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With too few nurses, it won’t take much to overwhelm hospitals this winter

Nurse Hannah Drummond routinely must watch patients for hours as they lie in the emergency department, waiting for a hospital bed upstairs. That includes patients so ill they use breathing machines or need hospice or intensive care, she said.

There often aren’t enough nurses to staff every bed at the Asheville, North Carolina, hospital where she works, Drummond said.

“We are barely holding it together now,” she said. “If we have an uptick in [COVID-19] cases—yeah. I have to honestly not think about it, or I cannot sleep at night.”

Even as a new COVID-19 variant starts to spread in the United States, staff shortages have made it impossible for many hospitals to operate at full capacity. That means they’re less prepared to manage an influx of patients this winter, whether those patients have complications from COVID-19 or other significant health problems.

Hospitals nationwide are canceling nonemergency surgeries, struggling to quickly find beds for patients and failing to meet the minimum nurse-patient ratios experts recommend. Some even have had to turn away critical patients.While hospitals are under the most strain in Midwestern and Northeastern states where COVID-19 cases are surging, workforce shortages also are creating problems in Southern states where cases are relatively low—for now.

Hospitals employ about 2% fewer people today than they did in March 2020, according to the federal Bureau of Labor Statistics. That may not seem like much, but for many facilities, it makes a big difference. Crucially, experienced nurses have been quitting in search of better pay, less stressful jobs and more time with their families. In some cases, they've also sought to avoid required COVID-19 vaccinations.

Last month, about 4% fewer hospital beds were staffed in Michigan than in November 2021, when 21,071 were staffed, according to the Michigan Health and Hospital Association, which advocates for hospitals in the state. 

In upstate New York, hospital capacity has shrunk by 10%, The New York Times recently reported. And about 9% fewer intensive care beds were staffed in Colorado last month than the same time last year, according to state data.

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A travel nurse at a Midwestern hospital, who asked to remain anonymous for fear of retaliation from her employer, said that as she moves around the facility, she passes scores of beds that have been blocked off.

“Every single floor, at least, has like five beds that are blocked,” she said. Rooms will be closed even when many people are waiting in the emergency room for admission to that unit, she said, because the hospital doesn’t have enough nurses to staff every bed. 

Short-staffed hospitals will be less able to add beds during a surge of COVID-19 or other respiratory viruses this winter.

Colorado Democratic Gov. Jared Polis has asked hospitals to add up to 500 beds by mid-December to handle COVID-19 patients, for instance. That may be impossible, said Dr. Anuj Mehta, a pulmonologist at Denver Health Medical Center who advises Colorado policymakers. “I struggle to figure out where we’re going to find the health care workers,” he said. 

The regular winter respiratory surge “alone could put us over the edge,” Mehta said.

Outpatient facilities and nursing homes also lack enough workers—for many of the same reasons that hospitals do—adding to the pressure on hospitals, state officials and health care experts say. Patients are staying in the hospital longer because there are no open beds in facilities where they’d normally go to recuperate. 

To help hospitals in the short term, governors in recent months have required overstretched facilities to cancel elective procedures, allowed hospitals to move to crisis standards of care—guidance for allocating scarce resources during an emergency—or asked President Joe Biden’s administration to send in emergency medical teams. Some governors also have called in National Guard troops to help long-term care facilities.

Hospital groups say more state and federal funding for nurse pay and training programs could help fix the problem. Nurse associations and unions, meanwhile, want hospitals to offer better pay, better schedules and lighter workloads, and to assure nurses that they’ll be safe on the job.

Employer-sponsored nurse appreciation days featuring free food aren’t enough, said Colleen Casper, executive director of the Colorado Nurses Association, a trade group. “Pizza and doughnuts aren’t going to cut it.”

Hitting a breaking point

Hospital employment fell in the early months of the coronavirus pandemic as facilities canceled non-essential procedures—a major source of revenue—and laid off workers to balance their budgets.

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Employment levels have yet to recover, according to federal statistics. Although hospitals have hired new workers since then, they’re also losing experienced staff to better-paying or less-stressful jobs.

Many health care workers are burning out, say nurses and experts who study the health care workforce. Health care workers now are juggling COVID-19 cases along with patients recovering from non-essential procedures and patients with other illnesses such as heart attacks and strokes. Many workers are exhausted and traumatized after watching so many COVID-19 patients die. 

“There’s been so many times when I would just cry during my lunch break,” the Midwest-based travel nurse said, “because there were 30-year-olds, 40-year-olds, who had no medical history, or maybe they just had hypertension, or were obese, and they would have to get intubated and transferred to the ICU, and they’d be dead within a week.”

Health workers increasingly are facing verbal and physical abuse from patients and family members mad about hospital wait times and COVID-19 safety rules. And hospital jobs have become more difficult as more employees have quit.

Amid the staffing crunch, nurses have been assigned more patients than experts recommend, moved to units outside their specialty or asked to do other tasks outside their purview, such as taking out the trash, say nurses and nurse associations. 

