The RN and RDH Shortage: Outflows
Third in a series contrasting nurse and dental hygienist shortages
Are nurses and dental hygienists leaving their professions at an accelerated rate?
Outflow data is more elusive than inflows. I’ve found it often based on surveys of providers sharing their potential future plans. This is still useful as a leading indicator of outflows and it gives us insights into workforce sentiments. But how many provider actually leave their profession in a given time period? How does one get accurate lagging data?
I’ll bucket outflows into two categories: retirement and quitting. If a nurse is burned out and leaves the profession in their 30’s, that’s quitting. They left the workforce earlier than reasonably anticipated.
If that same nurse leaves the profession in their 60’s, I’d call that retirement. They may have experienced and exhibited all the signs of being burned out. On their last day of work, they may have flipped their desk and yelled “Screw this, I’m outta here!” But that nurse has spent the majority of their adult working lives in the profession and they have entered into an age where few would be shocked that they hung up their spurs.
Retirement
A 2022 survey reported that 28% of nurses planned to retire within the next five years (source). The best available data on age distribution is from 2018 (source), but it suggests about 25% of nurses are age 60 or older. So the self-reported retirement numbers are in line with nurse age.
A 2024 survey revealed that nearly 1/3 of dental hygienists plan to retire within the next 6 years (source). Roughly 35% of total respondents were over the age of 55 and almost 30% of respondents had over 30 years of experience as hygienists. Again, the number of providers that are planning to retire sounds reasonable based on their age.
Quitting
My armchair definition of quitting is leaving the profession well before retirement age. Why would someone do this?
One reason would be that there are more professionals in the workforce than there are jobs. We’ve had the exact opposite problem (see the title of this article series), so I won’t explore that here.
The other reason someone would leave their profession early is that they don’t like it anymore. For this analysis, we need to explore burnout.
From the WHO (source):
“Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
feelings of energy depletion or exhaustion;
increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and
reduced professional efficacy.”
I think it’s important to distinguish between job dissatisfaction, which may be resolved by changing employers, and burnout, which is more likely to result in a provider leaving the profession. My next article will focus on turnover, which incorporates job satisfaction data.
Even prior to the pandemic, burnout was a growing concern in healthcare (source). In 2020, burnout was reported by 62% of nurses (source) and approximately one third of hygienists (source). A 2022 survey found 45% of nurses experienced burnout at least a few times a week (source).
So What are the Real Outflows?
We just don’t know and I think it will be difficult to find out.
We are in great need of regularly updating burnout data if we are to better anticipate this element of provider outflow. Again, this would be a leading indicator, not a lagging one.
To get true lagging data, one might suggest reviewing the number of active licenses by State. If we were to account for new licenses (inflows), then we could reach a reasonable estimate of how many licenses were made inactive. This would be useful, but it’s still is not a real outflow number.
Why? Because what all of these surveys and economic papers are actually searching for isn’t the supply of professionals; its the supply of professionals that are actively treating patients. Nurses, dental hygienists, and other providers can maintain an active license and partially or fully transition out of patient care.
They can move into healthcare administrative roles, work for manufactures or pharma companies as sales reps, teach at schools, or pursue a dozen other types of opportunities that are related to their profession but involve zero hours of patient care. This has a significant impact on true provider shortage and we struggle to measure it.
Take me for example. I was a full-time dentist in the first stage of my career, then in 2014 I transitioned to part-time when I accepted the position as Chief Editor at Dental Economics (an industry trade publication). In 2021, I fully left routine patient care when I became the Chief Dental Officer at Tend. I still maintain an active dental license and would therefore be counted as part of the dentist workforce, but I haven’t been a full-time clinician for over a decade. I have no direct impact on addressing the oral health needs of New Yorkers.
In the future, I think the most accurate data would be to capture provider hours of patient care per week. This would take into account full-time, part-time, locum/prn and temp workers, and the folks like me who have zero hours of patient care on a regular basis.
As we’ve shared, the shortage of registered nurses is expected to be eliminated by 2035 (source). We’ve based this on seeing how quickly we add water to the bucket (inflow) and how quickly we pour it out (outflow)… but how leaky is the bucket?