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Healthcare Insights by John August

Where Did All the Nurses Go?

Not unlike the foreboding headlines each day about the trajectory of the COVID-19 pandemic and its impact on people here and abroad, the exodus of healthcare workers from the health professions is major parallel news. The shortages of healthcare workers are frightening and demoralizing to the public and to the health professionals who have dedicated their lives to helping others.

Yet, just as the pandemic has revealed so many of the injustices in our society that existed long before its onset in early 2020, the shortages of nurses and allied health professionals, certified nursing assistants and home health aides that have accelerated during the COVID-19 pandemic are not new either. 

And the shortages and failure of our nation to have sustainable and healthy healthcare labor markets will not be achieved by use of methods employed in the past.

The bravery and dedication of America’s nurses have been displayed in front-page newspaper stories across the country throughout the COVID-19 pandemic. However, the pandemic has also been a huge strain on nurses and the healthcare system, due in part to limited staff and resources. The nursing shortage facing America began long before the pandemic propelled it into the headlines once again.

The United States has experienced nursing shortages periodically since the early 1900s. Multiple factors led to each shortage, from world wars to economic recessions. But the magnitude of the current nursing shortage, announced in 2012, is greater than ever before in this country.

Given the growing demand for healthcare services across a multitude of specialties, reports project that 1.2 million new registered nurses (RNs) will be needed by 2030 to address the current shortage.  Nursing schools and graduate nursing programs are working to accommodate the rising demand for skilled nurses and nurse leaders, but they also face challenges.” (“The 2021 American Nursing Shortage: A Data Study”, University of St. Augustine for Health Services Webpage, May 2021).

The shortages of healthcare workers must be reversed. And for those who continue to work in healthcare, attention must be paid to their mental and physical well being.  Much good work is going on in these areas. Efforts at recruitment are ramping up; new support systems for healthcare staff are being implemented to mitigate burnout.

At the same time, we should recognize that in the delivery of healthcare, no problem is unrelated.  The fact that our healthcare workforce has never been stable is symptomatic of the broader reality about American healthcare: that the USA spends more on healthcare than any nation in the world, but our population is not healthy.  Year over year, the USA population ranks about 37th in the world as to health outcomes, and well below all other wealthy nations. (According to World Health Organization data).

Decade after decade, the U.S. recruits millions of people into healthcare professions only to see vacancy rates and shortages skyrocket.  Decade after decade, the USA spends up to 20% of its entire GDP on healthcare, yet our population suffers from largely preventable chronic disease, the largest driver of healthcare costs and human suffering.  Decade after decade, technology becomes more prevalent, sophisticated, and effective, yet access to this science and technology remains highly disparate based on race, ethnicity, and class

Let’s consider the relationship of the need to transform healthcare from our current state, which still largely is a system, which intervenes only after people are sick.  Prevention of illness is the centerpiece of healthcare improvement and must be at the center of healthcare transformation.  As such, we must learn to think about a transformation of the healthcare workforce as one of the central means to transform care, and to make transformed care available and effective for all patients.

The health and well-being of the workforce must not be seen as an intervention either!  Rather, health and well-being must be integrated as part of the daily life of healthcare delivery for the healthcare worker.  Care experience, quality, safety, affordability, workforce well-being, engagement, and satisfaction must all be considered simultaneously, if the USA is to break into the highest level of healthcare outcomes in the world.

We have a long way to go. We also know what to do.

As an introduction to the ideas and suggestions in this article about how we must look in a transformative way about the workforce of the future watch this brief video:

Not My Father's Union | Labor Management Partnership (

The transformation of healthcare requires that healthcare services become more widely accessible and affordable.  We know that an integration of these services is also essential. 

Such a newly envisioned system requires that we rethink where healthcare services are provided; what skills are needed to provide those services, and how a new workforce ought to emerge. It must be seen as a lifelong career of stability in high wages and good working conditions, and just as importantly, it must provide high levels of engagement, satisfaction, and the opportunity for continuous growth and learning. 

There are many ideas that can be advanced about what a transformed healthcare workforce should be.  At least one idea or approach I want to share in this article is the idea of looking at the healthcare workforce holistically that is in one sense, from the “bottom up”.

Our natural tendency is to look at healthcare professions separately:  nurses, doctors, therapists, medical laboratory technologists, nurses’ aides, home health aides, coders, community health workers, drug and alcohol counselors, patient care technicians, pharmacists, social workers, psychologists, therapy aides and assistants, dietitians, environmental services aides, cooks, transporters, emergency medical technicians, phlebotomists, radiation technologists, bio-medical technologists, skilled trades, janitors, mechanics, infection control specialists, accountants, nurse educators, nurse managers, hospital and other facility administrators, and many more.

