National Estimates of the Reserve Capacity of Registered Nurses Not Currently Employed in Nursing and Emergency Nursing Job Mobility in the United States

Abstract

Objective:

In a large-scale disaster, recruiting from all retired and non-working registered nurses is one strategy to address surge demands in the emergency nursing workforce. The purpose of this research was to estimate the workforce capacity of all registered nurses who are not currently working in nursing in the United States by state of residence and describe the job mobility of emergency nurses.

Methods:

Weighted population estimates were calculated using the 2018 National Sample Survey of Registered Nurses. Estimates of all registered nurses including nurse practitioners who were not actively working in nursing based on demographics, place of residence and per 1,000 state population, as well as only those who were retired, were visualized on choropleth maps. Workforce mobility into and out of the emergency nursing specialty between 2016 and 2017 were quantified.

Results:

Of the survey participants, 61% (weighted N=2,413,382) worked full time as a registered nurse at the end of both 2016 and 2017. At the end of 2017, 17.3%, (weighted N=684,675) were not working in nursing. The Great Lakes states and Maine demonstrated the highest per capita rate of those not working in nursing, including those who had retired. The largest proportion of those entering the emergency nursing specialty were newly licensed nurses (15%, weighted N=33,979).

Conclusions:

There is additional and reserve capacity from which to recruit that may help to meet the workforce needs for nursing, and specifically emergency nurses and nurse practitioners, across the United States under conditions of a large-scale disaster. The results from this study may be used by emergency care sector leaders to inform policy, workforce recruitment, workforce geographic mobility, new graduate nurse training, and job accommodation strategies to fully leverage the potential productive human capacity in emergency department care for registered nurses who are not currently working.

INTRODUCTION

As specialized registered nurses with the knowledge and skills to care for patients across the lifespan and with the full range of acuities that include both physical and psychological patient presentations, emergency nurses are a crucial part of the interdisciplinary care team to the provision of disaster and emergency care.¹ Emergency nurses have a highly specialized skillset, requiring extensive training and orientation to the role.² The role of the emergency nurse, however, is affected by high levels of attrition, often attributed to challenges in the workplace environment, emotional stressors, and burnout.³ The complex skills required to practice effectively, combined with attrition rates, places limitations on the ability to rapidly recruit and train the full workforce needed for surge capacity or disaster response.^4,5 Little is known about the job mobility, or career movement in and out of the emergency nursing specialty. Emergency nursing workforce shortages as a result of either increased staffing needs during a disaster or public health emergency, an anticipated increase in impending retirements, or high turnover are timely and relevant to the interdisciplinary emergency care specialists.

The COVID-19 pandemic highlighted emergency nursing staffing challenges with massive, and at times geographically unequal, emergency department patient volume surges alongside corresponding demands in staffing capacity. Pre-pandemic, hospitals were already reporting high rates of nurse vacancy (9%) and staffing shortages.⁶ Increased pandemic patient volume can coincide with reductions in workforce capacity due to clinician infection, exacerbated by the need for clinician quarantine after potential or actual virus exposure. Absenteeism due to concern for family safety and staff themselves during a wide-spread infection further limits surge response capacity,^7–10 where past research suggests as much as 40–50% of the workforce might be unable to work during pandemic conditions.¹¹ Daily emergency department sick calls for nursing staff peaked at 19% for one New York City suburb hospital in March of 2020.¹² During a large-scale disaster or pandemic, reporting to work presents additional ethical challenges around the “duty to treat” when training or levels of personal protective equipment (PPE) are not adequate.¹³ The initial wave of the COVID-19 pandemic certainly presented PPE shortage issues.¹⁴ Reassigning staff from other inpatient areas, increasing work hours, advancing scope of practice for trainees, and activating retired or inactive clinicians are key components of emergency department surge preparation.¹⁰

In response to the urgent need for additional, qualified clinicians as the initial COVID-19 response unfolded, 38 states expedited the renewal of medical licenses for physicians coming out of retirement to support workforce needs.¹⁵ A number of Governors declared some type of state of emergency that permitted nurses licensed in other states to work in a specific state, among permitting other licensure changes.¹⁶ While discussions to meeting staffing shortages centered on recruiting emergency physicians and nurses back from retirement to bolster the emergency workforce capacity, the retired workforce capacity that existed to draw from in a large-scale disaster was not clear. There is a paucity of evidence—and an urgent need to define—the ability of the general and emergency nursing workforce to support large-scale disaster related surge capacity. Therefore, the purpose of this research was to estimate the workforce capacity of all registered nurses, including nurse practitioners, who are not currently working in nursing in the United States by state of residence and describe the job mobility of emergency nurses.

