After more than eight years working in a big-city hospital intensive care unit, Michelle Toney has seen a lot — drug overdoses, trauma victims, patients violently lashing out. It was rough, but she loved it: “That stress and adrenaline constant is something I used to thrive off of.”
Now, two years into the pandemic, she’s considering something she never had before: leaving the ICU. “I just can’t do it anymore,” said Toney (a pseudonym Grid is using to protect her privacy).
Across the country, nurses are quitting bedside jobs at an alarming rate — worn out, mentally and physically, from dealing with surge after surge of desperately ill covid patients, fear for their own lives and frustration with people who renounce lifesaving covid vaccines or even deny the virus is dangerous. The nurses who remain are left to care for more people with fewer resources, further fraying the fragile system and harming patients and healthcare providers alike.
Nursing has always been a tough job. A wave of hospital consolidations in recent decades has helped hold down nurses’ pay and contributed to understaffing. But covid has turned a problem into a crisis. More than one-third of nurses plan to leave their current role by the end of the year, according to a survey by Incredible Health, a nurse staffing company. The American Association of Critical-Care Nurses (AACN) recently found that 66 percent of acute and critical-care nurses have considered leaving the profession.
And there are signs that, in the wake of the pandemic, fewer new nurses are entering the profession — creating problems that could outlast the virus. Without systemic changes that address the forces driving the current shortfall, many hospitals simply won’t have the nursing workforce needed to provide good patient care.
“Having to care for so many patients and not being able to provide the care that you know is needed leads to immense moral distress,” said AACN president Beth Wathen. “Nurses have borne a collective, deep burden bearing witness to hundreds of thousands of deaths over the past two years … there’s an overwhelming exhaustion right now.”
Pre-pandemic, between 17 and 38 percent of nurses reported some depression, and female nurses — who dominate the profession — died by suicide at twice the rate of women who aren’t nurses. But “the pandemic has really amplified the burdens on nurses to a level that’s just untenable,” Wathen said.
Toney has vivid memories of her hospital’s first major covid surge, in November 2020. “I would go to work and see death all day,” she said. ICU patients are the sickest in any hospital, but the covid patients who came in needed higher levels of care than the unit’s normal patient load. Nurses began leaving with every new wave of infection, and the unit struggled under a workload that at times tripled.
Toney eventually started taking antidepressants, and she and her colleagues pleaded with upper management for mental health support, including help paying for therapy sessions. But nothing changed. “If more support were given when we were crying for help, maybe I could see myself staying,” she said. “It’s too late now. I just don’t have it in me anymore.”
Pizza parties and pats on the back
Understaffing is one of the major causes of moral distress and burnout. “It both increases the workload of nurses while also making them feel less valued [by their employer],” said Jane Muir, a nurse and nurse researcher at the University of Virginia.
For most hospital settings, “four patients per nurse or less is associated with increased well-being and reduced burnout,” Muir said. Hospitals often breached that ratio before the pandemic, but many have blown well past it during covid surges.
After hearing horror stories from other nurses, Daniel Potter, a nurse who lives in Kentucky, launched HospitalRatios.com in late February. With his 2-year-old child on his lap, Potter put together a basic website where nurses could share information about working conditions. More than 300 nurses had submitted information the first day the site was live. Only about 16 percent said their facilities had adequate staffing.
“For the longest time [during the pandemic] it was a pat on the back, the signs out front, the pizza parties … that worked for the first six months,” Potter said. “But after that, nobody ever really wanted to commit to any kind of increase, like a true long-term increase in pay to retain people.”
In some cases, nurses were even furloughed or asked to take pay cuts as hospitals canceled elective surgeries and ambulatory care, normally key revenue sources, to cope with the influx of covid patients.
Laura Stambach, a nurse who began her career at a New Jersey hospital during the pandemic, often juggled eight patients in the emergency room — and sometimes as many as 12. “You were always drowning. We didn’t have any help,” she said. The toll got to her. During that time, she “had more patients die than live, and right now I’m just kind of blacking that out,” she said. “At a certain point, you become almost immune to it because you have no other way of protecting your own emotions.”
Caring for unvaccinated covid patients after the shots became widely available added another layer of anguish. “Now that we have a vaccine, it’s harder to see people die because you know that it could have been prevented,” she said. After a year and three months, Stambach left for a more lucrative job as a travel nurse, working short-term assignments for higher pay that provide more time and money to take care of her mental health.
As patient loads have ballooned, many hospitals have piled new responsibilities on nurses, such as running outpatient covid testing for employees. “I’d have to go swab them in the middle of my work day, a few every hour,” said Clare Hourihan, an ER nurse in Buffalo, New York. With an already downsized staff, “you really can’t be walking away [that often] to do a covid swab,” she said.
