A nationwide nursing shortage has been projected since the late 1990s. An aging population, including the nursing workforce, will increase the strain on the healthcare system’s ability to provide quality care. In 2012, the average age of a registered nurse was 44.5 years, and more than one-quarter of the RN workforce was over the age of 50 (Buerhaus, Satiger, & Auerbach, 2009). According to the Bureau of Labor Statistics, an additional 712,000 nurses will have to go into the workforce to meet the projected increased demand of 26% between 2010 and 2020 (Bureau of Labor Statistics, 2012).

A national recession officially began in December 2007 and resulted in the loss of 7.5 million jobs, bringing the unemployment rate to 9.6%. During the same time period, the healthcare industry gained 428,000 jobs. Specifically, between 2007 and 2008 hospitals opened and filled an additional 243,000 full-time equivalent RN positions, the largest two-year increase in the past four decades. Staiger, Auerbach, and Buerhaus (2012) explored the relationship between the recent surge in registered nurse employment and the economic recession, attributing the sharp rise in RN employment to the continued high demand for healthcare services and registered nurses reentering or not vacating their positions due to personal financial uncertainty. This influx and retention of registered nurses may lead employers, educators, and policy makers to conclude that the nursing shortage has ended. However, it is estimated that more than a third of the recent gains in RN workforce can be directly attributed to the economic recession, and that approximately 118,000 nurses will exit employment by 2015, when the Congressional Budget Office projects that unemployment levels will decline to 6.1%—thus leaving the previous projections of a profound nursing shortage a reality.

There is an abundance of literature and anecdotal evidence on the association between registered nurse staffing and patient outcomes. The most notable, and most frequently cited, are empirical studies by Aiken et al. (2002) and Needleman et al. (2002). These studies demonstrated that nurse staffing directly affects rates of complications and harm, including hospital-acquired pneumonia, falls, development of pressure ulcers, higher failure-to-rescue rates, higher overall mortality rates, and increased nurse dissatisfaction and burnout. In a meta-analysis, Kane et al. (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007) found that for each additional patient a nurse is assigned, there is a 7% increased relative risk of pneumonia, a 45% increase in unplanned extubations, and a 53% increase in pulmonary failure. This review of 28 studies definitively linked RN staffing levels to patient outcomes. The more patients a nurse has, the more likely all patients are to suffer a medical complication.