Where Have All the Nurses Gone? Hospitals and Unions Clash Over the Staffing Crisis

Regarding the current state of nurse staffing in American hospitals, nurses and hospital administrators share one consensus: there are indeed not enough nurses on the front lines of clinical care. However, beyond that, the two sides find it difficult to agree on almost any other key issue.

From the causes of the problem and potential solutions to how to name it—hospitals define it as a "nurse shortage," while unions and advocacy organizations call it a failure of "safe staffing"—labor and management hold opposing positions on the details of the nationwide workforce crisis.

Hospitals say they are doing their best to recruit, but the market lacks a sufficient number of qualified registered nurses. The American Hospital Association had projected that 500,000 nurses would leave by the end of 2022, creating a total nationwide shortage of 1.1 million nurses.

During a recent Investor Day presentation, Sammie Mosier, Chief Nurse Executive at HCA, stated that the existence of the nurse shortage is beyond doubt. Hospital operators have been hoping that the so-called "workforce pandemic" would ease, as they say this crisis makes it difficult to fill vacancies created by staff turnover.

But nurse unions are unhappy with the term "shortage" and reject the view that the workforce crisis is a new problem for the industry. They argue that this wording lets hospitals off the hook for their role in creating vacancies, and they allege that any current nursing shortfall is a consequence of hospitals' own decisions.

This year, tensions between the two sides have erupted multiple times, with demands for increased staffing driving strikes at hospital operators such as Prime Healthcare, Robert Wood Johnson University Hospital, and Ascension St. Joseph.

"They don't acknowledge that they created (the shortage) through their management practices," said Margaret Franks, a registered nurse and regional director at the New York State Nurses Association. "The evidence shows this is not a nurse shortage, but a lack of nurses willing to work under current bedside conditions."

Franks believes that without first addressing workplace issues in American hospitals, any nurse recruitment effort is like building on quicksand—you might get people in the door, but you lack the foundation for success.

"We all have friends who left nursing, and they all tell us the same thing: We're not coming back. I'm not coming back to face eight patients," Franks said. "You can't build a team on a bad foundation. They would rather take less pay, or work five days a week, than work three shifts where they can't do their jobs properly."

Data shows the nurse talent pool is expanding, yet hospitals find recruitment increasingly difficult

The numbers present a paradox—the nursing talent pool is growing, but hospital recruitment is getting harder.

According to data from national nursing licensing bodies, the number of people passing the nursing licensure exam each year is increasing. New nurses are joining a talent pool that, as of 2022, included 5.2 million registered nurses, 89% of whom were still working in the profession, according to a biennial national survey conducted by the National Council of State Boards of Nursing (NCSBN) and the National Forum of State Nursing Workforce Centers.

Meanwhile, Julia Pollak, chief economist at the online job platform ZipRecruiter, said that compared to 2020, there are more nursing job postings this year.

For-profit hospitals are among the employers eager to hire. Executives at operators such as HCA Healthcare, Tenet Healthcare, and Community Health Systems have all reported paying high rates for temporary contract nurses since the pandemic began, making nurse recruitment a top priority.

Yet hospital nursing positions remain vacant, and the number of interested applicants has declined compared to previous years.

On ZipRecruiter, applications for nursing positions this year are down 11% compared to 2022. Pollak noted that companies now need to put in more effort to get each application. To generate one "qualified applicant," an average of nine people need to view the job posting—whereas in 2022, that number was only five.

Beyond online job platforms, the U.S. Bureau of Labor Statistics (BLS) monthly Job Openings and Labor Turnover data also confirms that recruiting nurses is becoming more difficult. Before the pandemic, at the end of 2019, filling a healthcare position took on average less than two months (calculated as the inverse of the hires-to-openings ratio). According to the latest BLS data, by September, the time to fill a healthcare position had risen to 2.2 months.

Pollak said that despite healthcare companies having begun raising salaries, offering signing and relocation bonuses, tuition reimbursement, and training stipends, recruitment difficulties persist. According to data from credit agency Fitch Ratings, average hourly wage growth for hospital employees approached 3.8% in July, higher than the average increase of 2.3% between 2010 and 2019.

But Pollak believes that although hospitals are "pulling out all the stops," most of these efforts have not worked. "Healthcare organizations have done a lot of work to increase job engagement," Pollak said. "The problem is, this is not a labor shortage that can be solved with pay alone."

Why are hospitals struggling to attract nurses?

Experts point out that although there are millions of registered nurses in the talent pool, the number leaving is also increasing. According to a study published in Health Affairs, more than 100,000 nurses left the profession in 2021 due to deteriorating working conditions caused by the pandemic. The researchers called it "the largest decrease observed in the past four decades."

In 2023, nurses who had left the profession told consulting firm McKinsey & Company that they left because they felt undervalued, underpaid, and unable to cope with increasing workloads. Nearly half of respondents in a McKinsey survey said unsafe working environments influenced their decision to leave direct patient care, an increase of 24% from the previous year.