METHODS

Design.

This retrospective, descriptive study used the 2018 National Sample Survey of Registered Nurses to estimate the current workforce capacity of registered nurses. Using de-identified and publicly available data, this study did not meet the definition of human subjects research according to the Revised Common Rule (45 CFR §46) in the United States and no human subjects ethical review or approval was required.

Data Sources.

The survey dataset for the 2018 National Sample Survey of Registered Nurses is available at the US Department of Health and Human Services website.¹⁰ The dataset was downloaded on January 14, 2020. The survey was developed and tested following the validity and reliability requirements in the Office of Management and Budget’s Standards and Guidelines for Statistical Surveys. This process for surveys administered by the U.S. federal government includes cognitive interviewing to validate survey items. In order to calculate state rates per capita, we utilized the total population estimate for each state from the US Census Bureau population estimates), which was downloaded on June 11, 2020.¹⁷

Participants.

Survey results from all 50,273 registered nurses who completed the original survey, inclusive of a subsample of emergency nurses who practiced in the emergency department setting in 2016 or 2017, were included in the analysis. All sampling and recruitment information is publicly available elsewhere.¹⁸ Briefly, registered nurses, including nurse practitioners, from the 50 United States and the District of Columbia were the source population. State license registries and the National Council of State Boards of Nursing were invited to participate in the survey using stratified sampling by state. The stratified sampling was conducted separately for registered nurses and nurse practitioners to ensure adequate representation for both levels of nursing practice.

Temporal Considerations.

The survey was designed to ascertain the nurses’ recollection of work characteristics on December 31, 2016 (time 1) and December 31, 2017 (time 2). The survey was administered in 2018, and several survey items also assessed if the nurses work characteristics had changed at the time of survey completion in 2018 (time 3) from December 31, 2017.

Variables.

The operational definitions of the variables used in the study are listed below.

Not currently working in nursing was operationally defined as a response of “No” to the survey question B1, “On December 31, 2017, were you employed or self-employed in nursing? Employed in nursing includes working for pay in nursing, even if on temporary leave”

Retired was operationally defined as endorsing retirement/already retired response options to any of the four following questions: C1 “Which of the following reasons contributed to your decision to leave the primary nursing position you held on December 31, 2017?” OR D8 “Approximately when do you plan to retire from nursing?” OR G6 “What are the primary reasons you were not working in a nursing position for pay on December 31, 2017?” OR H7 “What were the primary reason(s) for your employment change?” OR from the derived variable in the dataset indicating retirement as the reason for currently not working.

Emergency Nurse was operationally defined as indicating “Emergency Department, not Critical Access Hospital” to the survey item B13 “Which one of the following best describes the employment setting of the primary position you held on December 31, 2017?” OR the corresponding item for December 31, 2016 (H8), OR “Emergency” for the survey item B16 “For the primary nursing position you held on December 31, 2017, in what level of care or type of work did you spend most of your time? Mark one box only”

Career Mobility was operationalized as a change in primary work setting or type of care setting where the nurse spent the most time from December 31, 2016 to December 31, 2017; as well as changes in primary work setting from December 31, 2016 to December 31, 2017. Work settings included emergency; critical access hospital; inpatient; ambulatory care, hospital; hospital administration; hospital other; nursing home; rehabilitation; other inpatient; private clinic; ambulatory surgery center; other clinic; home health agency; university or college; other; not employed in nursing.

Demographic characteristics included state of residence on December 31, 2017, sex, age, race and ethnicity, marital status, highest academic degree achieved in nursing, current enrollment in a formal education program, recent nursing graduate status (2015 or later), and annual household income.

