In recent years, reports indicated future shortages in the nursing workforce. Now, the COVID-19 pandemic has vastly accelerated the problem. Pay discrepancies, crisis conditions, high tensions and burnout are driving nurses across the board to leave their hospital, region, or the industry entirely.
As a society, we need nurses and other providers to function. Without a sustainable solution to the nursing workforce shortage, the health care system risks collapse. Though many factors contribute to the shortage, nurses agree that solving this crisis is out of their hands. Instead, the responsibility lies with those at the federal, state, and institutional level.
Katie DeBlase’s nursing career began at Olathe Medical Center working with women’s medical surgery. She later spent two years in an asthma, allergy, and immunology clinic before transferring to her current role. She is now a staff nurse at Overland Park Regional working in the postpartum mother-baby unit.
Michael Deford has been nursing for nearly 12 years, beginning as a Licensed Practical Nurse (LPN), a title he and colleagues jokingly nicknamed Low Pay Nurse as LPNs often received lower pay for the same work as other nurses. After receiving his Bachelor’s in Nursing in 2014, he worked in a critical care unit before transferring to a neurological trauma surgical ICU. Deford became a travel nurse in 2016 and has traveled for contract positions since, practicing in Oklahoma, California, Colorado, and Washington, where he is currently on contract in Tacoma.
Staff Vs. Travel Nursing
As a staff nurse, DeBlase experiences the overwhelming impact of the nursing shortage daily. “The staffing shortages are just insane,” she said. “The hospital is in ‘helping hands’ mode, which means nurses float through the whole hospital to different floors that we shouldn’t be floating to.” She can be sent to any floor, even if she doesn’t have experience doing what is asked of her. “I’m just sort of expected to figure it out along the way, not complain, do what I’m told, and go where I’m told.”
According to DeBlase, one of the biggest problems nurses face is the nurse-patient ratio, which is often inconsistent and unrealistic. Travel nurses are brought in to help fill the gaps, but this attempt at a solution still brings about its own challenges. Though travel nurses are helpful, they are only there temporarily, leaving hospitals with periods where they do not have the extra hands on deck.
The presence of travel nurses can also invite tension as they make significantly higher pay than staff nurses. Travel nurses have historically made more money for a number of reasons, including managing both a permanent and temporary household while traveling and providing a cushion for any gaps between contracts when work is not guaranteed. According to Deford, travel nurses generally receive 25%-30% more in pay than staff nurses, which has always attracted those wanting to live a certain lifestyle.
However, crisis contracts throughout the pandemic are now closer to 400%-500% what staff nurses make, causing the sharp increase of nursing resignations. DeBlase has considered becoming a travel nurse solely for the pay and has several friends who left their bedside and hospital positions for the same reason. “They are only contractually obligated for 13 weeks, so if you can go somewhere for 13 weeks and pay off your house or your car or your kids’ school, why not?” she said.
As a travel nurse, Deford is content with his current position, crediting the benefits that come with it. He is able to work for the length of the contract, often several weeks to a few months, and then has the ability to take a month off for vacation before taking another contract position. Alternatively, staff nurses typically work three or four 12-hour shifts per week, every week of the year, including on weekends and holidays.
Throughout the past few years, Deford did try to return to hospital settings, but quickly ran headfirst into the realities of the shortage’s impact. In several instances, he and colleagues were denied promised pay or frequently received incorrect paychecks. As an ICU charge nurse in Colorado, while the COVID-19 pandemic was in full effect, he witnessed nurses being ground down by unmanageable nurse-patient ratios.
Typically, ICU nurses manage only two patients at a time because they require constant monitoring and intervention to prevent them from getting worse. At times, ICU nurses may have up to three patients, referred to as “tripleable” because they are not quite in need of intensive care anymore and are easier to manage with support from their team. “You really rely on your teammates when you’re in that situation,” Deford said. “But when 8 out of 10 nurses in the ICU all have three patients, it’s kind of impossible to manage.”
