Nurses: (yet) another COVID-19 casualty

November 09, 2022

Photo illustration of a hand and an IV with a green filter

By Tony Moore

Imagine you’re just getting your bearings as a new nurse. You’re excited about your future, about helping people, about having a job you love. You go home at night and relax — tired, but satisfied and confident you’ve made a positive difference in your patients’ lives.

But it’s early 2020 ...

... and you have no idea that the COVID-19 pandemic is about to hit.

When it lands in the U.S., you wonder how it will affect your job and your life. But you don’t have to wonder for long. The virus is soon in your hospital, your nursing home, your urgent care clinic.

People are sicker than you’ve ever seen before, and they’re dying — so many and so fast that managing death has become a bigger part of the job than managing patients’ health. The fallout: By summer 2022, more than 88 million Americans have contracted COVID-19, and more than a million of those people have died, according to the Centers for Disease Control and Prevention (CDC).

And you’re no longer working as a nurse.

Neither are a few hundred thousand other nurses who left the practice in droves during the pandemic.

“You just don’t expect to enter a profession and see so much death and dying,” says Karen Donelan, the Heller School for Social Policy and Management’s inaugural Stuart H. Altman Professor and Chair in U.S. Health Policy. “When you trained, probably everybody said, ‘What a great job, what a great profession you’re entering.’ And then you find out that in a pandemic, you don’t have as much control, and you’re probably doing a very different kind of work than you expected.”

A former associate professor of medicine at Massachusetts General Hospital and Harvard Medical School, Donelan studies the health care workforce and labor markets, including labor shortages and the impacts of workforce organi­zation on quality of care. Having designed and conducted hundreds of national and international surveys, she’s probed the experiences of thou­sands of patients and professionals in health care systems.

Now she’s turned her sights to the nursing shortage in the U.S. that began in 2020, a crisis that reverses a long-running upward growth trend in the field.

‘What do people do when there aren’t enough nurses?’

Donelan asks this rhetorically, noting that research shows that many nurses took a break from nursing, went back to school, left the profes­sion entirely, or became traveling nurses.

“One thing some facilities do is increase the number of patients nurses who remain on are expected to care for,” Donelan says. “But we know that’s not popular with nurses, nor is it always safe — especially for very sick patients.”

And it really mattered when health care facilities were bearing the brunt of the pandemic. Fueled by numerous COVID-related factors — stress, burnout, increasing or new mental health issues, or hostile workplace environments — nurses disappeared, and nursing-related job vacancies increased by up to 30%.

What’s more, in early 2021, when more nurses than ever were needed, the workforce was 13% smaller than when the pandemic began.

‘In long-term care, it really has not recovered.’

“Especially hard hit are our licensed practical nurses, who typically have been a major part of the nursing workforce,” says Donelan, adding that many losses have come from nursing homes. Donelan notes that there are more people trained to be nurses than actual nurses in the workforce, which fluctuates as economic and personal needs push people in and out of the profession. Now, though, the ebb and flow seems to just be an ebb, and that trend troubles Donelan, especially as COVID-19 wanes.

“We would have expected the nursing-home piece to start bouncing back a little better by now,” she says, noting that nursing homes tend to hire more new nurses, but these nurses are leaving the field. “If you graduated with a nursing degree and you’re working in a nursing home — it’s a very chal­lenging scenario for anyone, let alone someone in their first job out of college.”

During the pandemic, nurses absorbed patients’ fear, anger, and frustration in nonstop waves. And their own mental health challenges — exacer­bated by, or a result of, the pandemic — have been noted as a cause for the exodus, which has also contributed to historic problems of representation in the industry.

“We’re seeing tremendous interest in health care from people of color, but I think we still have so far to go,” says Donelan, who goes on to say that a recent study shows that the nation has lost ground in terms of Black students — particularly men — entering medical school and academic medical centers. “If we want a workforce that reflects our population, and we absolutely do for so many reasons, we just have to get better at this.”

So what does the future hold?

Donelan says facilities are focusing on how to retain workers, as well as on what steps might be necessary to bring back people who have left. They want their workplace to live up to the expec­tations of the field.

“I think most people enter the health professions because they really do care and they really do want to be in the middle of it when people are sick and need help,” Donelan says. “So if we can give them proper equipment, the proper support, the proper wages, people will see that this is still a good job that allows people to serve others in meaningful ways.”

As of summer 2022, a few bills are moving through Congress to address the nursing shortage. The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act; and the Workplace Violence Prevention for Health Care and Social Service Workers Act both would mandate improvements in the workplace setting. In addition, several states have similar legislation progressing.

The legislative efforts won’t affect those on the verge of retirement, which is nearly 20% of all nurses. But for young nurses, an improved work­place environment might help reestablish the upward trend in staffing.

“It may just be that all of this was a couple of years’ phenomenon, and we’ll adjust and we’ll smooth it out in the long run,” says Donelan. “I think that it’s a really good job, despite how hard it’s been in the pandemic. And we know there are more people interested in nursing than can be accommodated at current nursing programs, so I don’t think interest among people who aren’t working in the profession has waned very much.”

As for her students ...

... Donelan sees reason to be optimistic on the policy side, as a hopeful future takes shape at Heller every day.

“One of the things I love about being at Heller is that so many people care about these issues and are trying to figure out how to make it better,” she says, adding that her students are dedicated to finding solutions and understanding the policy challenges. “I taught an undergraduate capstone course last year, and that filled me with a kind of optimism I have not had for a long time.”

Donelan comes away from the classroom with a hopeful message for disillusioned workers. She stresses that she and her colleagues and students care — about nurses and other health care profes­sionals, their patients, and the future of health care, something they’re all dedicated to improving.

“If you’re in the health workforce and you feel sort of down or overburdened, there’s a lot of optimism and energy coming out of schools like this,” she says. “And I’m very, very happy to have students who are so committed to change.”