Work characteristics included advanced practice nurse practitioner status, full vs. part time status, typical hours worked per week, presence of telehealth in the workplace, secondary positions, travel or temporary agency employment. For those who remained in their positions, our analysis also included a survey item assessing if the nurse had considered leaving their current position in the last year.

Data Analysis.

Sampling weights were applied and the jackknife estimation procedure, a resampling technique for parametric estimation, was used to depict population estimates. Descriptive statistics (N and % for categorical, mean and 95% confidence interval for continuous variables) were used to estimate the characteristics of the emergency nursing workforce, stratified by emergency nurse practitioner and other type of emergency nurse. Data visualizations of 1) all registered nurses who are licensed, but not currently working in nursing and 2) licensed, but retired, were generated by state using choropleth maps. The maps were generated using totals and per 1000 population using the Census data. Sankey diagrams were generated as data visualizations of emergency nursing career mobility, depicting movement into and out of the emergency nursing specialty. Due to differences in the number of items addressing employment on December 31, 2017, compared to December 31, 2016, the latter year estimates included those who spent most of their time in emergency care, but whose primary employment was not a single hospital-based emergency department (Supplemental Figure 1). Because the 2016 items only addressed primary employment in a non-critical access hospital based emergency department, we filtered the analysis in Supplemental Figure 2 to exclude those with more flexible or temporary emergency employment in 2017. Descriptive analyses were conducted in STATA (Version 14.0, College Station, TX). Python (Version 3.8) R (Version 4.0.3) were used to generate the data visualizations.

RESULTS

This study included the 50,273 participants who actively held a license to practice as a registered nurse in the U.S. and completed the survey, for a weighted total of 3,957,661 nurses. Here, we report the weighted national estimates with unweighted estimates presented in online supplemental material. Of these, 61% (weighted N=2,413,382) worked full time as a registered nurse at the end of both 2016 and 2017. Table 1 depicts the weighted demographic characteristics of all licensed registered nurses who are currently not working in nursing, including a subset of those who were retired. Figure 1 provides a visualization of all nurses licensed, but not working in nursing in 2017. Figure 1 includes a panel of the estimated raw counts of nurses not currently working in nursing and a panel of these nurses per 1,000 people each state’s general population. These estimates are inclusive of those who were retired (17.3%, N=684,675). Figure 2 provides a visualization of all retired, but still licensed nurses in 2017, depicted with estimated raw counts and per 1,000 people in each state’s general population (9.7%, N=383,497).

Table 1.

Weighted descriptive statistics of demographic characteristics of all not working in nursing and retired in the national sample of nurses by retired status.

	Retired Only (N = 383,466)		All Not Working in Nursing (N = 684,789)
Demographic Characteristics	N	%	N	%
Sex
Male	2,454	6.4	5,341	7.8
Female	35,892	93.6	63,138	92.2
Age (mean [95% CI])*	67.7	[67.4– 68.1]	59	[58.4–59.6]
Race and ethnicity
Hispanic	1,726	4.5	5,478	8
White (not Hispanic)	31,713	82.7	53,003	77.4
Black (not Hispanic)	2,646	6.9	4,999	7.3
Asian (not Hispanic)	1,265	3.3	2,808	4.1
American Indian	115	0.3	137	0.2
Pacific Islander	153	0.4	205	0.3
Other	268	0.7	890	1.3
Multiple	460	1.2	959	1.4
Marital status
Married	25,922	67.6	48,072	70.2
Widowed, divorced, or separated	10,315	26.9	14,381	21
Never married	2,109	5.5	6,026	8.8
Highest degree in nursing
Diploma	8,398	21.9	10,546	15.4
Associates	13,230	34.5	23,351	34.1
Bachelors	11,772	30.7	26,159	38.2
Masters	4,448	11.6	7,601	11.1
Doctorate	422	1.1	753	1.1
Enrolled in a nursing degree or certification program	268	0.7	4,040	5.9
Recent graduate of first RN license program (2015 or later)	199	0.5	1,712	2.5
Household annual income in USD
≤25,000	2,262	5.9	5,752	8.4
25,001–35,000	2,646	6.9	4,383	6.4
35,001–50,000	5,292	13.8	8,491	12.4
50,001–75,000	8,360	21.8	13,011	19
75,001–100,000	7,784	20.3	11,710	17.1
100,001–150,000	6,634	17.3	12,052	17.6
150,001–200,000	2,684	7	5,273	7.7
>200,000	2,646	6.9	7,807	11.4

CI, Confidence interval; RN, registered nurse; USD, United States dollar.

