The purpose of this article is to provide a comprehensive overview of the issues that the COVID-19 pandemic amplified and created in the nursing workforce during 2020. Exemplars are used to highlight the issues, and to encourage action and innovation in the domains of workforce strategy, education, research, and policy in these challenging times. The authors recognize there are many more noteworthy programs in communities throughout the United States. However, this discussion is intended to showcase selected exemplars to provide the reader with an overview of ideas of what has been and is currently being done. Also, given the rapidly changing environment and quick innovations, the literature reviewed for this article includes peer-reviewed publications, publications in the lay press, and personal communications.

The HealthImpact Workforce Strategy Model

Addressing the opportunities and challenges in these six areas can strengthen the nursing workforce...A model of workforce strategy created by HealthImpact, the California nursing workforce and policy center, delineated nursing workforce strategy as six key areas: 1) exposing kindergarten through 12^th grade (K-12) and second-degree populations to nursing; 2) pre-requisite education requirements; 3) pre-licensure nursing education; 4) upskilling the existing workforce; 5) retention and well-being; and 6) workforce migration (see Figure). Addressing the opportunities and challenges in these six areas can strengthen the nursing workforce to advance health and address health disparities. Through this framework, the National Forum of State Nursing Workforce Centers brought together state leaders to articulate the impact and effects of COVID-19 on the nursing pipeline and workforce. This section discusses each of the six key areas.

Figure 1. HealthImpact Workforce Strategy Model

[View full size]

(Used with permission.)

K-12, Second Degree Students, and COVID-19
Exposing students in the K-12 system to the health professions can focus their efforts early to achieve their authentic health career pathExposing students in the K-12 system to the health professions can focus their efforts early to achieve their authentic health career path (Oxendine, 2020). Pre-pandemic, organizations created initiatives to attract K-12 students into nursing. For example, Johnson & Johnson, through their 2002 Campaign for Nursing’s Future, invested millions of dollars towards commercials, scholarships, grants, and partnerships to inspire people to join the profession of nursing (Donelan, Buerhaus, Ulrich, Norman, & Dittus, 2005). Through the Discover Nursing website and their partner organizations, Johnson & Johnson recruitment efforts made a positive impact, with more than one million people earning bachelor’s, master’s, and PhD degrees in nursing since the start of the campaign (Johnson & Johnson Services Inc., 2021).

The Foundation for a Better Life ([The Foundation], 2021) creates public service campaigns to communicate the values that make differences in communities. The Foundation created an initiative, Pass It On^®, designed to convey positive messages through a variety of media outlets to uplift viewers with positive values and encourage people to bring out the best in themselves. One of their billboard messages is, “Nursing a country back to health. Service.” (The Foundation, 2020); this billboard features a black female clinician. This positive imagery lifts the visibility of the health professions, especially in communities of color. The American Association for Men in Nursing (AAMN) Engage the FutuRN campaign (AAMN, 2019) is a program designed for members to reach high school and other young students at a time when they consider career planning. AAMN has resource documents to disseminate the program to target audiences.

This positive imagery lifts the visibility of the health professions, especially in communities of color. Early in the COVID-19 pandemic, nurses were described as “heroes” because of their willingness to be humanitarians, lifesavers, and enter dangerous situations (Morin & Baptiste, 2020). The action of nurses in the pandemic inspired a comic book, created by Marvel Comics in collaboration with the Allegheny Health Network, to tell stories and offer an insider view of everyday nurses who work tirelessly and courageously as heroes (Marvel, 2020). The comic book format raised awareness of the work nurses have performed during the pandemic for comic book fans and introduced younger audiences to the role of nurses.

In 2020, a concern emerged that post-graduation, students would delay entry into college until everything became more certain. A March 2020 study found that 35% of college-bound seniors intended to delay and take a “gap year” due to COVID-19, thereby affecting the potential nursing pipeline (Art & Science Group, LLC, 2020). Parents who lost employment may not be in the position to assist with college expenses; this may result in more student debt for those who choose to enter or continue college (DePietro, 2020).

...recent data shows schools across the United States have experienced an increased number of applicants to enter nursing school During the pandemic, two nursing schools in New Jersey -- Holy Name Medical Center and Bergen Community College -- had 380 and 800 applications for 90 slots, respectively Despite these initial fears, recent data shows schools across the United States have experienced an increased number of applicants to enter nursing school (Kowarski, 2020). During the pandemic, two nursing schools in New Jersey -- Holy Name Medical Center and Bergen Community College -- had 380 and 800 applications for 90 slots, respectively (Shanes, 2020).

