Why the U.S. Nursing Shortage Keeps Getting Worse

Updated Jan. 12

Nurses in both the U.S. and U.K. flexed their bargaining muscle over the last few weeks amid increasing pressure on the countries’ respective health care system due to COVID-19. About 7,000 nurses from two New York City hospitals, Mount Sinai Hospital and Montefiore Medical Center in the Bronx, returned to work on January 12 after going on strike for three days. That followed tens of thousands of National Health Services nurses who went on strike in the U.K. for two days in December—those NHS workers are expected to take to the picket lines again next week. Despite the geographic distance, these nurses are proximate in their demands: that their facilities address serious shortages of health care workers, including by providing higher wages.

The New York State Nurses Association (NYSNA) credited tentative deals on staffing ratios at both hospitals with leading to the end of the strike. The deal also included a 19% pay increase over three years. At Mount Sinai, the bargainers agreed to staffing ratios for all inpatient units with “firm enforcement,” the union said in a statement. The deal reached with Montefiore, entails “new safe staffing ratios in the Emergency Department, with new staffing language and financial penalties for failing to comply with safe staffing levels in all units,” according to the NYSNA.

“Today, we can return to work with our heads held high, knowing that our victory means safer care for our patients and more sustainable jobs for our profession,” the union said.

The striking nurses say that staffing shortages started years ago, but the problem has been exacerbated by the pandemic. Between 2020 and 2021, the number of working U.S. nurses dropped by over 100,000, the largest single-year decline recorded in four decades of data, according to an analysis of the Current Population Survey published in Health Affairs in January, 2022. The crisis has continued into 2023; as of publishing, 15% of U.S. hospitals reported shortages in critical-care staffing, according to data from the U.S. Department of Health and Human Services.

Matt Allen, a labor and delivery nurse and an elected leader for the NYSNA, said prior to the agreement that he and his colleagues at Mount Sinai Hospital in Harlem went on strike this past week in an effort to push the hospital to address understaffing, which he says threatens the quality of patient care.

“If COVID didn’t happen, I don’t know if we would be at this point right now,” said Allen. “One, it was just a traumatic experience for lots of us nurses to go through. But then, two, it’s further depleted our staffing by people retiring early, people burning out and leaving the profession or leaving bedside nursing.”

That toll continues to accrue, as the U.S. currently copes with a surge in COVID-19 cases thanks in large part to the new XBB.1.15 variant that is spreading rapidly across the country. As of Jan. 8, over 44,000 people in the U.S. were hospitalized with COVID-19—the most since August last year.

In New York alone, some 32,000 people were hospitalized with the virus in December, which as the chart below shows is the largest number of hospitalizations in over a year. Meanwhile, there are over 1,100 nursing vacancies between the two hospitals, according to the NYSNA.

The American College of Nursing says that shortages of nursing faculty and inadequate expansion of nursing schools in the U.S. have narrowed the pipeline for educating new professionals. Since the start of the pandemic, nurses have also been forced to fight to enshrine adequate staffing in union contracts. In addition to the effort in New York, an adequate nurse-to-patient ratio was a cornerstone of union bargaining that nearly led to strikes in Minnesota last month, and in California in November.

In Allen’s view, the central problem in New York state isn’t a lack of trained nurses, but rather that they aren’t being incentivized to remain in the profession. In New York, there are about 170,000 registered nurses who are not practicing bedside nursing, according to the New York State Nurses Association.

The problem appears to be national, and perhaps getting worse: A survey by the American Nurses Foundation conducted in January 2022 found that 52% of nurses polled nationwide said they were considering leaving the profession, up from 40% from a survey conducted in 2021.

Prior to the pandemic, the aging nursing workforce was already a concern—and it seems that the pandemic has disproportionately pushed younger nurses away from the profession, at a time they are desperately needed. The January 2022 American Nurses Foundation survey found that younger nurses were particularly likely to be unhappy in their careers, with 31% of those aged 25 to 34 reporting that they intended to leave their position within the next six months, compared to 18% among those 55 or older. A big reason why is that young nurses were especially likely to report being in poor mental health, with 66% of those under 35 reporting feeling anxious, compared to 35% of those 55 or older. Younger age is also generally a risk factor for nurse burnout, according to an August 2021 meta analysis published in the Journal of Advanced Nursing. This may be because less-experienced nurses are not used to handling extreme situations like a pandemic, including facing tough situations like watching patients suffer and die when nurses can’t provide standard health care.

According to Allen, the impact of understaffing during the pandemic for both patients and nurses has made him and his colleagues “angry” and “empowered to be taking a stand.” For nurses like him, he says, it’s been painful to work 12 or 24-hour physically demanding shifts, and then to leave feeling “horrible that you didn’t do enough for your patient.”

“There needs to be recognition of the toll this has taken on us,” he says.