^*Variable truncated at 78 years.

Figure 1.

State map of licensed registered nurses not currently working in nursing per 1000 population. Numerators for North and South Dakota (West North Central Other; n=2,776); Montana and Wyoming (Mountain Other; n=4,202); and Rhode Island and Vermont (New England Other; n=2,740) were calculated from bi-state, rather than single state, data and averaged across the 2 states for per 1,000 population of: MA=2.67; RI=1.40; CT=2.53; NJ=1.69; DE=2.28; MD=1.39; DC=0.78.

Figure 2.

Map of retired licensed registered nurses per 1000 population. Numerators for North and South Dakota (West North Central Other; n=1,514); Montana and Wyoming (Mountain Other; n=2,211); and Rhode Island and Vermont (New England Other; n=2,061) were calculated from bi-state, rather than single state, data and averaged across the 2 states. MA=1.73; RI=1.05; CT=1.78; NJ=0.82; DE=1.72; MD=0.64; DC=0.50.

A total of 2,278 participants indicated working in the emergency nursing specialty. These survey participants represent an estimated 6.1% of overall nursing workforce with a weighted total of 19,117 emergency nurse practitioners and 222,219 other emergency nurses included for analyses. Participants’ demographic and work characteristics are listed in Table 1, stratified by nurse practitioner status. Among all emergency nurses, 77% (N=186,384) worked full time at the end of both 2016 and 2017. By the survey completion in 2018, 14.5% (N=34,886) of all emergency nurses working or elsewhere in nursing at the end of 2017, in nursing, had left their position.

There was more career mobility in the emergency nursing specialty, compared to all working registered nurses with 74.7% vs. 81.4% remaining in the same position with the same employer; 9.3% vs. 6.3% in a different position with the same employer; and 16.0% vs. 12.3% with a different employer between 2016 to 2017. Table 3 (Figure S1) depicts career mobility into emergency nursing by December 31, 2017 (time 2, N=222,668) from any position, including not working in nursing status, on December 31, 2016 (time 1). Emergency nurses at time 2 included those with regular, primary employment in the emergency department as well as those who spent the majority of their work time in the emergency department during the year. This includes float pool, flex, transport, agency, critical access hospital, or other flexible staffing arrangements where the registered nurse was assigned to the emergency department setting more than other settings. Only 78% of the nurses remained in their position over the two dates. The largest proportion of those entering the specialty were newly licensed nurses (15%, N=33,979), followed by non-critical access hospital inpatient nurses (4.2%, N=9,352).

Table 3.

Career mobility into emergency nursing from December 31, 2016 to December 31, 2017 (N=222,668)^*

2016 Setting	Weighted n	Weighted %
Same emergency position	173.881	78.1
Newly licensed	33,979	15.3
Inpatient	9.352	4.2
Not employed in nursing	2.961	1.3
Other inpatient	1.670	0.8
Nursing home	1.447	0.7
Private clinic	1.381	0.6
Other	1.381	0.6
Hospital administration	1.202	0.5
Ambulatory care, hospital	512	0.2
Hospital other	468	0.2
University or college	401	0.2
Other clinic	356	0.1
Ambulatory surgery center	312	0.1
Home health agency	289	0.1
Rehabilitation/long term care	65	<0.1

Cells may not add to total N due to rounding and populations estimates.

^*Setting in 2016 for those who were in emergency nursing on December 31. 2017.

