Labor

Thousands of healthcare workers have waged strikes this summer to demand better staffing levels as the pandemic brought greater attention to what happens when a nurse must take care of more patients than they can reasonably handle.

In New York, a report from the attorney general that found nursing homes with low staffing ratings had higher fatality rates during the worst COVID-19 surges last spring helped spur legislators to pass a safe staffing law long-advocated for by the New York State Nurses Association.

While unions elsewhere face a steeper climb to win the success found in New York, through strikes and other actions, they're attempting to get new staffing rules outlined in their employment contracts.

Most nursing strikes include demands for ratios, or limits on the number of patients a nurse can be required to care for, Rebecca Givan, associate professor in the School of Management and Labor Relations at Rutgers University, said.

"And employers are very anxious about that because it threatens their bottom line, so often when a compromise is found, it's something that approaches a ratio but maybe has a bit more flexibility," Givan said.

Some have been successful, like the 1,000 Chicago-area nurses at Stroger Hospital, Provident Hospital and Cook County Jail who waged a one-day strike on June 24 after negotiating with the county over a new contract for nearly eight months.

They reached a tentative agreement shortly after the strike, stipulating the hiring of 300 nurses, including 125 newly added positions throughout the system within the next 18 months.

The deal also includes wage increases to help retain staff, ranging from 12% to 31% over the contract's four-year term, according to National Nurses United.

Meanwhile, 700 nurses at Tenet's St. Vincent Hospital in Worcester, Massachusetts, have been on strike for over 100 days over staffing levels. Nurses represented by the Massachusetts Nurses Association have been trying to get an actual nurse-to-patient ratio outlined for specific units in their next contract.

The two sides haven't come close to reaching a deal yet, and some nurses will travel to Tenet's headquarters in Dallas on Wednesday in an attempt to appeal to corporate executives, according to MNA.

At the same time, federal lawmakers wrote to Tenet CEO Ron Rittenmeyer seeking details on the chain's use of federal coronavirus relief funds amid the strike and alongside record profits it turned last year.

The hospital denied lawmakers' claims in the letter that Tenet used federal funds to enrich executives and shareholders rather than meet patient and staff needs, saying in a statement it strongly objects to the "mischaracterization of the facts and false allegations of noncompliance with any federal program."

The strike is currently the longest among nurses nationally in a decade, according to the union.

A number of other major hospital chains have contracts covering their nurses expiring this summer, including for-profit HCA Healthcare and nonprofit Sutter Health.

Unionized nurses at 10 HCA hospitals in Florida have reached a deal on a new collective bargaining agreement, though members still need to ratify it, according to National Nurses United. The details are still unclear.

And after joining NNU just last year, 2,000 nurses at HCA's Mission Hospital in Asheville, North Carolina, ratified their first contract Saturday, which includes wage increases and the formation of a nurse-led staffing committee.

Newly-formed unions take an average of 409 days to win a first contract, according to an analysis from Bloomberg Law. In the healthcare industry, new unions take an average of 528 days to win a first contract, the longest among all sectors examined.

Across the country at Sutter's California hospitals, disputes haven't been so easily resolved. Healthcare workers at eight Sutter hospitals planned protests throughout July "to expose the threat to workers and patients caused by understaffing, long patient wait times and worker safety issues at Sutter facilities," according to Service Employees International Union United Healthcare Workers West, which represents the workers.

Similar to the ongoing Tenet hospital strike, SEIU is highlighting Sutter's profits so far this year and the federal relief funds it received.

 

Article top image credit: Permission granted by Massachusetts Nurses Association

UPDATE: July 13, 2021: The 1,000 Cook County nurses who waged a one-day strike in June voted to ratify a new contract July 3 that stipulates the hiring of 300 nurses, including 125 newly added positions throughout the system within the next 18 months, according to the union representing them. The deal also includes wage increases to help retain staff, ranging from 12% to 31% over the contract's four-year term.

And the 1,500 healthcare workers at the University of Southern California hospital and clinics reached a tentative agreement and will hold a ratification vote next week, according to a spokesperson from the National Union of Healthcare Workers, which represents them. However, 1,400 USC nurses represented by the California Nurses Association will hold a two-day strike on Tuesday and Wednesday over a separate contract they’ve been negotiating with the university since November 2020.