Nursing Pre-requisite Education and COVID-19
COVID-19 had a wide range of impact on higher education, including nursing pre-requisite education. One of the biggest challenges for higher education was shifting traditional in-person instruction to online courses in a short amount of time. When state governors around the nation enacted restrictions on gatherings and limited elective procedures, pre-licensure nursing education programs found themselves caught between multiple guidelines. These recommendations included social distancing, use of personal protective equipment (PPE) in the workplace and in public, limitations of personnel needed in healthcare settings, and the closing of public buildings to reduce the gathering of groups. Program leaders have struggled with how to keep a holistic learning environment and ensure student engagement with the new learning format. Additionally, higher education institutions are challenged with ensuring student safety; quality education; healthy staff and faculty who can teach effectively; and financial solvency for the organization (Association for Career and Technical Education, 2020).

Program leaders have struggled with how to keep a holistic learning environment and ensure student engagement with the new learning format. The pandemic restrictions also presented the opportunity to utilize technology in new ways, such as videoconferencing lectures, and asynchronous learning. These innovations might not have happened without the COVID-19 pandemic. However, it is not clear if this shift to virtual learning provides the same quality as in-person instruction and it often varies greatly between types of classes. Nursing pre-requisite courses that require a laboratory experience (e.g., anatomy and physiology, microbiology) presented challenges in distance learning situations. If students cannot complete these courses, the workforce pipeline is adversely affected.

If students cannot complete these courses, the workforce pipeline is adversely affected.A new study at Pennsylvania State University and the University of Connecticut provided a rapid examination of the challenges that all students, especially underrepresented groups, are facing during the COVID-19 pandemic. When universities shut down and transitioned to distance learning, many students reported being in environments not conducive to learning. According to the study, students may encounter inadequate housing, multi-generational homes, the need to work more hours to earn money or take care of family members, and limited access to high-speed internet (McCormick, 2020).

Pre-licensure Nursing Education and COVID-19
Shifts in Learning Modalities and Clinical Placements. With the rapid shift in learning modalities, national organizations worked to assist educators with new resources. The Centers for Disease Control (CDC) released guidance to institutes of higher education that outlined levels of risk to consider when planning for instruction, housing, and hygiene (CDC, 2020c). The CDC recommended virtual-only learning options and activities, which constituted the “lowest risk” of infection. Other associations, such as the American Association of Colleges of Nursing (AACN) compiled expert recommendations and resources to help nurse faculty adapt to a fully online instruction model (AACN, 2020).

The pandemic made placing nursing students in clinical experiences... even more complicated.Prior to the pandemic, clinical placement opportunities for students were difficult to arrange due to limited clinical sites, the additional workload student presence can place on healthcare providers, and the growing number of nursing programs (Berry & Bitton, 2020). The pandemic made placing nursing students in clinical experiences, an already difficult aspect of nursing education, even more complicated.

In many communities across the nation, acute care and long-term care facilities shut down clinical placements as the pandemic intensified due to a lack of PPE, concerns about the spread of COVID-19, and the burden students would place on the workforce. Education programs adapted by shifting placements to community-based settings, such as long-term care and outpatient clinics. However, often these placements were interrupted due to patients who were positive for COVID-19 or lack of available staff due to COVID-19 outbreaks among providers. A study conducted by the Oregon Center for Nursing (OCN) found that almost all major healthcare facilities in the Portland Metro area modified or cancelled clinical placement for nursing students for the Fall 2020 term (Berry & Bitton, 2020).

Regulatory bodies of the nursing profession also had to adapt to this new learning style. The NCSBN compiled changes in education requirements for nursing programs in June 2020 to document the shifts states made to meet nursing student clinical experience requirements (NCSBN, 2020a).

In California and Washington nursing students were designated as essential workers...Ten major national nursing organizations also recommended that facilities connect with nursing education programs to leverage the ability of nursing students to contribute during the COVID-19 pandemic (NCSBN, 2020d). Implementation of recommendations to continue student clinical placement is at the discretion of facilities, who often have other competing national, state, and employer guidelines and procedures to follow to contain the virus and ensure safety. In California and Washington nursing students were designated as essential workers (i.e., workforce members essential to ensure the continuity of critical infrastructure to protect the health and well-being of communities) (California Department of Public Health, 2020; Washington [State of], 2020). This allowed nursing students to continue their ability to participate in direct care clinical educational activities.

