A little more than two months ago, the first COVID-19 vaccine was given in the U.S. To date, more than 44 million Americans have gotten at least one dose.
Besides offering protection for individuals and communities, the vaccine is also a shot of hope for health care providers — especially critical care nurses — who’ve been caring for COVID-19 patients nonstop for a year.
Yet even with ongoing vaccinations, decreasing hospitalizations and a dropping death rate, the pandemic is far from over. In fact, nurses say it will take much more than two shots to fix what COVID-19 has revealed to be broken in health care: nurse staffing and retention.
Because despite headlines about “nursing shortages,” such claims are the “beginning of a question — not the answer,” said Joanne Spetz, professor and director of the Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco. In fact, such claims should spark an interest in what’s going on “underneath the hood.”
So the Deseret News looked.
During the past three months, we talked with 35 Utah nurses — 20 of them intensive care unit nurses — from the four major health care systems in Utah and across 15 hospitals, about working in a pandemic. We also consulted health economists, workforce specialists and nursing experts about Utah’s place in the national landscape, and sought information from hospital administrators.
Here’s what we found:
- There is no overarching nursing shortage. While the pandemic has created an acute, immediate need for nurses, data does not support the idea of a broad, nationwide nursing shortage. Instead, the country has regional shortages and experience shortages, caused by a growing number of baby boomer nurses retiring, and hospital decisions about staffing.
- Utah’s nurses are leaving. Every nurse we spoke to knew at least one other hospital nurse who had left their job within the past 11 months — some knew handfuls. Nurses are retiring early, going back to school, taking lucrative travel nursing positions or finding a less stressful job.
While Intermountain Healthcare and the University of Utah Health wouldn’t answer questions about turnover, we compiled numbers from conversations with nurses and based on staff seniority and scheduling lists for the past 11 months as provided by nurses. They show that Intermountain Medical Center, the largest hospital in Utah, has lost at least 38 ICU nurses from just two of its five ICUs; Intermountain’s Utah Valley Hospital in Provo has lost at least 27 ICU nurses during that time period. The University of Utah Hospital has lost 68 ICU nurses from its four ICUs.
Turnover is common in nursing, especially in ICUs where nurses come to get experience before pursuing higher nursing education, but many experienced Utah nurses say the numbers during the pandemic are abnormally high. One Huntsman Cancer Institute ICU nurse has been there for four years, during which time roughly four nurses left. Yet since December 2020, her unit has lost nine experienced nurses.
- Utah is not a state with a nurse shortage. In fact, the number of registered nurses graduating in the state has increased 21% in the past five years — and is continuing to climb.
- Nursing experience in critical care is dropping. Working in the ICU has been a coveted position requiring years of experience. Yet, one 23-year-old Utah ICU nurse who spoke with the Deseret News said he was made a charge nurse in his ICU and considered an expert despite having only two years of experience. As older, experienced nurses retire, even an influx of new, younger nurses can’t replace that experience in hospitals at a time when nursing care is becoming even more complex. Experts call this the experience-complexity gap, which if left unaddressed can negatively impact patient safety and quality of care.
- Nurses said they are overloaded and exhausted. One Utah ICU nurse told us she was stretched so thin she had to care for a COVID-19 and a non-COVID-19 patient during the same shift. Many nurses say they’ve gotten daily texts from managers begging them to come in for extra shifts. In addition to their regular schedules, ICU nurses at the University of Utah Hospital and Huntsman Cancer Institute are required to sign up for two on-call shifts a month.
- Some nurses said they feel devalued. Some nurses described staff meetings as well as personal interactions during the past year where they’ve been told “a nurse is a nurse — anybody can do your job” and “don’t think you’re special,” and “be grateful you have a job.”
- Nurses said they are underpaid. Utah hospitals have brought in travel nurses to help carry the load, with contracts ranging from $3,000 to $5,000 a week — almost the amount some staff nurses said they make in a month. And when there’s a lull in patients, it’s staff nurses, not expensive traveling nurses, who get sent home without pay. Most nurses report no additional compensation for working on a COVID-19 unit, although the University of Utah is now offering $200 and $300 bonuses to those who voluntarily pick up weekday and weekend shifts, nurses said.
