More than a quarter of respondents to a large national nursing survey said they were planning to leave the nursing workforce.
Nursing has faced continued workforce retention issues, especially in hospitals and nursing and long-term care facilities.
Understaffing is a major contributing factor to this issue.
Over a quarter of nurses who responded to a 2022 national survey stated they planned to leave the profession.
The National Council of State Boards of Nursing (NCSBN) surveyed 335,000 registered nurses and licensed practical/vocational nurses in its 2022 survey. More than one in four respondents intended to leave nursing by 2027. Additionally, an estimated 100,000 registered nurses left the profession during the COVID-19 pandemic.
There are currently 4.5 million registered nurses in the US. In April 2023, NCSBN projected that almost 900,000 nurses might leave in the next four years unless changes are made. This is far from the first time an alarm about the nursing workforce has been sounded. Significant attention has been focused on a reported staffing shortage in American healthcare, including a physician shortage, and how this shortage can substantially increase over the next decade due to factors like the aging of the Baby Boomer generation. Coverage and concerns about this shortage have often focused on nurses.
The COVID-19 pandemic increased this focus and highlighted some of the demands placed on nurses, especially in hospital settings. However, none of the problems facing the nursing workforce—or that might be behind nurses leaving the profession—began during the pandemic. Nursing burnout has been a consistent issue. Nurses are often overworked, and their work settings are understaffed, two factors that lead directly to burnout and to nurses leaving their roles.
It’s common for hospitals and other institutions to require 12-hour shifts, often with rotating schedules, for nurses. This scheduling setup can quickly lead to burnout, often combined with patient-nurse ratios that are too high for nurse workload and patient safety. Nurse understaffing is linked to worse patient outcomes. It’s also linked to higher turnover for nurses and physicians. In a 2021 survey conducted across 60 US magnet hospitals noted for their excellence in nursing, 87% of nurses and 45% of physicians responded that improving nurse staffing was a top intervention for reducing overall burnout.
There’s been talk of establishing national minimum required nurse-to-patient ratios in hospitals nationwide, but no current federal regulations address understaffing. California and Oregon are the only states with statewide regulations regarding nurse-to-patient ratios in hospitals. California’s dates back to 1999, while Oregon’s will be implemented in June 2024. New York has staffing regulations specific to critical care or intensive care units. No specific ratios are required in a handful of other states, but hospitals are asked to report their nursing staffing. A national proposal was reintroduced this year.
Nursing unions and organizations have advocated for this type of change for decades. The American Nursing Association states:
“Appropriate staffing levels allow nurses to practice to the full extent of their licensure and expertise and allow nurses to provide quality nursing care to their patients. Amidst the nurse staffing shortage, it's important that our healthcare workforce is equipped to address this ongoing issue.”
Even as support for these movements builds, hospitals can face other problems with maintaining their nursing workforce. Data shows that many nurses choose hospitals for their first job after completing their degree programs and that they don’t always remain in these hospital roles.
Some registered nurses leave to advance their education and transition into nurse practitioner roles. These roles come with more autonomy and higher salaries; plus, they’re in demand. The United States Bureau of Labor Statistics predicts a 38% increase in nurse practitioner roles between 2022 and 2032. Other registered nurses leave hospitals for positions that come with scheduling freedom and the potential for higher wages, such as travel nursing or remote nursing, two options that grew in popularity during the pandemic.
However, hospitals aren’t the setting facing the worst turnover and understaffing. Nursing and long-term care facility understaffing has been a longstanding issue in healthcare. In 2022, President Joe Biden pledged to address this serious concern, and on September 1, 2023, the Centers for Medicare & Medicaid Services (CMS) proposed new staffing regulations for nursing and long-term care facility staffing. Under the new rule, facilities would need at least one registered nurse on duty at all times, and every resident would need to receive a minimum of about half an hour of direct care from a registered nurse, along with nearly 2.5 hours of direct care from a certified nursing assistant, per day.
Unfortunately, a report commissioned by CMS shows that this new rule does not provide adequate patient care. Additionally, a report from the Kaiser Family Foundation (KFF) shows that less than 20% of for-profit facilities in the country would be able to meet the rule. Staffing regulations for nursing and long-term care facilities remain a challenge.
Efforts to stop a nursing shortage have often been focused on recruiting a nursing workforce, but numbers show that recruitment isn’t the issue. For instance, although about 100,000 registered nurses have left the profession in the past two years, around 188,00 newly trained nurses graduated from nursing schools nationwide.
Reducing burnout is often mentioned as a top way to keep nurses in the profession. Addressing staffing concerns is one way to do this, but it’s not the only way. Additional options could include programs such as loan forgiveness, especially in rural communities with stark healthcare staffing shortages. An overall improved work environment focusing on employee safety is also recommended, and employee wellness and counseling programs are cited as beneficial. When talking specifically about nursing and long-term care facilities, increased wages and benefits, along with clear paths for career growth, are an option that can help with retention.