Wider hospital personnel shortages and pandemic restrictions on who can enter a patient’s room also resulted in many nurses taking on tasks that were done by others before covid hit — including delivering meal trays, mopping floors and even unclogging toilets. When family members were barred from visiting patients, nurses were often left to hold up an iPad to let the sick and dying say goodbye to their loved ones.
In the pandemic’s early days, nurses and other healthcare workers were buoyed by a grateful public. But that support has dwindled and in some cases morphed into outright hostility as the covid response became a politically polarizing topic. “I’ve had nurses spit at,” said Vicki Good, the executive director of nursing Mercy Hospital in Springfield, Missouri. “Suddenly we go from being the hero to the villain … physical and emotional violence against healthcare workers is escalating like never before.”
Incidents of nonfatal violence against healthcare workers increased about 60 percent from 2011 to 2018, according to the Bureau of Labor Statistics. In the early months of the pandemic, 44 percent of nurses reported experiencing physical abuse (including hitting, biting, choking and hair-pulling), and 67 percent reported being verbally abused by patients, according to one recent study. Nurses caring for covid patients were more likely to experience both kinds of abuse.
These increasingly fraught work environments can sap nurses of the very thing that called many to the profession in the first place: compassion. “Compassion fatigue goes beyond burnout,” said Robin Cogan, a school nurse in the Camden City School District in New Jersey. “You just feel like you don’t have anything left to give. It creates this detachment, like a protective mechanism,” to shield you from other people’s trauma, she said. “It’s a terrible feeling, especially when you’re a nurse and believe in the power of being compassionate.”
Burnout, moral distress and compassion fatigue are of course terrible for nurses, contributing to maladies as wide-ranging as heart disease and gastrointestinal issues to insomnia and depression. That stress doesn’t just affect nurses.
“In hospitals, everything that touches a patient goes through the hands of a nurse,” said Karen Lasater, a nurse researcher at the University of Pennsylvania. “When a nurse is depleted, the quality of care is just not going to be there.”
Research backs that up. Burned-out nurses are less likely to administer patient medications on time and more likely to lapse in infection control and to report patient falls. Hospitals with more burned-out nurses have higher mortality. Burnout is also linked with desire to leave employers, Lasater said, sapping units of a deep bank of knowledge that helps train and support new nurses.
Without major changes, this downward spiral of deteriorating work conditions and increased burnout will only continue. Stopping it is going to require more than pizza parties and yard signs. “We need system-wide change,” Wathen said. “This is not an individual problem; we need fundamental systemic change that addresses those things that are creating moral distress and burnout.”
The rise of travel nursing
Some nurses have coped with covid stress by taking lucrative temporary assignments at understaffed hospitals. These offer the flexibility to choose better conditions, or at least higher pay, and to take longer stretches of time off.
Before the pandemic, hospitals used travel nurse agencies to cover gaps created by staff nurses’ parental leave or summer vacations. But after covid hit, travel nurses became a vital tool to help hospitals cope with caring for waves of virus patients. As demand grew, so did the wages travel nurses could command — tempting many staff nurses to quit their jobs in favor of travel gigs.
Travel nurses can now make around five times the hourly rate they made as a staff nurse. And while the finances of staffing agencies are opaque, one analysis suggested they make profit margins up to 40 percent on placing nurses, according to Diana Mason, a policy professor at George Washington University’s School of Nursing. Travel nurse openings on one agency’s website list pay estimates as high as $6,890 weekly, a staggering figure compared with the $1,305 that the Bureau of Labor Statistics lists as the median weekly wage for a registered nurse.
Potter, who started the HospitalRatios.com website, said that his last hospital job was the first position he ever felt sad to leave. But after he was unsuccessful in lobbying for a raise, he opted for a travel assignment in nearby Indiana that would double his net pay.
“I’ve been with a great hospital for the last six years, but pay is just not matching anything else,” he said. “Six years later, we’ve got travel nurses that are making two or three times more than I was, and [management] kept denying our raises.”
While some nursing unions have earned better compensation from their employers nationally, nurses have struggled to earn better compensation. In the last 10 years, the median wage for registered nurses has risen only about 18 percent, to $77,600. The consumer price index, a measure of the dollar’s purchasing power, grew by about 19 percent over the same period — meaning that nurses’ pay is barely keeping pace with inflation.
