Abstract
The us nursing workforce crisis represents a danger to the quality and safety of patient care and an imminent threat to the nation's health security. The COVID-19 pandemic has exposed a range of perversities related to the nursing profession, including the inequitable financing and compensation of the nursing workforce, lack of workplace protections, and the perception that nursing is a subservient profession. It has also exacerbated workforce issues that predated the pandemic, leading to physical and mental exhaustion, lack of trust and perceptions of betrayal by hospital leaders, and moral injury and burnout. Nurses are critical to the sustainability of the US healthcare system, to the health of communities, and to the ability of the nation to respond to health security threats, including pandemics, natural disasters, and other large-scale emergencies. In the absence of an adequate labor supply of nurses, healthcare services are substantially degraded, hindering the country's ability to respond to emergencies and ultimately putting patients at risk.
The United States has over 3.8 million registered nurses, making them the largest component of the healthcare workforce. 1 In addition to providing patient care, nurses contribute to public health practice by dispensing and administering medical countermeasures, implementing infection control efforts, and expanding access to health services within historically disadvantaged populations. Yet as the United States is firmly entrenched in the third year of the pandemic, nurses are mentally and physically exhausted, emotionally demoralized, and many are exiting the profession. 2 Our current state of diminished health system readiness combined with the recent trend in nurse resignations leaves the US health system more vulnerable to future pandemics and disasters, especially catastrophic events. Importantly, the likelihood of these events is increasing due to climate change, increased interaction at the human–animal interface, the ease of intercontinental travel, growing populations that live in close quarters, and instability in the global geopolitical climate.3,4
It is critical to illuminate the factors driving the current exodus from the nursing profession and the potential scenarios that may result. This information will inform the practice and policy changes needed to rapidly stabilize and strengthen our nation's nursing workforce and to rebuild a workforce that has the capacity, knowledge, skills, and flexibility to respond to future threats.
Staffing Crisis
The current nurse staffing shortage is neither new, nor a surprise. One article published in 2017 projected a shortage of over half a million nurses by the year 2030. 5 Nursing shortages have been attributed to several factors, including the ongoing retirement of over 1 million experienced registered nurses by the year 2030 6 and an aging population that will require additional healthcare providers. 7 However, the pandemic has illuminated that while there are current and looming workforce shortfalls, unsafe working conditions and unsatisfactory compensation are systemic challenges that must be addressed. A video published in January 2022 by the New York Times documented these challenges, including nurses' job dissatisfaction amid allegations of corporate greed. 8 A letter signed in January 2022 by 195 members of Congress, which aims to cap fees charged by nurse staffing agencies, 9 further underscores the lack of focus among policy and health system leaders to fix what is at the root of the issue—poorly compensated healthcare workers who have bared the brunt of the COVID-19 pandemic. The American Hospital Association is complicit in its denial of the issues and some hospital systems have gone as far as filing temporary restraining orders and injunctions to block nurses from transitioning to new, better-paying jobs. 10
Staff shortages have led health system administrators to invoke mandatory overtime or to pressure nurses to take on extra shifts to help their coworkers, including when they are ill. 11 Nurses perceive this “culture of guilt and shame” as a betrayal of trust by their organizational leaders. Shortages of critical care nurses have been particularly acute, and multiple state and facility crisis standards of care declarations specifically cited lack of staffing rather than high hospitalization rates as the reason for implementation. While prompted by acute staffing challenges, efforts to rapidly train nurses to staff emergency departments and intensive care units reflect a lack of appreciation for the years of training they possess and a poor understanding of how nurses from different clinical specialties have different skill sets. Business plans view nurses as a collective cost line item on the budget that is devoid of distinctions related to patient outcomes, their essential role in teamwork and operations, and their clinical expertise. The failure to view nurses as “talent” within the healthcare workforce has undermined their expertise and contributions to patient care and has contributed to nurse burnout and low morale. It takes years for nurses to become clinically skilled and experienced; however, with little focus on or opportunities for professional advancement, nurses may feel less motivated to commit to a career in nursing.
