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Nursing Shortage

By Don Sadler

The U.S. health care system is facing an acute nursing shortage that was only made worse by the COVID-19 pandemic. This shortage is affecting every aspect of health care delivery, including perioperative services.

Before the pandemic, there were approximately 3.1 registered nurses in the U.S. Today this has dropped to 2.9 million nurses, according to the Bureau of Labor Statistics (BLS), and another half-a-million nurses are expected to retire this year alone. Open perioperative nursing positions have increased from 3% in 2012 to 11% in 2021. 

Within the next two years, the shortage of nurses in the U.S. is expected to reach 1.1 million. The BLS projects a total of about 194,000 nurse openings each year through 2030, or a rate of job growth of 9 percent annually. 

What’s more, a study conducted by the American Association of Colleges of Nursing (AACN) reports that one million nurses will retire by 2030. This is not surprising when you consider that the average age of perioperative nurses in the U.S. today is 46 years old and 76 percent of them are between the ages of 30 and 60.

Predictions Are Coming True

“The predictions of the baby boomer generation retirements in nursing are and will continue to have a strong effect on the perioperative nursing shortage,” says Sharon McNamara, BSN, MS, RN, CNOR. “The large number of retiring nurses has resulted in a deluge of open positions that are taking an average of six months to fill.”

Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president, perioperative services at Anmed Health, says that the nursing shortage we’re experiencing today “was predicted 10 years ago. It is due to a number of different factors including retiring baby boomers, the stress of the work environment and a lack of sufficient nursing school professors.”

Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN), calls the shortage of nursing school faculty a “pipeline problem. There are more applicants for bachelor’s and master’s level nursing programs than there are faculty and other critical resources available to prepare them,” she says.

Groah cites an AACN report showing that more than 80,000 qualified applicants were turned away from nursing programs in 2019 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors and budget constraints.

According to the 2021 AORN Salary and Compensation Survey, the top five reasons for the perioperative nursing shortage cited by nurses are:

  • Compensation and benefits
  • Staff changing employers or industry
  • Job burnout
  • Heavy workload/long hours
  • Job-related stress

Meanwhile, in a 2021 survey conducted by the American Nurses Foundation, 41 percent of nurses cited insufficient staffing as the reason they wanted to leave their job, and 47 percent said that their work is negatively affecting their health and well-being.

David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC, believes some causes of the nursing shortage are “multi-factorial. Each variable has numerous sub-variables and each compounds exponentially.”

“Nearly one-third of nurses leave the profession within the first two years of employment,” says Taylor. “If there were a few main causes of the nursing shortage, the most senior nursing professionals in the country would have devised a plan and fixed this problem years ago.”

Pandemic Increases Burnout

Practically every expert notes the impact the pandemic has had on nurse burnout. “We don’t have specific data on this yet, but there is anecdotal evidence that caring for COVID patients in unrelenting numbers is leading to stress, burnout, resignations and retirements among some nurses,” says Groah. “The pandemic caused a perfect storm.”

Groah cites a 2021 American Nurses Association (ANA) Foundation survey that found that 35 percent of all nurses are not emotionally healthy. And in a 2021 American Organization for Nursing Leadership (AONL) survey of 1,800 nurse managers, 75 percent said that the emotional health and well-being of nurses was their top challenge. In addition, 25 percent of nurse managers indicated that they were not emotionally healthy.

“Many nurses are working way more than a 40-hour week under extremely trying circumstances,” says Joanne D. Oliver-Coleman, BSN, RN, CNOR-E, who is the CEO of Healthcare Resources. “And during the height of the pandemic, they feared that they may be bringing home the virus to their families.”

Meanwhile, Taylor cites a survey in which 30 percent of registered nurses nationwide reported burnout. 

“Stress, anxiety, sleep deprivation, emotional exhaustion and depersonalization are some of the symptoms of nurse burnout,” he says. “These can decrease nurse retention rates and increase sick leave, which in turn increases nurse workloads and overtime compensation.”

According to Taylor, when ORs were reopened after being closed to elective procedures during the pandemic, perioperative nurses returned to “unrelenting schedules in order to work through the backlog of patients. There was literally no rest for the weary.”

Nurses have not had a chance to decompress and process the emotions and experiences they felt during the pandemic, adds Taylor. “It’s difficult to process the death of one’s patient when there are dozens of patients who need that bed, or to see truckloads of dead bodies and have to put on a happy face so you can care for the next patient,” he says.

ECRI: Staffing Shortages Threatens Patient Safety

Staffing shortages top a list of patient safety concerns released by ECRI, the nation’s largest nonprofit patient safety organization.

While the annual list is typically dominated by clinical issues caused by device malfunctions or medical errors, ECRI researchers say the most significant concerns at present are caused by crises that have simmered, but COVID-19 exponentially worsened.

“Shortages in the health care workforce and mental health challenges were broadly known and well-documented for years,” said Marcus Schabacker, MD, Ph.D., president and CEO of ECRI. “Both physicians and nurses were at risk of burnout, emotional exhaustion and depression prior to 2020, but the pandemic made both issues significantly worse.”

While both trends were known, their effect on patient care was not well documented. Now, ECRI researchers say inadequate staffing is actively jeopardizing patient safety. Due to staffing shortages, many patients are waiting longer for care, even in life-threatening emergencies, or simply being turned away.

With reports of more health care workers planning on leaving the industry, ECRI experts say patients could face even higher risks without proactive solutions. Without intervention, the chaos and understaffing in hospitals and other health care settings seen over the last two years could become the new normal for the foreseeable future.

“Health care and government leaders now must aggressively manage these challenges amidst a lingering pandemic and a weakened health system by prioritizing recruitment, retention and clinician resilience,” Schabacker said. “As leaders, their most important job is ensuring that patient health and safety are top priorities.”

