What do you think? Email us at editor@ nurseweek.com

By Diane Sussman December 27, 1999 The United States can look back on only a few times in the past century when the country had enough-let alone a surplus-of nurses. Far more of the nation's history has involved finding enough nurses to care for an expanding and aging population. Each shortage has had its own precipitating factors, ranging from war to wages to changing standards of care. "In every instance, what you find is that supply and demand have been out of balance," said Joan E. Lynaugh, PhD, RN, FAAN, associate director of the Center for the Study of the History of Nursing at the University of Pennsylvania in Philadelphia. "There is no one reason." The first major shortage occurred in the early 1920s as the nation recovered from the double strains of World War I and a deadly influenza epidemic that killed 500,000 people nationwide, including many student nurses. With the patriotic call to service gone, fewer women entered the profession, choosing other work instead. The result was that the United States faced a shortage of 55,000 trained nurses in 1920, while the Public Health Service, which cared for veterans, had 10,000 more positions open than it could fill. The years following World War II brought another shortage, as the country began building hospitals and Americans began settling down and having babies-a total of 77 million from 1946 to 1967. Many of those mothers were former military nurses who chose a life in the newly emerging suburbs over "going back to work at hospitals after the military," Lynaugh said. Since then, shifting trends in health care have produced fresh shortages. The critical shortage of the 1980s had its origins in the introduction of diagnosis related groups, Lynaugh said. "DRGs created a nervousness among hospitals that patients wouldn't come in, so they began laying off nurses to find a cheaper way." Nursing came to be perceived as a profession with diminished possibilities and fewer students applied. But the notion that DRGs would reduce the number of patients proved to be a colossal miscalculation – "suddenly all these people had diagnoses," Lynaugh said-and hospitals found themselves with too few nurses to care for them. Similar thinking followed the growth of HMOs, Lynaugh said, with premature layoffs leading to critical shortages in specialty areas. But the greatest nursing shortage, experts say, is yet to come, when an aging nursing work force, declining numbers of nursing students, an aging population, and sicker patients collide. According to the Department of Health and Human Services, by 2020 the nation is expected to have a shortfall of 635,000 to 1,754,000 nurses.