The students are trained to provide accurate COVID-related information.To accommodate the decrease in clinical opportunities, nursing education programs continue creative efforts to find new opportunities for students, including increased simulation-based learning experiences (SLEs), telehealth placements, ambulatory care settings, and prioritizing students in their final terms of study for the limited spaces. For example, a partnership established at the onset of the coronavirus pandemic between Public Health–Seattle & King County (PHSKC) and the University of Washington School of Nursing helps pre-licensure students gain required clinical hours by staffing a PHSKC public information call center. The students are trained to provide accurate COVID-related information. This frees licensed public health nurses for other duties. Nursing students at the call center also ensure adequate staffing so PHSKC can respond efficiently and effectively during a public health crisis when they receive hundreds of calls daily. Both PHSKC and the School of Nursing quickly established this opportunity to respond to an urgent public need for information and reassurance. The students benefit from a unique public service opportunity that also fulfills a graduation and licensing requirement.

Nursing education programs also engaged in more virtual simulation activities. Previous research completed by the NCSBN found that students who had SLE training for up to 50% of their overall clinical training experience had similar outcomes to those who had no SLE (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). These findings supported decisions of nursing programs as they transitioned students to screen based and virtual SLE to compensate for cancelled direct patient care clinical placements and was supported by NCSBN recommendations (Spector et al., 2020). One post-pandemic study found that an online clinical course created an environment that successfully engaged students and facilitated learning with a sense of togetherness during a global pandemic (Esposito & Sullivan, 2020).

Over the summer of 2020, it became clear that clinical placements could restart under some circumstances, although resuming these opportunities was not consistent across all states. In Oregon, for example, clinical placements resumed at critical access hospitals and other healthcare settings in rural areas not significantly impacted by the virus. In urban areas, however, hospitals and health systems continued to limit clinical placements into the Fall 2020 term (OCN, 2020b).

NCLEX^® Testing Delays. The NCSBN, which oversees the administration of the National Council Licensure Examination (NCLEX^®), typically can schedule a testing date for a new nurse within 30 days of graduation. Because of the timing of school graduation dates, May through July are often the busiest times for testing. In March 2020, the NCSBN and Pearson VUE closed testing centers and delayed NCLEX^® testing around the world during the highest period of demand due to safety measures and compliance with local public health department COVID-19 mandates (NCSBN, 2021a).

The initial delays caused confusion, frustration, and concern for both students and educators...The initial delays caused confusion, frustration, and concern for both students and educators from Spring through the Summer of 2020. The NCSBN responded by shortening the length of time to complete the test to four hours and removed the pretest items along with the special experimental section (NCSBN, 2020b).

In mid-April 2020, NCLEX^® testing occurred at 154 Pearson VUE centers. Testing centers proximate to urban areas were the first to open, though the test capacity was not what it was prior to the Pearson VUE shutdown in early March. More testing centers continued to open, and to extend hours of operation through Summer 2020. However, students at times had to wait several weeks to find an open NCLEX^® test seat (OCN, 2020a).

State Educational Waivers. The NCSBN tracks state-level pandemic waivers for nursing education, and many states made appropriate exceptions. For example, California, Mississippi, Montana, Nevada, South Dakota, and Wisconsin allowed up to 50 percent simulation for clinical practice with some stipulations. Arizona, Florida, and Maine allowed flexibility for nursing programs to substitute online teaching for face-to-face classes and to replace clinical experiences with simulation. Idaho fast tracked its nurse apprenticeship program to move nursing students earlier into clinical practice. Kentucky allowed for provisional licensure for exam applicants. Oregon and New York permitted nursing students to work or volunteer in clinical settings for educational credit under certain circumstances. The boards of nursing waived the requirement for prior approval for alternative learning modalities in Missouri and Nevada (NCSBN, 2020a).

Upskilling and Expanding the Nursing Workforce for COVID-19

When hospitals and health systems began preparing for a surge in hospitalizations due to the COVID-19 pandemic, many organizations looked inward to determine if existing staff could be utilized in areas where the greatest demand was predicted, such as acute care and critical care. As many states ordered healthcare facilities to cease elective procedures and many other types of services, nurses working in these areas became available to assist in the response to the pandemic. Some organizations worked to modify the staffing model to have non-critical care nurses work in critical care teams (Halpern & See Tan, 2020) or in public health and contract tracing activities (DailyNurse, 2020). Others developed strategies to cross-train employees from surgical units and clinics on the skills needed in response to the expected surge (Abir, et al., 2020).

