Rebecca is a nurse educator whose job title no longer matches reality. Her clinic serves the homeless and is so understaffed that Rebecca mostly functions as a triage nurse—and often more. On a recent Monday, one nurse called in sick with COVID-19, and another was on vacation, so Rebecca alone took on the 10-hour shift meant for three registered nurses (RNs).
“It’s already a very stressful place to work,” said Rebecca. The talent shortage, combined with inadequate pay and indifferent management, have brought her close to a breaking point: “It makes you feel hopeless and under-supported, like I can’t do this anymore.”
Rebecca’s experience is all too common. From the 5,000 nurses striking at Stanford Health Care to the 2,000 caregivers protesting at nursing homes in Pennsylvania, nurses are pushing back against stress at work. Understaffing, overwork and burnout are among the forces driving nurses to leave their employers, or to exit the profession entirely.
Healthcare professionals widely report that a shortage of nursing talent is at the heart of this crisis, especially since COVID-19. Plenty of data supports them. However, the shortage may be just as much due to churn based on stressful work experiences as any other factor. As University of Michigan School of Nursing faculty Deena Kelly Costa and Christopher Friese recently argued, “…there isn’t a shortage of nurses, but a shortage of hospitals that provide nurses with safe work environments and adequate pay and benefits.”
Nurses like Rebecca, and others interviewed for this report, seem to echo that. Many feel unheard, unsupported, and unappreciated in their workplace. They make career decisions not just for better compensation, but for more safety, flexibility, and control in their professional lives.
We at Clipboard Health, a marketplace for healthcare talent, seek to understand the root causes of this talent crisis and offer practical solutions to facility administrators. What accounts for the shortages and high turnover in healthcare? How do nurses decide where, when, and how to work? Most importantly, what can facility administrators do to better attract, support, and retain nurses?
The nursing talent crisis predates COVID-19, but the pandemic undeniably made it worse. In March and April 2020, 2.3 million healthcare workers dropped out of the profession due to furloughs, “early retirement” schemes, and the suspension of elective services. The industry has 430,000 fewer workers than it did in February 2020, and there were 1,968,000 job openings as of March 2022. The consulting firm Mercer estimates that the deficit of medical assistants, home health aides, and nursing assistants will grow to 3.2 million by 2026 if trends persist.
Why does this crisis endure if it poses such clear risks to the healthcare system as a whole?
At Stanford Health Care and a nearby facility, when 93% of union nurses voted to strike on April 25, 2022, many cited “exhaustion” and “burnout.” Definitions of burnout vary, but the World Health Organization says it can include depletion, exhaustion, cynicism, and reduced efficacy resulting from chronic workplace stress.
The risk is that Stanford nurses are the norm rather than the exception. A November 2021 study found that up to 90% of RNs plan to leave the profession within a year. 72% reported experienced burnout before the pandemic, and 39% now suffer mental health issues such as depression and anxiety.
The stress on nurses comes from myriad sources. Keke Richardson, a scheduling coordinator at St. Dominic Village, a skilled nursing and assisted living facility in Houston, Texas, said that during the pandemic, “If you were an essential worker, you were working around the clock.” Staff nurses at her facility couldn’t rest or take vacations like normal. Moreover, patients showed up from acute care much sicker than they would be normally. As a result, said Keke, “Anxiety was really high.”
Jared, a professional development practitioner in the mountain west, onboards and mentors nurses for a university health system. Following COVID-19, he said, “There is low morale across healthcare. Some [nurses] feel overwhelmed and some sense a lack of gratitude.”
Many people outside the nursing profession may not realize how much stress nurses endure in the course of a normal work day. Rebecca, introduced above, cited a disturbingly common source of stress: physical and emotional abuse from the patients themselves. She noted that facilities “...do almost nothing to help nurses with patient abuse.”
While working at an in-patient facility earlier in her career, she found that if she discussed an abusive patient with the attending doctor, “there wasn’t much compassion or understanding.” She gave the example of a “normal” day when, “My patient bit me, and then someone else threw their food at me and called me a [[obscenity]].’”
It is hard to overstate the consequences of burnout, low morale, and stress, whatever their source. A study at the University of Michigan found that female nurses, who account for 85% of all U.S. nurses, were more than twice as likely to commit suicide than the general female population and 70% more likely to take their life than female physicians. The study also noted that, compared to the general population, nurses are 90% more likely to experience “on-the-job problems” and 20% to 30% more likely to suffer from depression.
