Pandemic exacerbated looming nursing shortage, burnout

Linda Rider

By Rose Hoban

“Family and friends say I look exhausted all of the time.”

“Some days I absolutely dread going to work.”

“I started having to take an (antidepressant) in order to function without breaking down every day.”

These were just some of the dozens of responses to an anonymous survey in which the North Carolina Nurses Association queried registered nurses across the state on how they were doing two years into the pandemic. The survey, conducted last month, found that nurses continue to be affected by the effects of the pandemic. Many of the 229 nurses who responded to the questionnaire described themselves as experiencing burnout.

Those results really trouble Erin Fraher, a researcher on North Carolina’s health care workforce at the Sheps Center for Health Services Research at UNC Chapel Hill. Fraher has been watching trends in the nursing workforce in the state for the better part of three decades and last month, she told lawmakers that she’s “never been so worried about a workforce in my life based on the data.”

Fraher went on to tell lawmakers that before the COVID-19 pandemic, her data were telling her that the state faced a probable shortage of about 12,500 nurses in the coming decade. But since the pandemic has stretched nurses to their limit, leading many to consider and take early retirement, the state could have something closer to 21,00 too few nurses by 2033. 

Even as nurses were willing to cut loose anonymously, many are still reticent about speaking ill of their institutions for fear of retaliation by employers, said nurses reached by NC Health News. But surveys and data show that the health care workforce is likely to lose some of the most experienced staffers. 

The reasons are many. They include:

  • The stress that comes from working in a pandemic for two years with overextended personnel;
  • Financial woes besetting some health care systems and providers;
  • The ire at disparities in pay; and
  • More recently, animosity from the public. 

“The level of exhaustion is so real,” said Lisa Harrison, health director for Granville and Vance counties. 

“No more meditation or pizza parties… We need real concrete help.” – anonymous response

At the beginning of the pandemic, restaurants provided free meals to nurses and other health care workers, hospitals put up billboards praising their staffers, and members of the public offered applause every night. But as COVID-19 cases rose and fell, and the public became tired of mask mandates and infection-control measures, health care personnel grew wearier while also taking more of the brunt of the public’s frustration.

Some hospitals have done a better job than others at mitigating the burnout that’s come with the two years of surging workloads. Those hospitals that have taken the time and expense to prevent burnout likely saved money, according to Jane Muir, a nurse researcher from the University of Virginia. For her doctoral research, she did an economic analysis of the costs of burnout to hospitals.

Hospitals looking to prevent such fatigue among their staff nurses spend on average $11,592 per nurse per year to prevent the exhaustion, Muir found. Those costs include measures such as spending more on full-time staff to share the load, creating programs to improve patient safety and the quality so nurses feel like they’re providing better care, providing opportunities for professional development for nurses and increased vacation time. 

But doing nothing actually costs hospitals more, Muir’s analysis found. She calculated that when hospitals simply stayed with the status quo, they ended up spending about $16,736 per nurse per year on their nurses. That’s because they had higher turnover rates and incurred costs to recruit new nurses, get them up to speed and hire expensive fill-in nurses to pick up the slack.

“A lot of pretty raw feelings” 

People in all professions have left their jobs as the pandemic has spooled out, and nurses have been a part of the so-called “great resignation.”

Frustrated RNs may not have quit the profession completely, Fraher told lawmakers, but many have left their staff jobs for travel assignments that became more lucrative as the pandemic extended from weeks to months to years. “Travelers” have long provided temporary fill-in for busy hospital units. They work for temporary staffing agencies who recruit and place them. Often travelers make a lot more than the staff nurses they work alongside, something that was a frustration even before the pandemic.

“It used to be when someone decided they wanted to do travel nursing, it was to take a job across the country somewhere, not across the street to the competitor,” said Dennis Taylor, the immediate past president of the North Carolina Nurses Association.