---

This year is shaping up to be an active one for healthcare labor unions, whose members worked on the front lines of the historic COVID-19 pandemic that strained hospital resources and claimed hundreds of thousands of lives across the country.

In Massachusetts, about 700 nurses at Tenet’s St. Vincent hospital are currently waging the second-longest nurses' strike in state history, over staffing levels they want in their next contract, and nurses in a handful of other states have also threatened to strike or done so this year. At the same time, employment contracts covering tens of thousands of nurses employed by chains like HCA expire this summer.

After a tumultuous year for the industry, most large health systems came out unscathed financially, with many turning profits and most receiving federal relief funds. Unions are underscoring this trend in their campaigns.

Major healthcare worker unions were vocal last year throughout the worst of the pandemic, too. The Bureau of Labor Statistics only tracks strikes involving 1,000 or more workers, but among the eight work stoppages it tracked that began in 2020, five involved healthcare unions.

While not exhaustive, here's a look at some recent disputes between health systems and their unionized employees:

Cook County Health nurses waging 1-day strike

Over 1,000 nurses represented by the National Nurses Organizing Committee are slated for a one-day strike Thursday in Chicago. They work for Cook County Health at Stroger Hospital, Provident Hospital and Cook County Jail, and have been negotiating with the county for a new contract for nearly eight months.

Following the one-day nurses strike, over 2,000 social workers, technicians and other Cook County staff represented by Service Employees International Union Local 73 will start an open-ended strike Friday.

Staffing is a key issue, as is pay — according to SEIU 73, the county's latest proposal offers no pay increase for the year, and a 2% increase each year between 2022 and 2024.

A proposal that would boost health insurance premiums is also a central concern for the unions.

"The working conditions won't keep nurses there and the wage scales are not enough to attract new nurses," Consuelo Vargas, a nurse at Stroger hospital and nurse representative for the union, said.

Thousands of nurses in Illinois waged strikes last year, including a weeklong strike at the University of Illinois and another at Ascension's AMITA St. Joseph Medical Center in Joliet, Illinois.

A Cook County Health spokesperson did not respond to questions on how the hospitals will continue their operations through the strike.

Massachusetts hospital, nurses no closer to deal after more than 100 days on strike

On March 8, about 800 nurses at St. Vincent Hospital in Worcester, Massachusetts, began an open-ended strike when they couldn't reach an agreement with management on staffing levels in their next contract. The Massachusetts Nurses Association and hospital have been negotiating a new contract since November 2019.

The nurses are fighting for specific nurse-to-patient ratios that the hospital strongly opposes be included in their next contract. MNA has unsuccessfully lobbied for staffing ratios through the state legislature for over a decade, and in 2018, voters rejected a nurse-to-patient ratio measure.

Eleven weeks into the work stoppage, the hospital started permanently hiring replacement nurses. It posted at least 100 open positions online, though it's unclear how many roles have been filled. A hospital spokesperson did not respond to a question on those potisions.

Among the 800 nurses who went on strike, 200 have crossed the picket line to return to work, according to the hospital.

Throughout the strike, the two sides have only met a handful of times and currently have no future sessions scheduled.

USC healthcare workers threaten strike without setting a date

At the end of May, 1,500 healthcare workers at the University of Southern California's Keck Hospital, Norris Comprehensive Cancer Center and other university clinics voted to authorize a five-day strike. They still haven't set a date, though, according to the National Union of Healthcare Workers, which represents the USC employees.

Contracts expired in April, and similar to the Cook County nurses, a proposal that would increase health insurance premiums is a key issue at the bargaining table.

The union also wants pandemic preparedness measures outlined in the next contract, including emergency housing and hazard pay guarantees. Negotiations are continuing this week, an NUHW spokesperson said.

Some 96% of members voted to authorize the strike, though the union must set a date and provide a 10-day notice to the university to allow it to make arrangements to continue services through a work stoppage.

Montana nurses waged 3-day strike in June

Over 600 nurses at Logan Health in Kalispell, Montana, went on a three-day strike on June 1 after 19 months of bargaining for their first contract with hospital management.

The nurses joined SEIU Healthcare 1199NW in July 2019, and in their first contract want increased staffing through a nurse-led staffing committee and the reinstatement of charge nurses in every unit. They also want improved wages and benefits to help recruit and retain nurses in the rural region, according to a union release.

