A pandemic marked by demanding conditions for hospital nurses, understaffing and workplace violence has contributed to the worst workforce shortage in recent Texas history.
Vacancies for registered nurses tripled from around 6 percent in 2019 to 17 percent in 2022, according to new data released by the state. The shortage for licensed vocational nurses has more than quadrupled during the same time frame.
"It was not surprising to me," said Serena Bumpus, President of the Texas Nurses Association. "Our patients coming into the hospital are much sicker than we’ve ever seen before. Our hospitals are full more often than not because of COVID — patients who (delayed care) and now have long-term issues. We’re dealing with long COVID also."
The shortage, which is present in all parts of Texas, has been most severe in Central Texas. Pediatric ICU openings have also been the hardest positions to fill.
The survey of over 300 hospitals was conducted by the Texas Center for Nursing Workforce Studies. It provides the clearest picture so far of the nursing landscape in Texas, after many anecdotal reports of burnout and grueling conditions.
"Nurses are now finding their voice and saying, ‘we shouldn’t have to tolerate this anymore,' specifically around workplace violence,” Bumpus said. “So some nurses are choosing to leave to go find alternative places to work outside of the hospital setting."
Most hospitals in the report have seen nurses leaving for travel jobs, leaving due to insufficient staffing or deciding to retire early — the top three consequences of the COVID-19 pandemic on the profession.
Erica Yu, an Associate Dean at UTHealth's Cizik School of Nursing, has conducted exit interviews with nurses leaving their jobs over the past year.
"The number one reason is money," Yu said. "Nurses are taking this opportunity to make higher salaries whether they move to another hospital with sign-on bonuses or travel assignments. Other reasons are they're not happy with their current positions or burnout."
Hospitals across the state have employed a series of recruitment strategies to attract talent to apply to open positions, the report said. These include standard offerings like paid vacation and health insurance, but also flexible scheduling, merit bonuses and even sabbatical in some cases.
As far as the immediate understaffing woes, a large number of hospitals have temporarily moved staff like physical therapists and respiratory technicians from their traditional roles in order to support nurses spread thin. Other hospitals decided to change nurse-to-patient ratios.
The report's top recommendations to address the shortage is to ensure safe working conditions for nurses, particularly when it comes to staffing levels.
"We want to find that sweet spot in terms of the best patient care ratio where we’re able to provide high quality and safe care while preventing burnout for nurses," Yu said.
Another solution detailed in the report is to address workplace violence through ongoing surveillance and creating a culture that encourages reporting.
The impacts of understaffing ultimately trickles down to patients and the quality of their care, Serena Bumpus said. Fewer nurses could impact the quality of care and increase ER wait times.
"First and foremost, the more patients a nurse has the less time the nurse can spend with the patient," Bumpus said. "Sometimes this means hospitals have to close beds and patients then sit in the emergency department for hours or days on end. Being cared for in the ER — it’s a very hectic and chaotic environment, not an environment of healing."
These negative patient experiences due to understaffing can then whip back around and further hurt nurses.
"We’ve also seen in short-staffed hospitals there is a higher rate of workplace violence incidents," Bumpus said. "That’s due to the simple frustration that our patients have to wait longer, so they or their family members get upset and that exacerbates behaviors that we shouldn’t have to tolerate."
Hospitals are aware of the pressing need to invest in more nurses. Growing healthcare demand, both in terms of the volume of patients and how sick patients are, has prompted the majority of hospitals surveyed to up their budgets for registered nurses in recent years.
But this supply will not keep pace with demand, according to projections in the report. The shortage is expected to grow to 57,000 registered nurses in Texas by 2032.
Bumpus said solutions to address the issue need to come from a coordinated effort — both support from the Texas legislature, as well as changes within the industry.
"We can continue to churn nurses out of nursing schools all day long, however, if the work isn’t done inside the organization to foster a healthy work environment, we will continue to see nurses leave the bedside," Bumpus said. "It has to happen on both ends."