Provider burnout

If you ask nurses and hospital administrators about the state of nurse staffing, both will tell you that there are not enough nurses currently working the bedside. 

But that’s about the only thing they can agree on.

From the cause of the problem, to how to fix it or what to name it — hospitals label it a “nursing shortage,” while unions and advocates call it a “safe staffing” failure — labor and management are at odds about the particulars of the nation’s staffing crisis.

Hospitals say they are doing their best to hire, but that there aren’t enough accredited nurses available. The American Hospital Association said it expected to lose half a million nurses by the end of 2022, creating a total shortage of 1.1 million nurses nationwide.

During an investor day presentation in Nov. 2023, HCA chief nurse executive Sammie Mosier said there was no doubt there was a nursing shortage. Hospital operators have been hoping for a reprieve to the so-called “labordemic” that they say has left them struggling to replace nurses lost to attrition. 

But nurses unions bristle at calling the problem a shortage — and reject the idea that the staffing crisis is a new concern for the industry. They claim the term lets hospitals off the hook for their role in creating vacancies, and say any current shortage of nurses is the result of hospitals’ own decisions coming home to roost.

Tensions between the two sides boiled over in 2023, with demands for increased staffing driving strikes at hospital operators like Prime Healthcare, Robert Wood Johnson University Hospital and Ascension St. Joseph, among others.

“They don't own up to the fact that they have created [the shortages] with their practices,” said Margaret Franks, registered nurse and regional director for the New York Nurses Association. “It has been proven that it is not a nursing shortage, it is just a shortage of nurses willing to work in the conditions that are present at the bedside right now.”

Without first fixing the workplace problems in U.S. hospitals, Franks said that any nurse recruitment efforts are essentially building on quicksand — they may get people in the door, but they lack the foundation to succeed.

“We all have friends that have left nursing and they all say the same thing to us: We're not coming back. I'm not coming back to eight patients,” Franks said. “You can’t build up teams on bad foundations. They would rather take less money or work five days a week instead of three shifts where they can do their jobs properly.”

Data shows a pool of nurses, but hospitals are struggling to hire

The numbers present a paradox — the nursing talent pool is growing, and yet, it is getting harder for hospitals to hire.

The number of candidates passing the nurse licensure exam grows each year, according to the national nursing licensing agency. New nurses join a pool of 5.2 million registered nurses currently in the workforce as of 2022 — 89% of whom work in the industry, according to a national survey of nurses conducted biannually by the National Council of State Boards of Nursing (NCSBN) and the National Forum of State Nursing Workforce Centers.

At the same time, there are more job postings for nursing positions in 2023 compared to 2020, said Julia Pollak, chief economist at online recruiting platform ZipRecruiter.

For-profit hospitals are among employers desperate to hire. Executives at operators like HCA Healthcare, Tenet Healthcare and Community Health Systems have reported paying hefty rates for temporary contract nurses since the onset of the pandemic, leading nursing recruitment to become a top priority.

And yet, nursing positions at hospitals go unfilled as the number of interested applicants dwindles compared to years past.

On ZipRecruiter, applications for nursing positions have fallen 11% in 2023 compared to 2022. Companies are also having to work harder for each application, ZipRecruiter’s Pollak said. In order to generate a single “quality applicant,” an average of nine individuals must view a job posting — in 2022, that number was only five. 

Outside of online job boards, data from The U.S. Bureau of Labor Statistics, which produces monthly jobs data to track job openings and turnover, confirms that recruiting nurses is becoming more of a slog. 

Prior to the pandemic, it took less than two months to fill a healthcare job on average during the latter months of 2019, as calculated as the inverse of the ratio of hires to job openings. The time to fill healthcare positions rose to 2.2 months in Sept. 2023, according to the most recent data available from the BLS.

Difficulty hiring persists even as healthcare companies have started raising salaries, offering signing and relocation bonuses, tuition reimbursement and payment for training, Pollak said. 

Hospital employees’ average hourly earnings growth approached 3.8% in July 2023, above the 2.3% average growth reported between 2010 to 2019, according to credit agency Fitch Ratings. 

But, despite pulling out “all the stops,” efforts largely haven’t paid off, according to Pollak.

“Health organizations have done a huge amount of work to get more engagement on their postings,” Pollak said. “The problem is, this is not a labor shortage that is just solvable through pay.”

Why are hospitals failing to attract nurses?