A group of nurses at the hospital opposed to the union filed for a decertification election with the National Labor Relations Board in May, though the petition was withdrawn. The initial unionization vote in 2019 was a relatively close one: 372 to 199.

It's unclear whether any additional bargaining sessions are scheduled. A hospital spokesperson and union spokesperson did not respond to requests for comment.

Article top image credit: UFCW Local 400

By: Thomas Sugarman, MD and Hartwell Lin, MD

As COVID-19 surged through New York City this spring, local hospitals increased their ICU capacity by 500%. But despite this feat, they still hit a wall.

They didn’t have enough critical care physicians to staff those beds.

The takeaway: when it comes to pandemic preparedness, your clinical staffing plan is every bit as important as your facilities plan. You not only need more beds and providers; you also need the right expertise — plus systems to support and manage it.

As emergency physicians, we learned this firsthand while providing critical care relief in New York.

In April, California Gov. Gavin Newsom’s office asked our physician group, Vituity, to provide clinical support to New York City Health and Hospitals. In addition, we were charged with helping develop policy recommendations to prepare California for future COVID-19 surges.

When we arrived at our assigned hospitals, we were moved by the resilience of the New York City providers, who had been working tirelessly for weeks. At the same time, the process of integrating relief physicians with diverse backgrounds into clinical care proved complicated – especially as knowledge of COVID-19 changed daily.

Many local physicians assigned to the COVID-19 unit had minimal experience managing ICU patients. (Imagine a psychiatrist or pediatrician who hasn’t changed a central line since medical school.) As emergency physicians, we were comfortable with critical care procedures and resuscitation but were less experienced with ongoing management. We therefore depended on local physicians for both clinical direction and practical help navigating our new hospitals.

Fortunately, the strong climate of teamwork meant no provider was left behind. In addition, we were supported by Vituity critical care partners, who were available to advise and consult with front-line volunteers.

So how can health systems plan now to staff a potential surge? Here are our recommendations.

1. Adapt Your Clinical Command Structure

Because the New York City hospitals had far too many ventilated patients for the available pulmonology/critical care physicians to manage, they implemented an effective pyramid model.

• Native intensivists and pulmonologists (1-2 per hospital) served as both clinical experts and incident commanders who coordinated needed resources with hospital administration.
• Each COVID-19 unit was managed by intensivist fellows or physicians with critical care experience. Emergency physicians sometimes filled this role when needed.
• Finally, teams of clinicians consisting of an attending, resident, and intern from various specialties managed direct patient care. Physician assistants provided additional bandwidth, sometimes replacing interns and performing many procedures.  
• Additionally, dedicated clinical teams covered night shifts, and specialist teams were available for renal, infectious disease, cardiology and related consults.   

Relief clinicians were plugged into the pyramid based on expertise. Each team included local physicians familiar with the hospital.

2. Build Your Team in Advance

While the exact composition of your clinical pyramid will be situation-dependent, it’s never too early to start identifying key leaders. Imagine your hospital sees a three-to-ten-fold increase in critical patients. What roles you can fill from within your health system? If you notice gaps, start reaching out now to potential clinical partners.

Consider how you will integrate visiting doctors, including those working outside of their specialties. It’s vitally important that your local clinical leaders connect with incoming relief physicians to ensure they understand their responsibilities and points of contact.

Also consider logistics. When possible, centralize or outsource credentialing, travel, scheduling, training, orientation and related tasks to free up bandwidth for your front-line clinicians. It’s usually easiest to work with one or two organizations that can supply the specialists you need. Some physician groups also have the infrastructure to assist with the logistics.

3. Connect Daily with the Front Line

Finally, as a healthcare leader, stay engaged with your clinical teams. While centralized support is essential, rapidly shifting knowledge of COVID-19 requires agile decision-making that is best left to front-line providers.

Perhaps the best way to harmonize executive and clinical agendas is through daily outreach. Identify pain points and help to create solutions. Giving your teams just 10 to 15 minutes of undivided attention sends a message of support and solidarity.