“ECRI’s report is a roadmap to help prioritize patient safety initiatives and allocate necessary resources that accelerates organizations in their total system approach to safety,” said Brigitta Mueller, MD, executive director of patient safety, risk and quality at ECRI. “We are here to help health care and government leaders as they finally address these longstanding issues in a comprehensive, forward-thinking way.”

To identify the most pressing patient safety threats, ECRI analyzed a wide scope of data, including scientific literature, patient safety events or concerns reported to or investigated by ECRI, client research requests and queries, and other internal and external data sources.

ECRI’s Top 10 Patient Safety Concerns for 2022 report provides detailed steps that organizations can take to prevent adverse incidents and is available for download.

Unique Perioperative Challenges

The nursing shortage is especially challenging in the perioperative environment because of the highly specialized nature of perioperative nursing and the extra training required to get nurses up to speed. 

“There are more than 15 OR surgical specialties and each of them has technology specific to the specialty,” says Groah. “It can take OR nurses nine to 12 months to be oriented in one or two specialties and up to two years to be oriented in all surgical specialties.”

“Due to the omission of perioperative patient care in standard nursing curriculum, extensive specialized education and skills acquisition are required before new graduates can function effectively in surgical services,” says McNamara. “This requires an extended orientation period to prepare perioperative nurses.”

It also falsely gives the impression that perioperative nursing positions have been filled with nurses who can function independently. “In reality, the nurse shortages continue during the orientation period,” says McNamara.

One solution some organizations employ to help combat the nursing shortage is to use traveling nurses. “We have feedback from our members about the need to use travelers to meet the daily staffing needs in the OR, both in hospitals and ambulatory surgery centers (ASCs),” says Groah.

“More hospitals are now hiring traveling nurses to backfill,” adds McNamara. “These travelers who may not work weekends or take call are usually paid more than loyal, employed nurses.”

This can lead to low morale on the part of staff nurses, says Oliver-Coleman. “Agency nurses are sometimes being brought in to cover at three to four times the pay of staff,” she says.

“If nurses are going to work this hard, many will choose traveling which gives them controlled hours of work and higher pay,” adds Dennis.

Solutions to Solve the Shortage

While there’s no silver bullet, experts offer a wide range of potential solutions to help solve the nursing shortage. Taylor would like for there to be a national strategy devoted to solving the problem. 

“I’d especially like to see greater efforts to recruit and transition nursing students into professional roles in a timely manner and the creation of pipelines for clinical partners to help fill shortages,” says Taylor.

Hiring bonuses, tuition reimbursement, loan repayment, tiered referral bonuses and internship programs would also help, Taylor adds. 

“Hospitals can also offer concierge services like dry cleaning and automotive services to nurses that help them get their errands done during the day so they can relax while they’re off,” he says. “On-site day care can also benefit nurses greatly.”

Dennis would like to see more investment in schools of nursing by supporting relief of student debt. “So many nurses have large student loans,” she says. “The pay structure for perioperative nurses also needs to be re-evaluated.”

Oliver-Coleman stresses the importance of using experienced nurse mentors to help train new perioperative nurses. 

“Also use retirees as adjunct faculty and offer flexible hours whenever possible,” she says. “We all need to be more flexible with alternative staffing to include staggered shifts, agency nurses (with appropriate orientation) and part-time retirees.”

According to Groah, AORN has recently partnered with Chamberlain University to incorporate Introduction to Perioperative Nursing into its curriculum on four campuses, with plans to expand throughout their system.

“This program exposes nursing students to a clinical setting where they are a valuable member of a high-performance team,” says Groah. “Students can experience the importance of lifelong learning as technology advances, as well as vital connections with patients and their families.”

When these students graduate, they will better understand what the specialty of perioperative nursing entails and be ready to enter Periop 101: A Core Curriculum OR. This is AORN’s six-month program to train novice nurses in perioperative nursing. 

“Periop 101 is the premier perioperative nurse education program for RNs entering the perioperative specialty,” says Groah. “Hospitals and ASCs that use Periop 101 report quality improvement, reduced training time for staff and educators, and stronger staff recruitment and retention.”

New Think Tank and Task Force

To help solve the nursing shortage challenge, the ANA – in collaboration with the AONL, the Association of Critical Care Nurses (ACCN), the Healthcare Financial Management Association (HFMA) and the Institute for Healthcare Improvement (IHI) – is launching a nurse staffing think tank. 

The goal of the think tank is to link nurses and workforce experts who are interested in driving solutions to the nursing shortage. It will do this by reviewing data to uncover root causes of the shortage, identifying implications that may not have been considered, and developing strategies that health care organizations can implement within one year with measurable outcomes for impact.

These same five organizations have also launched a National Nurse Staffing Task Force with four key goals:

Provide a forum for a powerful dialog on a national scale to address critical issues.

Facilitate progress toward innovative solutions that are consistent with appropriate staffing in acute and critical care settings.

Build the nursing workforce through long-term sustainable recruitment and retention solutions.

Support and sustain a healthy work environment using principles and guidelines for appropriate staffing that correlate with optimal nurse satisfaction, care outcomes and patient safety.

Last September, the ANA called on the Department of Health and Human Services (HHS) to take concrete action to address the nursing shortage. Specifically, the ANA called on HHS to take actions to achieve pay equity and full scope of practice for advanced practice RNs, as well as to enhance nurses’ mental health support.

The ANA, AONL and HFMA have published an outcomes-based staffing report titled “The Business of Caring: Promoting Optimal Allocation of Nursing Resources.”  The report sets forth an action plan for improving the allocation of nursing resources.

A free download of the report can be found at




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