As the pandemic stretches on with no clear end in sight, one of the biggest unanswered questions is what this experience has meant, and ultimately will mean, for those who’ve been on the front lines throughout – the nation’s health care workforce – and the patients they serve.

An estimated 1.5 million health care jobs were lost in the first two months of COVID-19 as the country raced to curb the novel coronavirus by temporarily closing clinics and restricting non-emergency services at US hospitals. Though many of those jobs have since returned, health care employment remains below pre-pandemic levels, with the number of workers down by 1.1%, or 176,000, compared to February 2020, per the US Bureau of Labor Statistics.

Yet the need for health care workers has never been greater. Staffing shortages are now the nation’s top patient safety concern, forcing Americans to endure longer wait times when seeking care “even in life-threatening emergencies,” or to be turned away entirely, according to ECRI, a nonprofit patient safety organization.

In a letter sent in March to the House Energy and Commerce Committee, the American Hospital Association called the workforce shortage hospitals were experiencing a “national emergency,” projecting the overall shortage of nurses to reach 1.1 million by the end of the year. And it’s not just nurses: Professionals from medical lab workers to paramedics are in short supply.

The effects are being felt throughout the entire care continuum. In certain parts of the country, whole hospitals and medical departments have shuttered amid such shortfalls, leaving patients with less access to vital health care, including labor and delivery services and inpatient care for children.

With fewer clinicians working in the field, practitioners are finding themselves responsible for a larger number of patients, fueling soaring burnout levels that experts say raise the risk of medical errors and, accordingly, potential harm to Americans. The number of central line-associated bloodstream infections increased 28% in the second quarter of 2020 compared to the same period in 2019, according to the New England Journal of Medicinewhile rates of falls rose by 17% and pressure injuries increased by nearly 42% at skilled nursing facilities during the same period.

And the strain hasn’t let up. A February 2022 survey conducted by USA Today and Ipsos of more than 1,100 health care workers found nearly a quarter of respondents said they were likely to leave the field in the near future due to the pandemic.

Low morale has already translated into departures. Results of a September 2021 poll of 1,000 health care workers revealed that, since February 2020, 18% had quit their jobs.

Patients are feeling the sting in several ways. In January 2022, Saint Alphonsus Health System – a primary care provider for a region with a population of more than 1 million in Idaho and parts of Oregon – decided to temporarily close weekend operations at three of its urgent care centers and cut back hours at all 11 of its urgent care clinics for a couple of weeks when several staff members contracted COVID-19 and had to isolate. Though the situation has since normalized there, sudden, temporary staff losses have become par for the course during a pandemic that has sickened workers across all corners of the health care landscape.

Other staff cutbacks have been more permanent. In April 2022, Memorial Hospital of Carbon County, in Rawlins, Wyoming, announced it was ending its labor and delivery services due to staffing challenges. Now, the closest facility for expectant parents is about an hour and a half away at Ivinson Memorial Hospital, in Laramie, Wyoming.

“The cost of traveling nurses has played a significant role” in the decision, said Rod Waeckerlin, chair of the MHCC Board of Trustees, in a press release. “Labor and Delivery is a unique service line that requires intensive staffing. Unfortunately, as a result of the pandemic, MHCC has lost a number of nursing staff, forcing a reliance on traveling nurses and creating a financial imbalance operationally.”

The escalating demand for health care professionals has also led to a sharp rise in labor costs, as hospitals vying for workers must dangle larger pay packages. Hospital labor costs rose 37% between 2019 and March 2022, according to a recent report from consulting firm Kaufman Hall.

For hospital systems like Northwell Health in New York, the fluctuating labor market has presented both immediate and longer-term workforce challenges that have evolved as the nature of the pandemic has changed.

By the start of 2021, Northwell’s staffing focus shifted. It went from managing the influx of severely ill COVID-19 patients flooding its emergency departments and inpatient beds to adding personnel at its outpatient settings to treat more moderate cases.

With COVID cases ticking up once again at press time, Matthew Kurth, deputy chief people officer for Northwell Health, says the health system has pivoted to ensure testing centers and processing laboratories are staffed up enough to meet the demand.

But just as workers have adapted, many patients are changing how they access their health care due to the pandemic, which has created both opportunities and new challenges.

For example, many patients have become accustomed to using digital tools like telehealth to tend to their primary care needs, a practice Kurth says will likely continue beyond the pandemic. But while fewer people are being hospitalized for severe COVID-19, more patients are showing up with severe ailments, creating a backlog of cases at myriad facilities nationwide. Many of these cases stem from delayed care – people having postponed treatment either due to contagion fears or care restrictions enacted at the height of the pandemic.

“I think that the first wave definitely had an impact across the entire spectrum,” says Dr. John D’Angelo, chief of integrated operations for Northwell Health.