In Summary

Adding beds may be the easiest part of preparing for a COVID-19 surge. Don’t forget to give equal attention to clinical capacity, including onboarding, scheduling, and providing practical and moral support to your expanded teams. Ensure that leadership stays visible and keeps communication lines open. Having a well-prepared surge plan along with leadership support will go a long way toward improving patient outcomes and boosting provider morale.

Read more insights from the New York City delegation.

Thomas Sugarman, MD, helped coordinate and deployed to New York City with the Vituity delegation. He is a practicing emergency physician and assistant medical director.

Hartwell Lin, MD, led the Vituity delegation of more than 50 clinicians to New York City. He is a practicing emergency physician, regional director, and elected member of the Vituity Board of Directors.

Article top image credit: Ventdusud via Getty Images

Dive Brief:

• Hospitals and nursing homes in New York state will have to follow new staffing mandates under legislation Gov. Andrew Cuomo signed Saturday in a major win for labor unions that have advocated for such a law long before the COVID-19 pandemic.
• Hospitals will be required to form clinical staffing committees that include front-line nurses and other direct care staff when setting annual staffing standards for units, and the state health department can levy penalties against hospitals that fail to create or abide by the standards.
• The second law pertaining to nursing homes requires facilities to meet a minimum daily average of 3 1/2 hours of nursing care per resident. The two laws are set to go into effect in January 2022.

Dive Insight:

While staffing levels have always been a key concern for nursing unions, the pandemic highlighted the struggles of healthcare workers who say they sometimes take care of more patients than they can reasonably handle. Now they're using the COVID-19 crisis to advocate for change, either lobbying state legislatures or trying to negotiate new staffing rules in their employment contracts.

California is currently the only state with mandated staffing ratios on the books after landmark legislation passed there in 2004, though a number of other states have laws similar to New York's requiring nurse-led staffing committees.

California's law outlines nurse-to-patient ratios, or exactly how many patients a nurse can take care of in specified units, such as operating rooms and intensive care units.

New York's law lets hospitals form committees to set their exact standards, though at least half of the committee members must be front-line nurses or direct care staff.

"This law doesn't state that ratios must be stipulated, but inevitably that's what it means," Judy Sheridan-Gonzales, president of the New York State Nurses Association said.

The state health department will enforce the staffing plans with monetary fines for hospitals that are noncompliant, and will also establish new minimum staffing standards for ICUs and critical care units to be incorporated in each hospital's annual staffing plans.

The law also includes a provision to make each hospital's staffing data publicly available to staff and patients.

No federal staffing standards currently exist, and hospitals are generally opposed to such mandates, which they fear could hinder their operational flexibility. A spokesperson from the Greater New York Hospital Association did not respond to a request for comment.

New York was initially the hardest hit when COVID-19 arrived in the U.S., with nursing homes bearing the brunt as they dealt with an onslaught of critically ill patients.

A January report from the state's attorney general that found nursing homes with low staffing ratings had higher fatality rates lent momentum for both pieces of new legislation to pass, Sheridan-Gonzales said.

Article top image credit: Justin Sullivan via Getty Images

The biggest nurses union in the country is teeing up a fight with hospitals run by HCA Healthcare, Sutter Health and CommonSpirit Health as it heads into negotiations for some 65,000 nurses this year.

The COVID-19 pandemic exposed problems faced by nurses ranging from inadequate personal protective equipment to unsafe staffing levels, members of National Nurses United said at a press conference held virtually Friday.

The union said at least 405 nurses died after contracting COVID-19 during the pandemic, among the nearly 600,000 coronavirus deaths in the U.S.

"We walk into these bargaining negotiations with these painful memories," said Sandy Reding, a CommonSpirit Health operating room registered nurse and president of the California Nurses Association National Nurses Organizing Committee.

Heading into contract negotiations after more than a year on the ultimate frontlines of the pandemic, nurses are demanding greater protections for themselves and their patients. Union officials speaking on the call accused hospitals and health systems of cutting corners throughout the pandemic, putting patients, nurses and their families at higher risk of infection.

"This year and a half has been a traumatic one for nurses," said Khadijah Kabba, collective bargaining director for National Nurses United.

Hospitals ignored nurses' calls for increased staffing and training and clear protection protocols during the emergency, with deadly consequences, she said. In Cook County, Illinois, nurses were told to wear the same personal protective equipment for days from a box labeled "for single use only," she said.

