By Shannon Firth

The number of registered nurses plunged by 100,000 in 2021, representing the steepest drop in the RN workforce in 4 decades, according to a new analysis.

From 2019 to 2021, the total workforce size declined by 1.8%, including a 4% drop in the number of RNs under the age of 35, a 0.5% drop in the number of those ages 35 to 49, and a 1.0% drop in the number of those over 50, reported David Auerbach, PhD, of the Center for Interdisciplinary Health Workforce Studies at Montana State University College of Nursing, and colleagues.

"The numbers really are unprecedented," said Auerbach.

"But ... given all that we've been hearing about burnout, retirement, job switching, and shifting," and all of the ways the pandemic disrupted the labor market, including healthcare, "I am not super surprised either," he added.

While Auerbach said he and his co-authors can't definitively say what caused this shift, he does not think it's merely a problem of "entry and education" -- in other words, fewer people choosing nursing as a career.

There have been no "major changes" in the enrollment and graduation rates reported by the American Association of Colleges of Nursing (AACN), and the number of RNs completing the National Council Licensure Examination actually increased in 2020 versus 2019, according to the National Council of State Boards of Nursing, Auerbach said.

This suggests that the decline in younger RNs is more likely due to nurses "either pausing or leaving nursing. What we really don't know is whether this is a temporary or more permanent phenomenon," he added.

The overall decline was not spread evenly across sites, but instead was "entirely due" to a 3.9% reduction in hospital employment, offset by a 1.6% increase in nursing employment in other settings, the authors said.

For decades, the RN workforce grew steadily, from 1 million nurses in 1982 to 3.2 million in 2020. Though the profession saw a rocky period in the late 1990s, during which growth looked less certain, millennials reversed this temporary downward trend in the early 2000s, Auerbach and team explained.

In a prior analysis, Auerbach and colleagues found that the labor market for nurses had "plateaued" during the first 15 months of the pandemic.

Auerbach's team had previously projected that the supply of nurses would grow 4.4% from 2019 to 2021.

The data may reflect a mix of RNs leaving "outright" and those shifting to non-hospital jobs. The authors were unable to follow the same people from pre-pandemic to now, Auerbach noted. "Based on taking a snapshot of the world in 2019 and then taking another snapshot of the world in 2021, we're inferring from what we see ... what we think might have happened."

Auerbach said that he and his colleagues are close to ruling out childcare problems as a core reason for younger nurses departing. "We didn't see some huge reduction in nurses with kids at home," he explained.

However, if that had been the case, then the decline might be seen as something temporary that could be "ironed out," compared to more deeply rooted structural problems, like poor working conditions, he said.

Auerbach and colleagues stressed that more needs to be done to help early-career nurses who have endured a "trial by fire" during the pandemic, and that "more effective strategies" must be leveraged to reward nurses who have stayed on the front lines and to bring back those who have left.

On a hopeful note, Auerbach pointed to recent AACN data, which showed a "big jump" in the number of applications to nursing schools. Additionally, prior research found that "times of natural disaster or health crisis could increase interest in RN careers," the authors noted.

"That doesn't sound like people are just going to abandon nursing altogether," Auerbach said.