COVID-19 Is Reshaping California’s Health Workforce
A conversation with Joanne Spetz, director of UCSF’s Philip R. Lee Institute for Health Policy Studies
Evidence is mounting that American health care workers are quitting in large numbers. The health care sector has lost nearly half a million workers (PDF) since February 2020, and new data suggest that during the pandemic 18% of health care workers have quit and 12% have been laid off.
Even before COVID-19, many health care workers were struggling to bridge the gap between their professions’ noble ideals and the sometimes harsh realities of health care business practices. In a powerful article published in The Atlantic in November, journalist Ed Yong reported that the traumatic experience of caring for a deeply divided nation during a stubborn pandemic has pushed a growing number of health care workers to the brink. “COVID-19 [is] confronting even experienced people with the worst conditions they have ever faced and turning difficult jobs into unbearable ones,” Yong wrote. The unrealized promise of “some sort of normalcy has made the feelings of exhaustion and frustration worse,” one critical care nurse leader told Yong.
I recently interviewed Joanne Spetz, PhD, the director of UCSF’s Philip R. Lee Institute for Health Policy Studies, to find out how California’s health care system has responded to these unprecedented pressures. Spetz is an expert on health care finance and a member of the faculty of the Healthforce Center at UCSF. She has led studies of the registered nurse, nurse practitioner, and long-term care workforces and has conducted surveys for the California Board of Registered Nursing for more than a decade. This transcript has been edited for clarity and length.
Q: Do you agree with Yong’s bleak assessment of the state of health care work?
A: Yong identified the fundamental conflict between what physicians, nurses, and other clinicians are supposed to do to serve the best interests of their patients and the demands imposed by the business model of health care. This phenomenon, known as “moral distress,” has been an issue for a long time. He quoted nurses who said, “Yeah. I put eight people in body bags today, and I’m driving home and people are at the bar.” There is a human instinct to say, “What the heck are those stupid people doing? Screw them.” But that’s not how a nurse or a physician is supposed to think or wants to think — they want to provide care for anybody who comes in the door. But they are experiencing enormous frustration caused by the feeling that people don’t respect or appreciate how much doctors or nurses are doing for their patients. And then you just add the business model on top of it. Do people have insurance? Do they have access to primary care? The way our health system is financed creates structural inequities, and that just compounds this unease and stress.
Q: Why are so many health care workers leaving their jobs, and what are the implications for California?
A: Our survey (PDF) a year ago showed that many nurses felt the pandemic really tightened their teamwork. They appreciated that their organization’s leaders were communicating clearly, and it was clear that some organizations were doing very well. But it was also clear that others were doing terribly. It is widely variable.
That same survey also picked up a big decrease in the percentage of registered nurses in older age groups who were working compared to prior years. Somewhere between 40% and 50% of nurses 65 and up were working in 2018, and that went down to 33% in late 2020. There was also a decrease for nurses between 55 and 64 years old.
When we looked at the comments of participants, they totally made sense. “I have a chronic condition — why would I put myself at risk?” “I am too old to put myself and my family through this kind of health risk.” Some older nurses said things like, “I love being a nurse, but enough is enough. I’m too old to put up with this stress. I don’t have to keep doing this. I can retire now. I’m done.” There were nurses with spouses or partners who had been furloughed, some were at home doing the Zoom schooling and couldn’t work as much, and some asked for a leave of absence from their job.
Community colleges are the dominant point of entry for diversity in the nursing workforce, and Cal State plays a strong secondary role.
Early in the pandemic, younger nurses made comments like, “I’m a nurse. I serve. This is what I’m trained for. This is what I do.” Some nurses may have been increasing their hours and trying to pick up overtime shifts, partly to serve their community and partly because their household finances required it. Yong pointed out that those motivations and conditions might carry you for a year of the pandemic, but two years? Who can do that? That is a lot of household stress.
We have precipitous retirements happening across nursing, but also among physicians, respiratory therapists, home care workers, nursing home staff, and many other types of health care workers. The training pipeline should be able to fill those spots over time, but with this big bolus of retirement, I think we’re looking at a relatively ugly five years ahead before things balance out.
Q: What would you advise policymakers to do to expand California’s nurse workforce pipeline?
A: State policymakers could make sure that Cal State and community college nursing programs continue to grow and maintain their enrollments. The California Annual Nursing School Survey (PDF) for the 2019–2020 academic year indicated that public colleges and universities had declining enrollments. They didn’t have the resources to transition to remote learning as easily as private universities and colleges, which appear to have filled the gap caused by the public sector’s shrinking capacity. As a result, our overall supply numbers look good, but private programs are really expensive, and those students are facing more debt. And these are the kind of access issues that spark equity discussions. Community colleges are the dominant point of entry for diversity in the nursing workforce, and Cal State plays a strong secondary role.
Q: What are new nurses experiencing as they graduate into a COVID-19 world?
