Where Have All the Nurses Gone?
The issues involving crisis-level shortages of nurses and healthcare providers (for home health care, assisted living facilities) are somewhat different, although the level of crisis in each sector is comparable. The pandemic has made these worse – and more apparent to the public – but both sectors were in trouble well before the onset of COVID.
While general news articles blame the pandemic shortage of registered nurses (RNs) on COVID (most frequently-cited causes: burnout, stress, emotional exhaustion), just as we saw in our previous post on how the pandemic led to a public health disaster in the U.S., the roots of the U.S. nursing shortage go back much further, years before COVID-19 struck.
Most hospitals in the U.S. are now privately-owned and operated. Consequently, they are driven by the profit motive rather than the delivery of critical healthcare services. Given that approximately 50% of a hospital’s budget goes to staffing, the latter has been “streamlined,” i.e. minimized to increase profits. Not-for-profit hospitals, forced to compete with for-profits, have adopted the same practices to avoid being priced out of the market. Thus for practical purposes, there is little difference in how their budgets operate.
This is not a question of an actual lack of nurses – in 2015, for example, there were 2.7 million RNs in the U.S. Rather, hospitals’ “flex-staffing” (equivalent to the “just in time” production-delivery system we saw in the case of PPE in our previous post) has led to systemic understaffing, and which revealed gaping holes during the first wave of the pandemic. Even in the midst of the omicron wave – formally, the third – the U.S. has not been able to make up for chronic, deliberate understaffing. Today, the problem is not so much a lack of beds, but a lack of staffing to care for patients occupying those beds. And because remaining staff are diverted to COVID wards, millions of elective procedures (a major source of profit) have necessarily been postponed and or cancelled.
When staff shortages become chronic, existing staff cannot properly meet the needs of a surge in patients (even, for example, in the case of a major accident / natural disaster). It therefore should not be surprising that 66% of critical care nurses (who bear the brunt of caring for COVID patients) were considering leaving the profession when surveyed in September 2021 (before the omicron wave got underway), and 40% of ALL nurses were considering leaving.
Hospitals have dealt with persistent nursing shortages by “outsourcing” demand to private agencies, which contracted as middlemen for provision of visiting nurses in COVID “hotspots” as each wave has rippled through the country. This practice, engendered by stark necessity, cost hospitals approximately $24 billion in additional outlays, resulting in an increase in total labor costs of 14% (as of Sept. 2021), even though full-time (i.e. regular) employees fell during the same period by 4%, against a benchmark of an average increase in staffing requirements of 20% during the pandemic.
The visiting nurse business has proved enormously popular during the pandemic; in 2020, it increased by 35% in volume (and, predictably, profits). Visiting nurses, who sign short-term contracts for periods ranging from a few weeks to a few months, earn between $5,000 and $10,000 a week. They can go where they choose, and work when they choose, i.e. they can rest and recuperate between stints. Staff nurses, on the other hand, often work 12-hour shifts for weeks on end (when there is a chronic shortage, the term “days off” flies out the window), and it was inevitable that many would suffer burnout and emotional trauma during the multiple waves of the pandemic. And for this, they earn on average around $1,400 per week ($1,200 in rural hospitals). The pay disparity inevitably impacts the morale of staff nurses, some of whom chose to quit their regular jobs and go to work as agency contract workers.
Understandably, the term “price-gouging” has arisen in the discussion of visiting nurse agencies’ charges, but this issue really needs to be addressed at the federal level; individual states which attempt to impose caps on “excess profits” of, say, 10%, or a cap on service charges (e.g. 150%, i.e. “time-and-a-half”) would soon find themselves shut out of the market for visiting nurses entirely.
The outside observer of what is clearly a crisis in staffing – 99% of rural hospitals have declared staffing shortages, and 96% have noted that they have the most difficulty in hiring RNs – may well wonder why RN staffing levels are not regulated. Currently, only one state, California, has legislation (since 2004) regulating RN: patient ratios in hospitals (ratios range from 1:1 to 1:6, depending on the level of care demanded; ICU wards, where critically ill COVID patients are typically cared for, require a 1:2 ratio). Two other states (Illinois, Pennsylvania) have pending legislation to impose similar ratios on hospitals within their jurisdiction; unfortunately, similar legislation proposed in Massachusetts was defeated in 2018, thanks to $25 million invested by the American Hospital Association, which conducted a campaign opposing the bill under the guise of “freedom and choice,” an all-too-familiar slogan. Federal legislation regulating the standard nurse: patient ratios in all hospitals which receive federal funding (e.g. Medicare, Medicaid) is clearly needed, but seems an unattainable goal given the current donor base of Congressional members of both parties.
In the meantime, what is to be done? One solution – although it’s not a quick fix by any means – would be to increase the overall number of practicing RNs in the U.S. Despite COVID, applications to many B.S. programs in Nursing are up. But the American Association of Colleges of Nursing (AACN) has noted that in 2021, around 80,000 applicants to such programs were rejected due to a lack of teaching staff and clinical placements sites (66,000 rejected from B.S. programs, and 13,000 from graduate programs).
Herein we find yet another problem: teaching in nursing programs pays less on average than actual nursing; thus, many senior nurses with advanced degrees choose to remain practitioners or continue for a nurse practitioner degree (with even higher salaries), or do a few stints of visiting nursing each year rather than enter the teaching profession. In short, the U.S. cannot train more nurses in the short term because there aren’t enough qualified teaching faculty.
Here’s another problem: the RN nursing force is “counter-cyclical,” because the majority of RNs are married and remain outside the workforce while their children are young and while their spouses / significant others are gainfully employed. But because many U.S. schools went online during the first year or so of the pandemic, even those who might otherwise have reentered the workforce were unable to do so due to childcare / home schooling responsibilities. Thus, many qualified nurses were constrained in their ability to return to work (around 500,000 of the country’s 2.7 million RNs in 2015 were not working).
And finally: The peak baby boom year in the U.S. was 1957 – and the large cohort of nurses born in that year will turn 65 in 2022. Thus we must anticipate a larger-than-normal retirement cohort of highly experienced, long-term nursing staff.
Nurses today are university-educated professionals like teachers (later in this series, we will see that similar issues have arisen with the teacher crisis). Staff nurses earn a middle-class wage, but they are increasingly burdened by technology demands many older nurses have difficulty adapting to, by administrative burdens which take many RNs off the floor for extended periods each day they work (most nurses have entered the field not to engage with computers/paperwork, but to engage with human beings whom they want to care for and help), and COVID has greatly increased the levels of stress-burnout-overwork – much of which is caused not by too much patient contact, but too little.
Privatization of U.S. institutional healthcare providers over the past several decades created a crisis-in-waiting. COVID heightened it, but didn’t cause it.
Sources:
Covid will continue to highlight America’s nursing shortage in 2022 and the looming ‘silver tsunami’ (OP-ED)
Why is the U.S. perpetually short of nurses?
Post Covid-19 global nursing workforce challenges ‘too big to be ignored’
COVID-19’s Impact on Nursing Shortages, The Rise of Travel Nurses, and Price Gouging
We Know the Real Cause of the Crisis in our Hospitals. It’s Greed.
Why the U.S. Nursing Crisis Is Getting Worse
COVID-19 field nursing shortage but also inspired new generation of nurses