By Amanda D'Ambrosio

During the fourth wave of the COVID-19 pandemic, hospitals have closed beds, shut down elective surgeries, and called in federal assistance due to a shortage of a critical healthcare resource -- nurses.

Shortages of nurses and other healthcare workers are plaguing hospitals throughout the U.S., especially those in COVID hotspots. Mississippi has 2,000 fewer nurses than it did at the start of 2021. Even before the Delta surge, Louisiana had 6,000 vacant nursing positions. In Tennessee, healthcare worker shortages prompted the state's National Guard to support struggling health systems.

During the fourth wave of the COVID-19 pandemic, hospitals have closed beds, shut down elective surgeries, and called in federal assistance due to a shortage of a critical healthcare resource -- nurses.

Shortages of nurses and other healthcare workers are plaguing hospitals throughout the U.S., especially those in COVID hotspots. Mississippi has 2,000 fewer nurses than it did at the start of 2021. Even before the Delta surge, Louisiana had 6,000 vacant nursing positions. In Tennessee, healthcare worker shortages prompted the state's National Guard to support struggling health systems.

But the current nursing shortage isn't just in the numbers. The exodus of experienced nurses leaving the front lines, as well as turnover among early-career nurses, have led to a widening skills gap, creating major implications for a healthcare system in need.

An Ongoing Concern

Experts had raised awareness about a shortage in highly skilled nurses long before the pandemic. The Institute of Medicine published a report in 2011, calling for more nurse training to meet healthcare demands. The report recommended that 80% of nurses have bachelor's degrees by 2020, as well as a doubling of nurses who pursue doctorates.

Additionally, a paper estimated that from 2010 to 2030, more than 1 million registered nurses would retire from the workforce -- taking years of knowledge with them.

While the U.S. has been grappling with a projected nurse shortage for the last decade, many believe the pandemic has accelerated the rate of nurses leaving the workforce. Most recently, group of nurses called for the Department of Health and Human Services to "declare a national nurse staffing crisis," proposing workforce retention strategies and more training opportunities, among other solutions.

In a survey of 6,000 critical care nurses conducted in August, 92% said that they believed the COVID-19 pandemic depleted nurses at their hospital. Two-thirds stated that their experiences during the crisis have caused them to consider leaving nursing.

"Those are super concerning numbers," said Beth Wathen, MSN, RN.

"I think COVID has really changed things," she said. "It's almost impossible to describe to those who don't work in our environment the level of death and despair that nurses and other frontline healthcare workers have been witness to over the past 18 months."

What's Driving the Skills Shortage?

The pandemic has created unprecedented working conditions for nurses and other healthcare workers, said Shawna Butler, RN, MBA, a nurse economist based in Texas.

Nurses have been working with short staffs, increasing their caseloads. The influx of critically ill patients has overwhelmed ICUs and emergency departments, creating working environments that are untenable, or even unsafe. Additionally, many nurses have taken on the increased emotional burden of becoming sole support systems for patients in their dying hours, many of whom could not see their families.These intense working conditions drove seasoned nurses -- many baby boomers -- to retire earlier than they may have planned, Butler said.

"The pipeline of new nurses doesn't keep pace with retirement -- and with so much of the experience retiring from the workforce, much of the operational, safety, clinical, and institutional knowledge, history, and wisdom is lost," she said.

As nurses with 20 or 30 years of experience retire, hospitals are struggling to find skilled nurses to take their place. Instead, early-career nurses may be thrown into overwhelming, stressful critical care environments.

"I am deeply concerned when I am seeing new grads starting their career in emergency departments, or new grads starting in any of these critical care spaces," Butler said. "I'm really worried about them. I'm worried about the people who have to train them. And I'm worried about the patients."

While seasoned nurses are leaving the workforce, new nurses are also leaving clinical settings at higher rates. Wathen said that turnover is high, with early-career nurses staying at the bedside for only a couple of years. "We are starting to lose that experience depth that we used to have," she noted.

Some of these early-career nurses are also going back for advanced practice degrees -- which could be taking away from the current workforce, according to Peter Buerhaus, BSN, PhD, who studies the nursing workforce at Montana State University.

From 2010 to 2017, the increase in nurse practitioners reduced the size of the RN workforce by approximately 80,000 nurses, according to a study, which was co-authored by Buerhaus.

"You've got a lot of nurses who are younger in their career moving to advanced practice roles, which is a good thing," Buerhaus said in an interview. "But, it has further exacerbated shortages."

Necessary Skills Depend on Patient Acuity

Experienced nurses provide the critical thinking skills and clinical acumen needed in intensive care units and emergency departments, Wathen said. It's not just running basic procedures, but also looking at a patient and determining when something isn't right.

In critical care environments, skill sets needed on a team of nurses is highly dependent on the acuity and complexity of the patients, she added.

For example, nurse staffing on a 10-bed floor of patients who are not intubated might require less support and expertise than a 10-bed floor with patients who require mechanical ventilation, life support, extracorporeal membrane oxygenation, or other complex therapies.

"That's a whole different number of nurses and expertise that you need to manage those patients," Wathen said. "It's a really important concept to understand that it's not just sheer numbers."

Halting the Shortage

The current nursing shortage has created a dire picture for the future of healthcare. Health systems need to attract new nurses, as well as retain those with experience, to address the growing health needs that will result from the pandemic, Buerhaus said.

"The good news is that our estimates of the future growth in our profession before COVID suggested that we would grow the workforces by a million nurses," he added. That figure includes the replacements for baby boomer nurses leaving the field, as well as 1 million additional practitioners.

However, it is unclear if the effects of COVID on the nursing workforce may alter those projections.

Solutions to attract and retain nurses may include fostering better teamwork among healthcare leaders to engage nurses in high-level decision making, increasing compensation, and improving training opportunities for nurses who want to stay at the bedside. Another solution is to improve the public image of nursing -- and therefore, continue to attract people to the profession, said Buerhaus.

"Nursing at the moment is entering into a very dangerous time," he noted. Problems in the workforce should be highlighted and addressed, he added, but more positive messaging about the profession is needed.