During this time, HCA, the most profitable hospital chain, posted earnings of $3.7 billion in 2020, she noted.

"This pain fuels a righteous anger," Kabba said. "We have seen what your policies and greed have led to. Now we must put patients before profits." 

At bargaining tables this year, nurses will demand safe staffing, optimal PPE, and job protections in the event of illness from diseases including but not limited to COVID-19, Reding said.

HCA has collective bargaining agreements covering 10,000 nurses in five states up for renegotiation this year, according to NNU. Contracts expired at the end of May for HCA hospitals in Florida, Kansas and Missouri and will expire on June 30 in Texas and Nevada.

The largest U.S. for-profit hospital chain, HCA, faced labor disputes last year that included a weeklong strike among nurses at Riverside Community Hospital in California represented by the Service Employees International Union. The nurses threatened to strike again in December, along with nurses from two other Southern California HCA hospitals, though they reached a deal and averted the strike just before Christmas.

In North Carolina, 2,000 nurses at HCA's Mission Hospital in Asheville are currently bargaining for their first employment contract after successfully unionizing last September in a state with the second lowest union membership rate.

Concerns about staffing levels were a main reason nurses at the hospital pushed for union representation.

Officials at HCA, CommonSpirit and Sutter were not available for comment by time of publication.

National Nurses United is the country's largest nurses union, with 170,000 members across the country. The union achieved a second election victory in the past year when about 2,000 registered nurses at Maine Medical Center voted to join NNU in April.

The union is also currently lobbying for several bills in Congress, including the Workplace Violence Prevention for Health Care and Social Service Workers Act, and the Protecting the Right to Organize Act, which would penalize employers for tactics to discourage workers from unionizing. Both passed the House but need Senate approval.

Article top image credit: Retrieved from National Nurses United.

An open-ended strike involving hundreds of nurses at Tenet's St. Vincent hospital in Worcester, Massachusetts, is now in its 11th week. With few prospects for a deal on the horizon, the hospital is moving to permanently hire 50 replacement nurses, it said last week.

Roughly 800 nurses began the work stoppage March 8 over staffing issues they want addressed in their next contract. While staffing has long been a key issue for nurses unions, they contend the pandemic exacerbated it. Workloads and staffing concerns have some looking to leave the profession post-pandemic amid reports of burnout. The Massachusetts Nurses Association and the hospital have been negotiating the new contract for over 17 months.

Throughout the strike, now one of the longest among healthcare workers in recent years, the two sides have only held three rounds of negotiations — on April 27, May 1 and May 5. There are no future sessions scheduled.

"We have received no indication from the MNA that they intend to compromise anytime soon, and it is really not sustainable to have a full complement of temporary replacement nurses for a long duration strike," hospital CEO Carolyn Jackson said.

Once those roles are filled, 50 nurses on strike won't have jobs to return to.

Workers waging an economic strike for higher wages, shorter hours or better working conditions lose the right to return to work once their position is permanently filled, though they are put on a "preferential hire list" for the same role if vacancies arise, under the National Labor Relations Act.

Jackson said about half of the postings have applicants, though the hospital can't extend an offer until at least seven days after they are posted, per the expired collective bargaining agreement. The hospital is posting roles in small batches, and plans to post another 50 "in the not too distant future," she said.

On Saturday, the nurses held a rally to garner community support following the replacement announcement and were joined by U.S. Reps. James McGovern, D-Mass., and Lori Trahan D-Mass.

They've received wide support from other labor unions and public officials, including the Worcester city council and state legislative delegation.

The Massachusetts Building Trades Council delivered a letter to Jackson on April 28 that said it will not send its 75,000 members to the hospital for care until the strike is resolved, according to the union.

"The nurses remain unmoved by Tenet's unseemly threat, having fully expected Tenet to move in this direction, and see it as yet another desperate attempt to avoid negotiating in good faith with the nurses, while once again demonstrating the for-profit corporation’s complete lack of respect for the nurses and the valuable role they have in protecting the community," MNA said in a release.

About 700 nurses remain on strike while 140 have crossed the picket line and returned to work. Leading up to the strike, more than 100 nurses left the hospital for roles elsewhere or outside of nursing, according to both the hospital and the union.

