Experts say the nursing shortage is a public health disaster waiting to happen. But why does the shortage exist? And what can be done about it? This article will explore how post-acute and acute care nursing shortages interweave and touch on some innovative solutions that organizations can start using today to support their workforces.
Acute vs. post-acute nursing shortages
Acute and post-acute care exist in a delicate, interdependent balance. People arrive at an acute care setting needing immediate medical attention, they're stabilized, and if they need longer-term care, they head to a post-acute or short or long-term care center to rehabilitate. If they don't, they go home.
Shortages on one side of the continuum strain the other side. Sometimes, there aren't enough beds in a hospital to accept the long-term care residents who need critical care. Oftentimes, there aren't enough beds in a post-acute care center to accept patients who need longer-term assistance.
"Beds" is an industry term, but a lack of beds is not the problem; it's a lack of people. Ultimately, some patients receive lower-quality care because of these shortages.
Examining the common causes of acute and post-acute nursing shortages
1. Burnout and turnover
Healthcare is a high-stress profession, and people in high-stress professions are more prone to burnout. Burnout is a documented problem in healthcare, with 62% of healthcare professionals saying they are burned out right now. In 2022, the Surgeon General released a public health advisory highlighting the risk it poses to healthcare professionals.
Burnout on both sides of the industry can be partially attributed to the nursing shortage itself. As more people leave the industry, more people burn out, perpetuating the negative cycle. Mercer names “ongoing burnout” as a reason for their projected shortfall of more than 100,000 healthcare professionals by 2028, 73,000 of whom will be nursing assistants.
A shortage in nursing assistants will further strain more specialized healthcare professionals, as doctors and RNs may be required to begin filling in the gaps. The knock-on effects are as yet unknown, but the industry cannot afford increased turnover rates.
2. An aging population
The demand for healthcare services is increasing in both acute and post-acute settings, in part due to the growing over-65 population. The over-80 crowd is growing too, and it’s expected to more than triple to 1.6 billion by 2050. A 2019 survey of individuals aged 80 and above found that this cohort accounted for 15% of all emergency department (ED) visits.
Concurrently, healthcare professionals are reaching retirement age. Unfortunately, people aren’t rushing into the industry to replace them. Nursing, as our recent survey uncovered, is one of the “hero” professions being de-influenced on social media, especially among younger millennials and Gen Z.
Even if Gen Z was flocking to the industry, current education pipelines wouldn’t be sufficient to support them. In 2023, 65,766 qualified applicants were denied admission to both undergraduate and graduate nursing programs. Factors behind the denials included faculty shortages, lack of clinical preceptors and locations, not enough classroom space and limited budgets.
3. Increased burden of chronic conditions
An increase in chronic conditions is adding to the influx of patients in post-acute and acute care settings. A CDC study found that approximately 38% of people in the U.S. are dealing with at least one “major chronic disease.” Of those, 42% have two or more. The study also found that 90% of the $4.1 trillion that the nation spends on healthcare goes toward managing chronic conditions. If the trend continues, additional healthcare workers will be needed to keep up with the demand for care.
4. Lingering effects of COVID-19
Though the nursing shortage is not new, the high number of resignations during COVID-19 exacerbated it. The trends of burnout and turnover that peaked from 2020 to 2022 are beginning to reverse course. Without proactive solutions from the industry and policymakers, however, the coming “Silver Tsunami,” aging workforce, and shortage of healthcare professionals will overwhelm the small gains of the past few years.
5. Rising costs
Costs are rising, and that means that acute care and post-acute care facilities are walking a fine line in the attempt to deliver quality care to patients. Reimbursement and insurance pay rates in hospitals haven't been able to keep up with the rising costs of the past few years: Between 2021 and 2023, hospital labor costs increased by $42.5 billion. Furthermore, hospitals are spending $20 million each year battling insurance denials.
The CEO of University Hospitals in Cleveland, Cliff Megerian, MD, told Becker's Hospital Review: "Unlike other businesses, hospitals and health systems cannot simply adjust prices in response to inflation due to pre-negotiated rates and government-mandated pay structures. Instead, we are continually innovating approaches to population health, efficiency and cost management, ensuring that we maintain delivery of high-quality care to our patients."
In skilled nursing facilities, Medicaid reimbursements aren't covering the costs of delivering care. A recent report by HHS put the average Medicaid reimbursement at an average of $0.82 for each dollar it takes to deliver care. The reimbursement rate decreases when staff-to-patient ratios increase: as hours per patient day (HPPD) dip below three, the payment-to-cost ratio is 0.85, but when HPPD rises above four, it drops to $0.77.
At a time when the demand for care is continuing to increase in both sectors and increased skilled nursing facility staffing-ratio mandates at the state and national levels, these costs can (and have been) fatal to organizations across the country.
Examining the effects of the nursing shortage
Across the nation, hospitals, post-acute care and long-term care facilities are closing wings, departments or their entire operations. From July to October of 2024, 21 hospitals and health systems closed, closed facilities or closed departments.
Skilled nursing facilities, critical members of the long-term care delivery ecosystem, are faring similarly, with 46% limiting new admissions, 57% maintaining a waiting list, and 20% closing wings or floors due to nursing shortages. Not only that, but from 2020 to 2024, 774 nursing homes closed and 28,421 residents were displaced. At the same time, fewer new facilities have been coming online. In 2020, 73 new skilled nursing facilities opened; in 2023, only 37 did.
