With federal COVID-19 vaccine mandates looming, burnout at record levels, and many baby boomers nearing retirement age, a national nursing shortage is approaching that could shut down critically needed care.

“This is getting serious,” say Ann Marie Pettis, RN, an infection preventionist at University of Rochester (NY) Medicine and president of the Association for Professionals in Infection Control and Epidemiology. “In my own organization it’s frightening. We are having to shut down beds. We don’t have some ICU beds staffed.”

Given the situation, the American Nurses Association (ANA) recently sent a letter to the Department of Health and Human Services (HHS) calling for the Biden administration “to declare a national nurse staffing crisis and take immediate steps to develop and implement both short- and long-term solutions.”1

“We need to realize there has been a shortage for decades. The situation now is that it has reached crisis proportions,” says ANA President Ernest Grant, PhD, RN, FAAN.

The Biden administration has confirmed they received the letter and will issue a formal response.

“I think there are a couple of things the federal government could do,” Grant says. “First, take the lead to get all of the [stakeholders] in the room so we can get this problem fixed once and for all — for the short term and long term. Call in the players like the insurance companies, the lawmakers, the nurses, and regulatory agencies to address this problem. We realize that there is not one size that will fit all.”

Pay, Burnout Are Issues

Indeed, one proposal listed in the ANA letter is “work with the Centers for Medicare & Medicaid Services (CMS) on methodologies and approaches to promote payment equity for nursing service.” This might prove a shrewd approach, as President Biden has mobilized CMS to leverage compliance with his recently ordered healthcare vaccine mandates.

“CMS is so important because they are responsible for a lot of different costs,” says Julie Swann, PhD, department head and A. Doug Allison Distinguished Professor of the Fitts Department of Industrial and Systems Engineering at North Carolina State University. “Even though they don’t directly set salaries, they push the costs down so much. Other payers should be at the table as well. I understand that insurance companies had a great year last year because there were much fewer elective surgeries. They didn’t have as many costs on that side as they normally would have. Should we be putting in place hazard pay [for nurses]?”

This is the crux of the issue, with too many hospitals trying to get by on the cheap despite the dire working conditions during the pandemic, says Linda Aiken, PhD, RN, FAAN, FRCN, professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

“The country does not have a shortage of nurses, and I want to go on record with that,” she tells Hospital Employee Health. “We graduate 175,000 new nurses every year. People don’t want to work under these circumstances. [Hospitals] are not really offering the kind of financial incentives that would be reasonable in a national emergency. A lot of hospitals are not offering hiring bonuses. More importantly, they are not offering retention bonuses to the people who are there.”

Burnout is at record highs — which was a longstanding problem even before the pandemic.

“We are studying this — 62% of ICU nurses are experiencing burnout, but it is because it was already so high before COVID,” Aiken says.

States Move on Mandates

As this report was filed, New York was not backing down from a requirement for all healthcare workers (HCWs) to be vaccinated for COVID-19. Gov. Kathy Hochul signed an executive order on Sept. 28, declaring a statewide emergency due to healthcare staffing shortages. The emergency order coincides with an expired deadline that HCWs must be vaccinated for COVID-19. Some refused or resigned. The emergency declaration allows New York to temporarily suspend state requirements and allow HCWs from other states and countries to practice in the state.

A court also ruled that a group of workers claiming religious exemption could not be fired pending further review. Amid the chaos, some have floated the idea, particularly in other states, of letting unvaccinated nurses keep working temporarily to buy some time. “I think the mandate for vaccination of everyone in healthcare should hold under any circumstances,” Aiken says. “It’s totally science-based. There are plenty of nurses in the country, but it is a question of whether they are willing to work under the conditions that are being offered.”

Normally, the market forces of supply and demand would drive nursing wages up, but Aiken alleges groups of hospitals have “colluded” to keep these forces at bay. Nurses who are finding a way around this — putting themselves in a competitive hiring position — are making as much as $100 an hour, she says.