"The nurses see no likelihood that the hospital can replace them as the strike has been widely lauded throughout the nursing community across the state and the nation, as the nurses have been held up as being heroes for the stand they are making in the wake of the worst public health crisis in the nation's history," MNA said.

Article top image credit: Permission granted by Massachusetts Nurses Association

Labor unions have staged protests, gone on strike and even organized new members throughout the COVID-19 pandemic. National Nurses United is no exception — as the country's largest nurses' union with 170,000 members across the country, NNU notched two major election wins in the past year.

About 2,000 registered nurses at Maine Medical Center voted to join NNU in April, making it the largest successful union election with the National Labor Relations Board so far in 2021. And in September, 2,000 nurses at HCA's Mission Hospital in Asheville, North Carolina, successfully unionized in a state with the second-lowest union membership rate in the country, according to the Bureau of Labor Statistics.

Those nurses are bargaining for their first employment contracts, and will soon be joined by thousands of other NNU nurses across the country with contracts up for renegotiation this year. Staffing, safety, and other issues exacerbated by the pandemic are likely to be key issues.

The union is also currently lobbying for a number of bills in Congress, including the Workplace Violence Prevention for Health Care and Social Service Workers Act, and the Protecting the Right to Organize (PRO) Act, which would punish employers for a number of tactics used to dissuade workers from unionizing. Both passed the House but need Senate approval.

NNU President and registered nurse Deborah Burger reflected on nurses' experiences over the past year on the front lines, and outlined where the union is headed going forward. 

Editor’s note: This interview has been edited for clarity and brevity.

HEALTHCARE DIVE: Has NNU seen an uptick in organizing throughout the pandemic?

DEBORAH BURGER: Actually it's about the same pace, because it does take time to go through the entire process. And we actually had to go through the Trump years and the Trump labor board, and sort of a hostile labor board and a hostile union environment. The nurses in Mission Hospital in Asheville that voted to join the union were up against some really heavy union busting, both on the part of the employers there, and politicians. It's a testament to how committed nurses were to making sure they had a voice that protected them, and protected their patients and protected their community that they overcame intense union busting. Maine was also extremely hostile, but what was really helpful was having the community support them. They had a lot of support, so that made a huge difference.

After the North Carolina win, is there an impetus to get nurses in states with lower unionization rates to join NNU?

BURGER: We already represent nurses in Kansas, Missouri, Florida, Texas, Georgia, North Carolina, Virginia, West Virginia and Arizona. I mean we do represent nurses in what you would call right-to-work states, so nurses actually understand once they're given the information, what their options are. And they can be heavily intimidated, even in California which is not a right-to-work state.

How will NNU leverage nurses' experiences through the pandemic to get the contracts it wants?

BURGER: Nurses were working 12, 16 hours a day with no days off, and then you want to furlough them when there's finally a break. Nurses have bills to pay, they have mortgages and often times they're the primary breadwinner or the sole breadwinner of their family. So I'm sure that nurses are going to want to have a discussion on, you know, a commitment that if you're hired for 32 hours a week, you get 32 hours paid.

We're also still fighting to have adequate [personal protective equipment]. In California, we got a law that said that hospitals had to stock three months worth of PPE. So part of our negotiations will be to ensure that we get more protections written into our contracts so that nurses have a say over what inventory is in the hospital because nurses were told, "We've got adequate stocks now," but the transparency for supplies is not there.

What do you want the healthcare industry to do for nurses to improve burnout in the profession?

BURGER: What we want the healthcare industry to do is not put us in a position where we're under such moral distress. We had to make very difficult decisions because we didn't have the support and the resources from our employers. We didn't have the staffing that we needed. We didn't have the security that we needed. We didn't have the patient protections that we needed, you know, to be able to get testing for a patient when they come into the emergency room.

I think that that's probably one of the things that makes nurses the angriest, is that there wasn't a true lack of supply, there wasn't a true lack of the testing capability, there wasn't a true lack or inability to communicate to nurses when they were exposed. It was outright deception and lying to the nurses. Nurses are pretty forgiving, but when you're outright lying to them, they remember that, and they remember how badly it hurt them.