The flipside of burnout is understaffed facilities. A September 2021 survey of nurses by Morning Consult, a market intelligence firm, found that 80% of nurses were affected by the shortage of healthcare providers. How so? If one nurse quits a facility, the others take on more work, more overtime, more stress, and a higher risk of mistakes, which have recently led to legal repercussions that include prison time.
Understaffing can snowball into more resignations and more stress, as Rebecca’s experience attests. Despite being chronically short of talent, her clinic has refused to raise wages or offer better benefits. It is turning to recruiters to find more full-time healthcare providers, but thus far not tapping into the temporary market.
Short-staffed facilities have an impact on patients, too. A working paper from John Hopkins University’s School of Nursing finds that higher nurse-patient ratios are associated with declines in COVID-19 mortality.
COVID-19 increased the likelihood of short-staffing. Keke, the scheduling coordinator, used to cover the 339 beds at St. Dominic using staff nurses almost exclusively. However, as COVID-19 ratcheted up the pressure on nurses, some of her staff nurses left to become traveling nurses. If the job was going to be brutal anyway, why not make double what St. Dominic Village could pay? “Most [nurses] go where the money is,” said Keke. “We understood.”
Traveling and temporary nurses don’t necessarily have great work experiences, despite the better pay. According to Ima, a CNA in Texas, facilities don’t always treat fulltime and contingent nurses equally. “If you’re agency,” as she puts it, “no one will help you. They make you do everything.”
At many facilities, Ima says that shift nurses face resentment from their staff peers, who know (or assume) that shift nurses are paid more for the same work. She reports that sometimes, staff nurses neglect to help their temporary colleagues, overload them with more work than they can handle safely, and blame them if anything goes wrong. One facility is so notorious for its poor treatment of shift nurses that Ima will not work there anymore, even if there are no shifts available elsewhere.
Perhaps the hardest collective challenge to solve is the broken pipeline for nursing talent. The 2020 National Nursing Workforce Survey 2020 Survey found that the median age of RNs was 52 years old, while the median for licensed vocational nurses (LVNs) and licensing practical nurses (LPNs) was 53. Worryingly, more than one-fifth of surveyed nurses planned to retire within five years.
Nursing colleges aren’t prepared to replace the retirees. In 2019, the American Association of Colleges of Nursing (AACN) reported that enrollment increased by 5.1% in 2019, but its members turned down 80,407 qualified applicants for lack of faculty and resources to teach them.
Convincing nurses to become professors is not easy. The AACN says that the average nurse practitioner earns $110,000, while the average assistant nursing professor with a master’s degree takes home $79,444. Moreover, one-third of nursing faculty members are expected to retire by 2025, as their age skews even higher than their practicing peers.
Even RNs and nurses with more advanced degrees suffer financial uncertainty and are therefore unlikely to take a pay cut voluntarily. “People don’t become a nurse for the money or the benefits,” said Jared, and he noted that “Everyone has a side hustle when they’re nursing.” Rebecca is a case in point. Although she works four tens (four 10-hour shifts each week) at her clinic serving the homeless, she also picks up another shift nearby each week to make ends meet.
Financial strain is greater among CNAs, LVNs, and LPNs, who tend to earn a lower hourly rate. Ima, for instance, values the flexibility to work where and when she wants as a shift nurse, but a dry spell of a week or two can be harrowing. CNAs in single-income households are likely to live around the poverty line with a mean annual wage of $32,050.
In sum, nursing faces a wave of retirements, a shortage of resources to train new nurses, and an existing cohort of nurses who feel burnt out and financially strained. Healthcare facilities need to reckon with that reality, because their operations depend on those providers. It is hard to imagine a talent pipeline more in need of transformation.
American nursing faces more than a supply-demand issue. As our conversations with nurses and facility administrators revealed, the experience inside facilities is the crux of this talent crisis. How individual facilities treat nurses determines whether they’ll have the talent they need.
Based on our research and interviews, there are ways that facilities can improve the nursing experience and thereby attract and retain nurses more consistently.
Keke of St. Dominic Village staffs about 18 CNAs working every 24 hours and sees many of the same professionals return to her facility. The reason, said Keke: “We treat them like our own staff.”