Although hospital staffing challenges have changed with each new COVID wave, one concern has remained constant: the mental and physical burden that has been placed on health care workers.

At Henry Ford Health in Michigan, pandemic-related burnout and stress has led some professionals to leave in pursuit of more lucrative jobs contracting with staffing agencies while others have opted to exit the field altogether, says Jan Harrington-Davis, the organization’s vice president of talent acquisition and workforce diversity. She estimates the health system has approximately 3,000 open positions.

“I don’t think there’s any area that you could name that hasn’t seen a huge amount of turnover,” Harrington-Davis says.

Michelle Gaskill-Hames, chief operating officer for Kaiser Permanente’s Southern California and Hawaii markets, says though the situation has improved since the early months of COVID-19 in terms of cases and deaths, there remains a vital need for hospitals to address the anguish workers have experienced since Day One.

“As our surges are becoming smaller, more people are vaccinated and hospitalizations are down, many people are looking to put the pandemic behind them, but in the health care space, it’s not that easy,” Gaskill-Hames says. “There are just layers of anxiety, stress and fear. That doesn’t just go away.”

To help workers recover from pandemic-induced trauma, the health system launched Rise & Renew, an initiative that provides employees with counseling support.

At Mount Sinai Health System in New York, staff have been offered 14 one-on-one behavioral health counseling sessions and group workshops at no charge since June 2020, when the organization launched its Center for Stress, Resilience, and Personal Growth.

According to Jane Maksoud, the health system’s chief human resources officer, this program, coupled with efforts to allow as many as 10,000 team members to work remotely, is part of a broader retention strategy that hinges on meeting workers where they are to engage them with support, and allowing flexibility to whatever extent possible.

However, even as the country enters a less acute phase of the pandemic, some experts are skeptical that enough is being done nationwide to combat the enduring trauma of having worked on the front lines throughout COVID-19.

“My concern is that even though it’s getting talked about a lot, I don’t know if the support is reaching the clinical staff,” says Dr. Rajnish Jaiswal, associate chief of emergency medicine at NYC Health + Hospitals-Metropolitan in Manhattan. “Wellness programs that keep that in mind and allow folks to actually utilize them – I think that’s going to be the next big step.”

Jaiswal says getting back to a state of “normal” for many hospitals will also mean facing the same staffing problems that were present before COVID-19.

A coordinated response

Creative staffing solutions have also emerged from the pandemic. In the thick of initial COVID-19 surges, some hospitals addressed workforce gaps through rapid redeployment of existing staff to help in areas of high need. Medical specialists whose services were put on hold to stem the spread of the virus began pitching in to assist colleagues in caring for COVID-19 patients. Groups of nurses and physicians led by intensive care unit clinicians were formed to manage sicker patients.

“In some instances, we had physicians working for nurses because a lot of the burden was on the nursing teams to really deliver that consistent bedside care,” Maksoud says.

Similar tactics are being adopted at Saint Alphonsus, for example. To address its nursing shortage and ideally reduce wait times, the medical center is launching a pilot program that creates nursing care teams made up of registered nurses, licensed practical nurses and certified nursing assistants. With fewer nurses available to care for patients in that region, the goal of the program is to have fewer RNs be in charge of a larger pool of patients than they would traditionally without lowering care quality or safety standards.

“It’s kind of a way to spread that care team a little broader,” says David McFadyen, president of Saint Alphonsus Regional Medical Center.

At Virginia Mason Franciscan Health in Washington State, virtual care is proving helpful. Chief Nursing Officer Dianne Aroh says a centralized mission control center and virtual hospital that went into effect in 2019 provides real-time, systemwide surveillance that has helped deploy personnel more rapidly to departments experiencing capacity issues, while easing patient-flow bottlenecks and wait times.

“That’s a system I think that we will need to leverage in the future,” she says.

Whether due to labor costs, illness or burnout, the long-term ramifications of current health care workforce shortages are likely to be felt well after the pandemic ends.

Nationally, staffing shortages threaten to exacerbate what projections for years have characterized as a looming crisis. By 2025, the US is estimated to have a shortage of approximately 446,000 home health aids, 95,000 nursing assistants, 98,700 medical and lab technologists and technicians, and more than 29,000 nurse practitioners, according to a 2021 report conducted by industry market analytic firm Mercer.

Meanwhile, the need for health care is only going to rise as the elderly population grows. The number of individuals ages 65 and older is projected to increase from 54 million in 2019 to more than 80 million by 2040, according to the Department of Health and Human Services. The prevalence of chronic illnesses among younger people and children has also grown over time, with more than 40% of school-age children and adolescents having at least one chronic health condition.

While technology and workforce innovations may provide short-term relief, a diminished workforce signals a future where patients will likely have to become more active participants in their health care to achieve good outcomes.