You get the picture…we tend to look at each profession as an individual one.

Instead, we should:

·      Look at the skills and responsibilities of each profession integrated with one another with the goal of attaining the best outcomes for patients.

·      Look at how each of these professions is related to a continuum of career development from entry-level positions to more highly skilled positions.

Workforce shortages and vacancies in each profession must give way to these interrelated processes of integration: for continuously improving   patient-centered outcomes, and for continuous learning and growth of the whole workforce.

In his 2017 book, MIT Professor Paul Osterman writes: “The core principles of high-performance systems are investment in training and human capital of the workforce, broad task design and teamwork, employee involvement in problem-solving, and an atmosphere of cooperation and trust. These principles lead to better performance through several channels:  skill, motivation and commitment, and organizational social capital that leads to the sharing of ideas.” (Who Will Care for Us? Paul Osterman, Russel Sage Foundation, 2017, p.73).

The Role Of Collective Bargaining To Create The Workforce Of The Future

Many efforts are underway across the nation to address the crisis in the healthcare workforce.  Large multi-employer and single employer education funds have existed for many years in high density unionized markets including New York, Boston, Philadelphia, Metro Washington, DC, Minneapolis-St. Paul, Buffalo, NY, and across much of the Pacific Coast including California, Oregon, and Washington State. These trust funds are formed based on the principle of creating paths of “life-long learning”, encouraging those in entry level positions to strive for the attainment of higher level occupations.  

These funds are very successful, in no small measure due to the association of the trust funds with the unions where workers feel a sense of affinity to both work and their union. Mentoring and other support systems are common to these programs of career development.  Stipends to support the attainment of successful completion of courses are often a part of these programs as well.

These funds have the capacity to apply for grant money from federal and state sources, as well as to provide career counseling, and support and preparation for those long out of school to be able to more successfully enroll in and pass technical courses.

Apprenticeship programs have become more prevalent in healthcare settings as well, and most show great promise in the recruitment and deployment of individuals into new positions for themselves and in occupations that tend to have chronic shortages (medical coders, Certified Nursing Assistants, surgical techs, among others as examples).

Outside of these types of trust fund settings, most healthcare systems offer tuition reimbursement and other education benefits.

With all of this investment and attention, much more must be done to alleviate the shortage of nurses and other health professionals that existed pre-pandemic, let alone the accelerated nature of the staffing shortages due to the pandemic.

There are nearly two million unionized healthcare workers in the nation.  Collective Bargaining remains an opportunity to create the workforce of the future.  

Now more than ever, the opportunity exists to look at how collective bargaining must transform its fundamental purpose:  to adapt to the changes in all aspects of healthcare, and lead healthcare transformation itself.  

Moreover, we must look at the healthcare workforce as a whole, from entry level positions in home health and nursing homes and hospitals, to create a continuous journey of life-long learning and a more stable healthcare labor market overall.

What is missing, in my view, is that there is not a direct linkage in collective bargaining or in workforce planning and development between the elements of a transformed healthcare system and the development of a stable health care labor market.

No element of that transformation is more important than workforce planning and development.

So, what is missing?

What is missing is to make the foundation of collective bargaining the commitment to continuous, measurable, and demonstrable healthcare improvement.  The foundation to this improvement journey is creating and sustaining a highly engaged and empowered workforce at the frontlines of care. Paul Osterman was correct when he observed that what is needed is “investment in training and human capital of the workforce, broad task design and teamwork, employee involvement in problem-solving, and an atmosphere of cooperation and trust. These principles lead to better performance through several channels:  skill, motivation and commitment, and organizational social capital that leads to the sharing of ideas.”

Even if such a foundation of collective bargaining was to emerge, successful achievement of continuous, measurable, and demonstrable improvement will not be achieved without a fundamentally different approach to organization and design:  team-based care, with teams engaged in highly skilled problem-solving capacity in an atmosphere of trust and cooperation, along with broad task redesign.

How can this be achieved?

1.)  Where to find the workforce of the future has become more and more difficult as low paying health care jobs compete with other low-paying jobs where the work may be less stressful or complex.   It is time to recruit for entry-level positions from non-traditional parts of our community:  from those who are coming out of the criminal justice system, from community based organizations that serve populations in all aspects of crisis and healing.  Build databases on large scale and recruit through interviews, which offer a clear path from entry-level to more highly skilled positions.  In brief, recruitment must go beyond the traditionally unemployed and underemployed to a large segment of the population who are too often forgotten.

