The Nursing Shortage in the Pandemic: Strategies to Promote a Resilient Workforce

The COVID-19 pandemic served as a catalyst unlike any other to create both a labor and skills shortage in registered nurses (RNs) across the United States. There is a decreased supply of graduating nurses due to schools’ inability to accept all qualified candidates accompanied by an overall shift in RNs pursuing advanced nursing degrees. This decrease in supply is amplified by occurrences of early retirement for many nurses; over half of the nursing population is over the age of 50. As these nurses leave the workforce, they also take the skill acquired over the course of their careers. Concerns whether these impacts will negatively affect the efficacy of patient care remain in the forefront of many healthcare workers thoughts.

The idea of a nursing shortage is not new, as the United States has experienced periodic scarcities in nursing since the 1900s. However, the current state of nurse availability has been raising voices of concern. From 2015 to 2030, more than 1 million RNs will have retired from a workforce of currently 3.8 million RNs. By the end of 2022, 500,000 seasoned RNs anticipate retiring. In addition to supply constrictions, the demand for nursing will dramatically increase. The U.S. Census Bureau reported that by 2030, the number of U.S. residents aged 65 and older is projected to be 73 million; that number is currently 54 million.

As the older generation of nurses retire, they are no longer able to pass their knowledge to up and coming nurses, leading to concern over a skills shortage. This has the potential to impact the education of new nurses, which raises alarm for the effect on patients. More than 75% of RNs believe the nursing shortage presents a major problem for the quality of their work life, the quality of patient care, and the amount of time nurses can spend with patients. In recent studies, 98% of nurses see the shortage in the future as a catalyst for increasing stress on nurses, lowering patient care quality (93%), and causing nurses to leave the profession (93%).

Since the beginning of the pandemic, nursing schools have faced difficulty in obtaining hands-on experience for their students due to hospitals restricting access for anyone to limit the spread of germs. Hospitals began shutting down clinical rotations during COVID, unable to afford to spend valuable time and equipment on students, while simultaneously overworking veteran nurses. Some states like California decreased the number of required clinical hours after some nursing schools went fully remote.

Many schools are facing decreased aid from the government. The Centers for Medicare & Medicaid Services is reducing funding for nursing schools due to an internal error that occurred 10 years ago. The error caused for an estimated $1 billion for about 120 colleges.

Appropriate patient status determination and discharge status can also have significant financial implications for the patient. A discharge from observation status may result in a higher out-of-pocket expense to the patient compared to an inpatient discharge. Since observation status is an outpatient service, a Medicare patient pays 20% of billed charges for coinsurance.

An additional reason for the lack of RNs is the rise in nurses pursuing advanced degrees. From 2010 to 2017, the increase in nurse practitioners reduced the size of the RN workforce by approximately 80,000 nurses. ,175,000 RNs per year are needed and only about 155,000 graduate per year. 28,000 RNs are becoming NPs per year. Between 2008-2016, the percent of primary care providers in rural areas that were Nurse Practitioners jumped from 17.6% to 25.2%; Urban areas grew from 15.9% to 23.0%. This gives the potential for surpluses of NPs.

The COVID-19 pandemic served as a mechanism for nurses bordering retirement to decide to leave the workforce prematurely. The American Nurses Association predicts that 500,000 seasoned RNs anticipate retiring by 2022, and the US Bureau of Labor Statistics projects more than 1 million new RNs are needed for expansion and replacement of experienced nurses. Many nurses have taken on the increased emotional burden of becoming sole support systems for patients in their dying hours, many of whom could not see their families. 67% of surveyed travel nurses responded that they felt the healthcare system did not prioritize nurses’ health and mental well-being. In Mississippi, nurses are retiring early to avoid burnout: 2,000 fewer nurses than the beginning of 2021, not to mention the 6,000 vacancies they had prior. Two-thirds of nurse’s state their experiences during the COVID-19 crisis have caused them to consider leaving nursing.  The supply of nurses is not meeting the demand, and the disparity is amplified by the fact that nursing schools cannot viably accept all qualified candidates.

