Nurse Burnout: A Profession in Crisis
Submitted by Maureen Kroning, RN EdD
By Maureen Kroning EdD RN, Richard Ahrens BSN RN, Martha Krawczyk MSN RN, Ada Augustniak BSN RN, Karen Schaffer BSN RN
Healthcare organizations even prior to the COVID pandemic were stretched to meet the healthcare needs of patients, communities and society and were challenged to have optimal resources including safe numbers of healthcare workers. According to the American Hospital Association (AHA) there are many reasons for the shortage of healthcare workers. Reasons include: the increase in chronic diseases, increase in aging population, increase in behavioral health conditions, advancements in state of art healthcare delivery and the retirement of nurses and other healthcare workers (AHA). Rich Pollack, CEO of the American Hospital Association stated , “We are expected to lose 500,000 nurses by the end of this year, many through retirement bringing the overall shortage of nurses to 1.1 million” (AHA).
The COVID pandemic created the perfect storm with nurses retiring early and even quitting due to the overwhelming stress caused by the pandemic. As a Nursing Supervisor with over fifteen years experience it became increasingly more difficult to: staff hospital units, witness nurses working short staffed with less resources, seeing and hearing from patients as well as nurses that they want more care at the bedside and witnessing nurse burn out. Nurses need to speak out about the detrimental issues impacting the Profession of Nursing. The number of nurses leaving the profession is staggering and something that needs to be addressed. During the COVID pandemic, we saw many nurses retire, quit, and nurses leaving their current healthcare positions to work for a nursing agency or become a travel nurse.
A Nurse Manager, two staff nurses and a new nursing graduate working in the acute care hospital setting shared their view of why they think nurses are deciding to leave their current nursing jobs. Sadly most nurses reading this article, will likely relate to the stories that have contributed to nurse burnout and why nurses are leaving the profession and why we as a profession find ourselves in a critical crisis.
A Profession in Crisis
Today healthcare facilities are facing severe nursing shortages. During the COVID surge we witnessed many hospitals calling in the National Guard to help with critical staffing shortages. According to Kelliher (2022) even prior to the COVID pandemic the US was faced with both a Registered Nurse and a nursing faculty shortage. The pandemic just made the nursing shortage even more glaring and unfortunately it is anticipated to get much worse as we see large numbers of both nurses and nursing faculty retire or simply leave the profession in the near future. According to CNBC, 20-30% of front-line healthcare workers are considering leaving their jobs as a result of both post-traumatic stress from the COVID pandemic, as well as years of being undervalued.
The COVID pandemic exacerbated an already fragile profession that needed more resources as well as an overwhelming need for support from leaders in both healthcare and government. According to the American Association of International Healthcare Recruitment (2021) 78% of nurses surveyed believe COVID created unsafe staffing levels and 36% said they are considering leaving the bedside. “America’s healthcare system would collapse if one-third of the country’s nursing workforce vacated the bedside unless a massive pipeline of qualified talent is made available to healthcare providers” (American Association of International Healthcare Recruitment, 2021).
It is unfortunate that many people do not see firsthand what the day-to-day workload of a nurse is, just how hard they work caring for others in times of need and doing this with limited resources and support. According to Raso, Fitzpatrick & Masick (2021) “Organizational attention to nurse well-being, work environment and staffing is imperative”.
As a Nursing Supervisor, working in the hospital, it felt as though no sooner would a nurse complete their nursing orientation and at that same time two nurses would resign from their nursing job. As a result of increased workload, decreased resources and feeling undervalued, many older nurses voiced that they had decided to retire earlier than they had originally planned. According to the American Nursing Association (ANA) this year there will be more nursing jobs than any other profession with at least 100,000 additional nursing jobs available. The combination of both nurses who plan to leave the profession of nursing as well as those who are thinking about it would cause instability in the nursing workforce if it is not addressed and reversed (Raso, Fitzpatrick & Masick, 2021). However, not only are we seeing a large number of nurses retiring, we are also seeing a new trend of nurses leaving their healthcare jobs to take a job as an agency nurse or as a traveler nurse. According to Health Affairs.org, when the COVID surge occurred, travel nursing jobs rose 25% and paid up to $10,000 per week, an $8,600 increase from nurses working full time in the hospital. This pay discrepancy is something that needs to be addressed as well as understanding why nurses would leave their current nursing job to go work for a staffing or travel agency. I had the opportunity to sit down with a Nurse Manager, a staff nurse and a recent nursing graduate all working in busy hospitals close to NY City and each having left their full-time position in the hospital for other jobs. Each shared their view of why they left their current nursing job.
