The Vanishing Nurse: Staff, Patients in Peril

Around 1 million nurses may leave the field in the next few years, leaving the perennial “most trusted” profession absent at the bedside.

This cannot stand, nor can the powers that be allow it to.

“There’s always a silver lining,” said Brendan Martin, PhD, after reviewing the daunting numbers at a call-to-action meeting by National Council of State Boards of Nursing (NCSBN) on April 19. “The presentation of these critical results and the panel discussion will serve as an urgent call to action to tailor policy solutions aimed at fostering a more resilient, sustainable, and safer U.S nursing workforce.”¹

But for now, the nursing exodus is real. It was triggered by a pandemic, entrenched by a haphazard response, and then revealed in demographics indicating the old are retiring and the young are leaving early.

“Approximately 100,000 registered nurses and 34,000 licensed practical and vocational nurses left the workforce over the past two years, specifically due to the COVID-19 pandemic,” Martin said, citing an NCSBN comprehensive report. “Alarmingly, 41% of the RN total is comprised of nurses with a mean age of 36 and fewer than 10 years’ experience.”

One result of resignations and retirements is 62% of nurses across all levels reported an increase in their workload over the past two years. “Half of all nurses reported feeling emotionally drained, used up, fatigued, and burned out at least a few times a week, if not every day,” Martin said. “Over a quarter of the workforce reported they were at the ‘end of their rope.’”

As adages for desperation go, that is a breaking point, originally coined to describe tethered grazing animals who could no longer reach edible grass. The study results revealed significant declines in the clinical preparedness of pre-licensure RN students and similar drops in the practice proficiency of early career nurses due to shifts to remote and simulated education models.

“What does this all mean?” asked Martin, director of research at NCSBN. “Increased workloads, stress, and burnout have significantly strained the current U.S. nursing workforce, and the pandemic has disrupted traditional educational models. We project critical staffing shortfalls and reductions in the practice readiness of new nurse graduates at a time when more nurses than ever are needed to address the increase in inpatient demand.”

NCSBN research revealed 100,000 nurses left the workforce during pandemic, and 900,000 more intend to leave by 2027. The research was gathered as part of a biennial nursing workforce study conducted by NCSBN and the National Forum of State Nursing Workforce Centers.

The study authors analyzed a subset of the 2022 National Nursing Workforce Study. Reported trends represent population-based estimates. There were 29,472 registered nurses and 24,061 licensed practical nurses/vocational nurses across 45 states included. It represents the largest, most comprehensive, and rigorous examination of the U.S. nursing workforce since the pandemic began, Martin said.

Canaries in the Coal Mine

“This is a healthcare system issue. We’re like the canaries in the coal mine here, alerting the world,” Antonia Villarruel, PhD, RN, FAAN, dean of nursing at the University of Pennsylvania, said at the meeting. “We’re more than a cost center. We really are the oxygen of the healthcare system, and we need investment.”

Nurses have made it clear enough in labor disputes they want adequate support staff, schedule autonomy for work/family balance, and fair wages for a difficult job. Other suggestions in the NCSBN discussion included state and federal partnerships for both education and retention of nurses, particularly early in their careers. There also is momentum to remove licensing barriers between states and extend telehealth across state lines.

Gay Landstrom, PhD, RN, NEA-BC, FACHE, senior vice president and chief nursing officer at Trinity Health System, suggested using innovative ways to draw the expertise of retired registered nurses.

“Perhaps they can no longer hike up and down the floors or lift patients, but we can bring them in through technology to be a part of the team to help mentor early career nurses, to be part of decision-making, and sharing their wisdom,” Landstrom said.

A nurse commented on this prospect in one of the representative responses included in the NCSBN study. “I am retired and a widow. I’m active in church and help with my grandkids. I keep my LPN license because who knows. It would have to be light and low stress to return.”

