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The Health Care Workforce Shortage

Multiphasic problems and solutions

By Kenneth Botelho, DMSc, PA-C

Those numbers matter. Minnesota, like much of the country, is facing serious workforce pressure across nearly every part of health care. Hospitals, clinics, home care agencies and patients and families all feel it. Many related factors have created these problems and have led to the current workforce reality that a filled position is not the same as stable care delivery. What we can infer from these data is how they explain why health care can still feel unstable even after positions are filled.

The issue begins even earlier than hiring. Health care does not only need more people entering the system. It needs stronger pathways that help employees enter, learn, transition, integrate, advance and remain in the work of care. A pipeline gets people into health care but it is pathway capacity that helps them stay, grow, integrate and become part of stable care delivery. That distinction matters because the workforce shortage is often discussed in fragments: recruitment, vacancies, burnout, compensation, education cost, training capacity, turnover and retention. Each of these matter, but missing how they are all connected and what can be done to recognize and strengthen the connections is critical to reducing the problem.  

The shortage is not one shortage

The phrase “workforce shortage” can make the problem sound singular, as if there is one gap to close. But health care is experiencing several shortages at once. There is an entry shortage when people do not see accessible or affordable ways into health care work. There is a training capacity shortage when programs have interested students but not enough faculty, clinical sites, preceptors or supervisors. There is a transition shortage when graduates or new hires enter practice without enough support to become effective in real settings. There is an advancement shortage when workers cannot see a future that includes greater responsibility, compensation, respect or career growth.  

Another important consideration involves an integration shortage. This occurs when a health care employee is hired but never fully connected to teams, workflows, patients, mentors and the local knowledge that makes care function. These shortages may look separate, but they are directly related to each other, and failing to treat them as such results in problems that quickly compound themselves.

For example, weak home care capacity affects hospitals. Weak clinical training capacity affects future staffing. Weak onboarding affects retention. Weak retention affects continuity. Weak continuity affects patients.

Patients experience workforce instability as care instability. This is why the usual language of workforce supply is incomplete. Vacancies are not the whole story. Headcount is not the whole story. Hiring is not the whole story.

The deeper question is whether health care has built the pathways that allow people to enter, develop, stay and support stable care.  

Patients experience workforce instability as care instability.

Workforce Entry Issues

One part of the workforce challenge begins before a person ever enters a health care role. For many people, the path into health care is expensive, confusing, or hard to see. Some roles have clear educational structures and recognized credentials. Others remain essential but under recognized, under credentialed and poorly connected to advancement.  

In the direct care and home care workforce this is especially visible. Health care can be divided into the medical sector and the home care sector. The medical sector includes care provided in hospitals, clinics, procedural settings, as well as diagnostic and other facilities. The home care sector supports people where they live. These sectors may be discussed separately, but patients do not live in separate sectors. They move across them. Families move across them. The consequences of instability move across them.

When home care is unavailable or unreliable, a patient may remain hospitalized longer than necessary. An older adult may decline at home or a person with a disability may lose independence. A family caregiver may become exhausted and a clinic may see repeated destabilization that is not caused by a single disease, but by the absence of reliable support around the person.

In the medical sector, roles such as certified nursing assistants have a recognized credentialed pathway. That pathway is not perfect, and financial security is far from guaranteed. But it does provide a visible entry point into health care work and, for some, a step toward further education and advancement.



In the home care sector, many direct support professionals have historically lacked a comparable credit-bearing credential with a clear career path. That matters. People are more likely to enter and remain in a field when the work is visible, respected, credentialed, connected to growth and capable of providing a living wage with the potential to achieve financial independence.

Essential work cannot remain invisible and then be expected to remain stable. In Minnesota, efforts to create stronger credentialed pathways for direct support professionals point toward a more durable workforce strategy: one that connects entry, education, wage potential, advancement and recognition.

This is not just a workforce issue. It is a care delivery issue. When the home care workforce is unstable, hospitals, clinics, patients and families all absorb the cost. 

Training Capacity Bottlenecks

Another layer of the workforce shortage involves training capacity. When people want to enter health care, there is a lot they need to learn. Health care cannot expand its workforce without faculty, clinical sites, preceptors, supervisors, mentors and workplace educators. These roles are often treated as background support, but they are not background. They are infrastructure and without teaching capacity there are severe limitations on the future workforce

Clinical training does not happen only in classrooms. It happens in exam rooms, hospital units, home care settings, behavioral health environments, community agencies, rural clinics and long-term care facilities. Learners develop by watching, practicing, receiving feedback, making decisions and gradually taking on more responsibility.

Yet the people asked to support that learning are often already carrying heavy loads. Clinicians and staff are managing productivity demands, documentation burdens, staffing shortages, patient complexity and operational stress. In that environment, teaching can start to feel like extra work rather than essential work.

