Burnout and Staff Shortages

Staff Shortages Exacerbated by COVID-19-Related Burnout

Nursing staff shortages are not a novel crisis. These shortages, specifically with registered nurses (RNs), have steadily increased in the United States since 2015 and are expected to continue to increase until 2030. These shortages have numerous causes, including an aging U.S. population in need of increased health services, an aging nurse workforce where approximately one-third of the workforce is able to retire in the next decade, increased nursing staff turnover related to burnout, and nurses’ susceptibility to violence in the workplace.

However, COVID-19 exacerbated nursing staff shortages—89% of nurses in a survey reported that their organizations experienced staffing shortages resulting from the pandemic. The pandemic’s high workloads and unprecedented stress and burnout levels on nurses resulted in high turnover rates where nurses “reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), or burned out (45.1%) ‘a few times a week’ or ‘every day’ … [and] [m]ore than a quarter of the workforce also reported feeling at the end of their rope.” In 2022, over 95,000 RNs left nursing. With pre-existing nursing staff shortages, coupled with the stressors of the pandemic, the number of people in the nurse workforce will most likely continue to decline.

Similar to nurses, physicians also experienced concerning levels of burnout or work-related distress before the pandemic. Burnout is generally described as long-term stress due to a feeling of depersonalization in the workplace, lack of personal achievement, and exhaustion. The American Medical Association (AMA) calls physician burnout an “epidemic,” with nearly 63% of physicians reporting signs of burnout at least once per week. Physician burnout is more common than in other professions, with one study finding that physicians have “roughly 40% higher risk of occupational burnout than workers in other fields…” Doctors who are mid-career have historically been most acutely impacted by burnout, but physicians at every stage can experience burnout or significant work-related distress. Those physicians who reported feeling burned out cited a host of issues that caused stress and dissatisfaction with their profession, such as systems inefficiencies, increased demands of technology, medical record documentation, and other administrative duties leaving less time for patient care and other pursuits.

Further, the COVID-19 pandemic also exacerbated the physician burnout crisis. Researchers for the Mayo Clinic recently found that the physician burnout rate increased significantly over the first two years of the pandemic, with the sharpest increase in burnout rates occurring within the 12-month period between the end of 2020 and the end of 2021. The report noted that the pandemic brought a myriad of challenges for physicians that have evolved over time. In the early days of the pandemic, many physicians practiced without adequate personal protective equipment, which increased the individual risk of COVID-19 infection for which there were no treatments at the time. Some physicians were asked to practice outside their typical area of expertise or to deviate from normal standards of care. As the pandemic continued, even as these challenges improved, new ones emerged, as physicians and other healthcare workers encountered increased work burdens because of high patient volume and shortages in staffing due to COVID-19 infections. Also, “[p]oliticization of vaccination and antiscience attitudes altered health care workers’ relationships with patients and created new dimensions of moral distress.”

While physicians practicing in emergency medicine, infectious disease, and critical care have had the most direct impact from the pandemic, practitioners who had their surgical practices interrupted for a period of time due to COVID-19 temporary suspensions of operations suffered indirect hardships too. These day-to-day challenges against the backdrop of both significant societal change (e.g., gun violence and social justice movements) and personal struggles (e.g., childcare and economic concerns) faced during the pandemic had a profound impact on the physician workforce nationwide.

Due to COVID-19 related stress, nearly one in five physicians plans to leave their current practice within two years. The Association of American Medical Colleges (AAMC) projects the U.S. will face a shortage of between 37,800 and 124,000 physicians by the year 2034. The leading factors driving the shortage include a growing U.S. population and an aging population. The AAMC found that the U.S. population growth for those over the age of 65 will fuel high demand for physicians who care for older Americans. Other factors driving the shortage include a growing portion of the physician workforce that is nearing retirement age, an insufficient number of medical schools and residency training programs available to keep pace with the increased demand, and increased physician burnout and decreased satisfaction due to the COVID-19 pandemic.

Staff Shortages Deteriorate Patient-Care Quality

Nursing staff shortages have negatively impacted the quality of patient care. With a nurse shortage, the number of patients per nurse grows, affecting patient safety with a documented “increased risk of patient safety events, morbidity, and mortality.” Further, nurse shortages can heighten a patient’s infection risk, lead to medication errors, and increase children’s readmission rates. Fewer nursing staff also can lengthen wait times for patients to be seen by staff and create shorter visits.