Hospitals developed processes to identify staff with appropriate skills and knowledge to ease the transition to new units. Some hospitals prepared for the transition of current employees to these new practice settings by utilizing existing residency/training frameworks to transition staff, while others developed online orientation platforms (HealthImpact, 2020a). Hospitals developed processes to identify staff with appropriate skills and knowledge to ease the transition to new units. For example, Oregon identified various processes to assess which hospital units needed additional support and where staff might be reassigned (OCN, 2020b).

Many national organizations, such as the American Association of Critical-Care Nurses, the Emergency Nurses Association, and the American Nurses Association (ANA), created educational materials to care for patients with COVID-19. State nursing workforce centers, such as HealthImpact, and simulation organizations, such as the California Simulation Alliance and the Society for Simulation in Healthcare, created guiding documents for academia and clinical agencies to help integrate nursing students, new graduates, and retired nurses into the workforce (HealthImpact, 2021b). The table below lists selected COVID-19 educational resources from these organizations.

Table. Selected COVID-19 Educational Resources

An alternative care site is established when needs for medical care in a local jurisdiction exceed the capacity of the existing healthcare sites.The CDC created a document to guide states that considered opening alternative care sites for COVID-19 patients (CDC, 2020b). An alternative care site is established when needs for medical care in a local jurisdiction exceed the capacity of the existing healthcare sites. These sites are typically created in settings such as converted hotels or mobile field medical units, and can be set up as non-acute care, hospital-level care, or acute/critical care. One example responded to the overwhelming need in California during the fall/winter of 2020. California opened two of its 11 alternative care sites (The Guardian, 2020) and staffed them with disaster health volunteers.

Matching the correct skill sets with the settings has been a challenge. In one case, disaster volunteer nurses with acute care background were deployed to a skilled nursing facility and the facility administrator reported that the nurses were not very helpful, yet in other settings with robust orientation programs to alternative care sites, the disaster volunteer nurses contributed significantly (Pohl, 2020).

To augment the workforce during the pandemic, many states waived the requirement for continuing education units; reduced or removed the licensing fees; or took both actions for nurses who held a license in retired status (NCSBN, 2020c). Some states allowed nursing students to participate in the workforce during the pandemic. For instance, the Idaho Board of Nursing implemented their nurse apprenticeship program to allow nursing students to work under supervision of a nurse (Idaho Board of Nursing, 2020). The California Board of Registered Nursing determined that nursing students could work as supplemental staff (California Board of Registered Nurses, 2020).

Matching the correct skill sets with the settings has been a challenge.With the closure of K-12 education, many American parents felt the pressure of helping their children adapt to online learning while trying to continue working from home. Because of this, school nurses especially have been recognized as essential in the COVID-19 pandemic to ensure the health and safety of students by advocating for PPE and ensuring physical and mental health. However, there is a shortage of positions and available school nurses nationwide (Vera, 2020). For example, in Oregon, of the 136 school districts, 61 reported no registered nurses (RNs) on staff before the pandemic (Patterson & Grenier, 2020). Recruiting new school nurses, and supporting existing school nurses, has proven to be an enormous state challenge.

Expanding Advanced Practice Registered Nursing Scope of Practice

To increase the access to high quality and safe patient care during the pandemic, states granted waivers to suspend restrictive physician practice agreements for advanced practice registered nurses (AANP, 2020). Additionally, the Coronavirus Aid, Recovery, and Economic Security (CARES) Act codified into law permission for nurse practitioners, clinical nurse specialists, and physician assistants to certify eligibility for home care services for Medicare. However, many state statutes or regulations restrict certification for eligibility for home care services (Famakinwa, 2020).

Crisis Standards of Care

In municipalities or states hardest hit by the virus, the ability of healthcare facilities were overwhelmed by the number of patients. In these cases, the amount of resources, such as the number of ventilators, number of beds, or number of hospital supplies were insufficient for the healthcare needs of the patients. In these situations, the healthcare facilities changed the standard of care from conventional to maintain conventional, non-disaster standards of care implemented contingency or crisis standards of care.

Crisis standards of care has been defined as:

a substantial change in usual healthcare operations and the level of care it is possible to delivery, which is made necessary by a pervasive or catastrophic disaster. This change in the level of care delivered is justified by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations (Institute of Medicine [IOM], 2009, p. 18).