Post-acute closures and admissions limitations, in large part due to nursing shortages, are contributing to the “hospital discharge crisis.” The phrase refers to the difficulty of finding care for people who no longer need to be hospitalized but cannot go home.
In 2023, 4,405 of the country’s 6,120 hospitals had an average length of stay (ALOS) of 4.5 days, which includes “emergency department boarding,” nomenclature for people who remain in the emergency department after being cleared for discharge or because inpatient beds are unavailable.
Discharge delays are expensive. They cost the State of Florida an estimated $540 million in 2024 alone, and of patients waiting for more than 10 days, nearly 50% were awaiting discharge to a skilled nursing facility. Length of stay (LOS) is a key metric hospitals use to measure the delivery of care. It has been returning to pre-pandemic levels, but with increased demand for care, the rise in ALOS may continue.
Possible solutions for both acute and post-acute care
1. Address burnout and support employees
As burnout is a major cause of turnover, it's critical to address it at an organizational level. Regularly survey employees to find out what they need and guide investment in employee support programs.
Think about offering more flexible scheduling options, too. Flexibility is a high priority for today's healthcare workforce: 97% of professionals agree that they need more of it. Considering that 81% of healthcare workers also have personal caregiving responsibilities, providing employees flexibility becomes even more relevant.
2. Ensure adequate coverage
When there aren’t enough healthcare professionals to care for patients, patient care suffers right alongside healthcare-worker mental health. Have a plan for reducing required overtime, which can burn out employees quickly, and leverage external workers as needed to ensure adequate coverage when employees don’t want to work.
The non-traditional workforce will be key in addressing coverage gaps. A full 78% of healthcare professionals using the ShiftKey platform said that they would not be able to work in healthcare without the flexibility of working on their own terms, and 49% of them have 10 or more years of experience in the field.
3. Leverage technology
Technology can be instrumental in increasing employee engagement and satisfaction, a proven turnover-reduction strategy. Employee-engagement technology streamlines the entire employee-employer experience, from facilitating communication between departments and supporting new hires to collecting meaningful feedback and rewarding top performers.
Real-time location systems (RTLS) have multiple applications in hospitals and long-term care facilities, contributing to employee wellness and better patient care. RTLS save employees valuable time tracking down assets needed in the course of care and help protect them from patient violence. They can also integrate into EHR systems to become valuable tools for strengthening value-based care for patients.
Healthcare technology can also assist facilities with diagnostics, routine tasks, scheduling, forecasting and more. Emerging technology trends include artificial intelligence and machine learning, robotics and automation, predictive analytics, telemedicine and remote patient/resident monitoring and wearable technology.
The future of the nursing shortage
Acute care and post-acute care facilities are facing a similar workforce challenge: there simply aren’t enough healthcare professionals available to meet the demand for care. Organizations can take action now to support their workforces, leveraging technology and engaging qualified professionals who want to work but need more flexibility than traditional roles provide.
Addressing workforce issues on the organizational level will not be enough to stem the tide of the Silver Tsunami as it begins to flood hospitals and post-acute care centers throughout the nation. Educational resources are needed. Healthcare needs a rebrand on social media. And funding and reimbursement challenges must be overcome at a policy level.
Ready to see how workforce technology can help your organization?
Workforce technology platforms like ShiftKey offer alternatives to travel contracts and agencies, enabling facilities and hospitals to offer healthcare professionals flexibility without sacrificing the agility required to meet demand.
References
“Nursing Shortage” (NIH).
“Health Worker Burnout” (HHS).
“Social Media, Gen Z and the Future of Nursing” (ShiftKey).
“Solutions to Healthcare Burnout Report” (ShiftKey).
“The Future of the U.S. Healthcare Industry: Labor Market Projections by 2028” (Mercer).
“World’s Older Population Grows Dramatically” (NIH).
“Emergency Department Visits in Older Patients: a Population-Based Survey” (PubMed).
Nursing Faculty Shortage Fact Sheet American Association of Colleges of Nursing (AACN).
“Costs of Caring” (AHA).
“The Hospital Finance Misconception Plaguing C-Suites” (Becker’s Hospital Review).
“Report Reveals How Medicaid Payments Stack Up Against Nursing Homes’ Cost Of Care” (McKnight’s).
“21 hospitals closing departments or ending services” (Becker’s Hospital Review).
“2024 Access to Care Report” (AHCA/NCAL).
“Hospital Discharge Crisis” (ATI).
“Nine Things To Know About Length Of Stay” (Becker’s Hospital Review).
“Fast Facts: U.S. Hospitals” (AHA).
“FHA 2024 Patients Awaiting Discharge” (FHA).
“Access To Skilled Care Care Approaching Crisis Levels” (Skilled Nursing News).
“10 Ways to Combat Staff Burnout in Your Community” (ShiftKey).
“Guide to Employee Listening” (OnShift).
“How to overcome Nurse Burnout” (ShiftKey).
“Increase Employee Engagement And Retention” (CultureAmp).
“Six technology trends that are reshaping emergency departments and ICUs” (ShiftKey).