Intermountain nurses also repeatedly questioned the optics of their employer partnering with the Las Vegas Raiders by retaining naming rights for the $75 million dollar Henderson, Nevada, performance and training center, yet freezing company contributions to their 401(k) accounts for the second-half of 2020. Intermountain confirmed the freeze and said the contributions began again in January 2021. The naming rights fee was not released.
- There are zero Magnet hospitals in Utah. Considered the “gold-standard” for hospitals, the American Nurses Credentialing Center recognizes organizations that “provide nursing excellence” and “an environment conducive to attracting and retaining well-qualified nurses who promoted quality care.” Utah, Nevada and New Mexico are the only three states in the country without any Magnet hospitals.
So, how can all these factors coexist?
How can Utah nurses feel overworked in a state that is producing more nurses than ever?
Chris Brown Mahoney, a professor of management at Minnesota State University, Mankato and former registered nurse puts it quite simply: “You’re filling a bucket that has holes in it.”
The state of Utah has four major health care systems — Intermountain Healthcare, University of Utah Health, HCA Healthcare (known locally as MountainStar Healthcare) and Steward Health Care, which operate nearly all of the 35 acute, critical care hospitals in the state (not including specialty or children’s hospitals). Intermountain operates 16 of those acute care hospitals, HCA has eight, Steward has five and the University of Utah has one.
For comparison’s sake, neighboring Colorado has 56 acute care hospitals, while Iowa, a state with a similar population to Utah, has 40.
Intermountain Healthcare, in addition to being the largest health care system in Utah, is also the state’s largest employer — with more than 20,000 employees, including 10,296 nurses, “and hiring new nurses every week,” said Brad Gillman, a media relations manager with Intermountain Healthcare. Those nurses make up roughly 44% of the state’s active, directly involved in health care nursing force of 23,000 RNs.
The University of Utah employs 2,104 in-hospital nurses, according to the university’s health director of media relations, Kathy Wilets, and HCA has roughly 2,000 nurses in Utah, said Chris Taylor, MountainStar Healthcare assistant vice president of communications.
And it’s a constantly growing workforce.
Between 2014 and 2019, the number of active RN licenses went up by nearly 22%, according to a 2020 report from the Utah Medical Education Council titled “Supply of Nurses in Utah.”
In 2017, Utah had 1,401 nurse graduates who passed the licensing exam. By 2019, there were 1,823 yearly graduates — partly the result of a 2017 Utah Nursing Consortium and the Utah Action Coalition’s initiative, spearheaded by Teresa Garrett, assistant professor in the University of Utah College of Nursing who holds a doctorate degree in nursing practice.
The group of nursing leaders and community advocates successfully requested more legislative funding for nursing education to boost the number of graduates by 200 every year.
In the first two quarters of 2020, the number of passing graduates is already at 1,421. There are also three or four applications for every one nursing school slot, and qualified applicants are turned away every year, Garrett said.
“If such trends continue, the nursing supply is predicted to increase steadily over the next decade,” the council’s report proclaims.
Utah, by such accounts, has no problem filling its hospitals with new nurses. The question is, can they keep them there?
Utah’s nurse turnover in the second quarter of 2020 was 3,123 — an all-time high, and 39% higher than the same quarter in 2019, according to a new Utah Medical Education Council report on RN employer demand.
HCA was the only health care system to comment on its nurse turnover during 2020, noting it lost 150 nurses across eight hospitals — a similar number to 2019 — but hired 250, said Taylor.
“These changes correlate with the economic downturn in response to the pandemic,” the Utah medical council report notes. “It will be important to continue to track changes in turnovers and new hires in the near future in order to maintain a pulse on the impact of the pandemic on the state’s RN workforce.”
The razor’s edge
Pandemic or not, nurses don’t leave because they’re tired of caring for people, said Linda Cassidy, strategic advocacy manager with the American Association of Critical-Care Nurses. They leave for reasons that include problems at work, such as understaffing, low pay and underinvestment from management which can become “insurmountable barriers” to providing care.
In the “Critical Care Nurse Work Environments 2018” study, 60% of nurses reported inadequate staffing levels in their hospitals the majority of the time. The study also found that among nurses who planned to leave within the next 12 months, 52% said better staffing would very likely make them reconsider leaving.