Teaching, however, is not separate from workforce strategy, it is workforce strategy. If we want more clinicians and health care workers, we must support the people and practice environments that make learning possible. This means valuing preceptors, making teaching more feasible in busy practice environments, supporting clinical training sites, building partnerships between educational programs and employers and recognizing workplace teaching as part of the health care workforce infrastructure.

Calling for more graduates without supporting the environments that train them is like asking for more crops while neglecting the soil.  

Preparation Is Not Integration

A third layer of the workforce shortage appears after graduation, certification and hiring. Health care often assumes that once someone is credentialed and employed the problem is solved. Being prepared to enter practice, however, is not the same as being integrated into practice.  

This is true across many roles. A direct care worker entering home care, a medical assistant entering a busy clinic, a nurse entering a hospital unit, a PA or NP entering primary care or a physician joining a new system all face a transition from general preparation into being part of a durable, functional and integrated workforce.

That transition requires more than technical knowledge. It requires workflow fluency, role clarity, communication norms, escalation pathways, documentation habits, team trust, patient population awareness and an understanding of how care is provided to meet best practice guidelines in that setting. For clinicians, this gap is especially visible in primary care. A new clinician may quickly become responsible for chronic disease management, abnormal lab follow-up, inbox messages, medication reconciliation, referrals, preventive care gaps, patient communication and longitudinal follow-up.

In this setting, although medical knowledge is crucial, knowledge alone does not close the loop on an abnormal lab. Knowledge alone does not make a referral happen or tell a new clinician who to call when something feels off. An important part of managing a panel of patients inside a specific clinic with specific workflows, staffing patterns and community needs comes from well-developed channels for workforce integration.

That is why transition into practice is not simply a knowledge gap. It is an integration gap. Structured onboarding, mentorship, transition-to-practice programs, fellowships, bridge programs and early-career support models are vital. These should not be viewed as remediation, they are invaluable developmental infrastructure.

This need has become more visible as care has moved from smaller, community-based practice environments into larger health system structures. In smaller settings, some development happened informally through proximity, continuity, shared patients and longstanding relationships. Those systems were not perfect, but they often created natural opportunities for observation, mentorship, real-time feedback and role integration.

Larger health systems may be operationally necessary and more capable of scale, but they do not automatically reproduce those informal developmental supports. What once happened through proximity now has to be designed with intention. Most new clinicians are not asking to be rescued. They are asking, often quietly, for a system that helps them find their footing, build judgment and become part of the team.

Not every solution needs to be large, expensive or complicated. Some supports may be brief, repeated and close to the work itself: clearer escalation pathways, better early mentorship, structured check-ins, short case-based learning, supported preceptors and more intentional team onboarding. Small supports will not solve the workforce shortage by themselves, but they can help people become effective sooner and reduce avoidable churn.

Without teaching capacity there are severe limitations on the future workforce.

Assuring a Secure Future

Recruitment brings people into health care. Retention depends on whether they can see a future there. For direct care workers, that may mean a credentialed pathway, wage progression, role recognition and the ability to move into other health care careers if desired. For medical assistants or nursing assistants, it may mean career ladders that connect experience to opportunity. For clinicians, it may mean mentorship, leadership development, teaching roles, doctoral education, quality improvement, administration, or working to improve community health.

When advancement pathways are unclear, people leave. They may leave the job, the organization or health care entirely. Each departure creates another vacancy, another hiring cycle, another onboarding process, another loss of local knowledge and another disruption for patients.

Advancement does not always mean leaving the bedside, the clinic or the home. In fact, the best advancement pathways should allow those working in health care to grow without forcing them to abandon the work that their communities need. Working in health care should not make people choose between meaningful work and a sustainable future.

These pathways may look different across roles — direct support professionals, CNAs, medical assistants, nurses, PAs, NPs, physicians and preceptors — but the principle is the same. People are more likely to stay when they can see a path forward.

Improving Integration Strategies

The final layer is integration — not only integrating people into jobs, but integrating roles, teams, workflows and relationships around patients.

Health care organizations commonly measure vacancies, hires, productivity and turnover. These metrics are important, but they do not fully capture whether people are becoming part of stable care delivery. Integration means that people are not merely present in the system. They are connected to teams, workflows, patients, supervisors, mentors and organizational purpose. They know how care is best provided in the place where they are employed. They understand when to ask for help and who to call when they have to. They understand patient needs and how to build trust within their organizations.

This matters because, as stated earlier, patients experience workforce instability as care instability. This occurs through frequent caregiver handoffs and the need to repeat their story over and over again. It occurs when they receive inconsistent plans, face unnecessary waits for follow-up and wonder if anyone knows them. Families become the default coordinators when systems do not connect.