“One important factor is that nurses and doctors have been responding to this for about a year and a half,” Swann says. “That is a long-sustained time period for anything – certainly a pandemic. There is a concern that some nurses will decide to quit rather than to be vaccinated. It’s unclear how large that problem is going to be. Across the United States, we have an age distribution with a lot of people close to retirement age. If they are not happy in their job, then they are a little more likely to retire.”

Do Not Let Unvaccinated Nurses Slide

Swann concurs with Aiken that unvaccinated workers should not be given a reprieve due to the staff shortage. “People in healthcare and other first responder jobs could directly impact someone else if they are not vaccinated,” she said. “There are a number of other vaccines and other healthcare measures that someone in healthcare would generally take. They have to be up to date on all kinds of vaccinations. I am not comfortable with unvaccinated workers continuing [working]. Another thing people do in an emergency is that they [will have more nurses] working across state borders than they would normally allow. And they bring back people who are retired. We’ve got to get some relief for nurses and first responders to give them the ability to care for patients and the community.”

In in a time of crisis, consider which tasks can be performed by people without nursing degrees. That would give nurses time to focus on important things where their skill set is needed, Swann says.

Aiken supports the idea of federal intervention as long as it brings more resources for hospitals to employ more nurses or to bring in agency nurses and use other ways to staff up.

“I would hope that if the [nursing emergency] is granted, the focus would be put on permanent changes in hospitals that would prevent this from ever happening again,” she says. “That is desperately needed. It’s not that we just need to plug holes in staffing — we need to put in place some requirements. The main thing to be considered is that the federal government should pass safe staffing mandates in all hospitals that participate in Medicare. It’s long past time for that to happen, and the states are not going to do it.”

However, as a policy matter, the ANA does not support setting nurse-patient ratios for different types of care.

“This is not just a numbers thing.” Grant says. “We feel you also have to take into account the expertise or the experience that that nurse has. Is it a nurse who has been on the floor six months, or one that has been there 10 years? Also, are there other members of the healthcare team that may be there, including nursing assistants? Do you have the ability to flex [staffing] up and flex down? ANA has always advocated that staffing should be done in conjunction with hospital administration on individual floors.”

While Aiken believes that approach has failed, it could give Grant some negotiating room if he can sit at the table with the powers that be.

“We have to ensure that we have a valued nursing workforce and an environment that is safe and addresses the physical and mental fatigue that nurses are experiencing right now,” Grant says. “We have been carrying this burden for quite some time. It’s obvious that we need federal leadership to address this problem.”

In the ANA letter, Grant emphasized that “this severe shortage of nurses, especially in areas experiencing high numbers of COVID-19 cases, will have long-term repercussions for the profession, the entire healthcare delivery system, and, ultimately, on the health of the nation.”

The ANA cited several national examples of the crisis, with many hospitals losing nurses and demand exceeding staffing needs. Thousands of nursing positions are unfilled. Some hospitals requested support from the National Guard, the ANA emphasized.

Remove Practice Barriers

In addition to more staff, Grant urged HHS to remove practice barriers for nurses and increase the annual number of qualified students educated in the field. Moreover, nurses need help and techniques to address fatigue and mental well-being to maintain a resilient workforce, the ANA letter stated.

There also is a clear patient safety issue since staffing has been cited as one of the problems in a dramatic increase in healthcare-associated infections (HAIs) in 2020. Too few nurses translate to too little time.

“We know from studies that short staffing is associated with higher incidence of HAIs,” says Mary Hayden, MD, chief of infectious diseases at Rush University Medical Center in Chicago. “You have to have enough staff so they have enough time to practice hand hygiene at every point they are supposed to, change dressings, and monitor devices.”


  1. American Nurses Association. ANA urges U.S. Department of Health and Human Services to declare nurse staffing shortage a national crisis. Sept. 1, 2021.