Drummond, the Asheville-based nurse, said she usually doesn’t have time to eat lunch or go to the bathroom during her 12-hour shifts. “When you don’t have breaks, and you don’t eat, you’re more liable to make errors,” she said. “It’s absolutely exhausting.” 

Nancy Lindell, a spokesperson for Mission Health, the hospital system that includes Mission Hospital, where Drummond works, said in an email that the system is “working diligently to ensure nursing and other Mission Health roles are filled as quickly as possible with both traditional and creative solutions including recruiting international nurses, bolstering several nurse training programs, and robust recruitment bonuses.” Lindell noted that the need for health care workers is national and that worker shortages are also common in other industries.

Hospitals have tried to temporarily fill some nursing positions with travel nurses, who work for staffing agencies and move from state to state. But travel nurses can cost up to $200 an hour, hospital groups say. Hospitals typically pay nurses about $39 an hour.

Staffing agencies can charge high rates because hospitals are so desperate, said Jean Seaver, a hospital nurse executive who spoke to Stateline as president-elect of the Nursing Consortium of South Florida. “It’s like a bidding war. It’s crazy. It’s supply and demand.”

Governors and state officials are trying to help. New Mexico officials in October let hospitals adopt crisis standards of care and suspend non-essential procedures, for instance, citing nurse shortages

The New Mexico Hospital Association estimates the state has lost 450 hospital beds because of short staffing, a figure that includes both licensed beds and temporary beds created to serve additional patients.

Massachusetts officials last month told hospital systems with limited capacity to reduce non-urgent procedures. "The current strain on hospital capacity is due to longer-than-average hospital stays and significant workforce shortages, separate and apart from the challenges brought on by COVID,” said Massachusetts Secretary of Health and Human Services Marylou Sudders in a news release.

A Colorado committee created by the governor to manage pandemic response last week changed the state’s crisis standards of care to help facilities respond to workforce shortages amid high numbers of patients seeking care for a variety of reasons. 

The state’s initial guidance focused on how to allocate scarce ventilators and intensive care beds, Mehta said. “The nature of the pandemic now is very different.” The updated version takes a broader approach to triaging patients, Mehta said, such as by advising hospitals to identify less-sick people and move them into outpatient care.

No easy solutions

To address staffing problems, hospital groups are asking state legislatures for money to pay for travel nurses, worker bonuses and training.

The Michigan Health and Hospital Association and other groups that represent health care employers in the state have asked for $650 million to retain current employees and train new ones. 

Brian Peters, CEO of the Michigan Health and Hospital Association, said his members also would like Michigan to join the Nurse Licensure Compact, a multistate agreement that allows nurses licensed in other states to practice in member states, and for the federal government to make it easier for hospitals to hire clinical staff from overseas.

“We know we’re not getting out of this problem anytime soon without some very aggressive public policy change,” Peters said.

The New Mexico Hospital Association has asked lawmakers to spend $15 million a year on nurse training. New Mexico needs 6,000 more nurses, yet colleges in the state graduate about 1,200 a year, said association President and CEO Troy Clark.

“Even if we had no nurses retire, no nurses leave the profession, no nurses move out of state, it would take us five years to fill our current hole,” he said.

Historically, hospitals have preferred to hire experienced nurses over new graduates, who need on-the-job training. But that’s changing. Seaver, in South Florida, said the hospital system where she works plans to hire 500 new nursing graduates in the next year and a sister system plans to hire 600. “It’s easily double of what we would hire [normally],” she said. 

Hospitals still need veteran nurses to train all those rookies, however. “We lost the experienced nurses who would serve as their clinical coaches,” Seaver said. Her team is considering new approaches, such as letting one nurse oversee two recent graduates simultaneously. 

Nurses and nursing groups say hospital systems also must do more to retain nurses, such as by offering them better compensation, better schedules and a safe working environment.

For instance, Seaver said, hospitals could split the standard 12-hour shift into two six-hour shifts. They could offer nurses approaching retirement shorter shifts performing simpler tasks, such as managing admissions, discharges and transfers. They could reward longtime employees by giving them more control over which weekends and holidays they work. 

Drummond said her union, National Nurses United, wants the hospital where she works to bring in additional nurses to cover lunch breaks and improve staffing ratios. Ideally, she said, the North Carolina legislature would mandate minimum nurse-to-patient staffing ratios, as California has done since 2004.

The Midwest-based nurse decided to become a travel nurse in March 2020 in part because of the high pay. But she’s now so burned out she’s planning to quit. She said she’s been talking to a therapist and taking anti-anxiety medication to manage her stress, and she cut back to working three days a week.

She said she’d like to switch to cosmetic nursing. That might involve injecting Botox in a private office, rather than monitoring a patient’s heart rate in a COVID-19 intensive care unit.

“Whenever I tell people that, every single person is interested,” she said of fellow bedside nurses. “Because every single person is trying to look for an out from this.”

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

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Sara Eshleman/U.S. Navy

Staff shortages mean hospitals in many states are unprepared for another wave of COVID-19 patients.