Vacancies in nursing positions across Massachusetts have decreased, according to a recent report on the state’s workforce from the Massachusetts Health & Hospital Association, and while nurse and hospital leaders have acknowledged the positive benefits from this, they say there is still work to do.
The new data shows that one in every 10 nursing roles are now vacant compared to other post-pandemic years where one in every six roles were vacant — a 5% decrease. This displays improvements, but these rates are now what they were before the COVID-19 pandemic, said Aaron Winston, a registered nurse and committee co-chair for the Massachusetts Nurses Association.
“Before we start celebrating, we need to really take a hard look at what constitutes business as usual,” Winston said. “If you look at this data, there has been such a rush in the health care professions to kind of put the pandemic behind us and go back to ‘normal.’ But normal was not great.”
Valerie Fleishman, executive vice president and chief innovation officer of the Massachusetts Health & Hospital Association, said the vacancy decrease shows “major progress” within the past two years. New nurses are entering the field while those who may have previously left are returning, she said.
“There’s still huge gaps and strengths that exist, but we really like where the momentum is going,” said Sam Melnick, the Massachusetts Health & Hospital Association’s chief communications officer.
The decrease in nursing vacancies reflects a wider trend across health care in Massachusetts, which reduced industry-wide openings overall by 28%. Nursing-related positions made up five out of the top 10 roles that had the largest drops in vacancy rates.
However, in May, the Massachusetts Nurses Association recorded that 78% of nurses said hospital care quality has worsened within the past two years, with understaffing listed as the top obstacle for nurses.
Several Massachusetts nurses attributed working conditions as the reason why most nurses exit the industry, pointing specifically to long hours, inadequate time for necessary care and attention, insufficient pay and caring for too many patients at once. Most of these problems could be solved with better nurse-to-patient ratios, they said.
“There’s not a shortage of nurses,” said Massachusetts Nurses Association President Katie Murphy. “There’s a shortage of nurses willing to work under these circumstances.”
Murphy, who has been a bedside nurse and currently works as a critical care nurse, said she has heard anecdotally that conditions have gotten better at times but still hears that those changes are not necessarily happening where they should be, which she said is at the bedside.
“We have a long way to go,” she said.
The Nurse Journal ranked Massachusetts as the third best state to work as a nurse, after California and Colorado. It is one of the only states that has a nurse-to-patient ratio law enacted — a 1:1 or 1:2 nurse to ICU patient ratio — but does not have industry-wide requirements.
However, “just because it’s better doesn’t mean that it’s good,” said Winston, who previously worked in Virginia, where he said the conditions nearly resulted in him exiting the industry.
“There is still a burden [in Massachusetts], and the work of nursing is incredibly difficult,” he said. “What seem like relatively simple, innocuous policies in how hospitals are run profoundly affects how we are able to do the work that we have been trained to do.”
Solutions
The Massachusetts Health & Hospital Association launched its statewide Healthy Work Environment Academy for a cohort of 10 hospitals this past summer, and it will be starting its second round in March for 10 more hospitals. The program focuses on creating a healthy work culture to retain current nurses and attract new nurses.
The association has also organized resiliency and peer support programs and looked at ways to provide wraparound services for promoting a better work-life balance. These services include financial counseling, child-support and flexible scheduling.
Anecdotally, responses to the Healthy Work Environment Academy have been “incredibly positive,” Fleishman said.
The American Nurses Credentialing Center currently lists 17 hospitals as “magnet destinations,” so they are recognized for providing a healthy work environment to nurses. The Massachusetts Health & Hospital Association hopes to expand this designation to more hospitals statewide through the Healthy Work Environment Academy, Fleishman said. It is also looking into alternative positions for different care-team members, including virtual nursing and using artificial intelligence.
Patricia Noga, a registered nurse and vice president of clinical affairs with the Massachusetts Health & Hospital Association, pointed toward the Nurse Licensure Compact — a law allowing nurses to provide care in other compact states — expanding fields like nurse practitioners, midwives and nurse anesthetists.