A Nurse Manager Perspective
The Nurse Manager’s perspective is a perspective familiar to many nurses working during the COVID surge. The COVID pandemic exacerbated the occurrence of staff nurses leaving their hospital jobs to retire, resign, join a nursing agency or leave to become a travel nurse which was directly attributed to the stress, anxiety, fear of the unknown and the ongoing lack of resources, short staffing and not feeling valued by the healthcare organization. A Nurse Manager expressed that the fear, the uncertainty and the absolute unknown during COVID felt maddening as she remembers looking into the eyes of her staff, over their newly required surgical masks, recognizing their feelings of being overwhelmed with the same confusion and worry about not understanding just how COVID was spread, was it droplet, airborne, or contact transmission and how did we prevent and treat this new novel virus.
She expressed that working during COVID there were hour-by-hour updates on what Personal Protective Equipment (PPE) to wear to prevent contracting and transmission of this deadly virus. The hospital’s unit nurses had so many questions for their Nurse Managers such as do they wear full PPE, which mask was best to use, was it a surgical mask or an N95 mask, should they wear a face shield, should they cover their hair, do they go home to burn uniforms and some even questioned am I even going to be able to go home. The fear was sadly notably palpable as units converted semi private rooms into private rooms waiting for the inevitable COVID admissions. Patient rooms had posted step-by-step instructions on how to don and doff PPE to prevent contamination. .
The Nurse Manager shared how she vividly recalled the first COVID admission to her nursing unit, the patient's name, room number, the exact time and what nurses the patient was assigned to. She expressed how her heart ached as she witnessed pure distress, staff trembling, wide eyed, and some with tears of fear in their eyes yet, they pulled together and worked as a team to care for their patients. The staff worked while there was clearly not enough staff for the hospital units, a definite lack of critical care nurses and a lack of medical supplies. As a Nurse Manager, there was a need to support the staff’s fears and anxieties and to coordinate all the core hospital staff and ancillary departments. The Nurse Manager expressed that she felt like she was trying to assimilate four different puzzles into one and really did not have time to reflect on the gravity of the situation while submerged in it until the unit ran out of body bags and the storage space for those that died. The situation became even more dire as the very staff caring for the patients started to become ill after three long grueling months of caring for their COVID positive patients.
According to the American Association of International Healthcare Recruitment (2021), 75% of nurses surveyed said they experienced extreme stress or anxiety and 59% of surveyed nurses said they worked with or knew a nurse who became sick and even seriously ill from exposure to COVID at work, and 1 in 5 reported knowing a nurse who died from COVID. The lack of staffing, lack of resources and the flashbacks of the COVID surge were among the reasons this Nurse Manager left her full-time hospital position.
Staff Nurse Perspective
Thousands of nurses shared similar stories during the COVID pandemic. Units that were not originally intensive care units (ICUs), were made into ICUs. One nurse said that her unit was made into an ICU and she was a medical nurse who had to care for 5 ICU patients, 2 of which were on ventilators. One of her patient’s oxygen levels dropped down into the 70s and despite her interventions the patient could not recover. As the patient became increasingly restless and agitated, she called the Rapid Response Team (RRT) three times and no one responded and then she called a code blue. She said that it felt like an eternity while she manually ventilated the patient praying that someone would come to help save her patient. While she ventilated the patient the nurse wondered if another patient would die in front of her and if it was the moment she may even be exposed and get COVID. Eventually the RRT arrived and the patient was re-intubated. The RRT was delayed due to two other emergencies taking place elsewhere in the hospital. The staff nurse recalls that she felt angry, scared and placed in what would be a very familiar situation for most staff nurses, hence another looming stressor, will the patient and the nurse be alone during an emergency. Resources quickly depleted even more over the months, staff were stretched so thin, stress, fear, anxiety and despair were greatly compounded as nurses witnessed and cared for their own colleagues who contracted COVID-19, many witnessing their own colleague dying from this deadly virus. Nurses daily, hourly endured and re-lived these stressful, painful moments of resuscitating, cleaning, and wrapping patient after patient after they died all while comforting the grieving family from a distance over the phone or via Zoom. The nurses' tears were real, not only for the patient they lost but also for the families they witnessed anguishing over the loss of their loved ones.