As of 2021, approximately one in eight nurses had not gotten a Covid-19 vaccine nor do they plan to get one. A Texas hospital system had 153 people resign or were fired after refusing to get vaccinated. As the virus continued to spread, the American Association of Critical Care nurses conducted a survey showing two thirds of critical care nurses were considering quitting their jobs as well 67% of those surveyed were fearful of taking the virus home to their families. Nurses are reporting an overall decrease in career satisfaction in not only acute care facilities but long-term care and hospice settings as well.

Nurses have been forced to navigate through human and financial constraints, interpersonal conflict, and hostile work environments as the pandemic continued to move into its second year. This laid the foundation for nurses to leave the bedside, experience extreme burnout, mandatory overtime, and the inability to provide adequate patient care. Emotional and physical exhaustion, in addition to lack of personal accomplishment is a source of burnout which can lead to secondary trauma. Experiencing trauma leads to lack of sleep, poor appetite, job dissatisfaction and the inability to cope putting nurses at risk for post-traumatic stress disorder. Traumatic experience has been associated with having to prioritize who gets care and the high number of deaths.

Professional quality of life can be affected by both positive and negative aspects. It is not uncommon for someone to feel burnout in many aspects of life, but understanding burnout related to working in healthcare during a pandemic is very distinct. Burnout comes from the work nurses do and can manifest in very distinct ways which can have an impact on the people they are caring for. The current dynamics are 1) increased traumatic stress related to the pandemic, 2) cumulative grief with so much loss and death, 3) moral distress as nurses are having to practice differently challenging their ethics and what does not feel right.

Nurse leaders are also experiencing a high level of stress as the job demands increase and organizational constraints continue to soar. Constraints such as lack of beds, increased staffing ratios due to nurses leaving, and a large span of control. Leaders face not only patient and staff concerns but organizational constraints as well. Limited human and financial resources, interpersonal conflict, and a hostile work environment are also causes of nurse leader stress. Other concerns include the adoption of new staffing models to adapt to the shortage of nurses as well as how best to recognize nurses’ contributions to the difficulties of today’s work environment.

Finding joy in work is rare in this current work environment which has led to job dissatisfaction, lack of employee engagement, and a sense of well-being. This is not a new problem for nursing but one that has been grossly exacerbated by the pandemic. Burnout is an occupational phenomenon and not necessarily an individual’s problem; however, individuals must be healthy and resilient to the secondary trauma that occurs as part of the work. Therefore, strategies to create a resilient workforce require both support from organizations to create healthy work environments and nurses to practice individual resilient building skills.

A healthy work environment includes adequate staffing, strong collaboration, communication, authentic leadership, recognition that is meaningful and autonomy for the staff to make their own decisions. In order to achieve a healthy work environment, organizations must empower staff, which requires transformative leadership and shared governance. Many of these elements of healthy work environments are found in Magnet organizations or units that have been designated Beacon awards – highlighting these key elements of how to achieve well-being from an organizational perspective.

In addition to workplace health, individuals must practice increasing their own compassion through personal resilience building to counterbalance the risk of burnout. Of importance to note, practicing resilience should not be done to build barriers against a poor work environment. Instead, resilience – or the ability to grow and adapt from adversity – should be done to have strength against the potential hardships that are witnessed in caregiving, such as death, loss, suffering, and pain. Personal resilience building skills can include practicing gratitude, mindfulness or meditation, journaling or debriefing through writing, or self-care, such as exercise. These activities are valuable moments to pause and reflect on the importance and significance of the work of nursing and the contribution caregivers bring to the quality of patient’s lives. In practicing resilience building activities, nurses can potentially decrease burnout and secondary stress, which can lead to a longer, more fulfilling career in nursing.