Fleishman said the association is providing the “vehicle” for hospitals to develop career-ladder programs, which allows them to train nurses to perhaps move to another area of expertise or another specialty.
However, some nurses said rather than finding other avenues in the industry, what hospitals need to do is improve working conditions so they want to stay at the bedside instead.
Barbara Connor, a registered nurse, said a key staffing issue is nurses become trained and then leave the practice. The reasons, she said, could range from being liable for making a mistake — which could be exacerbated if a nurse is working long hours on an understaffed floor — to experiencing workplace violence.
“You could get a job doing something else that gives you a much better work-life balance, and you don’t have to worry about being sued or hit,” Connor said.
Many nurses have called for mandated nurse-to-patient ratios as the main solution for understaffing alongside stricter laws to protect them against violence in hospitals.
Noga said staffing is an “ongoing process,” since patients’ conditions can change rapidly and care teams then adjust for that. She said additional members of the care team and the training and competencies of nurses on a certain unit are other factors to keep in mind when thinking about staffing ratios.
“We trust that the nurses with their leaders are developing staffing plans that reflect the patient population they’re caring for,” Noga said.
Melnick added that, on a broader level, there is a focus to “keep people out of the hospital in the first place,” which could lower costs and remove some pressures on caregivers.
The Massachusetts Health & Hospital Association’s report states that “additional legislative action and targeted investments” are required to continue the momentum gained from programs like the Healthy Work Environment Academy to close workforce gaps and expand care. It is championing a bill alongside the Massachusetts Nurses Association and 1199SEIU Massachusetts to address and prevent workplace violence.
Several nurses pushed back against the term “burnout” because of its implication they are to blame for exiting the industry when many leave because of what they described as unsustainable working conditions.
“[Burnout] puts [the blame] on the nurse instead of where it really should be, [which] is the people who are scheduling the nurses, who are hiring the nurses, who are saying ‘yes’ and ‘no’ to bringing in more support,” said Sarah Bessueille, a registered nurse.
Winston pointed toward staffing as the heart of this issue because nurses then have to choose between what one patient deserves and what other patients need. If there are not enough staff, the demand becomes “untenable,” he said.
“People all the time, all across [the] state, say to me, ‘I left my shift an hour late because I had to document everything I had done,’ or ‘I had to sit in my car and cry for a half an hour because I was afraid I hadn’t done everything that I was supposed to do or I was afraid I missed something,’” Murphy said. “This wears you down when it’s people’s lives you’re holding in your hands.”
Vicki Good, chief clinical officer of the American Association of Clinical-Care Nurses, conducted her doctorate work on burnout and said bedside nurses are particularly susceptible to burnout because they are at the bedside around the clock. She added that nurses tend to react negatively to the terms “burnout” and “resilience.”
And while hospitals can spur burnout from inflexible scheduling and disregard for a caretaker’s input, nurses are also accountable for taking care of themselves so they can perform at the highest level, she said, making this a “joint responsibility.”
Several caretakers said the “bottom line” is the main reason for understaffing, so nurses are the first place hospitals look to when making budget cuts.
“We really have to be smart about how we’re spending our health-care dollars, but [hospitals] need to listen to the folks on the front lines who are providing the actual hands-on care,” Murphy said. “We have to have a seat at the table in figuring out the solutions.”
Nurses also raised concerns about liability and the physical and mental conditions behind burnout, all of which they said can be very taxing.
“If you make a mistake, you’re held liable for that and you could lose your nursing license,” Connor said. “And if you lose your nursing license, you have lost your livelihood. So there’s repercussions to making an error.”
Bessueille said hospitals might “think twice” before understaffing if more of the liability is shifted to them. She said she is “one of the fortunate ones” because she works at a union hospital, so she has support if she raises a concern, but other nurses’ concerns might be met with “deaf ears.”
Both hospital leaders and nurses have agreed that more work needs to be done.
“We’re paying so much money [for health care] and our outcomes falter behind other nations,” Murphy said. “There’s money in the system, but where is it going? [Nurses] feel over and over again it has to be at the bedside.”