As a traveling nurse, Taylor explained, “you could go make sometimes triple or quadruple your hourly rate, and then turn around and either come back to your original organization because they need people, or decide to stay on at that new organization.”

During the pandemic, those frustrations have at times boiled over, Taylor said. 

“I think that has led to a lot of pretty raw feelings among folks who had been working at institutions for 10, 12, 15, 20 years,” he said. 

Those kinds of rewards, Taylor said, pushed some nurses who were close to retirement to jump ship. 

“I think that, unfortunately, the signal that it sent to them was that we don’t value your tenure, your experience or your loyalty to the organization,” he said.

“I gladly left my job due to dissatisfaction and frustration with a broken healthcare system” – anonymous response

Those are the kinds of retirees that really have Fraher worried, she told lawmakers. They are the more experienced nurses bailing out of bedside care.

Four years ago, Fraher’s center published data showing that the average age of nurses in the state was 45 for metro-area nurses and 46 in rural parts of the state. Now, that average has crept upward as the entire workforce has aged. Many of those older nurses can find different jobs with less stress. 

Before the pandemic, Fraher projected the state would need about 125,726 nurses by 2033, but would only have 113,277 available, leaving a deficit of 12,500. If nurses within five years of retirement age decide to jump ship early, that would almost double the deficit to 21,032.

Fraher told lawmakers that pre-COVID, NC was forecasted to face an estimated shortage of 12,500 RNs by 2033. If burnout or other factors cause nurses to exit the workforce five years earlier, that shortage nearly doubles, she said. Image courtesy: Erin Fraher/ Sheps Center for Health Services Research, NurseCast

Taylor was one of those people. After years of critical care nursing and leading the state nursing association during the pandemic, he also decided to leave his position, for now. 

This week, Hugh Tilson, head of the North Carolina Area Health Education Centers, told lawmakers that his organization had surveyed employers to find that they were already having trouble recruiting and retaining staff to fill vacancies, especially for nurses. 

In November, AHEC found that many facilities reported “exceptionally long” vacancies for open positions. When it came to RN positions, responses from 19 types of facilities – from nursing homes to hospitals – reported long periods where they couldn’t fill vacant jobs, including 31 of 35 hospitals surveyed. RN retention was also an issue. 

“The important thing about our study is that it confirmed that these problems existed in the past, and COVID made it worse,” Tilson said. He said there needs to be coordination at the state level to consistently monitor, track and report to the legislature where the needs are in the health care workforce, otherwise, “we’ll be in the same place 10 years from now as we are now.”

Tilson also noted that health care institutions can’t “solve the nursing problem in isolation, but only if they work with the larger health care ecosystem and with other professions within health care. 

Public health workforce also stressed

In the public eye, the image of nurses in the pandemic has been that of someone covered head to toe in protective gear, hovering at the bedside of an ICU patient. But Lisa Harrison, the public health director in Vance and Granville counties, pointed out that her public health nurses have been just as much on the front lines, maybe more so, as they’ve been outside the bubble of a hospital and confronting an often angry public.

“Communicable disease nurses in local health departments, so many people forget the roles and responsibilities they bear in the case investigation and the contact tracing,” Harrison said last week. “The abuse they’ve received in these last two years doing their jobs has been profound and their exhaustion is also profound.”

Many public health nurses across the state have been “holding the line because they feel this just overwhelming dedication to community and public,” Harrison added. “The public heart thing is ‘I’m not going to leave here in the middle of a crisis, but as soon as the crisis abates, phew, I need a vacation badly and it needs to be a two-year vacation.” 

Those public health nurses often are confronted with anger from people who were pro-mask, anti-mask, pro-vaccine, anti-social distancing, Harrison added, saying you name the position, they’ve heard criticism about it. 

“Seeing the abuse they’ve received in these last two years doing their jobs has been profound and their exhaustion is also profound,” she said.

Harrison predicted that many public health nurses might look for an exit ramp soon, some temporarily, some permanently. 

“We’re gonna lose a lot.”

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