Although hospitalizations due to COVID-19 have settled far below previous peaks, the pandemic’s ripple effects on the health care workforce continue to strain capacity at many teaching hospitals. Among the direst shortages is that of nursing staff.
For example, at Ochsner Health, which runs 47 hospitals in the Gulf Coast region and is headquartered in New Orleans, a current shortage of 1,200 nurses has forced the system to close inpatient beds, resulting in patients waiting in already-strained emergency departments.
"In the Gulf Coast … what we’ve experienced is not different than what the rest of the nation has experienced, in that we’ve seen many nurses leave the workforce, either for early retirement or for other personal reasons,” says Leonardo Seoane, MD, executive vice president and chief academic officer of Ochsner Health. “We’ve had an increased turnover of nurses, and in our allied health areas too, which has created a significant crisis — and I think crisis is the appropriate word — in our ability to provide as much care as we would like to.”
Although there was a nursing shortage before 2020 fueled by many nurses approaching retirement, aging patient populations needing more medical care, and increasing burnout, the COVID-19 pandemic exacerbated the problem, as many nurses who were working at patient bedsides in hospitals left nursing due to overwork and moral distress.
“COVID made the working environment very unpleasant,” says Y. Tony Yang, ScD, a health policy professor at George Washington University School of Nursing in Washington, D.C. “Lots of stress; lots of safety issues.”
The McKinsey Global Institute, an economic research firm, projects a shortage of anywhere from 200,000 to 450,000 nurses by 2025, due in part to older nurses retiring earlier than expected and nursing colleges being limited in how many students they can accept.
These shortages have already had a profound impact on hospitals, costing them billions of dollars in additional labor costs and lost revenue, limiting opportunities for clinical training and research, creating further strain and burnout for current hospital staff, and potentially worsening patient care.
Now, teaching hospitals, including nursing colleges and medical schools, are sounding the alarm while also seeking innovative ways to allay the negative effects and create pathways for future nurses.
“It’s been a bit of a shock,” says Christine Bartlett, MSN, RN, associate chief nursing officer at Oregon Health & Science University (OHSU) in Portland, about adjusting to the current nursing shortages. “[But it has] motivated us to look at nursing differently, to ask the front-line staff ‘What does it take for them to be satisfied?’”
Qualified RNs were in high demand throughout the pandemic. Travel nursing agencies, which contract with hospitals to provide temporary labor, were able to lure many nurses away from full-time hospital positions by offering higher salaries and greater flexibility. That put hospitals in the position of having to hire temporary nurses at much higher rates than they were used to paying their full-time staff, putting more pressure on already financially strained hospitals and frustrating their staff nurses.
Hospitals and health systems across the United States are paying an additional $24 billion per year for clinical labor than they were before the pandemic, according to an analysis by Premier Inc., with travel nursing fees a major contributing factor.
In 2019, just 4.7% of nurse labor expenses went to contract travel nurses. That figure rose to 38.6% in January 2022, according to the American Hospital Association. While travel nurses accounted for 23.4% of total nurse hours in January 2022, they represented nearly 40% of all nursing labor expenses for hospitals.
“It’s taken this pandemic — a huge health care crisis — to look at how we can move nursing to the next level. We know doing it the same old way isn’t going to work anymore.”
Christine Bartlett, MSN, RN, Oregon Health & Science University
At Ochsner Health, for example, contract staffing costs have increased by nearly 900% since 2019, with the health system currently contracting with 600 travel nurses, according to Seoane.
“Those of us in health care know it’s a team sport and nurses are a critical part of the team,” Seoane says. “When we don’t have the cohesive team of our traditional nurses who are part of our health system and are trained a certain way, and we have traveling nurses who — while they are skilled — are only with us for a short time, it is difficult to build a team culture and work closely for our patients. It’s also much harder to train our learners and has an impact on our nurses because it adds extra work for [staff] nurses when they have to train the traveling nurses on how to do things in our system.”
Relying on travel nurses can also be bad for workforce morale, when staff nurses realize how much more money travel nurses are making and when high turnover creates inefficiencies, Yang explains.
“Unfortunately, nursing is not the area where hospitals traditionally want to spend more money,” he says. But the reluctance to invest in nursing staff is more costly in the long run.
As pandemic surges wind down and travel nursing salaries level out, many nurses are looking for full-time employment again, Bartlett says.
“Some of the travelers are looking for a home,” she explains. “They’re tired of not working within a team.”
But even as the market stabilizes, current and projected nursing shortages are pushing health systems and nursing education programs to adapt and innovate in order to both retain and build up the nursing workforce.
