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Where Have All the Nurses Gone?... (And What To Do To Keep Them)

Updated: Dec 28, 2021

Nurses, a vital part of the healthcare infrastructure, are in short supply. COVID-19 was the accelerant of this problem, but not the cause. This crisis has been a long time in the making.

Conventional wisdom says that COVID drove nurses out of the workforce. Fearing for their health and safety, older nurses chose to retire. Younger nurses elected to stay home. But a 2021 McKinsey & Company report paints a different picture.

The top reason affecting the decision to leave is insufficient staffing. The next four reasons (intensity of workload, emotional toll of job, don’t feel supported, and physical toll) also tie back to insufficient staffing. If you’re overworked, you don’t feel supported, and the emotional and physical toll of the job becomes harder to bear.

Patient acuity has been increasing in emergency departments for years. (ref.1) Yet most hospitals continue to base staffing solely on volume. Then along comes COVID-19, resulting in wide swings in hospital patient volumes and acuity.

At the outset of the pandemic, patient volumes dropped precipitously. Volume eventually rebounded, but with significantly higher acuity, not only from complications from COVID but also disease-related and a lack of preventive care. Failure to factor acuity into the staffing mix results in understaffing relative to workload. A nurse working at a 4:1 patient ratio pre-COVID now must spend 10 minutes out of every hour donning and doffing PPE, effectively creating a 4.7:1 patient-to-nurse ratio from a workload perspective. Add increased patient acuity from patients being sicker, and now that patient ratio may be the equivalent of 5:1 or 6:1. Is it any wonder that nurses are leaving?

Unfortunately, the calvary is not coming to the rescue. Nursing schools are not producing more graduates in the near future. This is not because of a lack of interest. Applicants to nursing schools continue to be robust, but tens of thousands of qualified applicants are turned away each year. School are unable to expand due to a lack of faculty and clinical rotations, and budget constraints. (ref 2.)

If the supply of nurses is finite, at least in the short term, and patient demand has not declined, then what does one do? Increasing salaries will have limited effect. An increase in compensation may stem the loss of staff− and even steal some nurses from your competitor− but once they respond in kind, the tide will shift and you will find yourself in the same situation as before.

To reduce nursing workload, I know of one hospital that is reducing patient ratios from 6:1 to 5:1 on the inpatient units. Changing patient-to-nurse ratios to reduce nursing workload sounds great, but if you can’t fill current positions, creating more positions only puts you in a deeper hole. You either must close beds to maintain ratios, which is not good for patients or your finances, or have your nurses work short, which will lead to further burnout and resignations.

If you can’t hire or retain enough nurses to meet your patient needs, then the only other option is to unload non-RN functions from your RNs. For example, there are many tasks that nurses perform that don’t require an RN degree: stocking supplies, changing sheets, assisting patients to the bathroom, starting IVs, and chart documentation.

Creating a Nurse-Led Care Team

It is time to develop an RN-led care team: a defined group of caregivers led by an RN and augmented by others, such as LPNs, techs, nursing assistants, paramedics, and possibly even scribes. RNs would work at the top of their training and degree. Other team members would perform valuable and necessary tasks to unload work from the RNs. This would address the excessive workload that nurses are reporting and improve retention and recruiting.

But how do you create an RN-led care team? Simply hiring additional techs or nursing assistants will be helpful, but how will you know if it will be effective? What’s the right ratio of RNs to RN extenders? Here’s how to develop a nurse-led team:

  1. Assess the nursing needs for your current patient demand. Workload is a combination of both volume AND acuity. If you look at only volume, then you are missing half of the demand component. In addition, if one staffs only to averages and doesn’t account for variation, then a department can be understaffed as much as 50% of the time.

  2. Compare your nursing needs to current nurse staffing to determine your nursing short fall. This is the amount of workload that needs to be covered by nurse extenders.

  3. Determine the type of work and workload that can be performed by nurse extenders.

  4. Calculate the right mix of RNs and RN extenders to meet patient demand/workload.

  5. Develop standard work for your new RN-led care team. There will be new roles for the team members that will need to be defined.

  6. Then, Plan, Do, Check, Act (PDCA)to improve the process.

Obviously, this is easier said than done. But given the current landscape, can you afford not to try?


  1. Trends in Emergency Department Visits, 2006-2014, Healthcare Cost and Utilization Project, Statistical Brief #227, Sept. 2017

  2. American Association of Colleges of Nursing, Fact Sheet, Sept. 2020

Joe Twanmoh, MD, is president and founder of Queue Management, based in the Washington D.C./Baltimore area ( To find out more go to

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