Hanging on through Omicron, then what? A pre-exit baseline of the U.S. emergency nursing workforce, 2018 to 2022, with implications for the 2026 NSSRN cycle

Emergency departments in the United States have quietly become the default safety net for the entire country. When primary care clinics close, mental health services disappear, or people lose their health insurance, the emergency room is often the only place left to go. It is where the uninsured, the unhoused, and those in crisis end up seeking help. This role was not part of the original design for these hospitals, but as other parts of the healthcare system have shrunk or failed to reach certain communities, the emergency department has absorbed the burden. The people working in these rooms are on the front lines of a system that is increasingly stretched thin, and their ability to function depends heavily on something that hospital accountants do not track: experience.

While hospitals keep careful records of how many nurses they have on staff, they rarely measure how much clinical wisdom those nurses possess. A nurse who has worked in an emergency room for twenty years sees patterns, anticipates problems, and guides new staff in ways a nurse with two years of experience cannot. This concentration of accumulated judgment is what researchers call "experience density." It is the depth of skill within a team, distinct from the simple count of bodies in scrubs. When a hospital replaces a veteran nurse with a new graduate, the headcount might stay the same, but the collective wisdom of the unit drops. This paper investigates whether that wisdom is vanishing from American emergency rooms and what that means for the patients who rely on them.

Kellen Squire, a clinical faculty member at the University of Virginia, analyzed data from two major national surveys of registered nurses, conducted in 2018 and 2022, to see how the emergency nursing workforce had changed over time. The goal was to establish a clear picture of the workforce just before a predicted wave of experienced nurses might leave, creating a baseline to measure future changes. The study focused on the years since a nurse first became licensed, using that as a proxy for how much experience they have brought to their current job. The researchers also looked at how many nurses reported feeling burned out, a state of emotional and physical exhaustion that often leads to quitting.

The data revealed a troubling trend that had been building for years before the pandemic even began. In 2008, nearly 42 percent of emergency nurses had been working for fifteen years or more. By 2018, that number had dropped to 28 percent. This means that in the decade leading up to the pandemic, the emergency department lost roughly one-third of its most senior staff. The average emergency nurse in 2018 had about eleven and a half years of experience, making the emergency department the youngest hospital setting in the country. In contrast, nurses working in other hospital units outside the emergency room still held onto their senior staff, with an average of fifteen and a half years of experience.

Between 2018 and 2022, the situation shifted in a way that offered a small glimmer of hope but also confirmed a deeper problem. During the acute phase of the pandemic, many senior emergency nurses stayed on the job, likely driven by a sense of duty. This caused the average experience level in emergency rooms to rise slightly, and the share of nurses with fifteen or more years of experience increased from 28 percent to 33 percent. However, this stability came at a cost. The study found that the feeling of burnout among emergency nurses skyrocketed. In 2018, about 34 percent of emergency nurses said they were leaving or considering leaving because of burnout. By 2022, that number had jumped to 61 percent. This was a much sharper increase than what was seen in other hospital units, where burnout also rose but not as dramatically.

The researchers used statistical methods to separate the effect of experience from the effect of the job setting itself. In 2018, the high rate of burnout in emergency rooms could be explained mostly by the fact that the staff was younger and less experienced. But by 2022, even after accounting for how long a nurse had been licensed, working in an emergency room was independently linked to a much higher risk of burnout. The odds of an emergency nurse reporting burnout were nearly double that of a nurse in a different hospital unit, even if they had the same amount of experience. This suggests that the emergency room environment itself had become uniquely toxic during the pandemic, creating a specific pressure that went beyond just having a younger workforce.

The study also looked at the nurses who are responsible for teaching new staff, a critical role for passing down knowledge. In both 2018 and 2022, the nurses in emergency rooms who were teaching or mentoring others had significantly less experience than their counterparts in other hospital units. This gap was narrowing, but only because the experienced teachers in other parts of the hospital were leaving, not because the emergency room was gaining them. The emergency department was already operating with a thin layer of senior expertise, and the rest of the hospital was beginning to catch up to that lower level of experience.

The researchers ruled out a few simple explanations for this crisis. They found that emergency nurses were not working significantly more hours per week than nurses in other units, so the burnout was not simply a result of working longer shifts. The problem was not the volume of work, but the nature of the environment and the lack of experienced support. The study also noted that the pipeline of new nurses coming from emergency medical services, such as paramedics, was strong, with emergency nurses being four times more likely than other nurses to have started their careers in EMS. However, this influx of new talent does not immediately replace the lost wisdom of the veterans who are leaving.

The paper concludes that the emergency department is facing a structural crisis of experience. The system is relying on a workforce that is becoming younger and more exhausted, while the patients who depend on these rooms are becoming more numerous and complex. The researchers warn that if the predicted wave of senior nurses leaves after the pandemic crisis eases, the consequences will be severe. Replacing that lost experience is not a quick fix; it takes years of training and practice to develop the clinical judgment that a veteran nurse possesses. The time it takes to train a new nurse to the level of a seasoned veteran is longer than the time it will take for the data to show the full extent of the loss.

The study sets a benchmark for the future. By establishing the state of the workforce in 2022, before a potential mass exit of senior staff, the researchers have created a testable prediction. If the hypothesis is correct, the next national survey in 2026 will show a sharp decline in the number of experienced emergency nurses. The author argues that waiting for that data to confirm the loss is too late. The damage to the system's ability to care for the most vulnerable populations will happen in the years between now and then. The solution requires recognizing that experience is a vital resource, distinct from the number of staff, and that protecting it is essential for keeping the emergency department functional for the communities that have nowhere else to turn.