Article top image credit: Permission granted by National Nurses United

Dive Brief:

• More than 22% of nurses say they may leave their current position within the year, with many planning to leave for another job outside of nursing or retire, according to a McKinsey report published Thursday.
• Nurses in long-term care settings were more likely to consider leaving their roles than those in inpatient settings, and female nurses were twice as likely to say they're considering leaving than male nurses.
• To recruit and retain more nurses, employers need to offer adequate compensation for expertise and effort, provide flexible scheduling options and give more support overall, McKinsey said.

Dive Insight:

The COVID-19 pandemic could drive a widespread exodus of nurses from the workforce, as insufficient staffing, workload and emotional toll are key factors pushing them to consider other jobs or check out of the labor force completely, the survey found.

McKinsey researchers surveyed 400 nurses across different settings in February and found a 60% increase in the number planning to leave compared with 2020's report.

More than half said they would leave for a role not involved in direct patient care or retire, "which was striking to us and just for the profession at large, which has had and will probably continue to have high demand for talent," Mhoire Murphy, a McKinsey partner and co-author of the report, said.

While nurses were hailed as heroes this past year, more appropriate and sufficient recognition topped the list of most desired initiatives — namely in the way of greater financial compensation that matches their experience and efforts.

They also said they needed more breaks to recharge either on the clock or through paid time off, and greater scheduling flexibility, especially through the use of new virtual care and remote work models.

Only about a quarter of respondents said they received mental health support during the pandemic, and many listed increased access to resources and active monitoring of nurse distress as key initiatives they'd like to see.

In another recent survey from the Kaiser Family Foundation and the Washington Post, 60% of front-line healthcare workers said the pandemic negatively impacted their mental health, and many said they aren't getting needed services. Feeling embarrassed or being unable to afford or get time off work were cited as top obstacles.

Communication and transparency is another issue among nurses the pandemic brought into focus. Employers can work to repair it through shared councils and committees to solicit nurses' input on "really anything that happens at the facility," Gretchen Berlin, a registered nurse and senior partner at McKinsey who co-authored the report, said.

Berlin was surprised by one finding: 17% of nurses said they are more likely to stay in the nursing profession given their experience during COVID-19.

"That, I think optimistically, poses a real opportunity for health systems and other employers to engage that portion of the workforce, and really retain them," she said.

Article top image credit: Getty Images

Worker shortages early in the COVID-19 pandemic led some states to temporarily waive licensing requirements, and many brought in traveling nurses as supply and demand ebbed and flowed among regional hotspots.

Now, as state emergency declarations begin to expire, legislators are looking for ways to maintain access to the nation's supply of nurses again and avoid scrambling through future emergencies.

A number of bipartisan bills moving through state legislatures could add more states to the Nurse Licensure Compact — a multistate agreement that allows nurses to have one license but the ability to practice in other participating states without having to pay for and obtain another license.

"The key factor of the Nurse Licensure Compact is interoperability, which seamlessly allows clinicians to flow from one state to another and serve an urgent need without going through a time-intensive relicensing process," April Hansen, executive vice president of nurse staffing firm Aya Healthcare, said.

"The pandemic exploited the fact that states who don't already operate with a mindset of interoperability are disadvantaged," Hansen said.

Allowing such interoperability would benefit traveling nurses and the systems that need them, but unions tend to oppose entering the compact because it would allow hospitals to more easily hire replacement nurses in the event of a strike. Those nurses are also often paid more than full-time staff, breeding some tension between the groups, which flared during the pandemic.

Thirty-four states are in the compact, as well as U.S. territory Guam, which joined in March. Fourteen states have pending legislation to join, including Oregon, where it's been introduced for the first time.

Many have either joined or tried even before the pandemic, Rebecca Fotsch, director of state advocacy and legislative affairs at the National Council of State Boards of Nursing said.

"But COVID was a kind of glaring example of how the compact could help," Fotsch said.

A number of West Coast states — Washington, Oregon, Nevada and California — have been previously unsuccessful in joining the compact, due in part to strong labor groups there, Fotsch said.

A handful of states in the upper Midwest have also held out on joining the compact, though there's momentum in some, such as Illinois, to add it to the nurse licensing pact.

The Illinois Nurses Association, a labor union representing nurses, opposes the bill that would accept licenses from nurses credentialed in other states. The group argues the varying education and skills requirements across different states can undermine quality of care.