In recent years, working conditions in hospitals have become more challenging, with nurses facing increasing workplace violence, injuries, and illnesses, as confirmed by industry data and experts. Nurses who remain on the job are experiencing higher rates of burnout because they are absorbing the workload of understaffed units, according to research from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. The research notes that this problem is cyclical, as burned-out nurses are more likely to seek employment elsewhere.

"The workforce is changing. They now value work-life balance more. And ironically, the staffing shortage actually makes healthcare jobs less attractive... forcing people to work crazier hours," Pollak said. "So we're seeing physician burnout reach crisis levels, with many leaving early before they would have otherwise worked longer."

This includes nurses who choose early retirement, said Therese Fitzpatrick, senior vice president of performance improvement at healthcare management consulting firm Kaufman Hall. She said poor working conditions in hospitals, such as inflexible 12-hour shifts, are driving experienced nurses away from the bedside.

The loss of experienced staff has downstream effects. Margaret Franks of the New York State Nurses Association noted that due to a lack of senior nurses, junior nurses struggle to receive proper training. She mentors new nurses at Vassar Brothers Medical Center, a 349-bed hospital in New York's Hudson Valley. Franks said Vassar has hired 123 nurses since the beginning of this year, but 93 have already left due to insufficient training.

"The problem isn't recruitment. It's actually about retaining the nurses who come in," she said. "Clearly they come. We have new nurses graduating, usually twice a year in May and December." Given that training each nurse costs approximately $88,000, Franks said hospitals are burning money when so many nurses leave before completing their training. "This year alone, that's $8 million down the drain," she said.

Nurses are finding other paths

Hospitals are increasingly competing for nursing talent with non-traditional employers—from retailers like Home Depot, CVS Health, and Walgreens to startups. Pollak said these companies are attractive because they offer nine-to-five schedules and less stress than hospitals.

Sarah Lacy is one nurse who left hospital work for a non-traditional employer. She quit her job in 2020 to work as a registered nurse at an ear piercing studio. The studio, called Rowan, is located in New York City, competes with hospitals for jobs, and specifically hires nurses to perform ear piercings. Lacy said the job gives nurses the opportunity to use their medical skills without the "verbal abuse and physical abuse" that some nurses experience in emergency rooms.

"When I first joined Rowan, I didn't plan to leave the hospital. At the time it was a part-time job, and I thought it was an interesting way to use my nursing skills in an environment that wasn't as stressful as bedside care," Lacy said. However, as she spent more time at Rowan, Lacy gradually embraced the idea of full-time work, piercing ears and training Rowan's new nurses. She said the biggest draw is the environment—the studio is clean and tidy, people are often at their happiest moments when they're in front of her, and she can use her clinical expertise.

"I don't know what it would take to pull me back to the bedside," Lacy said. "As nurses, we have an innate desire to help others and change lives. When you do that in such a fun way, it's transformative. Honestly, I really don't want to go back."

How hospitals can win nurses back

Although hospitals face difficulties in recruiting and retaining nurses, it is not an impossible task, said Pat Brown, executive vice president of human resources at Northwell Health. Northwell is New York's largest health system, operating 21 hospitals, and currently has an average of 900 registered nurse vacancies—roughly the same number as in 2019. Brown said the health system's turnover rate during the pandemic was only half the national average, and through investments in recruitment and retention, it has maintained staffing stability this year.

The hospital system has a network of partnerships with nearly 200 nursing programs. Northwell sends representatives to nursing career fairs and even has a presence on TikTok. Even so, "(nursing) supply is indeed constrained," Brown said.

Fitzpatrick of Kaufman Hall said other hospitals could benefit from similar recruitment and retention strategies, including partnering with nursing schools, offering less demanding virtual nursing roles, shorter shift options, and "phased retirement" for older nurses. "Organizations are essentially 'growing their own' (nurses) and are willing to make that investment because, from a long-term impact perspective, it makes financial sense," Fitzpatrick said. "When you weigh the upfront costs against contract labor costs, it can yield significant return on investment."

In the view of nurse unions, the strongest signal of investment in nurses is implementing nurse-to-patient ratio limits, which restrict the number of patients a nurse can care for in a given time. Debbie White, president of the New Jersey nurses union Health Professionals and Allied Employees, said ratio limits can send a signal to nurses that hospitals take patient welfare and workplace safety seriously. White recently appeared alongside Vermont Senator Bernie Sanders at a field hearing of the New Jersey Senate Committee on Health, Education, Labor, and Pensions (HELP), advocating for the benefits of fixed patient-to-staff ratios. She told Healthcare Dive that ratio limits may not bring back nurses like Sarah Lacy who have comfortably left the profession—but they can help stop the bleeding.

"I'm not saying nurses will return to the bedside," White said. "What I can promise is that nurses will stop leaving hospitals. If we solve this problem, we can retain our staff. That's when we can repair this profession."