Another study from December 2019 to February 2020 in New York and Illinois found that nurses’ caseloads were high — especially in New York City — and half of nurses in both states were already burned out before COVID-19 hit.
Such studies clarify the pandemic didn’t create staffing problems — it merely exacerbated a “preexisting condition,” said Matthew McHugh, a professor of nursing and associate director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
Too many U.S. hospitals were using “just-in-time” staffing, operating on “the razor’s edge” of having just enough staff to get by in noncrisis times, McHugh said.
Such an approach may work for companies that manufacture cars or T-shirts, because the amount of work to be done is “knowable and you can plan for it,” said Linda Aiken, McHugh’s colleague and a professor in nursing and sociology, and the founding director of the Center for Health Outcomes and Policy Research. “But you cannot specify the amount of care that a hospital might need to provide — it’s unknowable. Anything can happen.”
And it often does, which means nurses are often asked to stay later, come in earlier, pick up extra shifts or extra patients — all things that can lower employee morale, while increasing the number of nurses could improve patient safety.
Consider these findings:
- A 2018 analysis of more than 175,000 ICU patients across six studies found that higher nurse staffing levels reduced a patient’s risk of in-hospital death by 14%.
- Adding one more full-time RN in a unit per patient day would result in fewer deaths as well as less hospital-acquired pneumonia, cardiac arrest and even 24% shorter ICU stays.
- Alternatively, each additional patient added to a nurse’s load had a 7% increased chance of dying within 30 days of hospital admission, plus they increased the nurse’s chance of burnout by 23% and job dissatisfaction by 15%.
COVID-19 just made everything more difficult.
Of the 35 Utah nurses we talked with, nearly every one told us that staffing is a key factor in being able to care for their patients safely — and in many cases had been a struggle before COVID-19. They wanted to share their experiences but were afraid of losing their jobs or being punished by managers, which is why we’ve used only first names or initials and few professional identifiers.
- Before COVID-19, Eric would spend his entire ICU shift caring for one patient, occasionally two. Then the pandemic hit and he said he had five shifts in a row caring for three COVID-19 ICU patients, who were sicker than anything he’s ever seen. One night, on a 1:1 shift, his patient was so ill he said he entered their room and didn’t come out for seven hours.
- C. said she leaves her hospital feeling like she can’t do her best for anybody. “I can only be in one place at one time,” she said. “But you leave feeling like all your patients were waiting on you the whole day. It’s so unsatisfying — you feel like a bad nurse. Is it because I’m new and not used to everything or is it justifiable to say that we are being overworked?”
- One ICU nurse said when COVID-19 hit he ended up working 12-hour shifts, six days a week, and said he was asked to do even more. He got emails from management encouraging him to take care of himself, but in working “all these crazy hours,” it felt disingenuous, he said. He left full-time nursing in the fall and said many of his colleagues aren’t far behind.
“I’ve talked to a lot of the nurses and they’re really only in it for each other,” he said. “After this is done, they’re just done with it.”
- Sierra started on a hospital unit in January 2020 that was on day 100 of no falls by patients. Yet when the pandemic hit, the hospital began rearranging. Instead of caring for surgical patients, her unit became filled with higher-need patients but no extra staff. Within four months, the number of falls had jumped to 30.
“Everyone’s getting burnout,” she said. “It’s not normal to cry going to work and on your break, and most of my co-workers were doing that. Management told us to work hard and don’t complain.”
But they did hang a “thank-you sign” in the facility’s break room. Within days it was covered with other messages in red Sharpie: “Stop asking for overtime! We are tired already after our own shifts,” and “Please hire more people,” a message pointed to by more than eight other arrows.
Sierra said the sign stayed up for nearly a month and a half but nothing changed. She finally broke her two-year contract and paid back $6,500, but said she’d “do it all over again, it was that bad.”
Sierra never planned to leave the hospital — she had been working on the same floor where her mom began her nursing career in 1987.
“But the whole experience just turned me off to the hospital,” she said. “I don’t think I’ll ever go back.”
Garrett, with the University of Utah College of Nursing, fears such stories may become common.
“We’re taking a job that was already stressful and highly rewarding and we’re adding a layer of stress of the pandemic,” she said. “What I worry about in the nursing workforce is how we will get through the pandemic, and how many nurses we will have left after the pandemic. What are we doing today to make sure they make it till August or September?”
