Understaffing a major reason why a fifth more nurses could leave the field

A new survey reports that 85 percent of nurses said the quality of health care in Massachusetts hospitals had declined over the last two years.

A registered nurse and a nursing assistant wheeled out a patient after he is discharged from the COVID-19 floor at the West Roxbury VA Medical Center in January 2021.Erin Clark/Globe Staff

Nearly a fifth of nurses in Massachusetts plan to leave the field in two years or less, according to a survey released Wednesday by the Massachusetts Nurses Association.

The departures are likely to further strain already stressed hospitals, which spent $1.5 billion last year on temporary labor, 610 percent more than in the fiscal year that ended in September 2019.

“It’s terrifying,” said Katie Murphy, president of the Massachusetts Nurses Association. “But I get it. I really get it. No changes have been made. The crisis continues. I’m not surprised.”

The vast majority of those leaving nursing said they would retire. Others said they planned to take a job outside of health care or take another job within the health care industry.

Labor has become the paramount issue for much of the health care sector and was the focus of a discussion hosted by the Health Policy Commission, also on Wednesday.

An HPC report unveiled during the meeting further underscored the dire state of the workforce problems. Vacancy rates for registered nurses in Massachusetts hospitals doubled from 6.4 percent in 2019 to 13.6 percent in 2022. Health systems have paid handsomely to fill in the gaps, with average wages for contract nurses in Massachusetts 89 percent higher than the average wages for employed nurses.

However, what’s driving the problem isn’t a general shortage of nurses in Massachusetts. The report showed there were more registered nurses per capita in the state in 2021 than before the pandemic, rates that were higher than national figures. The total number of people completing nursing programs in the state also remained steady in the first year of the pandemic.

Instead, the report detailed nurses leaving hospital employment for other jobs within health care. The remaining hospital workforce has become less efficient, given the support they have to provide to recently graduated nurses or temporary traveling nurses who backfilled vacancies. Those stressors have created more turnover, creating a challenging work environment.

“The nursing story that the data has provided to us is really a story of turnover,” said Dr. Sasha Albert, the associate director for research and cost trends at the HPC, during the HPC hearing. “We have a large per capita number of nurses, but that doesn’t necessarily speak to where they’re working.”

The steady supply of nurses might also not be keeping up with the increased demands on hospital-level care. Some patients are remaining hospitalized longer, because they cannot be discharged to other facilities, given severe staffing shortages in nursing homes and residential care facilities. According to the report, employment at nursing homes and other residential care facilities was down 13.6 percent from the beginning of 2018.

The HPC report also hinted at challenges to come, saying Massachusetts had a higher proportion of nurses over the age of 50 than the US average, which has increased since 2019.

The nurses survey, taken by more than 500 nurses registered with the Massachusetts Board of Registration in Nursing from late February through early March, spelled out even further erosion of the workforce.

Among those planning to leave within the next two years, age or desire to retire was the biggest factor, with 40 percent saying that would be their main reason for leaving the field. However, working conditions, exacerbated by staffing pressures, were encouraging an equal number to leave — 20 percent said understaffing and feeling overworked was the reason, and 19 percent said feeling burned out and stressed was the cause.

Among nurses who had already decided to stop working in a hospital setting, 18 percent pointed to understaffing and having too many patients as the reason why they left.

Nurses have pointed to a bill that would develop nurse-to-patient ratios as a potential solution to the crisis, saying it would entice nurses back into the field. Nurse advocates again pointed to such legislation during the Health Policy Commission event.

“For two decades now, the nurses on the frontline have said we need enforceable limits,” said Julie Pinkham, executive director of the Massachusetts Nurses Association. “People have to know, what is it that is safe? What do I come to when I come to a floor? Because if the institution thinks six or seven [patients] is safe, and the nurse doesn’t ... I guarantee you they’re going to leave.”

Such proposals in the past have been met with fierce opposition from hospital groups, which have argued that staffing minimums create inflexible standards for hospitals regardless of their size, and bring with them unsustainable costs.

Hospital groups have yet to fully address the latest proposal. At the HPC event, Steve Walsh, president and CEO of the Massachusetts Health & Hospital Association, sidestepped comment on the bill, and instead said the state could create an AmeriCorps program for health care services that would provide a living allowance and funding to support their education and entry into the field. He suggested patient advocacy groups such as Health Care For All leverage their door knocking efforts, currently deployed for the MassHealth redetermination effort, to eventually recruit people from communities of color.

Walsh also said the marketing around working in health care needed to change, and businesses needed to become more flexible in what kinds of workers or schedules they were willing to accommodate.

Michael Curry, president and CEO of the Massachusetts League of Community Health Centers, said the state needed a moonshot initiative around workforce, focused on investments to bring people into the workforce, in particular from communities of color. But groups needed to come together in a war room to talk about the issues more comprehensively.

“We’re still not sitting in the room. And it’s repackaging the Tylenol, because these ideas exist around how to recruit, how to retain, how to do it in a diverse and inclusive way. But we have to invest in it,” Curry said. “Pay now or pay greater later. If we don’t do this, there’ll be another crisis. That will exacerbate everything we’re dealing with now, and it will make it even worse.”

An earlier version of this story misstated how much travel nurses are paid compared with staff nurses. As of 2022, average wages for contract nurses in MA were 89% higher than average wages for staff nurses. The Globe regrets the error.