Issue: May 2022
Disclosures: Belmonte, Livaudais and Thomas-Hawkins report no relevant financial disclosures.
May 18, 2022
5 min read

Understaffed schools, stressful environment and pandemic pose challenges for nursing

Issue: May 2022
Disclosures: Belmonte, Livaudais and Thomas-Hawkins report no relevant financial disclosures.
You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

We were unable to process your request. Please try again later. If you continue to have this issue please contact

Tina Livaudais, RN, BSN, MBA, has a good story to tell about getting involved in kidney care.

She began her career as a patient care technician for DaVita Kidney Care in 1995. In September 2021, she was named chief nursing officer for the company, which treats more than 200,000 patients.

“I always share details about my personal DaVita journey with current and potential nurses,” Livaudais, who lives in New Orleans, told Nephrology News & Issues. “I want each of them to know they can achieve the same level of career fulfillment,” she said.

Tina Livaudais

Nursing workforce

As head of a nursing force of more than 18,000, Livaudais has major concerns about finding new nursing recruits.

  • More than 100,000 nurses left the U.S. workforce in 2021, primarily driven by nurses younger than 35 years old leaving hospital-based jobs, according to an analysis published in Health Affairs. The nursing workforce decreased 1.8% between 2019 and 2021, marking the largest decrease in 4 decades, according to the study.
  • The U.S. Bureau of Labor Statistics predicts more than 275,000 additional nurses are going to be needed from 2020 to 2030 to provide patient care in the United States.
  • In 2020, the median age of RNs was 52 years, with more than one-fifth indicating intent to retire from nursing in the next 5 years, according to the 2020 National Council of State Boards of Nursing and National Forum of State Nursing Workforce Centers national survey of the U.S. nursing workforce. The pandemic has accelerated this trend, the survey showed.
  • Young people who are interested in nursing struggle to find a school that will accept them because of a major shortage of nurse educators. According to a recent report from the American Association of Colleges for Nursing (AACN), U.S. nursing schools turned away 80,407 qualified applications from baccalaureate and graduate nursing programs in 2019 due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors and budget constraints.

Shortage prior to COVID-19

Kear and Walz wrote that the nursing shortage began long before the stress and the high patient mortality from the COVID-19 pandemic made nephrology nurses think about whether it was time to walk away from the profession.

Kathleen Belmonte, MS, RN-CS, MBA, chief nursing officer for Fresenius Medical Care North America, agreed.

Kathleen Belmonte

“ ... Pre-COVID-19, there was already a serious concern as to whether the profession was going to be able to attract enough nurses to care for populations, and that also includes the [end-stage renal disease] ESRD population, the [chronic kidney disease] CKD population, moving into the future,” Belmonte said in a podcast earlier this year. “ ... [W]hen we talk to our nurses and ask them how they are feeling and what it has been like, they tell us that they are feeling stressed, they are exhausted, they are burnt out. And of course, when we hear our nurses telling us that they are burnt out, we are worried that a consequence of that may be nurses choosing to leave the field, leave the profession.”

Added Livaudais, “The larger health care community has been battling a critical shortage of clinicians for almost a decade which was exacerbated by COVID-19. Before 2020, the main concern was replacing retiring talent. However, the pandemic took a lean workforce and stretched it further than ever before. Inevitably, many nurses experienced burnout, and some left the field entirely.”

According to sources, there is no quick fix to the shortage.

“The solutions are just hard,” Charlotte Thomas-Hawkins, PhD, RN, FAAN, associate dean of nursing science, and associate professor and director of the Center for Healthcare Quality in the division of nursing science at Rutgers University School of Nursing, told Nephrology News & Issues. “The research I did in nephrology ... showed that dialysis units that have low RN staffing, as measured by patient-to-RN ratios, was predictive of negative nurse outcomes like burnout and intent to leave,” Thomas-Hawkins said. “The intent of nephrology nurses to leave their job is higher when they work in a unit that have persistently low RN staffing.

“That isn’t a new finding,” Thomas-Hawkins said. “We know that is true in hospitals and other settings.”

Thomas-Hawkins said it is clear outcomes are better in dialysis units when RN staffing is better.

“That was the problem with the COVID-19 pandemic,” Thomas-Hawkins said. “It exacerbated already existing problems with low RN staffing and a stressful work environment.”

Young nurses

Researchers acknowledge that stresses created by the COVID-19 pandemic have given nurses second thoughts about staying on the job. But most of those leaving the nursing profession are, surprisingly, not those at retirement age. In the Health Affairs paper, entitled “A worrisome drop in the number of young nurses,” David I. Auerbach, MS, PhD, and colleagues found younger nurses – not an older generation that was retiring – were the source of the exodus from the profession.

“Just before the pandemic, the total workforce size decreased 1.8 [%] through 2021, which was composed of a 4[%] reduction in the number RNs younger than age 35, a 0.5[%] reduction in the number of RNs ages 35 to 49 [years], and a 1[%] reduction in the number of RNs older than age 50 [years],” they wrote.

That will hurt growth in the profession because nurses typically stay in the workforce long term.

“A sustained reduction in the number of younger age RNs would raise ominous implications for the future workforce. Because RNs typically remain working in nursing over their career, a reduction of younger RNs in the workforce would exert an impact that is felt over a generation, in contrast to a modest reduction in long-run RN supply due to early retirement of the baby boomer RNs working into their 60s and 70s,” they wrote.

Favorable news

There is some positive news for dialysis providers searching for nurses. According to data released April 5 by the AACN, student enrollment in entry-level baccalaureate nursing programs increased by 3.3% in 2021.

As part of her effort to increase interest in nephrology, Belmonte works with FMCNA on a program that recruits graduate nurses from colleges and universities nationwide through a 12- to 15-month residency.

“Growing our own nursing talent gives us the opportunity to not only fill vacant nursing positions but also to mold novice nurses into future leaders within the organization,” Belmonte told Nephrology News & Issues. “Residents are supported holistically with a nurse mentor and the support of their cohort and leaders in the program. We are also continuing to evolve and expand the scope of this program to include opportunities to work in home therapies.

“It is a fantastic way to expose new graduates to nephrology nursing.”

Thomas-Hawkins also sees the increase in interest in nursing as an opportunity to expose nurses to other options. “I think there is a lot of opportunity in the area of chronic kidney disease for advanced practice nursing,” she told Nephrology News & Issues. “The new kidney care payment models and interest in value-based care “may help us redefine the nursing role.”

When asked about the future of nursing in kidney care, Livaudais said dialysis providers have recognized the value of keeping nurses healthy and appreciated.

“... [W]e are increasing wages, expanding training opportunities, which is vital when education opportunities are somewhat limited, building greater support for nurse well-being and new technology innovations to help drive recruitment efforts,” Livaudais said.

“Although the shortage won’t be solved overnight, we’re getting closer to identifying what nurses truly need and deserve.” – by Mark E. Neumann