Pay and morale
National mean pay for RNs is around $37.24 an hour, according to the Bureau of Labor Statistics.
Utah nurses told us starting wage is around $26 or $27 an hour, while in 2020 the state’s median nurse pay was $37 per hour — up from $30 in 2015, said Clark Ruttinger, director of Workforce Research and director of the Utah Nursing Workforce Information Center within the Utah Medical Education Council.
No hospital system would comment directly on nurse salaries, and Intermountain Healthcare, University of Utah Health and Steward declined to answer questions about whether nurses received any sort of hazard pay, bonuses or additional compensation during the pandemic.
Taylor said HCA did provide a one-time bonus to all full-time and part-time facility-based employees in November. HCA’s senior and corporate leadership also took a 30% pay cut in April, May and June to fund the company’s pandemic and quarantine pay programs.
Intermountain nurses said those who pick up extra shifts get bonus pay. Aside from that, they said they got a $50 gift card.
Salaries are also another pretty clear way to identify a shortage.
“If they don’t have enough people they would raise the wages,” said Mahoney from Minnesota State. “That’s what you do when you don’t have enough people. I don’t care if it’s babysitters or computer programmers or engineers, you raise the wages. But they’re not doing that, are they?”
It’s no surprise to Utah nurses the state has low wages.
ICU nurse Kyle Harvey believes it’s a combination of few major employers, a service-oriented population and, in some cases, an incorrect assumption that most nurses are women whose income is secondary to that of their husbands, and thus doesn’t need to be higher.
“I do it out of the goodness of my heart,” the 49-year-old said, “but I should be compensated for it. People are leaving because they can’t afford to stay.”
Those feelings were magnified as he watched travel nurses flood the state — making in a week what a typical staff nurse makes in nearly a month.
He would know.
He traveled as a nurse to California to help during its spring surge. This year his income will be nearly triple what he would have made just staying in the state.
He acknowledges traveling wages are extremely high right now, but even in non-pandemic situations, a trained ICU nurse hired by a hospital for an eight- or 13-week crisis contract makes more than a staff nurse. Such nurses don’t need to be trained by the hospital or paid a yearly salary and benefits, so it’s an expense many hospitals are willing to bear.
Ben Borys said he saw traveling nurses come in droves to Intermountain Medical Center in Murray, providing the same ICU nursing care he was. Yet he was getting $27 an hour while they were making around $80 an hour, he said.
He appreciated their help but kept hoping for some sort of hazard pay. Even $3 an hour more would have signaled the hospital noticed and appreciated the fact that he was working with COVID-19 patients 99% of the time.
“I just waited and waited for that little bit, and it never happened,” he said.
So he left and became a traveling nurse himself.
He went to California for a month, came home for a needed mental health break, then traveled again for another few months. Today, he’s back at Intermountain Medical Center as a traveler — making four times what he made as a staff nurse.
When he walked back onto the unit with his former colleagues, one of them wryly told him, “I hate you for doing this, but I love you for coming back.”
Intermountain has hired between 200 to 300 traveling nurses during the pandemic, paid for with a blend of federal and hospital funds, said Gillman with Intermountain. During a normal year, the system only brings on 20 to 30 nurses.
HCA said they’ve contracted with around 100 traveling nurses across eight hospitals, with a non-pandemic contract labor force of less than 2%.
Yet for Utah nurses who can’t pick up and travel or don’t want to leave their hospitals, the glaring pay discrepancy stings.
“Here we are in the middle of a pandemic and what we need are ICU nurses,” one Intermountain ICU nurse said. “How am I gonna live with myself 10, 20 years from now, when in the moment when we needed ICU nurses and I left? And they know that. They know we’re gonna stay because of our patients and our co-workers. They know the majority of us are going to stay and they can do whatever they want. They don’t have to pay us, we’re still gonna stay, because we feel that responsibility.”
Yet as soon as she finishes that thought, she pauses, remembering the panic attacks that she says now precede each night shift.
“There have been so many nurses that ... have said, ‘I don’t know if I’m going to be able to be a nurse after this is over,’” she said. “That’s been my big thing, too. I don’t know how much longer I can keep doing this the way that it is.”