Bedside nursing can be a particularly taxing job, with long hours, high stress, and physically, mentally and emotionally demanding work. When there are shortages, that puts even more strain on those who remain to take on additional work.
A 2021 survey of more than 6,000 nurses by the American Association of Critical-Care Nurses found that 92% of respondents said that the pandemic has depleted the nurse workforce at their hospital and that, as a result, their careers would be shorter than intended. Two-thirds said that their experiences during the pandemic have made them consider leaving nursing.
“It’s taken this pandemic — a huge health care crisis — to look at how we can move nursing to the next level,” Bartlett says. “We know doing it the same old way isn’t going to work anymore.”
Ochsner Health has begun leveraging certified nursing assistants and licensed practical nurses to perform more basic duties, freeing up registered nurses to focus on higher level care.
And OHSU is making an effort to improve staff nurses’ well-being by giving them a break from the grueling work at the bedside. In 2020, the health system launched a virtual intensive care unit (VICU), where trained nurses can monitor critical patients remotely, identify any patients at risk for deterioration, and advise bedside clinicians using two-way audiovisual equipment installed in each room.
Through the VICU, more experienced nurses can monitor and help guide those who are less experienced while also getting a break from the bedside work themselves, Bartlett says. OHSU has a similar program they call working in the “bunker,” where nurses can take a less stressful shift remotely monitoring patients and helping with paperwork and recordkeeping.
Staff nurses might also divide their time between bedside nursing and research or teaching.
“They get to use a different part of their brains,” Bartlett explains. “We’re looking at how to do this more and more across the organization to meet the needs of the teams. It allows them to be curious and explore other areas.”
“If you have fewer nurses available to work with students, it’s more difficult to get hands-on experience and develop skills they need to become effective practitioners.”
Y. Tony Yang, ScD, George Washington University School of Nursing
At some health systems, simply hiring more nurses, reducing work hours, and increasing salaries has improved staff satisfaction.
At Mount Sinai Hospital in New York, thousands of nurses went on strike in January and successfully negotiated a deal to hire additional nurses and increase salaries to alleviate conditions in those hospitals where they said nurses were overwhelmed and patients were at risk, according to The New York Times.
Throughout the country, nurses have been speaking out for better working conditions, not only for themselves and their colleagues, but for the sake of their patients.
“I’m proud of front-line staff for speaking up and saying we need a change,” Bartlett says. “And I’m proud of the leaders for responding.”
Securing the future
While improving working conditions for the current nursing workforce is a priority, another barrier to alleviating the shortages is a dearth of new nurses joining the field.
This is not for lack of interested and qualified applicants, either.
According to Yang, as many as 80,000 qualified applicants get turned away from nursing colleges because there are not enough nursing faculty, clinical sites, and resources to support larger class sizes.
Contributing to this issue is the fact that many highly qualified nurses can make higher salaries working at the bedside than they would teaching future nurses, Yang says.
“Less than 1% of nurses are prepared with a PhD [required for faculty appointments at most research-intensive colleges],” adds Laurie Lauzon Clabo, PhD, RN, dean of nursing at Wayne State University in Detroit. “Over the last number of years, we’ve seen a decline — slight but significant — in enrollment and graduations in PhD programs. This produces a really critical impediment.”
Because nurses are so fundamental to a functioning health system, nursing shortages can severely impact not only patient care, but also clinical research and training for nursing and medical students.
“If you have fewer nurses available to work with students, it’s more difficult to get hands-on experience and develop skills they need to become effective practitioners,” Yang says. “With fewer nurses available to assist with research, it’s going to get more difficult to recruit patients, collect data, and monitor patients. It will definitely have an impact.”
Some academic institutions are implementing programs to help encourage more people to pursue nursing education and, when qualified, to teach nursing students.
OHSU allows qualified staff nurses to take paid time away from their hospital duties to teach. It also offers opportunities for staff to have paid time off for education. And Ochsner has invested millions of dollars in scholarships and partnered with local universities, community colleges, high schools, and even middle schools to build up the next generation of nurses.
One key element to solving the health care workforce crisis is for medical schools, nursing colleges, and health systems to come together to find creative solutions, Bartlett says.
“What I would like to see — since schools of medicine and schools of nursing are closely situated — is a crossover in education,” she says. “Nurses don’t come out [of school] with just the nursing view, and physicians don’t come out with just a physician view. … The nurses are the eyes and the ears for the physician. … It’s important to build that relationship at the student level.”