It is a great time for innovation, but short- and long-term solutions must be focused on patient care, Villarruel said. Nursing work conditions are paramount for recruitment and retention, but anything cutting corners on patient care is going to be a non-starter. Indeed, that is happening now in short-staffed hospitals. Missed nursing care due to staff shortages tends to turn up in little but ultimately important things, like turning and repositioning the patient periodically and ambulating them out of bed. More importantly, medical errors increase because staff shortages compress time due to the temptation to try to do things a little bit faster. This can lead to staff safety hazards like needlesticks; other exposures; injuries from moving patients without help from colleagues; and the slips, trips, and falls that come with a hectic pace.

The aforementioned “silver lining” cannot appear soon enough but expect the nurses remaining to fight on.

“If COVID showed us anything, it is that nurses will work until there is very little left on their bones,” Beverly Malone, PhD, RN, FAAN, president and CEO of the National League for Nursing, said in a 2022 interview. “We will do the work that others are afraid to do. We will be there. From cradle to grave, we are your companion.”³

On April 17, Malone spoke at a meeting on recruiting international nurses held by the National Center for Health Leadership.⁴ A 75-year-old woman of color, Malone is a legend in the nursing world. She is a past president of the American Nurses Association, the former U.S. Deputy Assistant Secretary of Health, and for six years the General Secretary of the Royal College of Nursing in London — essentially the largest nursing union in the world. Thus, considerable weight was brought to bear when Malone pointed out ethical and moral issues must be considered in recruiting nurses from overseas.

“In the past, we have reached out, and the Philippines has been a prime example of almost a factory of wonderful, well-prepared nurses,” Malone said. “But it has not been as effective lately, and it has left the Philippines in jeopardy in terms of their own nursing workforce shortage.”

This has intensified recruiting in places that can least afford it — for example, the islands of the Bahamas, Malone said. “You may have an emergency room where there’s only one nurse who’s well prepared to run that,” she noted. “There are other nurses, but one senior nurse, and that is, of course, the one who’s recruited. It’s not the newer nurses — it’s the ones with the most experience. It cripples the entire emergency room, entire specialty areas of these healthcare institutions. Those are the kind of issues that we’re facing with international recruitment. Sometimes, it’s not viable for us ethically and morally to continue the way that we’re doing it.”

In a larger sense, the nursing shortage is a microcosm of the rest of society, which has undergone the so-called “Great Resignation,” as millions of Americans left their jobs. “The majority of workers who resigned from their positions cited low pay and lack of respect,” Malone said. “The healthcare industry has been the hardest hit. Nursing colleagues also report not feeling valued or listened to, desiring emotional stability, or seeking higher wages.”

The resignations set off a cascade effect. Turnover further lowers morale and job satisfaction and exacerbates burnout. “The remaining nurses are often assuming roles and responsibilities normally completed by a full complement of RN and support staff,” Malone notes.

The economic toll on healthcare organizations is staggering, with operating costs estimated at $24 billion annually above pre-pandemic expenditures.

A corollary to this public health crisis is the resignation or retirement of nursing faculty. “According to my colleagues at the National League for Nursing, 178 full-time faculty across 317 schools retired early or left their positions with a stated reason of COVID,” Malone said. “Currently, only 1.9% of the nursing workforce holds doctoral degrees compared with the 58% of faculty vacancies that require a doctorate. The [narrow] pipeline for recruiting future faculty also leads us back to the need to recruit internationally as a partial part of solving this problem.”

REFERENCES

1. National Council of State Boards of Nursing. Nursing at the Crossroads: A Call to Action. April 19, 2023.
2. National Council of State Boards of Nursing. The NCSBN 2023 Environmental Scan: Nursing at a crossroads — an opportunity for action. J Nurs Regul 2023;13:S1-S48.
3. Regis College. Nurses Station featuring Beverly Malone. June 16, 2022.
4. National Center for Health Leadership. A solution to the nursing shortage: International nurses? April 17, 2023.