Though there are millions of registered nurses in the talent pool, there are also more quitting, experts said. 

More than 100,000 left the profession in 2021 after the pandemic caused workplace conditions to deteriorate, according to a study published in Health Affairs. The researchers said it was a “far greater drop than ever observed over the past four decades.”

Nurses who quit the profession told consulting firm McKinsey in 2023 that they left because they felt under valued, inadequately compensated, and unable to manage increasingly intense workloads.

Almost half of respondents in the McKinsey survey said an unsafe working environment impacted their decision to exit direct patient care, an increase of 24% from the prior year. 

Labor conditions inside hospitals have grown more precarious over recent years, with nurses facing increasing on-the-job violence, injuries and illness, according to industry data and experts.

Nurses who remain struggle with rising rates of burnout as they shoulder the workloads of short-staffed units, according to a study conducted by the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research. The problem is cyclical, studies suggest, as burned out nurses are more likely to look elsewhere for a job.

“Workers are changing. They care more about work life balance now. And, ironically, the shortages of staff have actually made healthcare roles less attractive... and made people have to work crazier hours,” Pollak said. “And so we're seeing physician burnout has reached crisis levels, and there are many people who are leaving long before they otherwise would have.”

That includes nurses who choose to retire early, according to Therese Fitzpatrick, senior vice president of healthcare management consulting firm Kaufman Hall’s performance improvement practice. 

Poor working conditions at hospitals, such as inflexible 12-hour shifts, are driving senior nurses from the bedside, she said.

The churn of more seasoned workers has down-stream impacts.

With a shortage of senior workers, it’s more difficult for junior nurses to receive proper training, said New York Nurses Association’s Franks. She serves as a precept, or trainer for junior nurses, at Vassar Brothers Medical Center, a 349-bed facility that serves the Hudson Valley in New York. 

Franks said that Vassar has hired 123 nurses since the start of 2023, but 93 have already left due to inadequate training.

“The issue is not in recruiting. It's actually retaining once those nurses come in,” she said. “Obviously they're coming in. We have new nurses graduating, usually twice a year in May and December.”

With training costs approximately $88,000 per nurse, Franks said the hospital is burning money when so many nurses quit prior to completing their training. 

“That’s $8 million that walked right out the door alone this year,” she said.

Nurses are looking elsewhere for work

Increasingly, hospitals have to compete with non-traditional employers for nursing talent — ranging from retailers like Home Depot, CVS Health and Walgreens to start-ups. These companies are attractive because they can offer nine-to-five schedules and less stress compared to hospitals, Pollak said. 

One nurse who left her hospital job to work at a non-traditional employer is Sarah Lacy. She quit her job in 2020 to work as a registered nurse in an ear piercing studio.

The New York City-based piercing studio, called Rowan, competes with hospitals for jobs and exclusively hires nurses to pierce ears. 

The job gives nurses an opportunity to apply their medical skills without the “verbal abuse and physical abuse” that some nurses experience in the emergency room, Lacy said. 

“When I first joined Rowan, I had no intention of leaving the hospital. At the time, it was a part time job, and I thought it would be a really fun way to get to use my nursing skills in a situation that is not stressful, like the way bedside nursing is,” Lacy said. 

However, as she logged more hours at Rowan, Lacy came around to the idea of working full-time, piercing ears and training new nurses at Rowan. She said the biggest draw was the environment — studios were clean, people came to see her at some of their happiest moments and she got to apply her clinical expertise.

“I don't know what would be enough to draw me back to the bedside after this,” Lacy said. “As nurses, we have that innate desire to help people and to make a difference in people's lives. It’s transformational when you get to do that in a way that is so fun.”

“I really don't want to go back, if I'm being honest,” she said.

How hospitals can win nurses back

Although hospitals are struggling to hire and retain nurses, it’s not an impossible task, according to Pat Brown, EVP of human resources at Northwell Health. 

Northwell, the largest health system in New York, operates 21 hospitals and had an average of 900 open RN positions in Nov. 2023 — roughly the same number it did in 2019. 

According to Brown, the health system boasted a turnover rate during the pandemic that was half the national average and kept stable staff through this year due to investments in recruitment and retention.

The hospital system has a network of almost 200 nursing programs. Northwell sends representatives to nursing career expos and even has a presence on TikTok.

Still, “The [nursing] supply is definitely constrained,” Brown said.