Table 4 (Figure S2) is a data visualization of career mobility out of primary employment in the emergency specialty from an emergency nursing position on December 31, 2016 (time 1, N=177,536) into any position, including not working status, on December 31, 2017 (time 2). These emergency nurses at time 1 represent a smaller portion of the workforce compared to those depicted in Table 3. Due to the nature of the survey questions, Table 3 only represents nurses whose primary employment was in an emergency department setting at time 1, and does not include those whose primary employment focused on flexible assignments to the emergency department, such as the float pool, transport, flex, or critical access hospital nurse. Of these nurses, 89% (N=157,971) remained in their position into time 2. While 5% (N=9,232) retired from their primary employment in emergency nursing, less than 1% were not employed in nursing (N=1,243) indicating career mobility into other settings as a nurse even after retiring from the primary emergency nursing position.

Table 4.

Career mobility out of emergency nursing from December 31, 2016 to December 31, 2017 (N= 177,536)^*

2017 Setting	Weighted n	Weighted %
Emergency	157.972	89.0
Other hospital	5.912	3.3
Inpatient	3.639	2.1
Private clinic	3.018	1.7
Other skilled nursing or community health	2.219	1.3
Critical access hospital	1.829	1.0
Ambulatory surgery center	1.420	0.8
Not employed in nursing	1.243	0.7
Public clinic	195	0.1

Cells may not add to total N due to rounding and populations estimates.

^*Setting in 2017 for those who had been in emergency nursing on December 31. 2016.

Emergency nurses at time 1 reported career mobility into inpatient hospital units (2%, N=3,639) and private clinics (2%, N=3,018). Other hospital settings, besides inpatient and critical access, included hospital sponsored ambulatory care, hospital ancillary units, hospital nursing home unit, hospital administration, hospital consultancy, or inpatient mental health. Only 3% (N=5,912) of emergency nurses at time 1 moved into employment at these other hospital settings. Other Skilled Nursing or Community Health settings included nursing home, rehabilitation facility, correctional facility, nurse managed health center, school health, outpatient mental health or substance use treatment center, home health agency, clinic, occupational or employee health, public health, community health agency, other government agency, case management or disease management at insurance companies, or other consultancies. Only 1% (N=2,219) of emergency nurses at time 1 moved into primary employment in these non-hospital roles.

LIMITATIONS

These findings should be interpreted in the context of several limitations. We analyzed data obtained from a cross-sectional survey, which is subject to recall bias. No causal relationships can be inferred from these data. Based on survey methodology, we can reasonably infer that biracial and multiracial identities of many of the survey participants were under-reported for the race and ethnicity items.¹⁹ Emergency nurses working in freestanding emergency centers, non-hospital disaster response settings, austere military environments overseas, or non-hospital urgent care settings were not included. Thus, our results on emergency nurses and emergency nurse practitioners underestimates the total, national emergency nursing population. There were no survey items for participants to report working specifically in the emergency department in a critical access hospital. The study design was not intended to specifically quantify the actual readiness to return to practice among non-working nurses or emergency nurses.

DISCUSSION

We quantified national estimates of US licensed registered nurses who are not currently working in nursing and depicted the 1-year career mobility into and out of the emergency nursing specialty between 2016 and 2017. The importance of the knowledge to be gained from our results is to describe and contextualize the potential national inactive and retired registered nurse capacity nationwide for disaster and hospital surge response readiness, as well as to provide baseline results as a justification for further study of national strategies to address hospital emergency nurse vacancy rates outside of disaster. Our results indicate the need for interdisciplinary support for high-level national strategy and leadership for plans that include mobilizing the retired and non-working registered nursing population in times of surge demand for the general and, more relevant to this analysis, the emergency nursing workforce. In the context of the COVID-19 pandemic, our findings have important disaster planning and response implications for staff surge capacity generated by regional and statewide hotspots to meet increased patient volume and demand. Our study quantified additional and reserve capacity from which to recruit to deploy to support health workforce gaps in general and emergency nurse and emergency nurse practitioner staffing across the United States under conditions of a national emergency; our results only include those who hold a current license to practice nursing. Our results do not distinguish between those unable to return to a nursing job or the extent to which training and work accommodation would be necessary to engage non-working nurses as safe and productive members of the health care team. Future research is warranted to quantify the proportion of retired and non-working registered nurses’ willingness to enter or re-enter the emergency nursing workforce, and with what accommodations and conditions.

