Hospitals to Blame for Pandemic Nurse Shortage? It's Complicated

National Nurses United (NNU), a California-based union with 175,000 members, is blaming hospitals for nursing shortages that have arisen during the COVID-19 pandemic.

In a news release issued last Thursday, NNU said that chronic understaffing by hospitals has driven away many nurses who are not "willing to risk their licenses or the safety of their patients by working under unsafe conditions in hospitals."

The union claims there is no nursing shortage in the US as a whole, citing a 2017 report from the US Department of Health and Human Services (HHS) that found there will be enough RNs to meet the nation's health needs through 2030.

NNU does, however, admit that nurses are inequitably distributed across the country and that there are shortages in some areas.

The inadequate supply of nurses in some states, the union claims, is a direct result of hospitals' treatment of frontline nurses. Even before the COVID crisis, NNU alleges, hospitals understaffed every unit and every shift to maximize profits and "excess revenue."

Hospitals also have not maintained "a robust pool of nurses from which to draw when scheduling shifts," NNU states.

During the COVID pandemic, the union adds, "hospitals rejected nurses' advice…to prepare and plan for predictable staffing needs, including hiring and training more nurses, and cross-training current staff nurses to work in critical care departments. Instead, hospitals cut and laid off staff from units that had temporarily low patient census, and canceled RN traveler contracts."

The NNU's statement concludes with a call for hospitals "to immediately staff up every unit…and create a safe, sustainable work environment where nurses can feel confident about their ability to provide the best nursing care possible for their patients."

Some States Worse Off

In response to the union's charges, Robyn Begley, DNP, RN, senior vice president and chief nursing officer of the American Hospital Association, told Medscape Medical News, "Shortages of critical healthcare workers were projected long before the pandemic began…Hospital and health system leaders have used a variety of approaches to recruit, retain, and support their workforce."

Among those approaches is to offer unprecedented reimbursement to some nurses, especially in areas hardest hit by COVID-19. According to a recent report in Becker's Hospital Review , weekly pay for travel nurses has more than doubled to $3500 a week, and some positions pay as much as $8000 weekly for a 3-month assignment. By comparison, RNs earned a median of $63,000 in 2017, according to the National Nursing Workforce Survey for that year.

A recent McKinsey survey of large hospitals found that 84% of the respondents reported continued challenges with nursing workforce coverage. Turnover of nurses has increased 4-5 percentage points in the past 12 months, McKinsey found.

The top tactics that the hospitals have used to maintain their nursing workforce, the report said, include wage increases (31%), recruitment increases (30%), one-time bonuses (16%), and cross-skilling/upskilling nurses (10%).

None of this has availed hospitals in states where COVID is reaching new peaks. In Mississippi, for example, nearly 1000 hospital beds are unstaffed because of a shortage of healthcare workers, according to an AP article. Since the beginning of the pandemic, the state has lost nearly 2000 nurses.

Florida is also struggling with a nursing shortage in 70% of its hospitals, an NPR story noted. According to the article, "Miami's Jackson Memorial Health System, Florida's largest medical provider, has been losing nurses to staffing agencies, other hospitals, and pandemic burnout."

Gerard Brogan, RN, director of nursing practice for NNU, told Medscape Medical News that Florida offers a perfect example of what the union is talking about. "HHS projected a glut of nurses in Florida of 55,000 from 2017 to 2030," he notes. "So why are we seeing this massive shortfall of nurses in Florida? It's because Florida has a really poor reputation among nurses."

For example, Brogan said, some Florida nurses told him they worked in ICUs "that have only one nurse to five patients. That's dangerous and irresponsible. In California, where we have mandated nurse to patient ratios since 1976, there's a ceiling on how many patients a nurse can take care of in an ICU, and that's two patients.

"There's a scarcity of nurses in Florida who are willing to deal with those egregious working conditions. Some nurses close to retirement are leaving."

Critical Care Shortages

The shortages of ICU nurses across the US are the most concerning aspect of the workforce situation as the Delta variant continues its rampage, Peter Buerhaus, PhD, RN, a professor of nursing at Montana State University in Bozeman, told Medscape Medical News.

In areas ravaged by COVID, he said, the local supply of ICU nurses has already been exhausted. While there are also shortages on medical-surgical units, he states, "there's no way we have an available supply of these highly skilled nurses just sitting around, ready to jump into the ERs and ICUs. And those shortages are likely to continue. It takes several years to get those nurses up to speed and functioning in those areas."

Moreover, while some hospitals have tried to cross-train other kinds of nurses to provide critical care, he said, only some of those nurses are able to make the transition.

Buerhaus disagrees with the union's contention that the overall shortage of nurses was caused by hospitals. Even before COVID-19 came along, he said, there were other factors that combined to create conditions of scarcity. First, he noted, there are always "background shortages" across hospitals resulting from temporary changes in local supply and demand.

Second, the 1.2 million baby boomer nurses have been a large component of the workforce for decades, he said. Around 2010, they started to retire. Initially, about 60,000 a year retired; by 2019, the number had risen to 70,000. Many of those nurses were very experienced, skilled clinicians, and some had ICU experience, he explained.

Third, a growing number of nurses have entered advanced practice programs since 2012. "We estimate that reduced the number of nurses in the labor market [will decrease] by 80,000 a year," Buerhaus said. "So you've got 80,000 nurses leaving patient care for that reason and 70,000 retiring, and some hospitals having periodic shortages. And when you have short staffing, you've got nurses working harder, and they're unhappy."

Bad Actors

Buerhaus doesn't deny that "there are bad actors in the hospital world" that simply want to reduce their costs by keeping their nurse staffing to a bare minimum.

"However, I don't ever recall hearing a nurse saying directly or in a survey, 'We have an adequate staff.' Nurses always say we need more staff without consideration of other factors — the cost of that, or what you're trading away by acquiring more staff. The profession takes that position reflexively, and some unions have exploited that."

Brogan counters that, in his view, most hospitals short-staff their nursing units. "We have to fight tooth and nail with every hospital where we represent the nurses. I can't over-emphasize how difficult the working conditions are for nurses across this country. And the pandemic has been the final straw. Nurses are trying to get away from the bedside. The nurse practitioner role offers more pay, more respect, and more autonomy. Or they say, 'I'll go work in a clinic because it might be less hectic, and I'm frightened silly of making a mistake because of the poor staffing [in the hospital].'"

Brogan said he's encountering more and more nurses who are ready to throw in the towel. He cites a veteran nurse in Fresno, California who told him, "I'm not sure I can carry on. I just nursed a pregnant woman who's got COVID, and we've got a 19-year-old on a ventilator."

The true reasons for the nursing shortage, Buerhaus said, likely lie somewhere in between what the union claims and what the numbers show. "Between retirement and all the people going off to become NPs, the supply wasn't going in the direction we needed it to be when COVID hit. And some of the bad actor hospitals got hit even harder, because they didn't have enough staff to start with.

"It's a bit frightening, because if we were to see a big increase in retirement, we'd lose a lot of people with experience and valuable skills. I don't know what hospitals will be able to do about that."

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