Why are all the nurses quitting?
Part Two
It was a weekday afternoon, and I was picking up a few hours on the day shift. I had a couple years of experience at this point (two, maybe three?). My patient had a breathing tube in place so they couldn’t eat by mouth. I was inserting a small feeding tube through the nose of my patient into their stomach so they could receive nutrition in the form of tube feeds. There was an odd message on the machine that is used to place this tube. Naturally, I looked around to find a nurse with more experience to help me figure it out.
There is a running joke in nursing where one day you look around and you realize you are the most grown-up nurse on the unit and it’s a little bit terrifying the moment you realize it’s you. This was the day I realized it was me.
Fortunately, the nurse manager was a former bedside nurse with tons of experience, and he had the answer to my question. The feeding tube got placed, and nutrition was started. Boom! Patient outcome improved.
However, what happens when there’s no one to ask?
Last spring, the National Council of State Boards of Nursing (NCSBN) released a workforce study that was terrifying for those of us who work in healthcare. The study found that in 2021, 100,000 nurses left the workforce.1 This was the single largest drop in the workforce since 1980. In the years that have followed, the nursing workforce has been in flux.2 Something providers (like me) feel acutely. The NCSBN study also highlighted that an estimated one-fifth of the nursing workforce anticipates leaving the profession by 2027.
For a profession that acutely feels staffing shortages, that’s a hard statistic to read.
I have been in healthcare for over decade, and we’ve been talking about nursing shortages the entire time. Nursing staffing and nurse shortages are a multi-faceted problem without an easy solution. Healthcare is expensive. Reimbursements to hospitals are down and labor costs are up. One of the easiest ways to reduce overhead is to cut labor costs of which nurses are the main expense. That means hiring less nurses which makes the current nursing workforce care for more patients. This in turn worsens patient outcomes which in turn further reduces reimbursements (since many quality outcomes are driven by nurse’s care and tied to reimbursement rates. A little bit of a carrot and stick sort of situation.)3
In the aftermath of the COVID-19 pandemic, researchers are still sorting out the upheaval caused by such a massive stressor to a healthcare system that doesn’t work that well anyway. Part of this upheaval is not just the nursing staffing shortage, but the overall change to the nursing workforce. Between 2018 and 2023 the growth of the nursing workforce occurred predominately in nonhospital settings and away from in-patient, bedside care, which has perpetuated an ongoing nursing workforce shortage within the hospital environment.4
There is a plethora of science and research behind safe nurse staffing ratios. Nurse researcher Linda Aiken5 is among the best. While it’s challenging to summarize her work, essentially, she has decades of research demonstrating that lower nurse to patient ratios improve patient safety and less patients die. In a recent editorial6, Aiken states,
“Empirical evidence from many published studies indicates that better hospital professional registered nurse (RN) staffing is associated with better patient outcomes, including lower mortality and failure to rescue, shorter lengths of stay, fewer readmissions, fewer complications, higher patient satisfaction and more favorable reports from patients and nurses alike related to quality of care and patient safety.”
These are good things; we want them for ourselves, our loved ones, and the people we care for. Yet, the tension between labor costs and healthcare costs continues, while nurses at the bedside care for more patients with the expectation that the quality of their care will not worsen. It’s a virtually impossible situation.
Another unforeseen consequence of the pandemic is the loss of nursing experience within the in-patient environment.
Nurse researcher Patricia Benner delineates the arc of a nurse’s professional development into five phases: novice (nursing student to less than a year of experience), advanced beginner (new graduate to one year of experience), competent (two to four years of experience), proficient (three to five years), and expert (more than five years).7
A nursing student is considered a novice because they have no clinical experience or background context for patient conditions. These student nurses require specific instructions to achieve patient care goals. During the first year after graduation as nurses transition into clinical practice, they are considered an advanced beginner. Functionally, the main difference between an advanced beginner and a novice is that the advanced beginner feels the weight of the patient care responsibility and their independent license. This responsibility in turn increases the nurse’s recognition of clinical conditions. These nurses tend to pay close attention to their colleagues practice and find reliable sources of useful information (i.e. the nicest, most experienced nurse on the unit). You must reassure an advance beginner often, because being a new nurse is riddled with anxiety. It helps when you are surrounded by a bevy of experienced nurses. Right now, much of that experience is lacking, so young nurses are figuring more things out on their own and quitting because they don’t feel supported. This spurs further staffing shortages.
The competent stage of nursing occurs with one to three years of experience. The nurse’s ability to develop this competence depends on how varied and complex the patient population is. They judge patient conditions based on learned experience and learns how to predict and forecast patient needs as well as contingency plans for when things fall apart. This is when you encourage a nurse to “trust their gut” and follow through on vague feelings of doom related to their patients.
Nurses then move into the proficiency stage (years three to four) on their way to expertise (year five plus). The proficiency stage is marked by an enhanced ability to read a situation and how information related to patient responses to treatment is synthesized over time. You try to figure out why and how a patient situation is different. They refine their comparisons with other patient experiences over time. It’s the tingling, “spidey” sense people get when something seems off, but you can’t quite describe it.