Other hospitals may benefit from similar strategies to recruit and retain staff, including partnering with nursing schools, offering virtual nursing roles that are less demanding, shorter shift options and “phased retirement” for older nurses, said Kaufman Hall’s Fitzpatrick.

“Organizations are essentially growing their own [nurses], and are willing to make that investment, because when you think about the impact long term, it makes financial sense,” Fitzpatrick said. “It could have a significant ROI when you look at balancing the upfront cost against the cost of contract labor.”

The strongest signal of an investment in nurses, according to nurses unions, is implementing nurse-to-patient ratios, which cap how many patients a nurse can care for at a given time.

Ratios can signal to nurses that hospitals are serious about patient welfare and workplace safety, said Debbie White, president of New Jersey-based nurse union Health Professionals and Allied Employees.

In 2023, White appeared alongside Sen. Bernie Sanders, I-Vt., at a field Senate Health, Education, Labor and Pensions (HELP) Committee in New Jersey to argue the benefits of fixed patient-to-staff ratios. She told Healthcare Dive that ratios might not bring back the Sarah Lacys of the world who have contentedly left the profession — but they could help stop the bleeding.

“I'm not telling anybody that nurses will come back to the bedside,” White said. “What I will promise you is that nurses will stop leaving hospitals. And if we fix that problem, we will retain staff. That is when we fix the profession.”

Healthcare workers faced an escalating mental health crisis between 2018 and 2022 driven by increased burnout, harassment and a lack of support from employers, according to survey data published by the Centers for Disease Control and Prevention in October 2023.

More than 45% of healthcare workers reported feeling burned out often or very often in 2022, with the percentage of workers reporting feeling frequently burned out increasing from 11.6% in 2018 to 19% in 2022.

Reports of harassment more than doubled during the study period and the number of workers very likely to seek another job increased by almost 50%. In contrast, turnover intention declined for workers in other essential industries.

The CDC study compared U.S. healthcare workers’ mental health and well-being metrics to those reported by workers in other essential industries, finding health workers' mental health deteriorated at higher rates. 

Debra Houry, chief medical officer for the CDC, warned on an October call with reporters that the COVID-19 pandemic intensified longstanding industry challenges among healthcare workers like compassion fatigue, depression, anxiety, substance use disorders and suicidal thoughts.

“To label our current and long-standing challenge a ‘crisis’ is an understatement,” said Casey Chosewood, director and senior medical officer at the CDC’s Office for Total Worker Health, during the media briefing. “Many of our nation’s healthcare systems are at their breaking point. Staffing crises, lack of supportive leadership, long hours of work and excessive demands and flexibilities in our nation’s health systems all must be addressed.”

Healthcare workers most at risk of reporting negative mental health outcomes included those who experienced harassment on the job or worked in negative conditions. 

Among healthcare workers who reported being harassed, 85% reported anxiety symptoms, 60% reported depression symptoms and 81% were burned out, the report found. Negative working conditions, including being short-staffed, were also associated with higher rates of depression and turnover intention.

Burnout can further exacerbate short staffing concerns, because some workers who seek to depart their job are considering exiting the industry entirely, the CDC’s Houry said in the media briefing.

“Some are not just jumping from hospital to hospital, but they are quite concerned about the system in general,” Houry warned. “So clearly, this reiterates the need to sound the alarm that the focus needs to be on long-term systemic fixes.”

Employers can proactively address healthcare workers’ mental health problems by creating conditions that allow workers to participate in decision-making, increase trust in management, offer supervisor assistance and support for productivity, and decrease harassment, according to the CDC.

The agency’s National Institute for Occupational Safety and Health will launch a national campaign for hospital leaders this fall that helps providers “think differently about how to identify and remove barriers to health worker well-being,” Houry said.

The initiative builds on other government programs addressing burnout. In 2022, President Joe Biden provided $103 million in awards to combat burnout and promote mental health and wellness among the healthcare workforce. 

Also in 2022, the U.S. Surgeon General released an advisory on burnout among healthcare workers, noting that employers could play a critical role in reducing distressing work environments that contributed to burnout. 

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By Keypath Education

While shortages dominate headlines, the challenges within the nursing workforce extend far beyond the numbers. Increased demand for healthcare services, coupled with strained resources and an aging population, is leading to nurse burnout and creating a cycle of depletion within the workforce. As experienced nurses leave the profession, the loss of their expertise poses a risk to patient care and safety. Efforts to increase the number of new nurses entering the field don't address this gap in experience, raising concerns about how we will guide new nurses on their path to professional competency.  