While formal declaration by a state government is delineated in this definition, it is not required if demands for healthcare resources exceed the availability of those resources (National Academy of Medicine [NAM], 2020).

Crisis standards of care are essential to allocate limited resources to patients. Crisis standards of care are essential to allocate limited resources to patients. At the same time, the crisis standards of care can cause psychological and moral distress among health professionals that can lead to burnout (Hertelendy, Ciottone, Mitchell, Gutberg, & Burkle, 2020).

Tools were created to help facilities prepare their workforces for surges of COVID-19 patients (Hanfling, Dick, & NASEM, 2020; NAM, 2021b). The Fitzhugh Mullan Institute for Health Workforce Equity at The George Washington University (GWU) has created the State Hospital Workforce Deficit Estimator (GWU, 2021). This estimator monitors the baseline and surge staffing deficits for respiratory therapists, intensivists, hospitalists, critical care registered nurses, and pharmacists.

Impact of Telehealth on the Nursing Workforce

As COVID-19 swept across the country, the use of telehealth and telemedicine markedly increased. Several barriers were removed by the federal government to ensure that patients could access telehealth services regardless of where they lived. Telehealth visits to health systems in New York City jumped from about 50 visits per day to more than 7,000 per day in March and April 2020 (Wicklund, 2020). In Oregon, claims for telehealth services increased by 2800% in March/April 2020 compared to the same period in 2019, from 7,213 in 2019 to more than 210,000 claims in March/April 2020 (Oregon Department of Consumer and Business Services, 2020).

The increase in utilization of telehealth services was possible because of sweeping changes in the regulations governing use of telehealth services. These reforms included requirements that health plans cover telehealth services whenever possible and clinically appropriate; allow providers to use all modes of telehealth delivery; limit cost-sharing so it may not be more than for in-person visits; and ensure pay parity for telehealth services. Many deemed these changes as necessary for several reasons. First, it was important to ensure that patients exposed to COVID-19 could be screened and evaluated without incurring the risk of spreading the disease. Second, the reforms ensured that residents who would likely not receive care due to the cessation of elective procedures or the closure of many health clinics and provider offices could access healthcare services. At the Cleveland Clinic, about 200 nurses now provide telehealth nursing services that range from symptom monitoring to patient education as part of COVID-19 response (Cleveland Clinic, 2020).

...the easing of requirements on telehealth could end as the pandemic recedes.As these policy changes only waive current regulations, the easing of requirements on telehealth could end as the pandemic recedes. To ensure that telehealth is more fully integrated into the typical delivery of healthcare in the United States, healthcare analysts at the Brookings Institution and the John Locke Foundation developed a series of policy recommendations that include: ensuring regulatory flexibility in new laws and regulations on telehealth; utilizing telehealth in primary care; transitioning from pay-parity models to reduce the cost of telehealth services, and ensuring telehealth services are available to medically underserved populations (Turner Lee, Karsten, & Roberts, 2020).

Retention, Well-being, and Adverse Effects on the Workforce

Burnout, Exhaustion, and Moral Injury
Nurses are leaving their positions due to the “crushing” stress brought on by COVID-19 patient surgesIn a study of healthcare professionals’ mental health related to COVID-19 in 35 states, respondents reported high levels of depressive symptoms; concern about their health; tiredness; current general anxiety; and past and future appraisal of COVID-related stress (Pearman, Hughes, Smith, & Neupert, 2020). Surges in patient volume; equipment and PPE shortages; and regulations keeping families apart, especially in end-of-life situations, caused secondary trauma and moral injury. Nurses are leaving their positions due to the “crushing” stress brought on by COVID-19 patient surges (Fortier, 2020).

Furloughs, Layoffs, and Leaving the Profession
From approximately March through October 2020, thousands of nurses across the country experienced reduced work hours or were cut all together. While certain areas of the nation, such as the epicenter in New York City, suffered from a lack of nurses, nurses in upstate New York, Washington, California, Ohio, North Dakota, and Massachusetts, as well as many other states, were laid off or furloughed during one of the deadliest pandemics in history. This was largely due to the widespread lockdown in late March, which shut down ambulatory and outpatient facilities and cancelled elective surgeries, causing surgical centers to close. The public sought medical care only when it was an absolute emergency, causing a major deficit in the need for healthcare outside of COVID-19 units (Kirk, 2020). While some nurses traveled to areas in need of additional staff, many were unable to leave their homes and families, and waited for employment opportunities to return (Fadel, Stone, Anderson, & Benincasa, 2020). This resulted in many nurses experiencing financial and emotional distress.