Our study corroborates and extends previous research on nurse turnover. A 2019 survey of 164 hospitals, conducted at the hospital level for 164 facilities in 42 states, reported a registered nurse turnover of 17.8%.⁶ Further, emergency nursing experienced one of the highest rates of turnover among specialties, with a 19% rate in 2018 and 18.5% in 2019 for the surveyed hospitals. The average hospital lost $4.9 million per year in bedside nurse turnover costs alone.^6,20 In another large national survey of actively employed emergency, trauma, and transport nurses, one-third of participants in their twenties and one-fourth of participants in their thirties planned to leave the emergency nursing specialty within the next four years.²¹ As the COVID-19 pandemic has strained hospital revenue sources, interdisciplinary efforts to mitigate nurse vacancy and turnover is essential to maintaining ongoing fiscal stability. Our present study estimated that over one-third of nurse practitioners and over half of emergency nurses who remained in their position in 2017 had still contemplated leaving in the past year, demonstrating an ongoing vulnerability to national staffing crises in the specialty. Further analysis is needed to ascertain if retired or non-working nurses would be willing to enter the emergency care setting to address surge capacity needs under conditions of national emergency, and if incentives such as pay differentials would impact these decisions.

Unsurprisingly, the raw estimated counts of retired and non-working in nursing nurses were highest in the most populated states of California, Florida, New York, and Texas. We identified geographic variability in the state residence of nurses not working in nursing per 1000 population and higher rates of nurses not working in nursing in the Great Lakes and Upper Midwest regions and Maine. An ongoing challenge to the nursing workforce is an aging workforce. For example, Michigan is home to the 2^nd highest proportion of non-working nurses per capita (Figure 2). In a 2010 survey by the Center for Nursing in Michigan, more than one-third of registered nurses were over the age of 55, while the Center for Nursing in 2011 reported that 41% of full-time nursing faculty were 56 or older.²² The aging nursing workforce may, in fact, possess the technical skills needed to support future COVID-19 responses, but also represent the age group at highest risk for contracting the virus, and further, may view retirement as a final decision to leave the workforce. Survey-based research targeted to this population may be an avenue to assess this group’s willingness to return to the workforce to fill the gap in the event of staffing shortages. Further research is also needed to ascertain if factors that were not measured in our study contribute to state variations in the non-working nurse population. For example, continuing education requirements and license renewal fees vary by state, and discounts or sliding scale fees for maintaining a license after retirement also varies. Finally, regional average salary for the same work in nursing can vary. Thus, where it is more expensive for individuals to retain a license, more nurses may surrender their license upon retirement or leaving a position. Likewise, in regions where salaries and wages are lower, fewer nurses may maintain an active nursing career in life phases when child care expenses or other family caregiving responsibilities become a factor in family finances, single- or dual-family career decisions, or other personal effort-reward evaluations.

Our study contributes uniquely to the published literature by providing comprehensive estimates of non-working registered nurses on a national, and state-by-state basis. The results from this study may be used by emergency care sector leaders to inform national emergency (including pandemic) retired clinician recruitment policy, target recruitment efforts geographically, and address potential job accommodation strategies for retired nurses to fully leverage the potential productive human capacity of licensed registered nurses in emergency department care. Disaster planning and response for infectious disease surges should include established mechanisms to fast-track the rehiring of retired workers. The Department of Veteran’s Affairs and other federal agencies have exemplar mechanisms for this re-hiring process that can provide a model for other hospital employers. Examples of potential job accommodation strategies to fully engage retired nurses include continued investment in shifting emergency nursing to telehealth platforms whenever possible, where assessment, care and patient education might be delivered in a position with fewer physical job demands and shorter shift lengths.²³ The 2017 estimates from our study demonstrate that the pre-COVID-19 pandemic utilization of telehealth was grossly underutilized in emergency nurse care settings, with only 56% of emergency nurse practitioners and 49% of direct clinical care emergency nurses reporting telehealth was present in their workplaces. In addition, state-to-state variations in nurse scope of practice must be considered in disaster recruitment strategies across state lines. Variations in scope of practice has resulted in limited training in common efficiency-enhancing emergency department practices like nurse-initiated protocols in triage for nurses from states with prohibitive regulations.²⁴ Because the original survey did not consistently measure employment in a critical access hospital emergency department, we recommend revisions to future iterations of the survey and additional research to better understand the emergency nursing workforce in these 1,350 hospitals across the USA.²⁵