The Experience Gap 

The efficacy of the nursing workforce relies heavily on experience. Historically, blending a few new graduates into a seasoned workforce was well-tolerated because the thumb of expertise was on the scales, allowing time for teaching and mentoring new nurses through orientation and beyond.  

However, nearly one million Registered Nurses (RNs) are expected to retire by 2030, and they aren't the only ones exiting the workforce. According to the 2022 National Nursing Workforce Study by the National Council of State Boards of Nursing (NCSBN) and The National Forum of State Nursing Workforce Centers, around 800,000 RNs, approximately 20% of the workforce, plan to leave nursing by 2027.

With this turnover of experience, the preparedness of the new graduate workforce becomes crucial. However, an influx of new graduates creates yet another strain on the very same resources that desperately need them, due to the time and cost involved in bridging the divide between the academic preparation they've received and the practice-ready skillset they need to thrive in a clinical setting. 

Bridging the Divide Between Education and Practice 

Step one in aligning education and practice is alignment within education. With pathways to RN licensure spanning diploma programs and associate's (ADN), bachelor's (BSN) and direct-entry master's degrees (DE-MSN) – with differences in granting institution and program length – there are inherent differences in curriculum, standards and preparation. The bridge to practice is built on a shaky foundation without consensus from stakeholders on the critical competencies newly licensed RNs should have on entry to practice.  

The American Association of Colleges of Nursing (AACN) and the American Organization for Nursing Leadership (AONL) established a joint task force on academic-practice partnerships in 2012, prioritizing bridging the gap and outlining guiding principles, including collaboration, commitment and accountability. Ideally, this entails fostering meaningful collaborations between educational institutions and healthcare facilities to identify areas of improvement, align on divergent expectations and assess opportunities for mutual support, like accommodating more students for clinicals and scheduling clinicals to reinforce practical skills and problem-solving more effectively. In practice, many existing programs are ineffective, lacking the necessary transparency and collaboration.  

The final divide is that within the hospital, where the department leading educational and professional development and that leading the hiring and staffing of nurses generally exist in separate silos with separate goals and responsibilities. Integrating the efforts of education and hiring departments and aligning goals could shift the view of clinical experiences to be an integral part of orientation, treating students as future employees and building an effective placement-to-employment pipeline. 

Reimagining Clinical Skills Development  

The onboarding of new nurse graduates is time- and resource-heavy, not solely because the academic-practice gap exists but because with each new nurse, the depth and breadth of the gap are unknown. Hospitals often reinvent the wheel during orientation, paying for modules and classroom sessions - in addition to precepted time - to close the gap rather than making any assumptions that would leave new nurses unprepared at the end of orientation. 

Reimagining clinical skills development - how skills and competencies are taught, measured, tracked and communicated - with collaborative buy-in across the healthcare ecosystem could reduce these duplicative efforts and create a more effective transition to practice. The solution is twofold: rethinking competency with a holistic approach to the critical elements necessary to safely entrust a new nurse to a task and implementing a robust, tech-enabled solution to provide visibility and accountability along that journey for the new nurse graduates, educators and nurse leaders. 

A comprehensive onboarding experience contributes to the self-efficacy and confidence of new graduate nurses, hastening practice readiness and improving early job satisfaction, enculturation and, eventually, retention. Will closing the skills gap and reimagining competency directly replicate experience? Of course not. But, addressing the nursing workforce crisis requires more than just filling vacancies—it demands a fundamental shift in how we prepare and support nurses for clinical practice, building a sustainable solution to the continued development of a competent and resilient nursing workforce. 

Keypath Connect, powered by Keypath Education, reimagines the transition to practice to address the need for sustainable solutions for developing a competent and practice-ready nursing workforce. Learn more.

When COVID-19 cases surged in Texas in the summer of 2021, health systems buckled as bedside nurses dwindled. Houston officials warned that “a breaking point” was near due to the high demand of care and low supply of labor, according to the AP.

One organization impacted by this shortage was Memorial Hermann Health System, a 115-year-old organization with 17 hospitals across the Houston area. Turnover hit nearly 30% as the pandemic intensified, and the hospital saw the steepest decline in its nursing workforce in 20 years, according to the health system’s SVP and CHRO, Lori Knowles.