...thousands of nurses across the country experienced reduced work hours or were cut all together. In addition, the lack of enough PPE had an adverse impact on nurses. Nurses reported feeling betrayed by their management, and the public who lauded them as heroes, but did not prioritize their safety (Arnetz, Goetz, Arnetz, & Arble, 2020). The effects of not having adequate PPE during the onset of the pandemic caused some nurses to resign, retire, or leave the profession, which exacerbated workforce shortages (Samee Ali, 2020). The American Organization for Nursing Leadership (2013) created a workforce planning model and guide for individual institutions to plan for workforce needs.

Substance Use Disorders and Diversion
Nurses contending with substance use disorder (SUD) have unique challenges as the pandemic lingers on. Significant increases in substance use have been reported since March 2020 (Volkow, 2020). This may be related to social isolation. Success in recovery is contingent on social interaction in the form of individual therapy, group therapy, sponsor meetings, treatment programs, and such programs as Alcoholics Anonymous/Narcotics Anonymous. While many of these programs have adapted to online services, the impact of recovery has been felt. Absence of in person accountability may be a factor, as well as increased workload, concerns for self and family safety, increased work stress, financial concerns, and limited support services (Ruby, 2020).

Significant increases in substance use have been reported since March 2020While comprehensive national data is not yet available regarding healthcare professionals and SUD relapse during COVID-19, the prevalence of substance use in nurses and other healthcare professionals is no higher than the general population. In May 2020, the Addiction Policy Forum conducted a survey of 1,079 people with SUDs nationwide to understand the impact of the pandemic (Hulsey, Mellis, & Kelly, 2020). Approximately 20% of respondents reported that their own or a family member’s substance use had increased since the start of the pandemic. Additionally, Millennium Health, a national laboratory organization, found steep increases in cocaine (up 10%), heroin (up 13%), methamphetamine (up 20%) and non-prescribed fentanyl (up 32%) in a nationwide sample of 500,000 urine drug screens from mid-March until mid-May 2020 (Millennium Health Signals, 2020).

Since the beginning of the pandemic, the Iowa Nurse Assistance Program (INAP) has experienced increases in both relapses and return to substance use. Prior to the COVID-19 pandemic, in a six-month report period from September 2019 to February 2020, INAP had a relapse rate of approximately 15% (n = 16). During the COVID-19 pandemic, from May 2020 to September 2020, INAP had a relapse rate of approximately 17% (n = 19). INAP nurses are reporting increased periods of quarantine due to COVID-19 exposure which limits the ability to test or attend treatment, resulting in increased relapse potential (Ruby, 2020).

Deaths and Illnesses from COVID-19
...it is estimated that thousands of nurses have been infected or lost their lives while caring for patients infected with COVID-19. Limited data are currently available about the number of nurses who have contracted or died from COVID-19. However, it is estimated that thousands of nurses have been infected or lost their lives while caring for patients infected with COVID-19. The Guardian and Kaiser Health Network (2020) estimated that nurses comprise 32% of all healthcare worker deaths due to COVID-19 in the United States through their “Lost on the Frontline” initiative. The ANA also keeps a running list of nurses who have died due to COVID-19, submitted by family, friends or coworkers (ANA, 2020).

Social Determinants of Health Affecting the Nursing Workforce
Another compromising effect of the pandemic that inhibited the ability of nurses to continue to work in highly affected areas was lack of childcare and closure of schools. This often required parents to stay home with their children. As essential healthcare workers in many areas of the nation, nurses struggled to find family members, neighbors, and volunteers to care for their young children so they could return to work where their skills and expertise were greatly needed. Further complicating the situation, older children and adolescents were often left at home without supervision. This created not only emotional strain on nurses and their families, but financial strain and uncertain feelings of conflicting priorities between family and professional commitment. Some communities rallied to assist by providing volunteer childcare for groups of children or nurses rotated shifts to care for each other’s children (Fetters, 2020).

Many nurses reported concern about bringing the virus home to their families.Many nurses reported concern about bringing the virus home to their families. Often they would either stay elsewhere, such as at a hotel or a co-worker’s home, or sleep in a separate part of the home (Grey Ellis, 2020). Hotels donated millions of rooms to healthcare workers to prevent the spread of COVID-19 to members in their households (Florio, 2020). Nurses reported arriving home after working a shift caring for COVID-19 patients, removing their clothes in the garage before entering the house, immediately washing their clothes, and taking a shower before greeting family members (Fichtel & Kaufman, 2020). Some nurses reported that they did not see their families for weeks at a time to protect them from the possibility of contracting COVID-19.