Further, a lack of primary care physicians can delay the public’s access to care, which is critical in maintaining healthy communities. When people do not have access to primary care, they use the emergency room as a last resort, which increases healthcare costs. This puts an additional strain on emergency departments and can lead to patients boarding in the emergency department if the number of patients waiting to be admitted exceeds the number available beds on inpatient floors. Boarding is linked to increased medical errors and death.

Operational Impact and Challenges

Increased Travel Nurse Costs

With the nursing staff shortage during the pandemic, there was a rising demand for travel nursing. In January 2020, before the pandemic, the national average weekly rate for travel nurses in the United States was $1,894. The weekly rate for travel nurses rose by more than 50% throughout the pandemic, with the national average weekly rate exceeding $3,000 during pandemic peaks. There was a marked difference in pay between travel nurses and full-time staff nurses during the pandemic, where in 2022, travel nurses nationally were paid 103.3% higher than staff nurses. This difference in pay for the same amount of work left “staff nurses feeling angry, underappreciated, and underpaid compared with their traveling colleagues.”

As COVID-19 death and hospitalization rates decreased, the travel nurse demand decreased rapidly because paying the high travel nurse rates was unsustainable. While many nurses left staff jobs to become travel nurses during the height of the pandemic to earn more money, the decreased demand and weekly rate has led many nurses to exit the profession entirely. According to Aya Healthcare, in 2022, there are more than 200,000 open RN positions nationwide, doubling the number of positions that were open in January 2020.

The Temporary Workforce

The temporary workforce can cause cultural and cohesion issues between temporary workers, like travel nurses and full-time permanent staff nurses. The pay inequity perception between full-time staff and travel nurses has provoked animosity that has negatively impacted morale and necessary teamwork between the two groups. Some full-time permanent staff were “resentful and unimpressed” with travel nurses, resulting in a number of travel nurses feeling like outsiders. Many travel nurses felt that staff nurses bullied them. One travel nurse stated that “[w]e are just a Band-Aid, [staff nurses] don’t consider us part of the team.” Further, there was a perception that travel nurses had very little loyalty to their new workplace. A portion of travel nurses also received assignment preferences over staff nurses. This animosity prevented cohesion between the two groups.

On the other hand, the physician shortage crisis is changing the composition of hospitals’ medical staff. Recently, healthcare facilities have looked to hire contracted physicians and advanced practice providers, known as locums tenens, to fill vacancies. These doctors, once looked down upon by their peers who were employed or had independent practices, are now seen as highly desired by doctors and healthcare facilities alike because they are well paid and prevent hospitals from having to turn away patients.

Regulatory Challenges Due to Physician Shortages

The shortage can also present regulatory challenges for hospitals. For example, hospitals that fail to adequately staff their emergency departments, including their list of on-call specialists, run the risk of violating the Emergency Medical Treatment and Labor Act (EMTALA) if the staffing causes a delay in treatment or transfer and the patient suffers harm. EMTALA violations can lead to a number of penalties, such as exclusion from Medicare.

Meanwhile, when people do not have access to primary care providers, they use the emergency room as a last resort, which increases healthcare costs. This puts additional strain on emergency departments and can lead to patients boarding in the emergency department if the number of patients waiting to be admitted exceeds the number available beds on inpatient floors. Boarding is linked to increased medical errors and patient death, which may need to be reported to the state’s board of health.

Physician shortages in hospitals are also impacting other healthcare settings, such as skilled nursing facilities and rehabilitation centers that employ doctors too. When post-acute care facilities are understaffed, it can be a barrier to hospital’s being able to meet their regulatory obligation to provide a safe discharge for their patients.  A hospital’s inability to discharge a patient appropriately leads to longer lengths of stay and increased costs for hospitals and the healthcare system as a whole. Patients also suffer because they are at increased risk for getting an infection by staying longer than they need to at the hospital.

Conclusion and Possible Solutions

While nursing shortages existed before COVID-19, the pandemic exacerbated the shortage, affecting nurses’ burnout and turnover rates. The pandemic also exacerbated physician burnout. With the amount of nurses and physicians leaving healthcare, staff shortages are expected to increase within the next decade, perpetuating a nursing and physician shortage cycle.

Because the problem is multifactorial, there is no easy fix. Experts suggest there needs to be a multi-pronged approach to addressing the problem, such as increasing funding to expand the number of residency training programs, using telehealth and other technology to more efficiently manage physician time in seeing patients, expanding the reach of advanced practice providers to allow them to take more responsibility, and having hospitals create positive work environments by providing more opportunities for fostering professional well-being.