Patients do not experience care as separate organ systems, diagnoses, or tasks. They experience care as whole people trying to stay stable inside a life. Continuity is not nostalgia, it is infrastructure.

Stable relationships allow information, trust and judgment to accumulate over time. When those relationships repeatedly reset, care becomes less efficient, less reliable and less humane.

This is also where the workforce shortage connects to the larger problem of fragmented care. Health care has become increasingly differentiated: more roles, more specialties, more programs, more care options, more technologies and more sites of care. Differentiation is not bad. It allows expertise, access, innovation and specialization. Differentiation without integration, however, becomes fragmentation.

Adding more people into a fragmented system does not support stable care. It may simply create more handoffs, more role confusion, more disconnected care options and more places where patients and families have to coordinate the system themselves. This is why workforce strategy and system integration have to be discussed together.

If health care treats clinicians and care workers as fully replaceable units, it misses the developmental work that makes people effective in local systems. Judgment, trust, relationships, continuity and contextual knowledge mature over time. They cannot be replaced by scheduling software or productivity metrics.

Efficiency tools can help. Automation, artificial intelligence, lean management and decision support may reduce burden and improve reliability. But if these tools are used without attention to development and integration, health care risks treating people as interchangeable parts. Workforce integration is not separate from patient care. It is one of the conditions that makes good care possible.

Government Initiatives

Improved internal efficiencies around employment in health care will help address workforce shortage issues but additional remedies are required. Today there are nearly 10,000 open positions in Minnesota hospitals and health systems with a vacancy rate that rose from 6% to 13% between 2021 and 2024. The State legislature has worked on this issue from several perspectives, including a variety of loan forgiveness and educational grant funding programs, as well as created dual-training pipelines that promote an earn and learn approach. But they must do more especially in light of recent federal government policies, such as cutting Medicaid funding. Existing state programs need to be expanded and work must be done to accelerate entry into the workforce. This can be done, in part, by simplifying administrative processes at various state licensing boards and relaxing credentialing guidelines allowing more easy transfer for potential new health care employees credentialed in other states or countries. State funding programs need to expand access to include a wider range of accredited allied health programs such as lab professionals, respiratory therapists, medical specialty technicians and more.

The Minnesota House Workforce, Labor and Economic Development Finance and Policy Committee recently introduced a bill to establish a grant program designed to address “workforce shortages in the health care sector that are unlikely to be solved by normal market forces.” Lawmakers hear such bills regularly, however, and existing programs see demand exceeding capacity, demonstrating that access to training, not a lack of interest the field, is a barrier to solving health care workforce shortage issues.

Pipeline and Pathway Distinctions

Health care talks about pipelines for research and workforce issues. Developing a pipeline is a good metaphor for the important task of filling the many job descriptions involved with health care delivery. A pipeline, however, primarily describes movement, whereas a pathway describes development over time. A pipeline asks: how do we get more people into the system? A pathway asks: how do we help people grow, contribute, advance, integrate and stay?

Health care needs both. But a pipeline without a pathway creates churn. People enter, struggle, burn out, stall or leave. Then the system recruits again and calls it a shortage. At some point, we have to ask whether workforce shortages come only from outside the system — or whether part of the shortage is created by the way the system receives, develops and retains people.

In practical terms, this means a hospital cannot solve discharge delays if home care capacity is collapsing. A clinic cannot stabilize access if every new clinician is repeatedly onboarded into full complexity without mentorship. A PA, nursing, or medical assistant program cannot expand responsibly without supported clinical training sites. A direct care worker cannot remain in the field long-term if the role has no credentialed pathway, wage progression or advancement structure.

Public policy and grant funding can help create the conditions for this work, especially in rural and underserved communities. But pathway capacity cannot be built by funding alone. It has to be designed and tested through partnerships among health systems, educational institutions, community organizations, policymakers and the people doing the work.

A better workforce strategy would ask more connected questions. Which pathways into health care roles are visible, affordable and respected? Who is available to teach, mentor and support people as they move from training into real practice? What conditions allow a new hire not only to become productive, but to become integrated enough to stay?

Those questions do not replace the need to count vacancies or expand training programs. They can, however, make those efforts more realistic. A position that cannot be entered, learned, supported, advanced through or sustained will remain unstable no matter how often it is posted.

No single program will solve the health care workforce shortage. But a more accurate definition of the problem can lead to better solutions. The shortage is not only a shortage of people. It is also a shortage of pathway capacity: the connected infrastructure that helps people enter, learn, transition, integrate, advance and stay in the work of care.

If we want care that patients, families and communities can rely on we cannot build pipelines alone, we must build pathways.

Kenneth Botelho, DMSc, PA-C, is the founding director of the Doctor of Medical Science Program at The College of St. Scholastica and the president-elect of the Society of PAs in Family Medicine.