Understaffing, abuse spark turnover
By Te-Ping Chen
Paige Campbell became a nurse during the pandemic, wanting to make a difference. She landed a job after college working in the emergency department at a Fort Walton Beach, Fla., hospital.
Since then, she's been kicked, spat on and shoved to the ground. Last year, after an emergency patient strangled her, she left for a role remotely monitoring patients. Front-line nurses are in high demand, but she needed a break.
"All I could think was, 'I can't breathe, I'm going to die here, and who's going to tell my mom and dad?'" Campbell, 33, said. The incident unfolded after an ER patient she'd offered a blanket to became aggressive.
America's nurses are more educated than ever and can command six-figure salaries. Most have their bachelor's degree. Their income has boomed since the pandemic to a median $97,550 a year, and their hands-on work isn't easily automated away. Nursing schools have seen their ranks swell, minting thousands of new graduates every year.
They're also leaving the bedside in droves. Burnout and complaints about understaffing, verbal abuse and workplace violence are pushing many nurses off the front lines and into other careers where their skills are in high demand.
"There is no shortage of nurses in this country," said Jeff Doucette, chief nursing officer at healthcare analytics firm Press Ganey. "There's a shortage of nurses that want to work in the current environment."
Fifteen years ago, bedside registered nurses had an 11% turnover rate, according to data from NSI Nursing Solutions, a nurse-placement firm. The percentage of nurses leaving their jobs every year began to tick up even before Covid, when it spiked further. In the pandemic's aftermath, as more hospitals dangled salary increases, turnover eased. But last year, it rose again, hitting 18%.
One 2024 survey of 800,000 nurses found that roughly 40% said they planned to leave the workforce or retire in the next five years, with many citing stress, burnout and understaffing. In another survey this year, 43% said they were likely to leave bedside roles within the next year, up from 38% the prior year.
A recent University of Pennsylvania survey of 4,000 actively licensed nurses who'd left a job in the past five years found that while 56% are retired, 8% are working in other fields and the rest weren't working.
The revolving door is driving up expenses for hospitals that spend millions to recruit staff and fill gaps, and increasing costs for patients.
Health executives say worker churn also jeopardizes patient safety, intensifying the risk of patient falls, medical errors and missed cues. Senior nurses, in particular, bring vast stores of clinical intuition and operational expertise that help ensure unit safety, mentor less-experienced staff and keep complex hospital floors running efficiently.
A decade ago when managing emergency departments, Dustin Bass said he was accustomed to tapping his most tenured nurses to run triage. With a decade or two on the job, they could look across a room and spot who was having a heart attack.
"Now you have nurses running massive emergency rooms with 133 care spaces, and they've only been working for two or three years," said Bass, president of the Emergency Nurses Association.
Strained staff, rising violence
The American hospital system has grown more efficient, both in terms of footprint and staffing. There are fewer hospital beds, and the ones that remain are occupied on a more continuous basis. Hospitals have adopted software tools to optimize staffing, with nurses more regularly covering shifts on floors where they aren't usually assigned, to meet patient ebbs and flows.
It's a boon for productivity, health executives say. It's also a considerable strain on workers, whose days are more intense and less predictable.
A generation ago, nurses might have worked in a ward of patients recovering from routine surgeries. Today, more patients are seen outpatient, and those who remain tend to be sicker and more medically complex, requiring intensive monitoring. With the growth of clinical testing, nurses are also coordinating care with a bevy of specialists and inputting electronic health records -- often on 12-hour shifts with no more than a 30-minute break.
And they're bearing the brunt of the system's strains. Fewer hospital beds can jam up emergency departments with patients -- some who grow irate waiting for beds. Many hospital emergency departments, meanwhile, have become catch basins for people with unmet mental-health challenges in full-blown crises.
Across all floors, nurses describe a coarsening in attitudes among patients that often leads to friction, if not outright violence.
"The nurse is the face of the hospital, and we're constantly blamed for things outside our control," said Juliet Etienne, 29.