Patching the holes
It was 1981 and four expert nurses — Margaret Sovie, Margaret McClure, Muriel Poulin and Mabel Wandelt — were tasked with solving a pressing national problem.
Hospitals were hiring new nurses but couldn’t keep them. More than 100,000 nursing positions were empty and 80% of U.S. hospitals had inadequate staffing.
This new American Academy of Nursing Task Force determined that instead of rehashing the problems of turnover, they would study hospitals that were doing it right.
Their landmark study of 41 hospitals identified 14 forces of “magnetism” — qualities that “successfully attracted and retained professional nursing staff in a time of shortage,” as well as “shaped environments of excellence,” Poulin wrote in 2017.
The forces included quality nursing leadership, a management style that values and encourages employee feedback, flexible personnel and staffing policies, quality of care, nurse autonomy and others.
“Most striking was the large number of instances in which the word ‘listen’ was used by both the directors and the staff nurses,” according to the original Magnet study report. “It emerged frequently, for instance, in response to the question, ‘What single piece of advice would you give to a director of nursing who wished to do something about high registered nurse vacancy and turnover rates in her hospital?’ Typical of the responses given by the directors of nursing was this statement: ‘Listen to the staff ... the best consultants are on your own staff.’”
That report paved the way for an official “Magnet recognition” from the American Nurses Credentialing Center, a subsidiary of the American Nurses Association, and roughly 8% to 9% of U.S. hospitals — currently 552 — have earned such a label.
Magnet facilities have been studied for nearly 40 years and the “evidence suggests that no matter what gets thrown at the health care system, outcomes are better” in magnet hospitals, says McHugh with Penn Nursing. “There is no reason to suspect that COVID is any different.”
In 2005, four of Intermountain’s Utah hospitals were awarded Magnet recognition, and the organization expressed an intention to have “all its hospitals Magnet certified.”
Today, Utah has zero Magnet-recognized facilities.
When asked about what happened, Intermountain replied that it remains “supportive of the principles and goals of Magnet as they represent what is best for patients and caregivers.”
“Most of the nation’s hospitals do not seek the Magnet designation,” said Gillman.
(HCA’s Timpanogos Regional Hospital in Orem is the only Utah hospital that has a Pathway to Excellence designation, also from the American Nurses Credentialing Center, which is a complementary designation to Magnet that “emphasizes supportive practice environments that promote engaged and empowered staff.”)
Achieving Magnet status requires a “rigorous review and intensive survey process,” plus it’s expensive. Despite the cost, Garrett with the University of Utah College of Nursing said she’s a fan of the status because of the support it extends to nurses.
“Nurses deserve to be paid more. They also want to be treated as professionals and be at the health care decision-making table,” she said. “That goes a long way, if you’re called in to do an extra shift, or in lean times called off a shift and you can’t expect to have 12 hours of salary, that you know your opinion and your professional growth are valued and the organization is investing in you and your teammates. That helps raise up the satisfaction level when the salary can’t quite be there.”
Yet as the pandemic continues, some nurses worry that not only is the salary missing, but so is the the willingness, both from the general public and some bosses, to listen to them.
Just ask Sean Freeman.
Freeman remembers coming into a hospital cardiac catheterization lab in early 2020 to find his bosses sitting around a table covered in resumes. They were looking at nurses’ backgrounds and deciding where to send people when the surges began.
Freeman, who has 10 years of critical care experience, was later told he’d be sent to the ICU and required to work 12-hour night and weekend shifts.
He said he went to his director and reiterated that his wife is a physician and his daughter’s day care had strict hours (and was temporarily closed because of pandemic) so he couldn’t work the new proposed schedule. But he still wanted to help — was there anywhere else they could send him?
He applied for temporary leave so he could better arrange child care, as their nearest relative is in Wisconsin.
Several colleagues, including Ronda Catmull, who has 21 years of ICU experience, said she offered to take his spot in the ICU so he could stay in the lab on the same family-friendly schedule that was the main reason he took the job in the first place.
Freeman’s last shift was May 18. He was one of two experienced nurses (out of 15 in his unit) who left.
He said it didn’t have to be this way.
“I loved my job, I loved the management, I loved every single person that I worked with and what I was doing, it just didn’t really matter,” the 39-year-old said. “They let me walk out the door. I would have stayed forever.”