Antiquated hiring and staffing mechanisms also further constrain staff planning and deployment. Staffing shortages have led to a reliance on traveling nurses, who are more expensive and require additional resources to orient and train. Throughout the pandemic, there has been a mass exodus of nurses leaving to become travel nurses, who at one point during the pandemic were making as much as $10,000 per week—well beyond what staff nurses were compensated. 12 This has left staff nurses feeling angry, underappreciated, and underpaid compared with their traveling colleagues. 13 Recent economic analyses have found that nurses are willing to travel long distances to increase their compensation, suggesting that an integrated national labor market facilitates reallocating workers when demand surges. 14 The negative impacts of the reliance on traveling nurses might be balanced with a recognition that having some subset of the nursing workforce be highly mobile increases the national healthcare system's ability to respond in the short term. A mobile workforce, however, is not sustainable over a longer time period, is economically inefficient, and becomes problematic when combined with various aspects of professional, interpersonal, and organized labor.
Additionally, shortening nursing training programs has been viewed as a quick fix to the supply problem. Because of the pandemic, schools of nursing have allowed their students to graduate early to bolster the workforce. 15 These new graduates enter the workplace setting with less education and clinical experience than they would have otherwise received and are placed in situations with less supervision and mentorship. Giving underprepared nurse graduates such great responsibility without the necessary support not only puts patients at risk but it may also lead to the nurses feeling overwhelmed and burned out. Focusing exclusively on the supply side of the equation does nothing to address workforce sustainability, especially when new nurses were already struggling to transition into practice—even with 1-year nurse residency programs. Allowing nursing students to graduate prematurely supports the needs of the moment but compromises the sustainability of the future workforce. The current nurse crisis will not be solved by educating new generations of nurses to face the same toxic conditions that are already driving many seasoned nurses out of patient care. 16
Although we focus on hospital-based nurses in this commentary, we acknowledge that the current nursing crisis extends far beyond the hospital sector. For example, nurse staffing shortages are worsening in schools 17 and community health clinics. 18 Nurses working in long-term care have been disproportionately impacted by the COVID-19 pandemic, with over 1 million confirmed cases of COVID-19 in staff and over 2,300 deaths. 19 Over 400,000 employees have left jobs in nursing homes and assisted living facilities, leading to a dire staffing crisis. 20 As a result, many nursing homes and assisted living facilities have reduced admissions, further constraining hospital capacity as they are unable to discharge patients to these facilities.21,22 Long-term care facilities and home health agencies often rely on Medicare revenue, which limits their ability to offer competitive salaries and benefits or to compete with hospitals for nurses. Furthermore, systemic underinvestment and lack of integration of long-term care into the broader health system has hampered recruitment and retention efforts.23,24
Valuing the Expertise of All Nurses
There has been a longstanding call within academic nursing for nurses to practice the full scope of their license and to establish the baccalaureate degree as the minimum educational requirement for entry into practice. 25 Inadvertently, this expectation has led to a narrative that undermines the value of all types of nurses' contributions to health outcomes and healthcare delivery. The nursing profession needs to include nurses from all roles and specialties in workforce planning and execution, regardless of the level of nursing program they completed. Pursuing the highest level of preparation within the nursing workforce is a laudable goal; however, pressuring nurses to pursue advanced degrees inadvertently sends the message that being an excellent bedside nurse is less valuable or somehow a failure of effort or capability. Prioritizing the hiring of nurses with baccalaureate degrees minimizes the important roles that nurses with associate degrees contribute to patient care, and inadvertently reinforces a hierarchy that creates inequity and disrespect by valuing the contributions of some more than others. New nursing practice models should be inclusive, with investments in career advancement, rewards for excellence in bedside or point-of-care nursing practice, incentives to retain experienced nurses, and tuition renumeration.