Evidence suggests that concentration in hospital markets has been one factor producing the relatively stagnant income for nurses. Since 1975, the number of hospitals in the U.S. has declined from more than 7,000 to around 5,500, according to American Hospital Association data. The top 10 health systems own nearly a quarter of the hospital market, according to Deloitte, and the trend accelerated during the pandemic — often with help from federal relief dollars.
One 2020 study of concentrated hospital markets found that mergers slowed wage growth for nurses, although they didn’t affect wages for non-medical workers like cleaning or food staff. In assessing the possible impact of one recent merger, the Federal Trade Commission stated that it would likely affect nursing wages due to the market concentration.
Now, two years down the line, many hospitals say they are struggling to find enough nurses — and that travel nurse agencies are to blame. In late January, more than 200 members of Congress signed a letter to the White House, urging action on such price gouging from travel nursing staff agencies. “We have received reports that the nurse staffing agencies are vastly inflating price, by two, three or more times pre-pandemic rates, and then taking 40% or more of the amount being charged to the hospitals for themselves in profits,” they wrote.
The sudden and dramatic increase in travel staff rates came just as the federal aid from early in the pandemic was winding down, said Shawn Tester, CEO of Northeastern Vermont Regional Hospital in St. Johnsbury.
Tester said his small rural hospital has been feeling the financial squeeze of these soaring rates. Before the pandemic, the hospital would typically have between one and three travel nurses on staff at any given time. Currently, it has 13, and the monthly cost of paying those nurses and the two other travel staff — one lab tech and a respiratory therapist — is nearly $500,000 monthly. Its rates for these travelers were $65 hourly prior to the pandemic. Now, they cost $150 an hour, he said.
“As we know, the pandemic has an uncanny way of finding all the cracks in our system and making them wider, and that’s exactly what happened with nurses,” he said.
“One person’s supply and demand is another person’s price gouging,” said Joanne Spetz, director of the University of California, San Francisco’s Institute for Health Policy Studies. If offering more pay can get nurses to sign up for life on the road, “that’s basic labor economics,” she said.
Despite the challenges his hospital is facing in turnover, Tester is sympathetic to nurses leaving for travel contracts.
“Many of our younger nurses have a lot of debt, and that additional money is really attractive, so you can appreciate those decisions,” he said, adding that he hopes to welcome the nurses who took travel contracts back to their permanent positions, if they decide to return. Northeastern Vermont Regional Hospital currently has 30 permanent nursing positions open.
But despite the higher pay and flexibility that travel agencies have offered during the pandemic, their existence can actually harm nurses’ bargaining power in the long run. Rather than negotiating with and raising the wages of permanent staff, hospitals can tap the agencies to fill gaps with temporary nurses.
Filling the gaps
In 2000, Peter Buerhaus, a Montana State University professor who has dedicated much of his career to understanding the nursing workforce, and his colleagues projected a major shortage of nurses by 2020. But by 2017, despite signs for concern in some specialties and areas, his team projected an additional million nurses would join the workforce between 2020 and 2030, more than replacing the 640,000 they projected would retire, Buerhaus told Grid. Now, those measured but optimistic estimates are, like most pieces of the healthcare industry, in flux.
A more recent analysis that Buerhaus co-authored found that after those years of fairly steady growth, the supply of registered nurses declined by more than 100,000 in 2021, the largest single-year decline in more than 40 years.
But Spetz said that the question of whether there is a nursing shortage is more complex than simply whether or not there are enough nurses to fill the open roles: “When people say there’s a nursing shortage, the first question should be, ‘What do you mean by that?’”
She’s heard from nursing graduates who say that they’re unable to find jobs and employers who say they can’t find nurses with enough experience. There’s also divides between urban and rural areas; markets in cities like San Francisco may be oversaturated with graduates from local nursing schools, while areas like California’s Central Valley may have fewer nursing programs or graduates to recruit from, Spetz said.
Before the pandemic, Spetz’s findings were similar to Buerhaus’ earlier projections: In general, there were enough new nursing graduates to fill the shoes of boomer-age nurses who were retiring.
She found surveying nurses during the pandemic that those retirements might come sooner than expected. Older nurses understood the risks of working with a deadly virus before the vaccine was developed and left the workforce altogether.
“Nurses in the next age group were like, ‘I’m a nurse. I serve, I’m going to keep serving, but when this is over, I’m going retire,” Spetz said. According to past surveys, 11 percent of nurses in the 55 to 64 age group planned to retire within two years. During the pandemic, that figure more than doubled to 25 percent.
The most recent Bureau of Labor Statistics estimates suggest that there will be 200,000 openings for registered nurses by the end of the year, mostly due to retirements or exits. Data from the National Council of State Boards of Nursing indicates that about 150,000 registered nurses earn their licenses annually.
