Introduction:

In recent years, healthcare advocates have focused attention on the nursing shortage. Health Resources and Services Administration (HRSA) workforce projections indicate a shortage of 78,610 full-time equivalent Registered Nurses (RNs) in 2025 and 63,720 RNs in 2030 (HRSA, 2022). The shortage is exacerbated by multiple contributing factors including an aging population that will place greater demand on the healthcare system due to chronic illnesses, comorbidities, and the need for geriatric care. It is anticipated that the number of citizens aged 65 and older will increase from 58 million in 2022 to 82 million by 2050 (United States Census Bureau, 2023). The number of working RNs is also aging, and more than one-quarter of RNs report planning to leave their profession or retire in the next five years (AACN, 2024). Additionally, the number of RNs in the workforce has recently been impacted by the COVID-19 pandemic (Auerbach et al., 2022). While the number of RNs continues to decline, admission to nursing programs has remained stagnant. Nearly one-quarter of eligible applicants to RN programs are declined admission due to lack of appropriate clinical sites and clinical preceptors, limited classroom space, and educator shortages (National League for Nursing, 2024).

The nursing shortage has implications for quality of care and patient outcomes.  Ross (2022) cites multiple concerns with lower nurse-to-patient ratios. Access to care may be jeopardized, especially for those residing in rural areas. Suboptimal staffing contributes to medication errors, infections, and sentinel events. Institutions that can attract and retain adequate staff will be poised to minimize these implications. New graduate nurses have opportunity to be selective in their choice of first employer. Understanding factors that attract new graduate nurses may assist employers in accentuating those attributes to recruit and retain more nurses.

Measures, Procedures, and Findings

Senior nursing students enrolled in a Bachelor of Science in Nursing program at a Midwest university were surveyed to determine factors influencing choice in post-graduation employment. Institutional Review Board approval was obtained, and students were informed that participation was voluntary. An electronic survey link was emailed to students with a consent form. The self-developed survey included demographics, previous experience in healthcare, current community setting, desired community type after graduation, and early employment acceptance. 62 students were enrolled in the course and the total number of responses was 34, a response rate of 52%.

Of the 34 respondents, 88% were in the 20–29-year range. Most students, 69%, reported living in an urban area with a population of 50,000 or more. A vast majority of respondents, 78%, reported employment in the healthcare field during nursing school while 22% had no prior healthcare experience. At the time of the survey, 53% of respondents stated they had already accepted an RN position, and an additional 9% stated they had at least one job offer but had not yet accepted a position. 38% of students had not accepted a position and had not received a post-graduation job offer. Of those who had already accepted a post-graduation position, 78% stated the job was in an urban facility. Respondents were then asked to rank factors influencing their choices related to post-graduation employment on a scale from 0-100 with 100 being the most influential on job selection. Influencing factors and rank are included in Table 1.

Discussion

HRSA analyzed health workforce issues to help inform decision makers in public and private sectors. A major challenge identified in their 2023 report was the number of people living in a primary care Health Professional Shortage Area (HRSA, 2024). As of November 2023, around 102 million people were living in a shortage area. While physical location is not a factor that may be changed, healthcare administrators, governmental agencies, and policymakers should be encouraged to consider ways to attract healthcare workers to rural communities. Urban planning, recruitment, and retention efforts will be especially important for those in rural areas with healthcare shortages as these efforts may have a significant impact on population health.

Facility reputation and patient-to-nurse ratios were factors greatly influencing employment decisions for new graduates. Chen et al. (2019) studied the impact of nurse-patient ratios on job satisfaction and burnout. Nurses with higher patient to nurse ratios were more likely to experience personal burnout, job dissatisfaction, and have intention to leave their job. This cycle of higher workloads, burnout, and attrition may impact facility reputation, thus perpetuating the cycle of staffing shortages. Facilities that can recruit staff adequately to ensure optimal nurse-patient ratios may increase satisfaction, retention, and will likely benefit from improved reputations.

Students surveyed identified opportunities to work in specialty areas as important in job consideration. Facilities may consider creating pathways for new graduates to progress from generalist practice to practice in specialty areas. Finally, salary was identified as a top factor influencing employment. Employers must offer attractive pay to remain competitive in recruiting efforts, but recruitment focus should also include consideration for other factors such as residency programs, flexible scheduling, leadership opportunities, and a comprehensive benefits package for new employees.

Limitations and Implications

This study is a first step in examining efforts that may positively impact the nursing shortage through new graduate employment. A limitation of this study is sample size (n = 34). Further study is indicated to examine a larger number of new graduates across a larger geographical area. Future research should include factors affecting retention of new graduates after initial hire. The number of newly licensed RNs increased by 18% each year between 2018 and 2022, suggesting continued growth in the nursing workforce (HRSA, 2024). Now is the time to strategically plan for new graduate recruitment to positively impact the nursing workforce for generations to come.

References

American Association of Colleges of Nursing. (2024, April). Nursing workforce fact sheet. https://www.aacnnursing.org/news-data/fact-sheets/nursing-workforce-fact-sheet

Auerbach, D. I., Staiger, D. O., Donelan, K., & Buerhaus, P. I. (2022, April 13). A worrisome drop in the number of young nurses.  Health Affairs. doi:10.1377/forefront.20220412.311784

Chen, Y. C., Guo, Y. L. L., Chin, W. S., Cheng, N. Y., Ho, J. J., & Shiao, J. S. C. (2019). Patient–nurse ratio is related to nurses’ intention to leave their job through mediating factors of burnout and job dissatisfaction. International Journal of Environmental Research and Public Health. 16(23), 4801. doi:10.3390/ijerph16234801

Health Resources and Services Administration. (2022). Nurse workforce projections, 2020-2035. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/Nursing-Workforce-Projections-Factsheet.pdf

Health Resources and Services Administration. (2024, May). State of the U.S. health care workforce, 2023. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/state-of-the-health-workforce-report-2023.pdf

National League for Nursing. (2024). NLN releases new survey results of nursing schools and programs showing persistent challenges to addressing the nursing shortage. https://www.nln.org/detail-pages/news/2023/09/25/nln-releases-new-survey-results-of-nursing-schools-programs-showing-persistent-challenges-to-addressing-the-nursing-shortage

Ross J. (2022). Nursing Shortage Creating Patient Safety Concerns. Journal of Perianesthesia Nursing. 37(4), 565–567. https://doi.org/10.1016/j.jopan.2022.05.078

United States Census Bureau. (2023). 2023 national population projections tables: Main series. https://www.census.gov/data/tables/2023/demo/popproj/2023-summary-tables.htm