Intensification of Physical, Emotional, and Moral Suffering
Multiple studies have captured the physical, emotional, and moral exhaustion experienced by nurses during the pandemic. Nurses have reported experiencing depression, anxiety, posttraumatic stress disorder, substance use disorder, moral injury, and in severe cases death by suicide.26,27 Burnout, already at alarming rates, intensified during the pandemic.28-30 Underresourced and highly stressed units experienced disruptions in workflow, communication, and teamwork, exacerbating existing challenges. 31 Shortages of personal protective equipment meant some nurses had to care for infected patients without proper protection, intensifying feelings of betrayal. The volume and prolonged exposure to critically ill and dying COVID-19 patients, often with their families absent, left nurses without opportunities to acknowledge and process their grief. Not surprisingly, for professions like nursing that are primarily a female profession, family-related responsibilities intensified their exhaustion, creating untenable ethical choices about where to focus their time and attention. Arguably, having to make such choices intensified nurses' feelings of abandonment and betrayal by their employers, government, and communities.32,33
Lack of Inclusion of Nurses in National Health Security Policy and Planning
Despite the obvious and important role of nurses in public health emergencies, their voices have been largely absent in health security policy and planning. While a variety of different roles and responsibilities would likely be fulfilled by nurses as outlined in federal and state pandemic response plans, strategies, and frameworks, they are rarely if ever clearly and deliberately identified as being nursing-specific, creating potentially debilitating gaps in national health security. For example, Goal 3 of the National Biodefense Strategy is to “ensure biodefense enterprise preparedness to reduce the impacts of bioincidents,” including “support[ing] the effective deployment of medical countermeasure stockpiles.” 34 As COVID-19 has demonstrated, nurses are integral players in the mass administration of medical countermeasures in all states, with roles that include collecting patient histories, conducting medical assessments, administering medications, and monitoring for adverse events. Despite this, nurses remain absent from inclusion in these plans. Future healthcare preparedness and response planning should seek to remedy this lack of inclusion by ensuring that nurses are represented at all levels of policy development and implementation, and in the evaluation of the impact of decisions on the workforce, patient outcomes, and community trust.
Potential Future Scenarios
The size and aggregate skill set of the future nursing workforce will depend, in large part, on how various organizations and legislatures act in the coming months. We describe 5 potential scenarios here.
Scenario 1: Great Resignation
Surveys suggest many nurses are considering leaving the profession. 35 Unless rapid action is taken to improve their pay or conditions, many of them could leave. Nurses may feel a moral obligation to continue working during the crisis, obscuring another large wave of resignations that may occur once the pandemic is over. This would mean permanent reductions in health system capacity, and desperate recruiting efforts.
Scenario 2: Unionization Wave
Although nurses have been historically resistant to unionization, younger nurses are more open to it. A 2022 analysis of Maryland nurses surveyed showed that only 30% of experienced nurses felt that a union would have improved their work experience, whereas 64% of new nurses or students (those with 0 to 3 years of experience) felt that it would have. 36 These findings suggest that as older nurses retire, the younger nursing workforce will become more union-friendly. The current nursing workforce situation is perfect for industrial action, from a union's point of view. Nurses are extremely angry, many of them feel betrayed by management, and they have a lot of bargaining power.
Scenario 3: Staffing Agency Takeover
If staffing agency nurses continue working at hospitals and earning more money than their coworkers after the pandemic, the situation might encourage many of their coworkers to do the same thing. This could create a cascading effect whereby most hospital nurses work through staffing agencies rather than directly for the hospitals, which could become the new norm in the nursing labor market. Such a fundamental and far-reaching change in the structure of the workforce would have many effects that are difficult to predict. One possibility is that staffing agencies, already making substantial profits, start to have the pricing power of pharmaceutical companies, and/or that they become a vehicle for collective action by nurses to improve their pay and conditions, and bargain for the contracts they prefer.
Scenario 4: Muddling Through
It is possible that nurses' dissatisfaction will not lead to action in the form of substantial resignations or unionization. It is possible that almost all the people who would exit nursing already have, and that once conditions return to normal, nurses will be content with a job that returns to the prepandemic pay and working conditions. In this scenario, there will not be much future disruption, and the people who have resigned will be replaced by new nurses without any structural change.
Scenario 5: Reward and Recovery
Most nurses showed a willingness to stay if they are appropriately compensated for their work. If action is taken soon to improve pay and working conditions, then resignations will be low, and many nurses who have left the profession will come back. This scenario would require that healthcare organizations examine their budgeting process, pathways for advancement, shared governance, and investments in culture change and intensification of resources to support nurses to practice healthfully within their scope.