As a charge nurse, in addition to monitoring up to three patients, Deford also managed the flow of patients coming in and out of the ICU, supervised new and travel nurses, and responded to all overhead emergencies. Depending on the emergency, this response could take up to several hours. “Any patient that I was supposed to be caring for had nobody at the wheel during that time,” he said. “I had to rely on other nurses to look out for them even though they had their own patient load they were trying to care for.”
Challenges Beyond Burnout
Though burnout is frequently cited as a factor for the nursing shortage, the true issues run much deeper than just exhaustion. Whether they are working long shifts, weekends, and holidays or are away for six months at a time, both staff and travel nurses miss out on time at home and with loved ones. According to Deford, who has hardly spent time with his wife in their brand new home in Colorado, travel nurses must be willing to put everything else on hold.
Despite the challenges, one of the deciding factors for Deford’s transition to travel nursing was to disconnect from the amount of time spent in a hospital, witnessing waves of declining performance and constant turnaround of staff. “You see how many people are leaving when you stay in a staff position,” he said. “You watch everybody else leave and that wears on you a little bit. There’s a rotating cast of faces and it’s easier to be one of the rotating faces than to watch everyone leave.”
For nurses like DeBlase who remain in the hospital environment, the tense atmosphere surrounding COVID-19 and safety protocols, such as masks and social distancing, have added to the daily obstacles. “As things go on, it’s getting more and more uncomfortable to interact with some people just because of how political everything has become,” she said. “It’s hard to have people argue with you and diminish what it means to go into work every day, especially when every time I go in I risk having a patient with COVID-19 or who doesn’t know they’ve been exposed. It’s tiring more than anything.”
Regardless of location or position, the impact of the shortage is universally affecting nurses’ mental health. Both Deford and DeBlase have experienced severe stress and at times struggled with depression, turning to coping methods such as medication, meditation, exercise, and seeking support from colleagues and loved ones.
Though DeBlase has yet to utilize her facility’s free 24/7 therapy service for nurses, she feels comfortable knowing it’s there. Deford similarly believes it’s important to afford the time and resources to find something that helps, regardless of whether that is therapy or something as simple as exercise or talking it out. “Find what works for you,” he said. “Just trying to white knuckle it through doesn’t work.”
During a peak in the pandemic, Deford personally struggled with mortality, falling into a dark place for a period of time where he faced consistent intrusive thoughts. “I lost more patients and saw more patients die in a two-year period than I had in my whole career by far, it’s not even close,” he said. Watching so many patients die, he began to wonder what it would be like “when the lights go out.” Every night for several months, he struggled to sleep, instead thinking about what it would feel like when he too passed away and worrying that maybe death wasn’t as far away as he thought.
Besides fears for his own mortality, Deford also worried about the well-being of his patients. Watching hospitals in ‘helping hands’ mode, as DeBlase described, Deford saw many inexperienced nurses having to learn procedures on the spot and be expected to carry them out correctly, including ventilating patients. Nurses have always been expected to maintain continuing education, but now it appeared that simply having a license was considered good enough.
He expressed concern to a manager, bringing up the possibility of adverse patient outcomes and resulting lawsuits if patients received subpar care. His manager responded that while lawsuits are an issue, they don’t happen very frequently – sidestepping concern for the patients’ well-being entirely. “That blew my mind,” he said. “She was only thinking of the lawsuit, and I was thinking that people could die because they aren’t being cared for as they should be.”
Deford believes ‘burnout’ is a catchall phrase that is easier to hear and stomach than the reality of the moral injury nurses are facing. “You see somebody die and you know that you were trying to get the doctor to pay more attention all day long but they were too busy, and then by the time it’s too late to really do anything,” he said. “That’s the stuff that is a real problem.” According to him, watching patients decline unnecessarily because nurses aren’t receiving the support they need is contributing to the high numbers of people leaving.
Throughout challenging times, especially during the ongoing COVID-19 pandemic, nurses are having to advocate for themselves to receive the support they are desperately lacking. Though family and friends may have historically been strong support systems, some nurses are stepping away. Loved ones arguing about politics surrounding health care and COVID-19, asking for gory and grim details, or generally dismissing the stress nurses are facing because it’s considered a necessary evil of the job, are all pushing nurses away.