Additional strategies to enhance workforce capacity during surges include increasing part-time employees to full time, reassigning staff from other inpatient areas, tiered staffing, and increased scope of practice for trainees. While 22% of emergency nurse practitioners and 15% of registered nurses reported working part-time in 2017 in our study, strategies to increase the hours for these employees may be met with limited success due to secondary employment. Our data demonstrated an estimated 27% of emergency nurse practitioners and 16% of emergency nurses were already working for a second employer, thus exacerbating regional workforce shortages when these dual-employed individuals are ill, in quarantine, or opt-out. Our career mobility findings also indicated there is a very small potential pool of skilled emergency nurses who have left the specialty to work in other settings that could return to the emergency department setting for surge capacity. Our results indicate strategies should focus on training for other inpatient nurses who have never worked in the emergency department setting. Caution is warranted to meet quality and safety standards if this training is insufficient. In a survey of emergency nurses, over half of participants already practicing within the specialty reported the need for additional training in stress management and critical thinking skills.²¹ Over one-third of actively practicing emergency nurses reported the priority need for additional training in decision-making under pressure, emergency equipment, crisis management.²¹ It is reasonable to deduce that non-emergency nurses would require additional training and extensive support to provide adequate job performance in the emergency department. In addition to the above mentioned supports, resources to provide vacation, rest, and recuperation and other assistance for clinician mental health challenges are needed during and after major disaster.²⁶ A final strategy to enhance surge capacity is to increase the scope of practice, or provide early graduation for clinicians who are currently enrolled in training programs. With 41% of emergency nurse practitioners, and 20% of emergency nurses enrolled in formal education or certificate programs, further assessment is warranted on surge capacity strategies that leverage these high rates of ongoing educational advancement.

A plausible alternate perspective on emergency nursing turnover is that it is a positive phenomenon in any given nurse’s career trajectory. The proportion of emergency nurses enrolled in formal education and certificate programs in our study provides the opportunity to reimagine and leverage turnover as a potentially positive and capacity enhancing step to advanced clinical or leadership positions for the emergency care sector. Removing the constraints of a department-specific budgets and full investment in expanding capacity for the emergency nursing specialty can be modeled after existing federal policy, like the nursing faculty loan program. The nurse faculty program is a federal loan forgiveness program that does not require the participant to remain employed by the same organization, as long as the participant fulfills the role of a nurse faculty member after graduation. Likewise, federal loan repayments for working in any hospital setting as an emergency nurse or nurse practitioner should be considered. Novel federal policy and repayment programs that support the didactic and coursework time for nurse residency programs or internships/fellowships for experienced nurses to enter a new clinical specialty and develop specialty skill sets are policy innovations needed to meet the ongoing, and increasing demand, for a nursing workforce in both pandemic and non-pandemic conditions.

Specific to the unique skills and preparation for the emergency nursing specialty, the largest proportion of those entering the emergency nursing specialty were newly licensed nurses (15% of all emergency nurses in 2017). Specialty preparation for both bedside emergency nurses and nurse practitioners is a promising area to explore and deepen interdisciplinary collaboration with emergency physicians.^27,28 Reforming physician grand rounds and conferences to structure additional co-learning with emergency nurses and nurse practitioners presents one promising opportunity.²⁹ Integrating nurse residencies and fellowships with existing graduate emergency medical education into activities and case conferences enhances interdisciplinary co-learning within the specialty. Several challenges to these reforms and integration towards interdisciplinary training include variations in accreditation, university credit, schedules, and inequalities between nurse and physician faculty, leadership, and administration.^30,31 Compared to physician residency programs, with graduate education structures and financial reimbursement support from coding and billing practices to government and insurance payers, nurse residency and fellowship programs are professional development carved from the hospital’s operational budget or grant funding.^30,31 Despite substantial return on investment for nurse residency and fellowship programs to reduce turnover, these programs are still vulnerable to discontinuation in each hospital budget cycle or budget deficit.³² Integrating emergency nursing and physician interdisciplinary learning opportunities has promising implications for long-term employee retention.