Rapid Action Needed
American healthcare is in crisis. In January 2022, military support teams and the National Guard were brought in to help civilian hospitals experiencing staffing shortages during Omicron-driven patient surges. 37 Additionally, worsening staff shortages prompted the US Centers for Disease Control and Prevention to loosen its COVID-19 guidance for healthcare personnel, enabling facilities to immediately call back infected or exposed workers who have no symptoms, if necessary. 38 This policy reversal is clear evidence of the dire situation the US healthcare system has found itself. To be clear, the staffing crisis is not limited to nurses, as other healthcare provider communities also face many of the issues identified earlier in this commentary. The contributions of respiratory therapists, hospital pharmacists, clinical lab staff, other allied health professions, emergency medical services providers, and physicians during the COVID-19 pandemic are substantive and the challenges they have faced are equally onerous.
Despite the gravity of the situation, health system administrators continue to deny the root causes of the nursing crisis. 39 However, some efforts are underway to better support nurses, including loan repayment programs 40 and the recent release of the Nurse Staffing Think Tank Priority Topics and Recommendations, 41 which highlighted several areas that need to be addressed, including work environment, the need for a more diverse workforce, and schedule flexibility. The challenge is that many of these recommendations will take months, if not years, to achieve. In the meantime, the health system is continuing to hemorrhage nurses and rapid action is needed to halt resignations and support and strengthen the nursing workforce. This is critical to building and sustaining national health security and ensuring a robust health system and workforce that can care for patients during catastrophic health threats.
Immediate workforce stabilization actions include the following:
Increase compensation packages immediately; changes should include hazard pay during emergencies, increased pay differentials when nurse-to-patient ratios exceed certain thresholds, and increased pay when additional ancillary staff (eg, certified nursing assistants, unit secretaries) are not available Authorize nurse leaders and point-of-care nurses to create and manage staffing and human resource allocation based on safe standards Intensify authentic leadership engagement, trustworthy communication, and decisionmaking with point-of-care nurses Integrate wellbeing into work; improve transparent and easy access to and uptake of mental health and other support resources without retaliation, breeches of confidentiality, or risk of job security Develop and implement a guaranteed break and paid respite policy for nurses delivering point-of-care services Create alternative staffing pools that honor the limits of nurses who are fulfilling their job commitments by avoiding habitual requests to work extra shifts Reimagine human resources policies to implement options to retain existing staff in another role within the organization; offer part-time or casual employment opportunities and remove barriers to reemployment
Long-term workforce stabilization actions include the following:
Create federal/state legislative initiatives to: (1) guarantee minimum nurse-to-patient staffing levels based on safe standards; (2) educate and retain the nursing workforce through substantial tuition subsidies and loan forgiveness; expanded investment in programs to support resilience, wellbeing, and lifelong learning; and expanded incentives to work in rural or underserved urban settings; (3) remove barriers to using mental health and recovery programs from licensure requirements and reporting requirements; and (4) create a state or national nurse corps that can be deployed during crisis situations
Expand and fund career development pathways for nurses in all roles, specialties, and settings
Redesign payment structures that finance the nursing workforce to reflect value of nursing's contribution and address inequities in compensation, authority, and role
Implement plans to adequately distribute nursing staff across health systems or geographic regions
Increase nurse preparedness and understanding of the clinical and organizational implications of crisis standards of care declarations (either state or facility level)
Dismantle the barriers to access mental health and wellbeing services by all healthcare workers
Increase retirement and healthcare benefits
Create an ethical framework and create decision support tools to guide equitable workforce distribution during emergencies based on hospital needs, nurse experience and expertise, and patient volumes
Eliminate mandatory overtime
Conclusion
Nurses are critical to the sustainability of the US healthcare system, to the health and wellbeing of individual patients and whole communities, and to the ability of the nation to respond to health security threats. The current nurse staffing crisis can be resolved if workforce stabilization strategies are enabled by state and federal legislative bodies and adopted by hospital and health systems administrators.