Since starting a job as an emergency department nurse in New Orleans last year, she's been kicked and spat on and had a patient throw a full dinner tray at her. Still, she said she can understand why emergency patients sometimes boil over. On occasion, she's seen them wait more than 30 hours for care.
An analysis of records from 1,500 hospitals by the University of Michigan Medical School and the Beth Israel Deaconess Medical Center in Boston found ER wait times spiked during the pandemic and stayed high through 2024, the most recent data available. During the winter months, when hospitals are busiest, nearly 5% of patients wait over 24 hours for a hospital bed.
"You have people in their most vulnerable times of their life, and their call button's not getting answered because the nurse is overworked, their loved one's not being seen," said Amy Stimpfel, associate professor at Villanova University's M. Louise Fitzpatrick College of Nursing. "It's bubbling up from a system that's sort of broken."
Press Ganey, which compiles reports from a large national hospital sample, found 2.4% of nursing staff were attacked in some manner last year. The rate is up 26% from 2017, the furthest back the survey data go, and amounts to well over 1,000 attacks a month.
This is likely an undercount, since many incidents are never reported, the company said. Assaults can run the gamut from common problems like getting shoved to, in rarer cases, severe attacks such as stabbings.
Surveys by nursing associations and unions peg rates significantly higher: A recent survey of 1,300 nurses by National Nurses United found 33% said they'd been slapped, punched or kicked in the past year, with another 12% reporting being groped or inappropriately touched.
Almost two out of five healthcare workers have considered leaving their jobs because of safety concerns, according to a Harris Poll survey last year commissioned by Verkada, a security-tech firm.
Holly Jazwinski, a 42-year-old emergency-room nurse in Danville, Pa., said she loves bedside nursing. But last summer, a patient punched her in the face, broke her glasses and attempted to stab her with them.
"Now I have this sense of anxiety every time I go to work," Jazwinski said. "I started to feel a little defeated, like what am I even doing here?"
She's currently getting her master's in nursing, which will allow her to pursue other jobs, including in education.
Today's bedside nurses have more career options than previous generations -- an advantage for workers and a challenge for hospitals trying to keep them on the front lines.
Nurse practitioner roles, which require more advanced training and offer more pay, are mushrooming as more states have given them license to independently practice. Careers in virtual nursing and settings like urgent care are also growing.
"Hospital work is hard work," said Teresa Connolly, enterprise chief nurse executive at the Phoenix area's nine-hospital HonorHealth system. "The hours are long, the shifts are not always pretty."
One of its nurses recently quit to become a nurse practitioner, offering cosmetic treatments that patients often pay for in cash. "I can't compete with that," said Connolly.
The system is partnering with a local university to conduct research on why young nurses are leaving the profession early.
Christian Stone, a nurse in Washington, D.C., spent five years working in different emergency departments before leaving to join an urgent-care clinic. He said he wanted to help people and loved the department's tempo, but he was routinely the target of screaming patients. One man bit him.
Wait times were often long and tempers short, he said, as patients without primary care showed up seeking help for minor ailments.
"I do miss it," Stone said of bedside nursing. "But now I don't hate coming to work every day."
An expensive loss
Part of the challenge in fighting turnover is that, on a spreadsheet, nurses can look like a costly line item, said Omid Razmpour, a former ICU nurse and a researcher at Emory University. And many hospitals already face severe financial pressure, including higher operational costs and rising ranks of uninsured patients who still require care.
Nursing unions often complain that management staffing and pay decisions are driving nurses off the front lines.
"If you talk to the C Suite, it's easy to say, 'Hey, give us resources for a physician,' because they're going to generate X amount of revenue," Razmpour said.
But losing a nurse is extremely expensive. Razmpour analyzed turnover costs at Emory Healthcare and found it costs the Atlanta-based health system around $78,000 anytime a nurse leaves. Costs can pile up as hospitals fill gaps with more expensive, often contract, workers and try to recruit and train full-time replacements, he's found.