Underlying factors related to stress, physical and mental health, and inequities present in the nursing workforce for decades were exacerbated by the COVID-19 pandemic. COVID-19 has taken a greater toll on Black and Latinx communities; nurses of color have also been disproportionately affected (Renwick, 2021). In a study by Nguyen and colleagues, Black, Asian, and minority ethnic healthcare workers in the United States and United Kingdom had an increased risk of contracting COVID-19 as compared to non-Hispanic, white healthcare workers (Nguyen, et al., 2020). Approximately one third of nurses who have died from COVID-19 are Filipino, even though they make up 4% of the nursing population in the United States (National Nurses United, 2020).

Vaccine Distribution Equity and Hesitancy
Early in the pandemic, the National Academics of Science, Engineering, and Medicine (2020) outlined a framework for equitable allocation of the COVID-19 vaccine. In Phase 1, high-risk healthcare workers and first responders are prioritized with an additional emphasis on equity using the CDC Social Vulnerability Index (CDC, 2020a). Mass rollout of a limited supply of vaccine that also requires specific and significant storage and handling precautions makes allocation and distribution more challenging. However, frontline nurses and other healthcare providers in major metropolitan areas could not obtain vaccinations despite being in the Phase 1a population because, in some situations, non-frontline staff received their vaccinations before frontline workers (Emanuel, 2020).

Some nurses have voiced hesitancy to receive the COVID-19 vaccine. Some nurses have voiced hesitancy to receive the COVID-19 vaccine. In a survey conducted in October 2020, approximately 36% of nurses surveyed by the American Nurses Foundation (2020) reported that they would not voluntarily get vaccinated if their employers did not require it. Reasons reported for vaccine hesitancy included concerns such as: the COVID-19 vaccine development is occurring too quickly; healthcare workers have not received enough information about COVID-19 vaccine safety; side effects; administration; skepticism or lack of clarity about the COVID-19 clinical trials process; and mistrust about the COVID-19 vaccine development.

COVID-19 and Migration of Nurses

Licensure Exceptions and the Nurse License Compact
States that do not participate in the Nurse Licensure Compact (NLC) typically rely on the migration of nurses from other states to augment the number of practicing nurses. As areas of the country experienced surges of COVID-19 cases at varying times during the pandemic, nurses in the workforce traveled from different parts of the country into those hot zones.

State boards of nursing oversee licensure or recognition of out-of-state nurses to practice within the state. States not affiliated with the NLC initiated waivers from usual endorsement processes for out-of-state licensees to practice. The NCSBN tracks information about emergency action by states (NCSBN, 2021b).

At no other time in the history of the United States has the NLC been more critical for nurse licensure regulations... The practice of telehealth among NLC states and the capability to swiftly respond in natural disasters or assist where staffing shortages exist in other NLC states are two other benefits of the compact. At no other time in the history of the United States has the NLC been more critical for nurse licensure regulations than the COVID-19 pandemic.

In Summer 2020, In Focus magazine, a publication of the NCSBN, highlighted the agility of NLC states compared to non-NLC states, and their need to create emergency orders to move nurses between states as needed. NCSBN posits if every state had been in the NLC, expedited access to “licensed, qualified and competent nurses” who meet the same uniform licensure requirements would have been in place (Grossenbacher & Kappel, 2020, p. 7). 

International Migration of Nurses
Prior to the pandemic, one in every eight nurses practiced in a country other than the one where they were born or trained. The global shortage of nurses is estimated at 5.9 million nurses. Nearly 89% of these shortages are concentrated in low- and lower middle-income countries (Buchan & Catton, 2020).

Many countries experienced shortages of nurses before COVID-19...The WHO and the International Council of Nurses (ICN) report, State of the World’s Nursing (SWON), reviewed the international supply of nurses and gave a snapshot assessment of how the COVID-19 pandemic is impacting on the global nursing workforce, including a specific focus on how patterns of nurse supply and mobility may change “after” COVID-19. SWON reported that the COVID-19 pandemic has had variable impact on the nursing workforce in different countries and examined a core group of factors. SWON identified three different phases of COVID-19 impact and policy response (first wave, transition, and the “new normal”), and articulated key nurse workforce policy issues for each phase (WHO, 2020a). Many countries experienced shortages of nurses before COVID-19, and the impacts of COVID-19 further exposed those staffing gaps.