The nursing shortage pushed Memorial to test new staffing models, explore upskilling efforts and invest in staff support. HR teams across the U.S. made similar changes, Knowles noted, as they responded to the pandemic and other crises that marked 2020.

“The employer-employee pact that had been in place for so long fundamentally shifted,” Knowles said. “We met a confluence of pressures and influences we had never seen before. And organizations looked directly at HR to solve all of that.”

Still, Knowles chose to look on the bright side. “I’ve seen so many amazing things come out of this time,” she said.

It started with staffing

Memorial Hermann is a large operation. It employs more than 32,000 people across its 265 sites, which includes 17 hospitals. It’s one of the largest nonprofit healthcare systems in Texas, and the biggest in Houston.

“Our vision is to create healthier communities now and for generations to come,” said Knowles, who has served as the organization’s CHRO for five years. “We talk about that all the time. It shapes how we think about the work we do. It shapes, from my perspective, how we think about our people.”

This mission guided Memorial as it first began to deal with the labor shortage and related challenges. Like many healthcare organizations, it turned to contract nursing, a fix Knowles was quick to critique. She noted its expense — rates for travel nurses exploded during the pandemic. In January 2020, the national average weekly pay rate for travel nurses was $1,894, according to nurse staffing platform Vivian Health. By December 2022, that figure had risen to $3,173.

Knowles also noted another downside of using contract nurses. “It’s detrimental to culture. It creates challenges with equity. It’s all these things when a large percentage of your workforce aren’t your employees who you’re paying a premium for.”

To ease these frustrations, Memorial Hermann looked to its internal staffing agency of more than 1,000 floating employees. Through this group, the organization now offers a number of flexible work programs, each prioritizing something different. One program caters to employees who want more time off, offering 13 weeks of work, followed by six weeks off. Another allows employees to work at the four closest hospitals to their homes. Yet another enables nurses to earn a higher rate by working at whichever hospital needs them most.

Memorial Hermann still uses contract nurses, but usage is down by more than 80% since the height of the pandemic, Knowles said.

“We’ve had to be creative to meet the needs of people while still providing great care to our patients,” Knowles said.

What emerged at Memorial: ‘Well Together’

As Knowles witnessed the events of 2020, she received a daunting task from Memorial Hermann CEO David L. Callender. 

“We’re in the fall of 2020 and it’s dawning on all of us that COVID is not a short-term affair,” she recalled. “My CEO says to me: ‘We’re about to see a level of PTSD we’ve never seen. We’re going to have to figure out how to address that here.’”

Knowles wondered how to tackle such a project. She landed on listening: First to experts, then to her fellow leaders and finally to her employees.

As she listened, she learned. Her first realization was about the nature of the trauma she and her colleagues were experiencing. “This wasn’t going to be traditional PTSD. This was going to be collective,” she said. “And people were going to have to manage their day-to-day lives while going through this.”

Knowles next needed to learn how her people would manage this stress — and how her organization could help them through it. So, with HR, hospital chaplains, employee wellness directors, and physicians and nursing leaders, she began to study the employees that make up Memorial Hermann. The team borrowed a tactic from marketing and conducted a persona study. Eight types of employees emerged.

“Then we stepped back and said, ‘If those are the people who work here, what do they need?’” Knowles said. “We did entire listening tours, town halls to find out what people wanted. What can we do for you?”

People needed help with child care. People needed help dealing with inflation. People needed access to greater flexibility. To respond to these needs and unify their approach, Knowles and her team created Well Together. Well Together is a model for Memorial Hermann’s employee experience, Knowles said, that seeks to ensure its workers are:

• Encouraged to grow and develop.
• Supported in body and spirit.
• Inspired by a shared purpose.
• Valued as an individual.
• Connected.

This model orients Memorial Hermann’s approach to people, Knowles said. “In every decision we make, how do these five pillars show up?” 

Knowles and her team began to create, design and implement benefits that corresponded with each of the five pillars of Well Together. Memorial Hermann tossed its old-fashioned tuition program, for example, and created a new benefit that addressed the barriers of its predecessor. “You as an employee don’t have to worry about the money changing hands,” Knowles said. “It just goes directly to the school. And you get money for the books and the fees.”

One focus of Memorial Hermann’s new programming is mental health. Employees can now make appointments to see in-house mental health professionals during the workday. They can also call on staff trained in psychological first-aid to help them through emergent mental health needs they encounter on the job.

‘We are doing much, much, much better.’

