More than a quarter of registered nurses licensed in Washington state do not work here.

This revelation is one of many that came after months of analysis by the University of Washington Center for Health Workforce Studies, which published in March some of the most comprehensive data to date on how many nurses work in the state, where they work and who they are.

The report shines light on data that will help explain where nurses are working – and where they are needed.

As the state’s health care system has received an almost unprecedented stress test from the demands of the coronavirus pandemic, Washington’s existing needs and imbalances have become more apparent.

As the health care system has been called on to shift resources and personnel to ensure it is prepared to handle an influx of COVID-19 patients, nurses have been asked to work longer hours, move to new care settings and deal with shortages of critical supplies, including personal protective equipment. Other nurses have been furloughed or laid off as many nonessential procedures were paused.

The supply of nurses has long exceeded demand, and the pandemic has disrupted an already fragile pipeline tasked with ensuring the health care system is adequately and properly staffed. It has also disrupted the professional and personal lives of many nurses.

“Trying to match the demand and the supply is always challenging,” said Paula Meyer, executive director of the Nursing Care Quality Assurance Commission. “And I think this (the pandemic) will add one more challenge right now, immediately with layoffs and then with opening up the economy.”

The University of Washington study painted a detailed picture of nursing in the state before the pandemic. Among its central findings were the following:

There are about 62,393 registered nurses working in Washington, but nearly 30,000 more – 90,975 nurses – are licensed to work in the state.

More nurses work in urban settings than in rural ones, and this divide is more distinct in Eastern Washington, where half the number of nurses work in rural settings compared to urban settings.

The new data also revealed the care settings where registered nurses in Washington work. More than half of the state’s nurses work in hospitals and ambulatory care centers, making up about 68% of the workforce.

Long-term care settings and community health settings only make up 15% of the nursing workforce in the state. Both sectors have proved vital as the state continues the challenge of staving off the work effects of the COVID-19 pandemic.

In long-term care settings especially, finding registered nurses was a challenge before the pandemic. Skilled nursing facilities are required by state law to have a registered nurse on site 24/7, but shortages in long-term care settings persisted before the pandemic.

“We know that we don’t have enough people there,” Meyer said.

The pandemic has exacerbated that problem.

Or, as one assisted living facility reported to the Sentinel Network, which surveys health care settings in Washington about their workforce, “The most affected roles, during this crisis, are the same roles that were most affected prior to the outbreak. However, the resulting effect has been amplified. These positions include care staff members such as caregivers, medication aides and nurses.”

Throughout 2019, nurses represented by several unions made headlines by striking and threatening to strike in different parts of the state, including in Spokane, to keep their sick leave plans, to push for increased staffing or to address pay concerns.

While those negotiations continued into the new year in some cases, contracts were settled on the whole, just in time to face a new challenge: a respiratory virus with no cure and potentially deadly consequences for some patients.

Nurses are on the front lines. New graduates, retirees and out-of-state health care providers answered the call to aid the outbreak of COVID-19 in Washington and fill any gaps.

Since Feb. 1, the nursing commission has issued 3,857 temporary practice permits, which allow nurses to fully practice while they wait for a full background check to come through. These are primarily nurses coming from out of state to help.

“It’s an all-time high,” Meyer said of the number of applicants in that time frame. “We were busy.”

So busy, the nursing commission asked the governor’s office for additional funds to help staff its office.

The commission has also issued 364 emergency interim permits since March 24. These permits allow recent nursing school graduates to enter the workforcewhile waiting to take the national nursing exam, which was put on hold during the pandemic. (Testing centers are set to reopen in May, enabling new graduates to take their exams and get their licenses without need for an interim permit.)

More than 600 nurses have volunteered to help fight COVID-19 from in and out of state.

“The year 2020 was designated the year of the nurse (by the World Health Organization) because of how critical nurses are to people,” Meyer said.

The timing for such a designation seems prescient. In hospitals around the country, nurses are treating COVID-19 despite a lack of PPE and despite staffing issues that have been at the forefront of nurses’ concerns as they respond to the pandemic.

Unions have called on federal and state leaders and agencies, as well as hospitals, to protect their workers from the outset.

PPE shortages nationwide and globally have led to unprecedented practices and guidelines for health care workers. Some hospitals are asking staff members to reuse some items if they can or are sanitizing materials for reuse. Other hospitals are turning to local community partners for PPE in lieu of backed-up supply chain orders.

“Our big concern around PPE is that extended use and reuse should not become the new norm,” said Sally Watkins, executive director at the Washington State Nurses Association. “We need to eventually get back at some point, God willing, to what we call ‘the green zone,’ where people are practicing the way they’ve been trained – where people are using one-time-use things one time.”

Some nurses have quit due to PPE shortages and not feeling safe or protected while taking care of COVID-19 patients, Watkins said. Other nurses have been furloughed, laid off or forced to pivot in the midst of COVID-19.

With Gov. Jay Inslee postponing all elective surgeries and nonurgent procedures for two months, many hospitals dropped to low census numbers and furloughed staff. Other hospitals have tried to repurpose staff members.

Sofia Aragon, executive director at the Washington Center for Nursing, said the furloughs might be an opportunity for some nurses to consider other work settings, including nursing education, which needs to expand for the nursing workforce to grow statewide.

Moving nurses from one workplace setting to another is not as simple as it sounds, because nurses tend to specialize or stay in one care setting, Aragon said. Nurses are required to do continuing education to be licensed in Washington, but those requirements have been waived by the commission so nurses can focus on the pandemic at hand. Many skills in different facilities where nurses work are transferable, but a nurse must feel comfortable performing those tasks.

“The nurse has to show competency,” Meyer said, pointing to the state law the lays out how nurses must be prepared to do their jobs.

Furloughed nurses in the job market could also be competing against recent graduates for jobs in coming months.

“From a new grad perspective, one of their biggest concerns is, ‘Where am I going to get a job?’ This is going to be a pretty challenging landscape for them right now,” said Jo Ann Dotson, director of the bachelor’s nursing program at WSU College of Nursing.

Nursing schools received permission to be flexible with soon-to-be graduates who could not do their final practicums due to the pandemic.

Some schools used simulation, and Dotson said students at WSU still had far more clinical hours than are required to graduate. WSU nursing students also were able to offer their skills, working with the local health department and community sites to provide virtual care and support to designated elders in the community, who cannot receive visitors or socialize during the pandemic.

Leaders are already thinking about the future, in the interim and into the fall, when there could be another surge in COVID-19 cases coinciding with flu season.

“We’re always looking at, ‘Do we have enough nursing students going into the pipeline?’ ” Meyer said.

Aragon said the pandemic could be used by nurses as an opportunity to change systems going forward, especially in terms of testing and personal protective equipment.

“They have an opportunity to change systems, so we don’t have to furlough or shut down elective surgery because we’re confident in terms of practice regardless of emergency,” Aragon said. “That’s an exciting thing and something we can take care to learn from the experience and make it better, so we don’t have these massive shutdowns because in the long term, we still need everybody and still don’t have enough.”