Often tapped to fill shortages in other nations, Philippine nurses are the backbone of many healthcare facilities across the world and thus disproportionately planted on the front lines against COVID-19. In California, nearly 20% of registered nurses are ethnic Filipinos in a state where less than 4% of the population is Filipino (Pierson & Santos, 2020).

The Philippines initially issued a resolution on April 2, 2020, halting the international departure of workers in 14 health professions, including nursing, for the duration of the nation’s COVID-19 state of emergency. After complaints, this ban was partially relaxed so healthcare workers with existing overseas contracts could leave, if there was transport available. However, future applications for healthcare jobs abroad were halted until further notice (Calonzo, 2020). It is unclear if the country will find enough nurses to address the shortage of healthcare workers furious about being barred from taking positions waiting for them in other countries.

Conclusion

The pandemic has exposed underlying issues and has created new issues...The effects of the COVID-19 pandemic on the nursing workforce will be felt immediately and for an unknown amount of time in the future. The pandemic has exposed underlying issues and has created new issues in the recruitment; educational preparation; upskilling of incumbent workers; retention and well-being; and understanding of the migration of the nursing workforce and pipeline (NAM, 2021a). Increasing efforts to recruit a diverse group of potential nursing students; institute a coordinated workforce data collection system; and modernize state statutes, regulations, and rules related to nursing education, licensure, and scope of practice need to be initiated to respond to this pandemic and future disasters (Jones-Schenk & Leavitt, 2020). Future work should focus on tracking, trending, funding, and creating innovative interventions to support the nursing workforce pipeline both during the pandemic and in the recovery phase.

Acknowledgment. The authors would like to acknowledge the following members of the National Forum of State Nursing Workforce Centers and other colleagues for their assistance with this manuscript:

• Randall Hudspeth, PhD, MBA, MS, APRN-CNP/CNS, FRE, FAANP, NEA-BC – Executive Director, Idaho Center for Nursing
• Linda B. Roberts, MSN, RN – Manager, Illinois Nursing Workforce Center
• Rhonda Ruby, MS, RN – Program Coordinator, Iowa Nurse Assistance Program
• Sofia Aragon, JD, BSN, RN – Executive Director, Washington Center for Nursing
• Pamela Lauer, MPH – Program Director, Texas Center for Nursing Workforce Studies
• Rebecca Wiseman, PhD, RN – Director, Maryland Nursing Workforce Center

Authors

Garrett K. Chan, PhD, APRN, FAEN, FPCN, FCNS, FNAP, FAAN
Email: garrett@healthimpact.org

Garrett K. Chan is President and CEO of HealthImpact, the California nursing workforce and policy center. He leads workforce initiatives in California and nationally. He is a member of the National Forum of Nursing Workforce Centers.

Jana R. Bitton, MPA
Email: bitton@up.edu

Jana R. Bitton is Executive Director of the Oregon Center for Nursing and President of the National Forum of State Nursing Workforce Centers. She leads nursing workforce initiatives in Oregon and nationally. She is a member of the National Forum of Nursing Workforce Centers.

Richard L. Allgeyer, PhD
Email: allgeyer@up.edu

Richard L. Allgeyer is Research Director of the Oregon Center for Nursing. He has designed and conducted statewide studies investigating the nursing workforce and participates in initiatives to improve the nursing workforce pipeline and strategy.

Deborah Elliott, MBA, BSN, RN
Email: delliott@fnysn.org

Deborah Elliott is Executive Director of the Center for Nursing at the Foundation of New York State Nurses and Nurses House. Her work contributes to the advancement of the profession through the promotion of education.

Laura R. Hudson, MSN, RN
Email: laura.hudson@iowa.gov

Laura R. Hudson is Associate Director of Continuing Education and Workforce for the Iowa Center for Nursing Workforce. She leads workforce and education initiatives to advance the nursing pipeline and strategy within her state and nationally. She is a member of the National Forum of Nursing Workforce Centers.

Patricia Moulton Burwell, PhD
Email: patricia.moulton@ndcenterfornursing.org

Patricia Moulton Burwell is Executive Director of the North Dakota Center for Nursing and Director of the National Forum of State Nursing Workforce Centers. She leads nursing workforce and policy initiatives within her state and nationally. She is a member of the National Forum of Nursing Workforce Centers