Memorial Hermann will continue to look to Well Together as its guiding principles in employee experience for at least five years, Knowles said. In the meantime, Knowles watches its impact spread.

“The feedback from our teams and employees has been really positive,” Knowles said. “They feel supported. They feel cared for as individuals. We are doing much, much, much better.”

She acknowledged the challenge of finding hard evidence that illustrates the impact of Well Together. But Memorial Hermann’s turnover is “down by half from where it was at the top of the pandemic,” Knowles said.

With Well Together continuing to grow, Knowles said her biggest takeaway from its creation is transparency. “It’s scary to go to your workforce and to be vulnerable,” she said. “It’s hard to ask hard questions about how they’re doing and what they need. Because there’s a sense that you may not be able to provide.”

Even so, Knowles said this radical transparency has been “transformational” in allowing her organization to create strategies that answer to the needs of its employees. HR leaders pursuing similar goals should do likewise, she said.

“Press yourself to do things that feel a little bit scary,” she said. “Try things. Don’t be afraid to do a pilot. If it doesn’t work, move on quickly.”

More than a third of nurses said it’s extremely likely they’ll change jobs in 2024, according to a survey by staffing firm AMN Healthcare. 

The results suggest frustration is still high among nurses in the wake of the COVID-19 pandemic, and turnover will likely remain elevated in 2024, the report said. 

Higher compensation and increased staffing are key to improving job satisfaction, according to the report. Three-quarters of nurses said better pay was extremely important to them, while 68% reported allocating more nurses per patient was crucial in their workplaces.

The survey from AMN is the latest report to find mounting employee discontent after the pandemic, when burnout pushed nurses to consider leaving the profession. 

During the public health emergency, health systems faced heightened labor costs as pricey temporary staff and a more competitive market made it expensive to hire — which added significant strain to hospital margins in 2022.

Those pressures are now alleviating, but hospitals will still likely need to offer higher salaries and better benefits to attract and retain staff, according to a December report from credit agency Fitch Ratings. 

But nurses aren’t so confident conditions are improving for them. The AMN survey, based on responses from 1,155 nurses nationwide, found just 20% believed 2024 would be better than 2023, and 37% predicted the year would be worse for nurses.

Overall, 55% reported they were extremely or somewhat likely to change jobs in 2024. Similarly, 35% said it was extremely likely they’d adjust their hours or schedule, according to the report.

“Turnover and volatility in the nursing workforce have been endemic over the last several years,” Robin Johnson, group president of nursing solutions at AMN Healthcare, said in a statement. “That trend is likely to continue until nurse concerns are addressed.”

Schedule flexibility is also increasingly important in the wake of the pandemic, including options for part-time work, telehealth or hybrid roles, per diem arrangements or travel nursing jobs. 

Fifty-eight percent of surveyed nurses said better schedules or hours were extremely important at their workplaces. 

Wellness and diversity programs were less valued by respondents, suggesting tangible benefits like higher pay, improved staffing and better schedules were more essential to retaining staff. 

Just over 40% of respondents said more wellness programs were extremely important, while 26% said more diversity among nurses was extremely important. 

Physicians’ decisions to leave their practices is a complex choice “with multiple interdependent factors,” and is not solely impacted by burnout, pay or frustrations with electronic health records, according to a qualitative study published in ​​the Journal of the American Board of Family Medicine.

The study, which interviewed physicians who left their ambulatory care practices between 2018 and 2021, found that they were motivated to increase time off, have more flexibility or receive higher earnings. However, other departing physicians reported higher compensation would not have persuaded them to stay.

Physician practices can better retain clinicians by addressing risk factors for departure including workflow distribution across team members and ensuring adequate staffing, the report said.

Physician turnover has risen steadily over the past decade, with attrition rates rising 43% between 2010 and 2018 from 5.3% to 7.6%, according to a study published in July 2023.

The COVID-19 pandemic further increased turnover, with over 71,000 physicians exiting the industry between 2021 and 2022, according to a report from Definitive Healthcare. Exiting physicians often sought retirement early, burned out of the profession or struggling to adapt to providing care via telehealth. The study also linked EHR burden to physician burnout and turnover.

However, the ABJM study found that burnout and EHR burden wasn’t the primary motivator for physicians exiting their practices. In fact, many physicians who left their jobs didn’t leave the industry. Fifty-four percent of the physicians who left their ambulatory practices departed for new positions, pointing to the importance of local leadership and culture in retention.