A: In general, hospitals aren’t rolling in profits. Their margins are highly variable, and they have significant infrastructure they must maintain and reinvest in. There’s so much uncertainty, and hospitals have an incentive to hire just the number of nurses they need for right now. But to deal with the workforce issues in the longer term, they should be hiring the number of nurses they know they’re going to need in the future.
Before the pandemic, hospital chief nursing officers said in surveys that they had significant shortages of experienced nurses and a glut of new graduates. Now, because of the pandemic, baby boomers are retiring more precipitously and taking their experience and expertise with them. New graduates need to get hired, be mentored by more experienced nurses, and be supported as they transition from novice to expert. Mentoring a new hire takes time, so the more novices you bring in, the greater the stress on your incumbents. Hospitals are going to have to figure out how to incentivize retiring nurses — maybe just to work part-time in almost more of a mentoring and coaching role for new hires.
Now that long-festering issues like staffing shortfalls, stress, toxic work cultures, and weak leadership have come into the open, the health care industry has no choice but to deal with them.
Hospitals also have to ask what they can do to partner with a community college or a Cal State so their graduates are able to take an operating room elective and move faster into perioperative care or other specialties where retirement numbers are large. That means probably staffing more richly than their budgets have historically allowed. You need to have structures in place to ensure that the mentoring is efficient so those new graduates don’t end up landing jobs in Nevada or Texas or Georgia or somewhere else, which will result in California never getting them back. We’ve got enough of them graduating to replace baby boomers as they retire — but only if hospitals hire them.
Finally, we have to deal with and support the emotional well-being of staff, as Yong wrote. Moral distress and the ongoing stress and trauma of nurses and physicians can’t be resolved by just giving them the Headspace app. That’s like saying, “We’re going to put the burden of dealing with this back on you” to a workforce that cannot take any more burden. Hospitals need to have leadership that cares about the well-being of the staff, the camaraderie, the teamwork, the emotional health, and the ability to rest. It’s hard to do that if you’re worried about being short on nurses. Clinicians need to feel like they’re in organizations that deeply appreciate how hard they’re working for patients and recognize the importance of listening to them.
Q: Are employment opportunities plentiful in skilled nursing facilities?
A: Nationwide, compared with before the pandemic, there seems to be a persistent 10 percentage point drop in nursing home employment. From my back-of-the-envelope calculation, at least 10% of nursing home residents died of COVID-19. So these decreases in nursing home employment could be completely concordant with reductions in the number of residents now alive in nursing homes.
Nursing homes probably are seeing lower admission rates. My mother-in-law has increasing care needs, but would we put her in a nursing home right now? No way. If you could possibly take care of somebody at home, you’re going to, because a lot of nursing homes have not done tremendously well in the pandemic. It’s very difficult to prevent infection transmission in that setting, no matter how hard you try, which surely makes workers nervous about taking jobs in long-term care facilities. We’ve found that very few workers who lost their jobs during the pandemic shifted to jobs in long-term care (PDF), which isn’t surprising given the risks and low wages that are found in these jobs.
Q: Marginalized communities where families were hardest hit in the pandemic are the same places where workforce shortages cause the biggest problems for safety-net providers. How is that workforce coping with the stresses?
A: Safety-net organizations tend to not have as much money as they need for hiring or infrastructure maintenance. They’re more likely to report shortages and have vacancies. They’re more likely to be using temporary and traveling physicians and nurses. And they are often in the same communities that have had more difficulty with access to vaccines and the other pandemic public health measures.
Some employers are listening to their staff in a way they didn’t before — they have been forced to listen because the alternative is crippling shortages.
A lot of these organizations have mission-driven leadership, which can help compensate for the financial disparities. But you still have to attend to the stress. We will probably find that safety-net hospital staff have been more likely to experience the kinds of things that lead to this deep moral distress and the post-traumatic stress disorder phenomena that Yong wrote about. I think the safety net has surely been more challenged through this. We still have probably 7% to 10% of our population without health insurance. Those individuals are more likely to be walking into the safety net for care — and that compounds the financial stresses that the safety net deals with.
Q: What is the potential for this pandemic experience to lead to better situations for the health care workforce? Is this certain to be permanently damaging?
A: We have the opportunity to learn from our mistakes and to be proactive. As I said, some nurses in our surveys said their hospital’s leadership had stepped up and that their team cohesion had improved through the trial of the pandemic. Some indicated their commitment to the mission of their work had been solidified through this experience. And some employers are listening to their staff in a way they didn’t before — they have been forced to listen because the alternative is crippling shortages. These can’t be short-term changes, and the longer the pandemic has dragged on, the more obvious it has become that some aspects of health care work were unsustainable. Now that long-festering issues like staffing shortfalls, stress, toxic work cultures, and weak leadership have come into the open, the health care industry has no choice but to deal with them. This will be good for workers and patients in the long term, even if that’s hard to see while we are in the messy middle.