To address many hospitals’ nursing shortages, hospitals did hire agency and travel nurses. Even though the staff were grateful for their help, there were many mixed feelings from staff when working side by side with an agency or travel nurse.Travel nurses had contracts that stated how many patients they could take on an assignment and some contracts even stated that they did not have to care for patients with tracheostomy or patients on ventilators. This left the staff nurse with taking care of a greater number of patients and often patients that were with a higher acuity that the agency or traveler nurses had to have. This situation caused animosity between the staff nurse and the agency or traveler nurse especially as a new admission was still coming to the unit, the agency or travel nurses would tell the staff nurse that by their contract they did not take any more patients yet the unit staff did not have that option while the agency or travel nurse was making three times the salary.
The staff nurses felt that many travel nurses do not have a “stake in the game” and often move on to the next assignment, so many, not all, do not take the time to develop relationships among the staff. Many support staff and practitioners find it difficult to work with travelers as they don’t know them well enough and have not built a relationship with them. Travel nurses should be there to fill in the gaps, but it seems that some organizations are using them as a form of staffing and not hiring new staff nurses. Having consistent staff helps the unit build comradery. Often patients verbalize that they have a different nurse every day, part of this being the fact that there are not enough nurses on one unit to cover the needs of the unit. Travel nursing continues to lure nurses away from their current nursing jobs for the opportunity to travel, enticement of higher pay, better patient nurse ratios and various incentives and stipends (Hansen & Tuttas, 2022). To add to this, traveling doesn’t necessarily mean that the nurse has to travel a far distance from home, you can “travel” and still be within distance of where you live. According to the staff nurse, nurses are leaving the bedside due to feeling burned out due to short staffing, unsafe ratios, lack of respect from patients and family members, and being underpaid while agency and travel nurses were reaping the financial benefit of the care they provided.
New Graduate Perspective
An interview with a recent nursing graduate, employed for just over a year at a large medical center, shed light on just why nurses are feeling burned out and may leave their current nursing job not long after graduating to work as an agency or travel nurse. The new nursing graduate explained how one of the last nights she worked made her realize she did not want to remain employed at her current hospital position. She told me how she was working about 2 hours on a COVID positive unit when the Nursing Supervisor told her to go to the Emergency Department (ED) because they had a high number of critical care patients and one patient needed to be brought for a Computerized Tomography (CT) scan. The patient had suffered a cardiac event and should have been placed on a cardiac monitor but the ED did not have any cardiac monitors left, since all the monitors were being used by other patients. As a new nurse, working for less than a year she felt so scared and insecure about her ability to safely care for the patient going to CT scan. Then after she returned from the CT scan, she was told to bring the patient to the Cardiac Open Heart Unit and stay with the patient. She described crying that night and feeling that after being on a COVID unit, she could infect vulnerable patients in the Open Heart Unit with COVID. It was that night that she knew she wanted to resign from the hospital and become a travel nurse. This new nursing graduate said this was just one example of feeling overwhelmed, insecure, helpless and worried for the safety of her patients as well as herself and her colleagues. She said she figured if she was going to feel this way, at least she should be compensated financially and as a travel nurse she would be. As a Nursing Supervisor for over 15 years in the acute care setting, I knew too well just what this new nurse was feeling and how many times I have felt that same way. Nurses far too often have verbalized stories like this and have often witnessed or experienced situations just like this which is occurring daily in nursing, is unacceptable and it is attributed to nurse burnout and the current crisis the Profession of Nursing is in.
There is a critical need to address nurse burnout. Unfortunately, addressing nurse burnout is a double edged sword, because until we hire more nurses and address the nursing shortage nurse burnout is here to stay and we will see even more nurses leaving the profession. It is vital that more nurses are trained, recruited and retained to meet the healthcare demands of the future. To train more nurses we first need to recruit and retain more nursing faculty. This is essential in order to increase nursing school admissions. In order to establish more nursing schools and train more nurses we need clinical placement sites, preceptors, and faculty. In 2021, 91,938 qualified applicants were turned away from nursing schools throughout the country at entry level, baccalaureate level, masters level, and doctorate level because of the aforementioned reasons (American Association of Colleges of Nursing, 2022). Increasing funding for nursing schools will allow more classroom space, and the ability to recruit and hire more nursing faculty.