An expert nurse occurs when a nurse moves from implied expectations to focusing on the changes or in a situation and developing an alternative to a changing condition by creating new possibilities because you have seen some STUFF at this point in your practice. This happens almost intuitively and make sense as the most effective response. It’s when a nurse focuses less on the vital signs of the patient and more on what must happen to fix those vital signs. I’m convinced that among the qualities that make a good bedside nurse, the integration of technical skills with time management, and a strong intuition combine to recognize subtle shifts in a patient’s condition that save the patient.
Here are practical ways short-staffing and a less experienced nursing work force impact your experience at a hospital:
Unanswered call lights so patients can’t use the bathroom or receive pain medications in a timely manner
Waiting on hold for lengthy periods of time to get an update on a family member’s care.
Late medication administrations because the nurse is too new to understand the shortcut with the medication scanning tech. It doesn’t work for the millionth time so she skips scanning the one pill and realizes too late that the doctor changed the order. So now she has a med error on her hands, but she doesn’t have time to fully process it because she has two or three or four or five more patients who need medications, and all at nine am.
Less time at the bedside helping patient and families understand their conditions and answering questions.
Missing crucial changes in patient condition
Less personal hygiene (like baths) getting done for patients which raises the risk of a hospital acquired infection (for which the hospital will not get reimbursed. It’s a vicious cycle!)
Recently, I looked around the intensive care unit where I work. Of the twelve or so nurses on the unit, two nurses had more than three years of experience. In the twelve to sixteen months after the peak of the pandemic, probably fifty percent of the nurses with five or more years of experience left the ICU environment for other positions. Some within the hospital, some for further education, and some for other work environments with a better schedule. This is anecdotal, but many of them were tired and frustrated at the bedside. It’s challenging to wear protective gear and a tight-fitting N-95 mask for twelve hours at a time.
Now, imagine this in practical clinical terms with you have a group of competent nurses but few who are proficient or experts. In practical terms, that means that intuitive knowledge when a patient is worsening is missing most of the time. I could provide numerous examples of this, but the overarching theme is that the lack of nursing experience within in-patient environments requires a higher level of vigilance from other providers: physicians, residents, and advanced practice providers. Healthcare is a team sport where nurses are integral to achieving patient care goals.
Even though I am fortunate to work with some good nurses, they are new to their job, and their inexperience makes them miss things that matter in a high acuity ICU with sick patients. This requires a higher level of vigilance from myself and my co-workers which creates a narrower margin of error. For example, a nurse with less experience simply turns up oxygen on patient when the vital signs require it, watches those vital signs improve, and moves along with their day. Afterall, the patient seems “fine”, and the oxygen saturation is better, so it’s fixed?
I happen to catch the higher oxygen requirement in my (obsessive) chart checking and I raise an eyebrow, which prompts to go to the patient’s bedside to assess the situation. I notice that the patient is less interactive and is working harder to take a breath. The combination of these three things, plus the knowledge that they got their breathing tube out less than twenty-four hours ago concerns me and I order a series of diagnostics to determine what sort of clinical change the patient is experiencing.
This same situation with an experienced nurse? They are standing in my workroom telling me about it and expressing concern or tracking me down on the unit to let me know. That’s a narrow margin to intervene with a patient who is clearly decompensating.
That’s just one of the unintended consequences of nurses quitting or being too busy to figure it out.
Fortunately, a recent nursing workforce stability study by the Journal of the American Medical Association (JAMA) found that the RN workforce has largely recovered following 2021-2022 and by 2035, it’s predicted to be close to pre-pandemic forecasts.8 This study also found that the workforce growth was led by RN’s under thirty-five years old, further reinforcing the inexperienced nurse trend, and that the drop in hospital nurse employment was among RN’s over forty (aka the expert nurses).
In another gross oversimplification of a complicated topic, the easiest way to change this conversation is to hire more nurses and improve the staffing ratios, meaning each nurse is caring for fewer patients. That is an expensive proposition, particularly as hospital administration tries to do more with less money. Ultimately, it’s a matter of priorities: spend more and have better outcomes or continue with the current pattern and risk losing more nurses because they can’t handle the increasing workload.
Hopefully, the leveling out of the nursing workforce translates to more nurses staying at the bedside—specifically providing in-patient care, but I have a sneaking suspicion this conversation will continue because it’s tough to be bedside nurse. It’s an incredibly rewarding job, but it’s tough.
NCSBN Research Projects Significant Nursing Workforce Shortages and Crisis | NCSBN
Projecting the Future Registered Nurse Workforce After the COVID-19 Pandemic | Health Policy | JAMA Health Forum | JAMA Network
If you’re really brave you can click into this and wade through piles of outcomes and quality measures tied to reimbursements. Core Sets | Partnership for Quality Measurement (p4qm.org)
New insights on a recurring theme: A secondary analysis of nurse turnover using the National Sample Survey of Registered Nurses - ScienceDirect
Linda H. Aiken • Emeriti & Retired Faculty • Penn Nursing (upenn.edu)
Nurses matter: more evidence | BMJ Quality & Safety
(PDF) From Novice To Expert: Excellence and Power in Clinical Nursing Practice (researchgate.net)
Projecting the Future Registered Nurse Workforce After the COVID-19 Pandemic | Health Policy | JAMA Health Forum | JAMA Network