Opinion: The Registered Nurse Shortage

I have reported often about the severe and increasing shortages of nurses both in Virginia and nationally.

At some point in nearly everyone’s life, we literally will not be able to live without the help of a nurse, whether for injury or illness or just declining overall health.

We need both the nurses and ourselves to be safe when that happens. We will have to fill the shortages, first by recruitment and retention. Perhaps simultaneously by increased legal immigration of qualified nurses from other countries.

This article will focus first on what RNs were paid in 2021, both in Virginia and nationwide. We will examine it in absolute and in relative terms. Virginia in 2021 was competitive on pay in relative terms. But wages may be insufficient in absolute terms to address the shortages.

Then we will discuss what else needs to be done to recruit, train and retain more nurses. I mentioned in an earlier article that RN instructors in training programs are one of the biggest needs.

The Census Bureau and Bureau of Labor Statistics have captured the large increases in registered nurse (RN) pay across the board and the doubling of the pay of travel nurses in 2021. Those pay surges were driven by COVID supply and demand and funded partially by federal emergency money.

You will see that, by what I consider a useful calculation, Virginia RN’s median wage compensation is 18th among the states when adjusted for each state’s cost of living index. Virginia is the top-paying state among adjacent states and the District of Columbia.

Regardless of the reason, it was past time that we paid them more. We need the pay raises to stick. It is the only way over the long run to begin increasing the supply.

I say begin because there are other factors driving nurses away. Safety is a huge factor.

Wages.  I have built from federal data a spreadsheet of registered nurse wages by state and a lot of relevant data to assess their economic well-being in 2021.

The results for 2021 are informative and are not intuitive.

The data enable calculations of three different perspectives:

1. Relative national value: the median annual wage of state RNs divided by the state’s cost of living adjusted to the national average cost of living to provide the adjusted national valueof the wage. This is an important figure in the attractiveness of each state to RNs. Virginia finished 23rd.
2. In-state value of the median annual wage of state RN’s divided by medianhousehold income in each state.  The calculated figure shows how an RN can support the average Virginia household as the sole breadwinner. That figure calculates to o.95 in the Commonwealth, meaning that an RN in Virginia could not quite achieve the median household income by himself or herself.
3. In-state value of the median annual wage of state RN’s adjusted for (divided by) medianper capita income in each state. This figure calculates to 1.77.

There are other ways to measure the economic value of being a nurse, but those are useful ones.

1. the first reflects the competitiveness of RN wages with other states; and
2. the second reflects the financial competitiveness of being an RN within in each state.

As for competitiveness, Virginia RN 2021 median annual wages were, at $76,680 in absolute terms,

1. ranked 18th among states when adjusted for cost of living; and
2. near the bottom (45th) compared to state median household income.

By every measure, the most valuable place to practice as an RN is California. Wages are driven there by the severity of the shortage, the worst in the country.

California RN average wages are almost 150% of the California median household income. And the RN median wage, $125,340, is still the highest at $88,143 after adjustment for California’s extraordinarily high relative cost of living.

The highest values of RN wages. After California, the leaders in adjusted national value of RN wages, second through sixth, are:

• Washington
• New Mexico
• Georgia
• Michigan
• Texas

Again after California, the states with the highest RN average wages relative to state median household income, second through sixth are:

• New Mexico
• Oregon
• Hawaii
• New York
• Alaska

The lowest values of RN wages. The states with the lowest values of RN wages adjusted for cost of living are, 50 through 46:

• Hawaii
• District of Columbia
• South Dakota
• Maryland
• Vermont

Again, other than D.C., the states with the lowest values of RN wages compared to state median household incomes are, 50 through 46:

• Maryland
• New Hampshire
• South Dakota
• Iowa
• Utah

Among surrounding states, Virginia’s cost-of-living-adjusted value of the RN median wage was the highest at 18th. North Carolina was immediately behind Virginia at 19th. Tennessee was 31st, West Virginia 36th.

The range of cost-of-living-adjusted wages was from California’s $87,201 to Hawaii’s $57,460. Virginia was at $75,540.

These are only statewide numbers. If we had all of that data for each jurisdiction in Virginia, we would of course see different relationships, but the same calculations would be valid.

Whether the wage differences regionally are balanced out by the cost-of-living differences would be an interesting study.

But statewide, Virginia in 2021 paid RN’s competitive wages when adjusted for cost of living, especially regionally.

If wages were the only issue, Virginia would be OK.

Shortages and safety. But the challenges to the profession are not simply wages. A report of a survey of 1500 nurses in 2021 gave a glimpse at the state of dissatisfaction:

Only 12% of nurses are happy where they are.
Over 80% feel burnt out, underpaid, frustrated with their administrators, and that this past year (2021) has affected their mental health.

Read the whole report. It is bracing.

You will discover things such as that only 2% of the ER nurses were happy where they were.  Ninety percent of nurses practicing clinically felt burnt out.

The report concluded from the data that the “Real Reasons for the Nursing Shortage” were:

• Inadequate staffing
• Not getting equal pay for equal experience
• Not receiving hazard pay
• Not having adequate back up
• Not getting full breaks
• Not being able to take sick days
• Not being able to turn down extra shifts

Citizens can’t fix that.

Only employers, with state oversight to maintain nurse and patient safety, can do it.

I hope private sector nurses unionize to speed the process.

Bottom line. I have written about this here before but I will again. Inadequate nurse staffing is out there, most visibly in hospitals, freestanding ERs and nursing homes but also everywhere they practice.

Both RN employers and the state have ethical responsibilities to shut down services that are not properly staffed.

We have facilities open right now with insufficient nurses to safely operate all of the services they offer. I have done the research and have published the results many times before.

Hard choices have to be made, but at the state level oversight starts with accurate data and sufficient inspectors.

The inspectors, or I should say inspector positions, are largely registered nurses. The Department of Health will need to raise the salaries of the inspector positions until they are filled.

VDH has data available on nurse shortages if it has the personnel to monitor it, but currently is unable to my knowledge to correlate shortages with requirements by individual services in order to intervene.

The institutions know.

If necessary VDH should write a regulation to get the data they need at sufficient level of detail to make the necessary correlations for intervention.

The nurses, and the patients, demand it.

– by James C. Sherlock

(This story originally appeared in Bacon’s Rebellion.)