Instead, nurses like DeBlase and Deford are turning to people who “get it.” Colleagues in all areas of nursing who can empathize with the struggles they are facing have been people to turn to when times get hard. DeBlase unexpectedly found support on the platform TikTok, where a community of nurses can exchange jokes, discuss challenges, and grieve together.
Most importantly, nurses are demanding better. During peak waves of COVID-19, some areas saw desperate pleas for help, with nurses — including DeBlase — receiving spam-like emails asking them to volunteer their time or return to the workforce if they had recently left.
Deford, knowing the extreme toll burnout can take, consistently urges colleagues to advocate for themselves. “I shout from the rooftops as often as possible to my coworkers to not do those things,” he said. As a charge nurse in the past, he was frequently reprimanded for reminding colleagues not to take extra shifts if they needed a break and to step away when necessary.
Solving the Nursing Shortage
Unfortunately, gratitude, self-care, and self-advocacy are not long-term solutions, as the problems plaguing the nursing workforce are beyond the individual level. Nurses are doing the best they can, but aren’t in a position of power to change anything, and have frequently seen that suggestions and pleas to management never go higher than direct supervisors. Instead, general corporate responses are handed back down, leaving no room for argument or advocacy.
Neither nurses nor immediate managers have control over issues with pay, determining how many people are needed to do the job safely, or ensuring a consistent and reasonable nurse-patient ratio. Throughout a five-month contract with one facility, he never met the nursing director, despite multiple denied attempts to speak with her over the phone.
“The power to make change has been intentionally removed from the people who do the job,” said Deford. “Not just nurses, but immediate managers.” He believes any substantial change would need to happen at the federal, state, and institutional levels.
To create material change, community efforts will have to extend beyond showing support. Deford recommends that those interested in helping repair the nursing industry and improve the shortage should join unionization efforts and picket lines and join them loudly. Because the biggest problems, he believes, are a confluence of decisions made over the last decade, serious structural change will have to occur.
Until that happens, Deford and DeBlase urge people to remember that nurses are doing the best they can within their abilities. As frustrating as receiving care might be right now, it also serves as an example of how much the entire system is struggling. “It’s always been a given that if you go to the hospital, there will be people there to take care of you,” Deford said. “But that system is crumbling now.”
Deford has witnessed patients fly to other states to receive a hospital bed, simply because none were available where they lived. The ripple effects of the pandemic on the already struggling infrastructure of the health care system continues to demonstrate weaknesses that can’t continue much longer. As COVID-19 moves in and out of the news cycle, nursing conditions haven’t changed, and in some cases have gotten worse.
Although he saw the pandemic as a perfect opportunity for American governance to prioritize restructuring and repairing the health care system, unfortunately, that is still a far-off dream rather than reality. “There’s no one I know who works in nursing who isn’t crumbling a little bit, and it’s easy to see how things could fail even more spectacularly than they are right now,” he said. “Please take care of yourselves because there might not be anybody there when you go to the hospital.”
Unfortunately, the labeling of health care workers as heroes throughout the pandemic, accompanied by performative displays of gratitude such as banging pots and pans and clapping in the streets, has done nothing to realistically support nurses. Instead, nurses worry that being labeled a hero does exactly the opposite. “We know where that goes next,” Deford said. “‘You’re such a hero, what you do is so amazing! And you know what heroesdon’t do? They don’t complain, so get back to work.’”
Instead, Deford recommends offering tangible help, such as offering to babysit or pet sit to give nurses a break. For hospital nurses like DeBlase, having food sent from members of the community during long days is a great way to show support. However, the best way to show up for nurses in her opinion is to simply follow the rules.
“The smallest way to show that people are still hanging in there with us and supporting us is making our jobs less difficult by doing what you’re told to do, even if you don’t agree with it,” she said. “Having empathy, compassion, and patience, is more helpful than it seems like it would be. Understand that I’m not trying to be away from you for hours at a time, I’m not trying to take forever to do something for you, I’m just stretched thin.”