Physicians included in the study were driven to leave their current practices by a number of factors, including isolation, the corporatization of medicine, the pandemic and inbox burden, difficult patients, volume and intensity of work, and advancement opportunities.

The study recommended increasing opportunities for physician recognition, development and advancement, as well as distributing responsibilities across team members and ensuring adequate staffing across disciplines and roles.

In addition, though no providers listed the EHR as their primary reason for departing, the study suggests that the EHR could be optimized and providers could receive more technical support to diminish documentation burden.

More than three years after the onset of the COVID-19 pandemic, only 1% of primary care clinicians surveyed by the Larry A. Green Center and the Primary Care Collaborative in 2023 believed their practice had fully recovered from its impacts, and 61% characterized U.S. primary care as “crumbling.”

Nearly 80% of respondents felt the current workforce is undersized to meet patient needs, and just 19% of clinicians report their practices are fully staffed.

The results are emblematic of a “larger national crisis” and policymakers must act to reinforce primary care, said Rebecca Etz, co-director of the Larry A. Green Center, in a statement. “ ... It is not a matter of if, but when there will be another pandemic … If we don’t act soon, primary care won’t be there when it happens.”

Though the COVID public health emergency ended in May 2023, researchers found that burnout is still lingering among primary care providers — 32% percent of clinicians reported feeling high levels of burnout, stress and moral injury.

Sustained staffing shortages are also contributing to providers’ stress, the report found.

In 2023, fewer clinicians reported their practices were fully staffed compared to the year prior, according to the survey. The national physician shortage worsened during the pandemic, as providers left the field due to burnout, or after financial troubles forced facilities to conduct layoffs. Unchecked, the American Medical Association projects the staffing shortage will grow to a deficit of between 17,800 and 48,000 primary care physicians by 2034.

Remaining providers often have more to do. Staffing shortages have led clinicians’ administrative tasks to increase by up to 15%, according to The Council for Affordable Quality Healthcare.  According to the Larry A. Green Center survey, patient volumes have also increased, both from backlogs of care and from new patients whose former providers’ practices may have shuttered during the pandemic.

While the vast majority of providers in the survey report pessimism about the industry's future, other clinicians are seeking alternate forms of employment.

The AMA released a report in July 2023 outlining an increase in private practice consolidation. The report found the percentage of physicians working in practices at least partially owned by a hospital or health system increased by almost 8% between 2021 and 2022, driven in part by providers hoping to negotiate higher payment rates with payers.

“This is, perhaps, not surprising given that physician payment in the Medicare program declined greatly between 2001 and 2023 after adjusting for inflation in practice costs and that a large majority of physicians describe the burden associated with prior authorization as high or extremely high,” the AMA report noted.

Though working with a hospital or a healthcare system may be a salve for the immediate wound of administrative and regulatory woes, consolidation can lead to decreased physician earnings and increased costs for patients seeking care.

The rate of physician burnout in the U.S. more than doubled during the first years of the pandemic, with physicians reporting higher levels of exhaustion and cynicism and lower levels of personal efficacy in 2021 compared to 2019, according to a study published in JAMA Network Open in October, 2023.

Burnout levels varied by demographic, with women physicians, less experienced physicians and primary care physicians reporting higher levels of burnout than male physicians, more tenured clinicians or internal medicine providers. 

Professional factors can insulate physicians from burnout, the study concluded. Physicians who spent less time on administrative tasks, worked in roles outside of primary care and those who were more highly compensated were less likely to report high levels of burnout. 

Physician burnout is defined as a state of emotional, physical and mental exhaustion caused by prolonged stress in the workplace, according to the study. 

Prior to the pandemic, burnout expenses related to physician turnover were projected to cost health systems $4.6 billion annually.

Burnout has increased since the start of the pandemic as providers coped with higher workloads and reported hostile work environments. Many physicians have left the profession as a result, prompting the U.S. Surgeon General to issue an advisory in 2022 declaring that combating provider burnout must be a priority for healthcare systems.

The JAMA study surveyed the same 1,373 physician faculty members of the Massachusetts General Physicians Organization in 2017, 2019 and 2021. The survey found that over a quarter of physicians experienced burnout each year, while over 35% did not experience high burnout in any year.

Certain providers were more likely to experience burnout. Women physicians and primary care physicians were more likely than male physicians and internal medicine physicians to report high exhaustion scores. Primary care physicians also expressed more cynicism about their work.

