaliation), support diversity, and include nurses in key organizational decisions.

Conclusions
In conclusion, there are several root causes for the gap between the nursing workforce and population needs.

Fig. 1
Fig. 1 This figure shows different aspects of nursing human resources for health including availability, accessibility, acceptability, and quality.Data adapted from Wakefield et al and America's Health Rankings. 6,7FTE: full-time equivalent; RN: registered nurse.

22 ( 5 )
Insufficient information and research: Inadequate funding of nursing research due to lack of prioritizations from funders has led to fragmented and uncoordinated care, which lacked the focus on evidence-based medicine.23(6) Not optimized service delivery: Service delivery has suffered from reduced quality, equities, and accessibilities.

Fig. 2
Fig.2This figure shows the states with highest estimated nursing shortage.Data adapted from USAHS.9

Fig. 3
Fig.3This diagram shows the labor market for nurses before the coronavirus 2019 (COVID-19) pandemic given the parameters (demand D1, supply S1, need N1, and wage W1) leading to a shortage of C1 to B1 to meet the prepandemic demand and E1 to B1 to meet the prepandemic need.During the COVID-19 pandemic, the demand increased to D2, the supply decreased to S2, the need increased to N2, and the wage to W2, leading to a larger shortage of C2 to B2 to the meet the pandemic demand and E2 to B2 to meet the pandemic need.Data adapted from Scheffler et al.26

addition, cuts in federal funding augmented the public health nursing shortage. 6 (3) Inadequate leadership/governance: Existing policies do not support building nursing skills to advance equity, providing telehealth, treating substance abuse, delivering
3,18es, or preparing for pandemics, and they restrict nurses' ability to diagnose and manage patients.3,18(4)Flawed medical products/technologies: There are several reasons why technology contributed to the nursing gap.

Table 2
Root cause analysis (5 WHYs) for the inability of nursing workforce to meet population needs across the United States Avicenna Journal of Medicine Vol. 13 No. 4/2023 © 2023.The Author(s).Improving the Nursing Shortage in the US Al Mohajer 209

Table 3
Tasks required for policy recommendations Investing in relevant research: Government funding should increase to strengthen evidence-based nursing research as a significant focus.Research priorities should include the nursing workforce, public health collaboration, improving equities, performance and outcome measures, improving diversity, nursing well-being, eliminating structural racism, restructuring payment models, disaster preparedness, and advancing technologies.