2.) Make entry-level positions, especially those of home health aides and nursing assistants, much more value-based and productive, teaching skills that go far beyond basic maintenance of clients and patients to observation of conditions, use of video and other digital means to communicate and coordinate care, take vital signs and perform treatments.  Most importantly, evolve these entry level jobs to become a more highly skilled part of an overall team of care coordination and prevention of illness and injury.

3.) Make improvement science a part of all healthcare education at every level of the healthcare occupational continuum.  Improvement science is built on collaboration and problem-solving all within an atmosphere of psychological safety.  The methodologies of improvement science are all based on common tools and approaches:

The groups set a goal, timeframe, and data-driven baselines

The groups brainstorms “tests of change” to apply to the problem to be solved

The groups use well known Plan, Do, Study, Act (PDSA cycles) which aids the group in determining whether or not the test of change creates an improvement.  If it does, the group pursues that idea further and expands its application; if not, the group quickly abandons it and creates new tests of change for another PDSA cycle. 


4.) Adopt whole systems change in every healthcare delivery setting designed to achieve measurable improvement.  Generate the goals and metrics for the system from the frontline of care and then have a joint labor-management executive committee oversee, support, and build accountabilities for achievement of those goals.  Do away with action plans and “death by initiative” (the more initiatives advanced the less accomplished) and instead establish metrics that matter in key areas of improvement:  quality and safety, patient experience, affordability and productivity, and workforce health, security, and having the best place to work.  The frontlines hold the answers to these questions so long as they are given the information and data as well as the support and freedom to truly collaborate in a trusting and safe atmosphere.  If each unit/team in the system identifies 6-8 metrics that matter and they are achieved, the foundation for continuous improvement of all aspects of care delivery will be established.  These are the key elements of high performance healthcare. This is the place to mitigate healthcare burnout and stress:  proper staffing, time off for rest and breaks, and other forms of support must be discovered and implemented at the frontlines of care.

Finally, we know that a highly engaged workforce is a workforce that will stay in their occupations.  I share the following data from a previous article, which shows the relationship of participation in high performing teams and high engagement.  This comes from a study of hundreds of high performing teams at Kaiser Permanente, among the few unionized environments where team based care and high performance are central to the goals of the collective bargaining relationship

·      Efficient work procedures in department (71%)

·      Know about department goals (78%)

·      Understand how my job contributes to our goals (89%)

·      Confident management would respond to unethical behavior (74%)

·      Comfortable raising ethical concerns to supervisor/management (78%)

·      Department operates effectively as a team (71%)

·      Department doing things to improve patient safety (86%)

·      Usually enough people in department to do job right (54%)

·      Kaiser provides resources necessary to work effectively (77%)

·      Steps taken in department to ensure employee/ physician safety (87%)

·      Encouraged to suggest better ways to do work in department (78%)

·      Supervisor recognizes me when I do a good job (73%)


(Culture Matters, An Investigation into UBTs, Workplace Culture and Performance, Executive Committee of the LMP Strategy Group, January 17th, 2012, J. Peter Nixon, Director of Metrics and Analytics, Office of Labor Management Partnership)


The percentage scores on each question represent the engagement score from the employee engagement survey.  Since we know that the average employee engagement score across the nation is 20-30%, seeing these scores ranging from the 54th-89thpercentiles speaks clearly to the relationship of high performing teams, high engagement, and retention.


We cannot wait long for the healthcare workforce of the future to emerge.  Vacancies and shortages continue to climb. Care and coordination of care remains unattained.  Large-scale reduction in the preventable chronic conditions remains out of reach.  Regular and population-wide preventive screenings, health education, and peer-to-peer support are out of reach for our population. Mental health, dental care, hearing and vision screening and health are nowhere near available


We must build the workforce of the future not to fill vacant occupations, but as part of the teams which require new skill sets, problem-solving capability, and having the support to maintain their own health and well being.


The healthcare segment of our society employs nearly 22 million people or 14% of the workforce overall.  Yet we have shortages…not unlike the crisis in healthcare overall, where more than $4 trillion is spent each year for a population which ranks 37th in the world on health outcome measures, it is clear that overall the nation is not getting what it pays for.  A reorganization, retraining, re-skilling, and retention of a new healthcare team-based model of work is central to achieving a new system of care. 


We will likely wait a long time for policy change to achieve what our people need. Instead of waiting we have the means and the capability today to build a new health care system in our communities from a transformed collective bargaining table. 


About the author: John August is the Director of Partner and Healthcare Programs at the Scheinman Institute.