In summary, there is an additional surge capacity from which to recruit to meet the workforce needs for emergency nurses and nurse practitioners across the U.S. The COVID-19 pandemic has exemplified the need for expanded, and reimagined, nursing staffing needs. Using the findings, and implementing the recommendations, from this study can inform not only the current pandemic, but future disaster health emergencies in the U.S. We identified geographic variation in those no longer working in nursing and retired nurses as potential surge capacity personnel. Our results further demonstrate turnover in the emergency care specialty, with the largest proportion of those new to the specialty joining as newly licensed nurses. The results from this study may be used by interdisciplinary emergency care sector leaders to inform policy, workforce recruitment, workforce geographic mobility, new graduate nurse training, and job accommodation strategies to fully leverage the potential productive human capacity in emergency department care for registered nurses who are not currently working in nursing.

Supplementary Material

1. Figure S1. Career Mobility into Emergency Nursing from December 31, 2016 to December 31, 2017.

Note: setting in 2016 for those who were in emergency nursing on December 31, 2017

2. Figure S2. Career Mobility out of Emergency Nursing from December 31, 2016 to December 31, 2017.

note: setting in 2017 for those who had been in emergency nursing on December 31, 2016

Table 2.

Weighted descriptive statistics of demographic and work characteristics of the national sample of emergency nurses by nurse practitioner status.

	Emergency Nurse Practitioner (N = 19,117)		Other Emergency Nurse (N = 222,219)
Demographic characteristics	n	%	n	%
Sex
Male	2,829	14.8	49,177	22.1
Female	16,288	85.2	173,042	77.9
Age (mean [95% CI])*	43.2	42.1–44.4	41.6	40.8–42.4
Race and ethnicity
Hispanic	2,950	15.4	29,177	13.1
White (not Hispanic)	12,948	67.7	160,398	72.2
Black (not Hispanic)	2,292	12.0	13,022	5.9
Asian (not Hispanic)	587	3.1	9,267	4.2
American Indian	8	<0.1	1,000	0.5
Pacific Islander	65	0.3	3,111	1.4
Other	46	0.2	1,933	0.9
Multiple	220	1.2	4,311	1.9
Marital status
Married	13,728	71.8	146,598	66.0
Widowed, divorced, or separated	2,229	11.7	33,000	14.9
Never married	3,160	16.5	42,599	19.2
Highest degree in nursing
Diploma	27	0.1	6,422	2.9
Associates	57	0.3	78,621	35.4
Bachelors	306	1.6	120,843	54.4
Masters	17,464	91.4	15,578	7.0
Doctorate	1,266	6.6	267	0.1
Enrolled in a nursing degree or certification program	7,878	41.2	44,111	19.9
Recent graduate of first RN license program (2015 or later)	906	4.7	30,622	13.8
Household annual income in USD
≤25,000	3	<0.1	1,000	0.5
25,001–35,000	13	0.1	667	0.3
35,001–50,000	556	2.9	8,667	3.9
50,001–75,000	910	4.8	40,977	18.4
75,001–100,000	2,797	14.6	56,110	25.3
100,001–150,000	8,048	42.1	63,844	28.7
150,001–200,000	4,049	21.2	33,777	15.2
>200,000	2,741	14.3	17,178	7.7
Work characteristics
Full-time employment	14,940	78.2	18,6864	84.1
Part-time employment	4,133	21.6	34,155	15.4
Hours worked per week (mean [95% CI])	37.0	35.0,38.9	37.6	36.8,38.4
Telehealth in workplace	10,790	56.4	10,8865	49.0
Considered leaving position last year, but remained	7,626	39.9	11,4221	51.4
Secondary position, in addition to primary employment	5,095	26.7	34,311	15.4
Travel or temporary agency employment
Primary employer	1,067	5.6	7,311	3.3
Secondary employer	1,906	10.0	3,089	1.4

^*Variable truncated at 78 years.