The study echoes previous research. Over 60% of primary care providers in a July 2023 survey said the field was “crumbling” amidst staffing shortages. Only 1% of PCPs surveyed felt their practice had fully recovered from the impacts of the pandemic, and nearly 80% felt the current workforce was undersized to meet patient needs.

Over the past four decades, women working in healthcare have reported significantly higher levels of stress and burnout than their male counterparts worldwide, according to a new literature review.

Gender inequity in the workplace, poor work-life integration (i.e., being encouraged to prioritize caregiving over professional development) and a lack of autonomy at work correlated with increased burnout, according to the study published February 2024 in Global Advances in Integrative Medicine and Health.

Some professional and personal factors insulated female healthcare professionals from burnout. Women who worked in supportive environments that offered flexible schedules and employee recognition, or those who had strong relationships inside and outside of the workplace reported higher levels of well-being.

For the review, researchers studied healthcare professionals’ well-being — their integrated mental and physical health as it relates to life satisfaction, sense of purpose and ability to manage stress — and absence of well-being, or burnout.

The analysis drew from 71 studies of well-being among healthcare professionals published in 26 countries from 1979 to 2022.

In a quarter of the studies, women in healthcare said work-life integration fueled dissatisfaction. Women said they were encouraged to prioritize the needs of their children and families over their own personal and professional development, even when they earned higher incomes than their partners.

Another quarter of articles found limited professional autonomy and poor working conditions contributed to women’s burnout levels. Women were more likely than men to feel “powerless” and constricted by time pressures, as well as to spend more emotional energy on complex patients than their male colleagues, according to the study.

The study warned burnout could have “devastating effects on healthcare professionals and the quality of patient care. “ Its authors advocated for increased training for gender sensitivity and bias, as well as the structural challenges women in healthcare occupations face. 

The research is significant due to women’s dominance of the healthcare industry, according to the study. As of 2021, women made up 78% of the workers in the U.S. healthcare and social assistance sector, according to the Bureau of Labor Statistics. 

Burnout has increased since the start of the pandemic as providers coped with higher workloads and reported hostile work environments. Many physicians have left the profession as a result, prompting the U.S. Surgeon General to issue an advisory in 2022 declaring that combating provider burnout must be a priority for healthcare systems.

For caregivers — many of whom are women — burnout has been even worse. Healthcare workers with high childcare responsibilities were 80% more likely to report burnout and more likely to consider reducing their hours or leaving their roles, according to a study published in JAMA.

Nearly three-quarters of healthcare professionals say the time or effort needed to complete clinical documentation hampers patient care, according to a survey published by the American Medical Informatics Association in June 2024.

Documentation tasks follow healthcare workers home too. More than 77% of respondents reported finishing work later than desired or working after hours due to excessive documentation.

The survey comes as a number of technology companies are touting generative artificial intelligence tools that aim to cut down the amount of work needed to document care in medical records.

Documentation burden is a long-term problem in the healthcare industry. Clinicians say they spend hours on note-taking and other administrative tasks in electronic health records — sometimes after work hours — contributing to burnout and siphoning time away from direct patient care. 

The latest survey by the AMIA, which surveyed more than 1,200 healthcare workers across the country, found many clinicians still report spending excessive time and effort recording patient care.

Clinicians also noted EHR usability problems, another long-reported challenge in the sector. More than 44% disagreed that it was easy to document patient care in the EHR and greater than 66% of respondents said they had not seen a recent decrease in the time or effort needed to complete documentation tasks.

The survey comes as the healthcare sector has shown increased interest in generative AI note-taking products, which technology companies say will alleviate documentation burden and burnout.

Companies like Oracle, Amazon, NextGen Healthcare, Google and Microsoft-owned Nuance Communications have developed tools that listen to conversations between clinicians and patients and draft clinical notes. HCA Healthcare, one of the largest hospital chains in the country, said it would roll out its Augmedix AI scribe to more emergency departments.

Other healthcare organizations say they’re interested in implementing generative AI products soon. A survey published in 2023 by Klas Research found more than half of organizations are looking to put the tools in place within the next year, and a number of executives with a strategy said they’d use it for documentation at their companies.

But there are still concerns about generative AI products, with leaders citing worries about accuracy and reliability. Other experts have argued a too-rapid deployment could replicate biases and widen health inequities.