Despite this regular influx of newly credentialed nurses to replace retirees, hospitals are concerned that they won’t be able fill gaps that arose during the pandemic — not just in sheer numbers of workers, but in experience lost.
Beth Oliver, chief nursing executive at Mount Sinai Hospital in New York, saw many of the retirements Spetz uncovered in her survey firsthand. When covid hit, the hospital system reassigned all its nurses to essential covid-response units rather than furloughing or laying off non-covid staff. After that first wave subsided, tired and traumatized staff began retiring or departing for travel nursing gigs.
“They were enticed to join traveling nurse assignments, which really offered ridiculous amounts of money that we couldn’t compete with,” Oliver said.
Fight over staffing levels heads to statehouses
To many nursing researchers, solving the nursing shortage is conceptually simple: Increase staffing levels, and foster a work environment that makes them want to stay.
“The single most important thing that hospitals can do to recruit and retain nurses is to employ more nurses,” said Linda Aiken, founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. “It takes enough nurses to retain nurses.”
She recently found that 57 percent of nurses who worked in hospitals prior to the pandemic said their units were understaffed. During the pandemic, that ticked up to 67 percent.
California has tried to solve staffing issues by mandating minimum nurse-to-patient ratios. In 2004, the state set staffing requirements for different units of acute-care hospitals, requiring nurses to care for no more than four patients in the emergency room and two patients in the ICU, for instance. It remains the only state to do so despite over two decades of research documenting the benefits of safe nurse-to-patient ratios.
Opponents of the measure feared the mandate would lower the skill level of the state’s nursing workforce, but the proportion of highly trained nurses actually increased. Hospitalized patients in California receive on average three hours more nursing care a day than patients in other states because of the mandate, according to one 2021 study. That extra care pays off for patients; if New Jersey and Pennsylvania hospitals had nurse staffing ratios like California’s, Aiken and colleagues estimate that there’d be about 10 to 14 percent fewer surgical deaths each year.
But recent efforts to pass a federal bill similar to California’s, and staffing mandates in other states, have failed despite studies suggesting they would benefit hospitals’ bottom lines.
Enacting the proposed 4-1 staffing ratio in New York in facilities serving roughly a quarter of the state’s Medicare patients would have prevented 4,370 deaths among hospitalized Medicare recipients from 2019 to 2020, researchers estimate, while shortening cumulative patient stays by roughly 388,160 days and reducing readmission rates. That would have saved these hospitals a projected $720 million.
“There’s a clear economic case for hospitals to do this,” said Lasater, a co-author of the study. But efforts to enact staffing laws in other states have run into intense lobbying from the industry, she said. The American Organization for Nursing Leadership, part of the American Hospital Association, says that “mandated nurse staffing ratios are a static and ineffective tool” that ultimately doesn’t create safer working environments.
Establishing staffing standards and making other systemic changes, like creating more flexibility around 12-hour shifts, will help address burnout, experts say. But making real change will also require reducing the stigma around mental health problems among nurses, Good said.
“We go into nursing to take care of people, and so to admit that we need to be taken care of is an oxymoron,” she said. “We need to embed [mental health] support without people asking for it, because if we depend on people to go ask themselves, they’re probably not going to reach out.”
Good’s hospital set up peer support groups, where nurses regularly check in with one another and some are trained to spot the signs and symptoms of someone who might need more professional help. “That helps us intervene before [a nurse] goes too far down the road of moral distress and burnout,” she said.
Lawmakers have also begun to address the issue. The Lorna Breen Act, which President Joe Biden signed into law in March, provides $135 million to support similar programs and decrease stigma. It is named after a physician who died by suicide during the pandemic. For many nurses working at hospitals, such help can’t come soon enough.
Hourihan, the ER nurse in Buffalo, is supposed to see about four patients during a shift, depending on the severity of her patients’ illness. Instead, as the pandemic has pushed back important preventive care and the impact has trickled down to the emergency room, she’s been assigned to as many as six patients during day shifts and between eight and 10 at night. She’s also seen many colleagues leave for other opportunities. Hourihan estimates that of the 40 staff members who worked in her unit before the pandemic, she’s one of seven or eight who remain — the turnover has affected around 70 percent of her unit.
She’s now considering clinical research or other careers as an “escape plan.”
“Obviously, no one expected a pandemic to happen, but we’re trained to be adaptable and deal with it,” Hourihan said. “But seeing how the higher-ups in the hospital turn their back on everything, seeing the public care less about the people around them, just really made it difficult to want to do this anymore.”
Thanks to Lillian Barkley for copy editing this article.