Across the country and the state, nurses are quitting — often for better-paying employment as travel nurses, who work on short-term contracts to cover full-time employees’ leaves of absence and staffing shortages. Hospitals are struggling to fill the gaps in patient care left behind, but nurses said the changes that would make them stay — retention bonuses, financial incentives to work extra shifts, guaranteed rest breaks — have yet to be meaningfully implemented.
The numbers of nurses have already dropped significantly. According to a survey of 80 Washington hospitals by the Washington State Hospital Association, 6,100 nurses are needed to fill existing vacancies in the state. Even with 2,957 travel nurses currently working across the state on 13-week contracts, 3,143 positions remain open, and filling them is taking longer than it used to. According to the association's survey, the average duration of an open registered nursing position increased by 54% between 2019 and 2021.
Meanwhile, nurses still on the job are coping with the pandemic. As of Dec. 15, 44,067 Washingtonians have been hospitalized with COVID-19, according to the state Department of Health, with the highest rates of hospitalization in Snohomish, King, Pierce, Clark, Yakima, and Spokane counties. Washington hospitals have also been tasked with taking in critically ill COVID-19 patients from other states.
While only 2% of the state’s health care workers have left their jobs after refusing to get vaccinated against COVID-19, those departures have disproportionately impacted staffing in rural hospitals, reported Washington State Hospital Association’s Cassie Sauer at the group’s November media briefing. She noted that some medical services were still “constrained” in rural hospitals.
This can be especially challenging for the nurses who work in those hospitals. Paul Fuller is one of them. Based in Wenatchee, Fuller works as a critical care nurse. He’s responsible for placing peripherally inserted central catheter lines and arterial lines, and responding to Code Blue emergencies.
Before he became a stat nurse, Fuller worked in his hospital’s intensive care unit ICU at the height of the COVID-19 pandemic. He recalled returning from work on days after taking care of COVID patients. He’d shower and sleep in isolation from his family in an effort to protect them.
“For us, it’s our burning house for firefighters or active shooter for police. This is the situation where nursing gets really intense,” he said.
As the COVID-19 pandemic continues, Fuller has said goodbye to many of his colleagues. He’s seen capable co-workers depart for more lucrative opportunities as travel nurses, to be replaced temporarily by travel nurses or new full-time employees. But even among the new hires, Fuller said, he has seen significant turnover.
“The amount of experience that left, it was just painful,” he said.
Media coverage of health care workers’ experiences during COVID-19 often compares the ICU to a war zone. Before he became a nurse, he was an Army medic, and sees similarities between his deployment in Iraq and his experience as a nurse during a pandemic. COVID-19, he said, exacerbated existing staffing shortages and concerns about policies related to consistent scheduling and time off.
“Deployments don’t create new problems,” he said. “They just make all the problems that you had before worse.”
It’s clear from accounts like Fuller’s that the conditions that led to the current staffing shortage have been in play for a long time. That’s borne out by data and analysis from the Washington State Hospital Association. According to Chelene Whiteaker, the association’s senior vice president for government affairs, the nursing shortage “had been on the horizon for some time, and yet I think the pandemic has accelerated it in ways that were just unforeseeable,” as it did in many industries.
Whiteaker also said the state has not been able to graduate new nurses into the industry at a rate that keeps up with the state’s population growth.
While news reports have centered on health care workers leaving their jobs in opposition to COVID-19 vaccine mandates, the vaccine has had less of an impact than the hospital association had initially expected. Only 2% of health care workers in Washington left their jobs after refusing the vaccine, but the vast majority did not. In association’s Nov. 15 media briefing, CEO Cassie Sauer said that in addition to the 2% who had been let go, about 94% of hospital staff in the state had been fully vaccinated against COVID-19, and the remaining staff had received exemptions or were “in the process” of getting vaccinated.
The association’s data doesn’t provide a full picture of the primary reason registered nursess are quitting: In a breakdown of responses given in exit interviews, 27% of departing RNs listed “other” as their reason for leaving. More likely explanations are burnout (cited by 10% of respondents) and the draw of travel nursing (15%).
Unlike their counterparts in full-time positions, travel nurses receive temporary, 13-week assignments to fill coverage gaps at hospitals. The higher pay can be an incentive for nurses looking to leave their jobs. Recent job postings for travel nurse positions in Washington offer salaries of up to $6,000 a week. For comparison, the average income for a registered nurse is much lower: $91,000, or about $1,750 a week, for salaried employees and $78,000, or about $1,500 a week, for hourly workers, according to a compensation report compiled by Medscape, a health care industry website. That differential can be burdensome for hospitals, making travel nursing an impractical solution to the staffing shortage, said Whiteaker.
“There's only so many people that do this work that it's not a long-term solution, because you're actually not creating more nurses. You're just pulling nurses that are working in other areas into those traveler contracts,” she said.
The pay disparity can also lower morale for nurses who retain their permanent positions but work alongside travelers.
“Imagine spending the entirety of this pandemic at the bedside, and the person next to you is a traveling nurse making upwards of three- to four-times as much while the hospital apparently can’t find resources for retention bonuses or incentive pay,” said Harborview Medical Center nurse Tracy Mullen in a news release from the Washington State Nurses Association circulated in October.
The state hospital association’s proposed policy solution to the staffing shortage takes a long view, with the goal of eventually ending the shortage by building greater capacity to train nurses and finding clinical placements for them. But when it comes to addressing the acute crisis they’re facing in ICUs across the state, nurses and the professional organizations that support them have other solutions in mind.
“For us, it’s our burning house for firefighters or active shooter for police. This is the situation where nursing gets really intense,” Paul Fuller said. During the height of the pandemic, he worked in the ICU at Central Washington Hospital and saw many of his colleagues leave for less stressful or more lucrative opportunities. (Courtesy of Washington State Department of Health)
In its October news release, the state nurses association outlined a series of policies hospitals could implement quickly to assuage nurse burnout levels and provide them with better working conditions. The association called for hospitals to end mandatory overtime policies, guarantee safe rest breaks, offer retention bonuses for frontline workers who’ve stayed in their roles, provide incentive pay to workers taking on additional shifts or working outside of their usual departments and post enough positions “to achieve safe staffing levels” — and actually work to fill them.
“We’ve heard near-unanimous agreement around the problem. That’s great,” said Toppenish-based critical care nurse Julia Barcott in a statement accompanying the state nurses association’s news release. “But only one voice in this conversation has the ability to immediately begin fixing this problem, and that’s the hospitals.”
Some have implemented changes like these. According to the state hospital association’s survey, 85% of hospitals offered an extra-shift bonus, 61% provided retention bonuses and 37% had increased base pay for nurses.
Critical care nurse Paul Fuller’s hospital initially offered a COVID bonus, but the policy changed when vaccines became available, he said. He has considered leaving for a travel job, but he’s raising a family in Wenatchee, and values the long-term interactions between patients and providers that come with working in a rural hospital. He doesn’t want to leave his workplace and community behind.
But if nothing changes, he suspects that he’ll continue to see colleagues leave for higher-paying positions elsewhere. And in the meantime, Fuller still works with patients who are extremely sick with COVID-19, many of them dying.
“When you go to deployment, you can’t always be in crisis mode,” he said. “It’s been two years of crisis.”