The first shift at St. Dominic Village begins with a tour of the facility and a thorough review of what CNAs are expected to do during their shifts. Keke ensures that contingent nurses have the same number of patients and same workload as her staff nurses. She also encourages shift nurses to speak with her if they have issues on the floor.
Keke’s approach would certainly resonate with Ima, who says, “It’s not just about the money. It’s about feeling appreciated.” In facilities where nurses—full time and temporary—are bullied, overworked, or mistreated, staffing inevitably becomes a problem. Thus, at facilities feeling the talent crunch, the first step is to investigate the culture of the nursing department.
Higher pay, though helpful, is a stopgap solution that does not address the larger issues in hostile environments, which struggle to attract talent. Nurses need to feel like they belong and are supported.
For ease of scheduling, Keke uses two 12-hour shifts: 7 am to 7pm and 7 pm to 7 am. These avoid high-traffic hours in Houston, sparing nurses a long, frustrating commute. She found it helpful to eliminate the 2 pm to 10 pm shift because no one seemed to want it.
While an overnight shift can be rough, it’s essential to professionals like Ima. By day, she is an LVN student and single mother to a four-year-old daughter. She can only work overnight shifts. A facility with three eight-hour slots would be less appealing because Ima would only be able to work one shift and therefore miss out on four hours of pay. Even after earning her LVN, Ima plans to work on a temporary basis. She values the flexibility to make her own schedule.
When Jared was job searching six months ago, working four tens was “non-negotiable” for him. Four years ago, he felt it would have been unusual to make that request. Now, he says, facilities are willing to take any time providers can offer. “There’s a lot of flexibility right now if you want it,” he said.
Rebecca agreed that a predictable schedule is “worth a ton,” but many facilities don’t make the connection between scheduling and quality of life. For example, a friend of hers working in a neuro ICU was, day-by-day, switched between a day shift and night shift, meaning she could never get decent sleep. The facility wouldn’t consider a more predictable schedule, so she quit. The facility might have solved the problem by, say, interchanging between three weeks of night shifts and three weeks of day shifts with at least a weekend or two off for recovery.
When nurses have the flexibility and autonomy to work where and when they choose, their experience is certain to be better. Without that control, family responsibilities—and childcare costs—add pressure to an already stressful profession. “Allow for people to have actual lives,” as Rebecca advised.
Jared commends his current employer for trying to address staff retention with better pay and benefits—notably, tuition reimbursement and fertility benefits. He also applauds his facility for doing a “listening tour” with nurses. “To actually feel you’re heard is important,” he said.
Jared offers a good example of how his employer responded to a stressor felt by many nurses. Following the conviction of RaDonda Vaught, a nurse prosecuted for a fatal drug error, Jared’s facility held a virtual town hall to discuss how they would prevent that scenario. “This won’t happen here,” was the message, said Jared. It was comforting for him.
At some facilities, however, administrators might be afraid to listen. If Ima is being bullied by full-time staff, would management be willing to resolve the issue? Would they be nervous about losing more talent in a tight market? To address a wider talent crisis, facilities sometimes need to adjust the culture they create. Ima encourages facilities to “create a non-hostile environment for shift workers.”
Rebecca, too, stresses the need for managers and leadership to sit and listen to nurses. That means listening to their concerns about compensation and patient abuse. In few professions aside from nursing, it would be unthinkable to ask that employees accept physical and emotional violence on a regular basis. When nurses experience that, they need to be heard, and they need real solutions.
he healthcare industry has a ways to go in making nurses feel safe and supported in their careers. However, if enough facilities, providers, government entities, and technology firms coalesce around this elusive goal, much can be done.
The job of nursing cannot and will not match Wall Street compensation. But to be sustainable, nursing should be a profession in which people can attain financial security, be assured of their personal safety, and have the support of management. If not, who will choose to become—or remain—a nurse?
Hence, Rebecca’s top advice to facilities: “Pay nurses more so we feel valued. It is a really hard job involving emotional and physical labor for 12 hours straight. If you’re being paid $28 per hour to be screamed at and pooped on, it doesn’t feel great.”
No single facility can fix the nursing talent crisis, but each one can navigate the shortage by taking its own steps. In facilities that treat temporary staff as their own, allow flexible scheduling, and listen to employees, finding talent will not be nearly as difficult. Nurses want a dignifying experience at work, and one way or another, they will find it.
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