Working Paper

Nursing Before and After COVID-19: Outflows, Inflows and Self-Employment

Published: 2024

Nurse shortages world-wide and increases in self-employment among nurses which were accelerated and highlighted during the COVID-19 pandemic prompted us to study labour dynamics of nursing qualified people. Specifically, we analyse inflows to and outflows from the healthcare sector of two cohorts of nursing-qualified women and men, and transitions from salaried employment to self-employment. One cohort includes nursing-qualified workers who were employed in the healthcare sector in January 2020 and the other includes an earlier (pre-COVID) cohort of nursing-qualified workers who were employed in the healthcare sector in January 2016. Using Dutch monthly administrative microdata, we compare the inflows and outflows from employment and from healthcare employment for these two cohorts for one year before and three years after the respective baseline months (periods 2019-2022 and 2015-2018).

Our findings indicate that current shortages are likely to increase further. It also seems unlikely that the female-dominated nature of the nursing occupation will change with an increase in outflow from the healthcare sector that is larger for men than for women. At the same time transitions from salaried employment to self-employment in the healthcare sector were increasing for nursing-qualified men and women over time. This was most prevalent among single mothers with a child under the age of 12, younger female workers (under 35), and women who were not born in the Netherlands. During the worst months of COVID-19 somewhat higher inflow into healthcare employment was observed for nursing-qualified persons who were not employed or employed outside the healthcare sector, but such increases were temporary. Overall, the pandemic accelerated nurse shortages through reduced retention and increased self-employment, and its impact is still felt at the end of 2022.

The relative pay rises for nurses in 2021 and 2022 are unlikely to have been enough to compensate for the lack of flexibility and autonomy, so non-wage employment characteristics need to change too, which is an important observation for policy and practice. This seems borne out in the “choice” by single mothers of young children to become self-employed: here the immediacy of needing the ability to say no to particular working times through self-employment seems to win out over the need for financial security through permanent salaried employment. The question arises whether self-employment can be a solution (with employment and financial security provided in other ways), or can salaried employment provide more of what self-employment provides (e.g., more autonomy, some say in timing of work) or provide support in finding/paying for childcare. Potential reforms to salaried employment could offer higher pay for the less popular shifts to induce some workers to voluntarily put their hand up for these shifts, leaving employees who cannot work such shifts due to personal circumstances free to work more amenable shifts (for the normal pay). Alternatively (or additionally), large employers, like hospitals, could do more in terms of providing in-house childcare at low cost to employees.


Centre Member

Guyonne Kalb

Centre Friend

Jordy Meekes


Kalb, G. & Meekes, J. (2024). ‘Nursing before and after COVID-19: outflows, inflows and self-employment’, Life Course Centre Working Paper Series, 2024-03. Institute for Social Science Research, The University of Queensland.