In order to receive a nursing license in Illinois one must verify their graduation from a nursing program, pass a state exam, file their application, submit documents for a background check, get their fingerprint taken by a licensed vendor and pay all necessary fees. Illinois also has continuing education requirements for RNs and LPNs, mandating 20 contact hours every two years.

Neighboring Missouri is a compact state and doesn't have that continuing education requirement, Victoria Dameron, a nurse and INA vice president, said.

Some nurses have been out of school for several years, "that doesn't seem like a long time, but for a nurse things change, especially within the last year, things change every week," Dameron said.

If the legislation passes and Illinois joins the compact, the state will maintain authority over issuing licenses, fees and disciplinary issues, according to NCSBN. But it would also agree to accept other state standards as acceptable.

Nurse licensing is just one medical credentialing reform issue spurred by the pandemic. Staffing shortages that could persist due to widespread burnout have states looking at other ways to broaden their access to healthcare workers.

Following a trial period with pandemic-related rollbacks, a number have bills that could permanently allow providers to virtually treat patients in states they aren't currently licensed or located in. And others in states such as Louisiana and Pennsylvania would expand nurse practitioners' scope of practice by eliminating the need for them to sign a practice agreement with a supervising physician.

It remains to be seen whether lawmakers will end up tossing the old rules permanently, though many efforts have bipartisan support.

Article top image credit: Fotolia

Dive Brief:

• Demand for traveling nurses is up again as the delta variant of COVID-19 causes a series of coronavirus surges in hot spots around the country. Aya Healthcare showed a 14.3% increase in available jobs from Aug. 9 to Monday with the greatest need in states like Texas, California, Florida, New York and Tennessee, according to a report from Jefferies analysts.
• Crisis jobs in geographic areas with a dire need for more staff accounted for 71% of Aya's total job openings. Fastaff travel nursing, another company that focuses on rapid response assignments, saw an 8% increase week over week in available jobs as of Monday.
• Rising demand is boosting bill rates too, with maximum salaries reaching $7,000 a week for nurses, according to the report. Hospitals today are "probably paying 10% to 20% more than they were paying" during previous COVID-19 waves, Kathy Kohnke, senior vice president of client relations at Fastaff, said.

Dive Insight:

Travel nurse demand has fluctuated with COVID-19 waves throughout the pandemic, spurring systems with severe shortages to pay steep rates for needed staff. After a short reprieve this spring amid vaccine rollouts, rising cases of the delta variant coupled with more non-COVID care are again straining hospitals and their workers.

States like Florida, Louisiana and Oregon currently have their highest levels of confirmed COVID-19 hospitalizations since the pandemic started, according to Centers for Disease Control and Prevention data released Friday. Staffing shortages are so dire in Oregon and Tennessee that those states' governors are deploying National Guard members to help hospitals.

Aya Healthcare is seeing more demand and open positions than during any other waves of the pandemic, Chrystal Fugett, vice president of recruitment, said.

As hospitals see higher volumes across the board with COVID-19 patients and others returning for non-COVID-19 care, this time around, "nearly every single unit is in need of staff," Fugett said.

Burnout is another major issue dwindling the supply of available healthcare workers.

In the beginning of the pandemic, staffing companies would post temporary crisis positions that were 60 to 72 hours a week so one nurse would be responsible for what two nurses might typically do. Nurses today are exhausted and saying "absolutely not," to positions with those hours, Fugett said.

At Fastaff, demand for temporary nurses reached a record in December, but the amount of current open jobs is just 3.7% lower than during that peak, according to the Jefferies report.

"The demand right now feels and looks probably greater than the first three spikes," Kohnke with Fastaff said.

Nurses who have worked the past 18 months are trying to finally take time off, just as systems continue treating COVID-19 patients while working through backlogs of delayed procedures, she said.

She doesn't think demand or rates will go down anytime soon as the delta variant remains unchecked and upticks in non-COVID-19 care require more staff. This year's flu season will also likely look different than the last, she said.

"Reduced population immunity due to lack of flu virus activity since March 2020 could result in an early and possibly severe flu season," according to the CDC.

After the 18 months they've just had, nurses are reevaluating their careers and some are considering leaving their roles, retiring or switching to travel jobs with higher pay, Kohnke said. "I think it's going to take us a while to get people back in their swim lanes," she said.

Article top image credit: Getty Images