Outlook for nurse supply and demand shifting amid COVID-19

The COVID-19 pandemic has catapulted shortages to the forefront of concerns regarding nurse staffing and quality of care. Until recently, worries surrounding the nursing shortage were mainly focused on a projection of the estimated workforce five to 10 years from now.

“I would not have said we had a nursing shortage a month or two ago,” said Sophia Thomas, president of the American Association of Nurse Practitioners. “Fast-forward to now, I think we do have a shortage.”

Several of the current nurse-staffing shortage concerns brought on by the pandemic are rooted in the dearth of personal protective equipment, or PPE, for front-line workers treating COVID-19 patients. Without proper protection, more members of the workforce are becoming ill and unable to provide care.

As a result, nurses providing care run the risk of spreading the disease to patients, colleagues and their families, thus increasing the number of patients while potentially becoming patients themselves.

Following best practices of infection control can also mean stretching nurse staff thin. While treating an acute case of COVID-19, a nurse might only be able to provide care to that one patient, or sometimes two, according to Ernest Grant, president of the American Nurses Association. This sort of one-on-one care ties up resources but is necessary to mitigate the disease’s spread.

“Even in a non-acute care setting, you may have other nurses who are taking on more patients because a nurse who normally would’ve had a chance to share that patient load is now tied up in an isolation room and is unable to provide that care,” Grant said.

With proper protection, however, some nurses who have tested positive continue to treat patients to meet rising demands. Thomas has spoken to colleagues at facilities with nurses who tested positive and are still practicing because they aren’t showing symptoms and need an income, and their hospitals need every staffer as they become overrun. Once a nurse starts showing symptoms, however, they must take sick leave.

Prior to the outbreak, most of the focus was on the impending retirement of the baby boomers, which will mean decades of nursing experience exiting the workforce. The number of boomer RNs peaked at 1.26 million in 2008 with 60,000 to 70,000 retiring annually since 2012, according to research published in the Journal of Nursing Regulation by Peter Buerhaus, professor in the College of Nursing and director of the Center for Interdisciplinary Health Workforce Studies at Montana State University, and his colleagues.

That raises some concerns about the number of nurses in the workforce, though that facet of the problem may not be severe. The baby boom generation produced about a million nurses in the country who have been steadily shifting into retirement, with about seven to nine years to go before most are out of the workforce, Buerhaus said.

But Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, believes the current graduating nursing classes across America are offsetting the loss of the baby boomers as several nursing schools have high enrollment and long waitlists for their programs. “We have the most robust nurse supply that we’ve ever had in this country, and it continues to grow,” Aiken said. “We’ve added a million nurses to the workforce in the last decade.”

Buerhaus, however, said the influx of new nurses feeds fears of a quality shortage. “You have large numbers of nurses coming into the field, which is terrific, but they’re not necessarily replacing the retiring nurses in a one-to-one way,” Buerhaus said, noting that a young nurse joining the workforce isn’t really equal to one with two to three decades experience.

As hospitals see an influx of COVID-19 patients, experienced nurses are desperately needed to help lead their younger colleagues through the crisis. Problematically, that group’s older age puts them at particularly high risk for COVID-19, which would render them unable to care for patients or lead their younger staff, added Maggie Hansen, chief nurse executive and senior vice president at Hollywood, Fla.-based Memorial Healthcare System.

Still, as the outbreak exacerbates staffing shortages, hospitals need all available resources on the front lines. Some hospitals, Thomas said, have asked retired nurses to return to work, even though they too are at higher risk.

Despite these growing concerns, facilities have responded quickly with strategies to combat staffing issues by allocating nursing and other resources to departments and front lines where they’re needed.

Hansen said that her system has reduced elective surgeries, unnecessary outpatient procedures, imaging, outpatient testing and cardiovascular intervention procedures, among other things. The staff in those departments, both nursing and those not considered mission-critical to the COVID-19 pandemic, are redeployed daily to hospital departments where they are needed.

“Your labor pool and your ability to deploy has to be as nimble as the front line has to be in responding to the changes,” Hansen said.

Hansen also said her system set up a PPE manufacturing plant at a Memorial Healthcare facility that had been closed. Available healthcare staff are manufacturing their own PPE there for nurses and front-line staff, whom the system won’t let work without proper protection.

The ability for a particular staff member to be shifted where needed is restricted for some, depending on the state where they’re licensed. According to Thomas, only 28 states and the District of Columbia allow nurse practitioners to practice to the top of their education and training. Among other requirements limiting scope of practice, the remaining states require nurse practitioners to have a written agreement from a physician to provide patient care outside their regular site of employment—a regulation that she called outdated.

“There’s no evidence to support the need for these written agreements when it stops nurse practitioners from providing patient care,” Thomas said. “We are calling on the nation’s governors to suspend legislative and regulatory barriers that prevent NPs from providing patients with full and direct access to all the healthcare services that NPs are clinically educated and prepared to provide.”

Some states and the CMS have temporarily lifted restrictions on NPs, increasing their ability to care for patients during the pandemic.

As the crisis develops, new resources and technologies have been implemented to help nurses deal with changing departments and responsibilities.

The American Association of Critical-Care Nurses launched a COVID-19 online course “specifically addressing the most serious reported symptoms from COVID-19,” according to a release from the organization. The webinar is free to all nurses and aims to “refresh their skills and cross-train staff.” Within a few hours, the release stated, 14,000 individuals were enrolled with numbers continuing to climb.

Technology is also working to prevent staffing shortages by limiting nurse exposure. MarinHealth Medical Center in Greenbrae, Calif., has implemented in-house virtual nursing stations that act as in-room nurse’s aides, said Karin Reese, chief nursing officer and interim chief administrative officer.

The telehealth service lets patients in isolation speak to their nurses, doctors and specialists face-to-face via video; this reduces staff exposure, minimizes the need for PPE and provides patients much more interaction while in isolation, according to Reese. “This provides nurses a level of safety, but also a level of feeling like they can still touch their patients more often than they would being fully garbed in PPE head-to-toe,” Reese said.

Looking forward as the crisis continues to develop, Hansen said it’s not all dire. It’s just difficult right now, and that what nurses of all ages learn from this experience will be extremely valuable. However, she expressed concern for the future of nursing. Hansen asked, after seeing what nurses are going through right now and the risks involved in personal safety, will those interested in nursing be scared out of the profession?

Actually, the crisis may have the opposite effect.

“It’s just like when 9/11 happened, and you saw an uptick of people who were wanting to join the military in order to help defend the country,” Grant said. “I think the public is starting to recognize the important role that nurses play, and I wouldn’t be surprised if we saw an uptick in the number of applications of people wanting to go into nursing as a profession.”