While nurses and hospital leaders say it’s a positive that there’s been a recent decline in nursing vacancies, they also say there’s still work to do.
New data from the Massachusetts Health & Hospital Association (MHA) show that one in every 10 nursing positions is vacant, compared to other post-pandemic years when one in six roles was unfilled. While that’s an improvement, it only gets the vacancy rate down to where it was before COVID-19, according to Aaron Winston, a registered nurse and committee co-chair for the Massachusetts Nursing 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 MHA, said the decrease in vacancies 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,” added Sam Melnick, MHA’s chief communications officer.
The decrease in nursing vacancies reflects a wider trend across health care in Massachusetts, which saw a 28% reduction in openings industry-wide. Five of the 10 positions that experienced the largest drops in vacancy rates were nursing-related.
MNA survey: 78% of nurses say hospital care quality has declined
However, in May, the MNA recorded that 78% of nurses said hospital care quality has worsened in the past two years, with understaffing listed as the top obstacle.
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 MNA 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 in critical care, said she has heard anecdotally that conditions have gotten better at times. But she also 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. The Bay State is one of the only ones 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 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 seems 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.”
MHA launches program promoting healthy work culture
The MHA launched its statewide Healthy Work Environment Academy for a cohort of 10 hospitals last summer, and it will start a second round in March for 10 more hospitals. The program focuses on creating a healthy work culture to retain current nurses and attract new ones.
The MHA 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 HWE have been “incredibly positive,” Fleishman said.
The American Nurses Credentialing Center lists 17 hospitals as “magnet destinations,” so they’re recognized for providing a healthy work environment for nurses. The MHA hopes to expand this designation to more hospitals statewide through the HWE, Fleishman said. It’s also looking into alternative positions for different care-team members, including virtual nursing and using AI models.
Patricia Noga, a registered nurse and MHA vice president of clinical affairs, 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 and remote monitoring as growing opportunities for nurses.
Fleishman said the MHA is providing the “vehicle” for hospitals to develop career-ladder programs, allowing them to train nurses to perhaps move to another area of expertise or specialty.
Nurses say improvements are needed in regards to bedside care
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 bedside.
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,” because patients’ conditions can change rapidly and care teams must 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’s a focus to “keep people out of the hospital in the first place,” which could lower costs and remove some pressures on caregivers.
The MHA’s report states that “additional legislative action and targeted investments” are required to continue the momentum gained from programs like the HWE to close workforce gaps and expand care. It’s currently championing a bill alongside the MNA and 1199SEIU Massachusetts to address and prevent workplace violence.
Nurses say enough with the term ‘burnout’
Several nurses pushed back against the term “burnout,” saying it implies they’re to blame for exiting the industry when many leave because of what they describe 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 to 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, 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 Critical-Care Nurses, conducted her doctorate work on burnout and said bedside nurses are particularly susceptible to it because they’re 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 caretakers’ 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.”
Concerns about who should absorb liability
Nurses also raised concerns about liability and the physical and mental conditions behind burnout, all of which they say 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. 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 moving forward 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.”