For new nursing graduates or nurses re-entering the workforce implementing nurse residency programs can be beneficial for healthcare organizations. Many nursing graduates have not had the clinical training needed as a result of the COVID pandemic. Many healthcare facilities banned or limited nursing student clinical placement. Nurse residency programs can help provide the support and training nursing graduates need and will help the nursing graduate feel valued and that they are an important member of the team. Nurse residency programs can align with local nursing schools to ensure nurses are prepared and empowered to begin or establish their nursing career. Residency programs need to ensure that new nurses are taught the importance of implementing evidence-based nursing practice, critical thinking, prioritization, delegation, communication and clinical skills. Residency programs can be instrumental in retaining new nurses.
Retaining the nurses we currently have in healthcare is another essential step to address nurse burnout and the nursing shortage. Nurses need adequate training and support with proper orientation programs so that they can be adequately prepared to provide safe and quality patient care. Currently, to address the ongoing issue of short staffing, nursing staff need to be supported by administration and recognized and appreciated for the work they are doing. Providing nurses with incentives and recognition for hard work can go a long way in retention. This is especially important as we see many nurses being asked to work extra nursing shifts due to short staffing. There needs to be a robust action plan to address the nursing shortage and we need nurses to help guide that plan.
It is essential to listen to what nurses are saying about why they are leaving the profession of nursing. Nurses are wonderful at problem solving and developing strategies to address issues they encounter daily. The crisis the Profession of Nursing is in must be addressed with the input from nurses. We must recognize and show appreciation for the work nurses continue to do with limited resources and often without proper staffing. Nurses strive to give the best care that they can give to their patients, communities and society, they just need the tools and support to do this. As a society, we need to do this before all nurses are burned out and leave the Profession of Nursing. For then we will find ourselves without someone at the bedside to care for us when we most need it.
- American Association of Colleges of Nursing (2022). Nursing school see enrolment increases in entry-level programs, signaling strong interest in nursing careers. Retrieved at: https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/25183/Nursing-Schools-See-Enrollment-Increases-in-Entry-Level-Programs#:~:text=WASHINGTON%2C%20D.C.%2C%20April%205%2C,seekers%20from%20entering%20the%20profession.
- American Association of International healthcare Recruitment (2021). One year into COVID-19, one-third of nurses are considering leaving the bedside. Retrieved at: https://aaihr.org/blog/2021/04/06/covid-nurse-survey-2021/
- American Hospital Association. Hospital Workforce Shortage Demands Immediate Action. Retrieved at: https://www.aha.org/lettercomment/2022-01-27-hospital-workforce-shortage-crisis-demands-immediate-action
- American Nurses Association. Workforce. Retrieved at: https://www.nursingworld.org/practice-policy/workforce/
- CNBC. COVID has made it hard to be a healthcare worker. Now many are thinking of quitting. Retrieved from: https://www.cnbc.com/2021/05/31/covid-is-driving-an-exodus-among-health-care-workers.html
- Hansen, A., & Tuttas, C. (2022). Professional choice 2020-2021: Travel nursing turns the tide. Nurse Leader. https://doi.org/10.1016/j.mnl.2021.12.018
- Kelliher, R. (2022). Meeting the Need: How Nursing Schools are Addressing the RN Shortage Exacerbated by COVDI-19. Diverse. Retrieved at: https://www.diverseeducation.com/health/article/15288476/meeting-the-need-how-nursing-schools-are-addressing-the-rn-shortage-exacerbated-by-covid19
- Yang, Y & Mason, D. (2022). COVID-19’s Impact On Nursing Shortages, The Rise Of Travel Nurses, And Price Gouging. Health Affairs. Retrieved at: https://www.healthaffairs.org/do/10.1377/forefront.20220125.695159/#:~:text=In%20April%202020%2C%20during%20the,%245%2C000%20and%20%2410%2C000%20per%20week.
- Raso. R, Fitzpatrick, J & Masick, K. (2021). Nurses’ Intent to Leave their Position and the Profession During the COVID-19 Pandemic. Nursing Administration. 51(10) 488-494.
- DOI: 10.1097/NNA.0000000000001052 Retrieved from: https://pubmed.ncbi.nlm.nih.gov/34519700/
- United States Department of Labor. US Labor of Statistics. Registered Nurses. https://www.bls.gov/ooh/healthcare/registered-nurses.htm
- A Nurse Manager, two staff nurses and a new nursing graduate working in the acute care hospital setting shared their view of why they think nurses are deciding to leave their current nursing jobs. Sadly most nurses reading this article, will likely relate to the stories that have contributed to nurse burnout and why nurses are leaving the profession and why we as a profession find ourselves in a critical crisis.