a repeat cp

A repeated cross-sectional study of nurses
immediately before and during the COVID-19
pandemic: Implications for action
Linda H. Aiken*, Douglas M. Sloane, Matthew D. McHugh, Colleen A. Pogue,
Karen B. Lasater
Center for Health Outcomes and Policy Research, School of Nursing, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
ABSTRACT
Background: The shortage of nursing care in US hospitals has become a national
concern.
Purpose: The purpose of this manuscript was to determine whether hospital nursing
care shortages are primarily due to the pandemic and thus likely to subside or due
to hospital nurse understaffing and poor working conditions that predated it.
Methods: This study used a repeated cross-sectional design before and during the
pandemic of 151,335 registered nurses in New York and Illinois, and a subset of
40,674 staff nurses employed in 357 hospitals.
Findings: No evidence was found that large numbers of nurses left health care
or hospital practice in the first 18 months of the pandemic. Nurses working
in hospitals with better nurse staffing and more favorable work environments prior to the pandemic reported significantly better outcomes during
the pandemic.
Discussion: Policies that prevent chronic hospital nurse understaffing have the
greatest potential to stabilize the hospital nurse workforce at levels supporting
good care and clinician wellbeing.
Cite this article: Aiken, L.H., Sloane, D.M., McHugh, M.D., Pogue, C.A., & Lasater, K.B. (2023, January/February). A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic:
Implications for action. Nurs Outlook, 71(1), 101903. https://doi.org/10.1016/j.outlook.2022.11.007.
ARTICLE INFO
Article history:
Received 29 August 2022
Received in revised form
21 October 2022
Accepted 30 November 2022
Available online December 8,
2022.
Keywords:
Burnout
Nurse understaffing
Patient safety
Pandemic
Introduction
The Surgeon General (2022) recently issued a public
advisory declaring health care clinician burnout to be
an urgent public health issue in need of immediate
action. The American Hospital Association (AHA) in a
March 1, 2022, letter to Congress proclaimed workforce
challenges a national emergency that demanded
immediate attention (AHA, 2022). There is little doubt
that many hospitals failed to perform well during
the Covid-19 emergency (Fleisher et al., 2022;
Joint Commission, 2021). Bloodstream infections,
which had declined 31% in the 5 years preceding the
pandemic increased 28% in the pandemic’s first
months (Patel et al., 2021) with similar disappointing
*Corresponding author: Linda H. Aiken, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104-4217.
E-mail address: laiken@nursing.upenn.edu (L.H. Aiken).
0029-6554/$ -see front matter 
 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
https://doi.org/10.1016/j.outlook.2022.11.007
Available online at www.sciencedirect.com
Nurs Outlook 7 1 ( 2 0 2 3 ) 1 0 1 9 0 3 www.nursingoutlook.org
trends in other infections, falls, and pressure ulcers
(AHRQ, 2021; Rosenthal et al., 2022). The AHA’s proposed solutions to the nursing care shortage included
increasing the national supply of nurses, recruiting
nurses from abroad, addressing clinicians’ “behavioral
health needs,” and investigating anticompetitive
behavior of travel nurse agencies. Are these the highest priority solutions to the problems of hospitals not
being able to recruit and retain enough nurses? Our
study of hospital nurses in a large, repeated cross-sectional study before and during the pandemic adds a
new perspective on where to look for solutions to the
shortage of hospital nursing care.
The solutions may have been in plain sight for two
decades. In 2002, two landmark studies (Aiken et al.,
2002; Needleman et al., 2002) documented significant
associations between hospital patient-to-nurse workloads and patient mortality and nurse burnout. Each
one patient increase in nurses’ workloads was associated with a 7% increase in the odds of risk-adjusted
patient mortality, a 23% increase in the odds of high
nurse burnout, and a 15% increase in the odds of nurse
job dissatisfaction (Aiken et al., 2002). A large body of
research (Aiken et al., 2018; Lake et al., 2019;
Lasater et al., 2021c; Lu et al., 2012; Sloane et al., 2018;
Wynendaele et al., 2019) confirms the association of
hospital nurse staffing and work environments with
patient outcomes and nurse retention.
The only major policy response to chronic hospital
nurse understaffing and poor work environments in
20 years has been the implementation in 2004 of a mandated minimum nurse staffing requirement in hospitals
throughout California (Aiken et al., 2010; McHugh et al.,
2011a, 2012). The unfunded mandate resulted in patients
in California hospitals currently receiving, on average, 2
to 3 more hours a day of registered nurse care than
patients in other states (Dierkes et al., 2021). Similar safe
nurse staffing legislation has been considered in other
states but despite research estimating improved patient
outcomes and cost savings (Lasater et al., 2021a, 2021b),
no other states have implemented minimum hospital
nurse staffing requirements.
This study leverages data from the largest repeated
survey of registered nurses aggregated by their
employing organizations both immediately preceding
the pandemic and 18 months into the pandemic. Data
document baseline measures and pandemic-related
changes in nurse burnout, job dissatisfaction, intent to
leave, patient safety and quality of care, nurse staffing,
work environments, and confidence in hospital management. Our findings reveal that nurses’ concerns
and adverse outcomes which were magnified by the
pandemic were evident before the pandemic. We
explore how nurse understaffing and poor work environments before the pandemic were associated with
nurse wellbeing and intent to stay with their employer
during the pandemic, a perspective that is essential in
identifying and prioritizing policy actions and managerial changes in hospital workplaces to retain nurses
and keep patients safe.
Methods
Data
This study uses repeated cross-sectional data from
two surveys of all registered nurses in New York and
Illinois collected prepandemic (December 16,
2019
February 24, 2020) and during the pandemic
(April 13, 2021
June 22, 2021). All actively licensed registered nurses in New York and Illinois were invited to
participate in an online survey. The resulting dataset
includes repeated measures in two cross-sections of
data from 151,335 nurses (81,263 prepandemic; 70,072
during). Respondents indicated their employment status, including whether they were currently employed
in health care in a hospital setting, employed in health
care but not in a hospital, employed but not in health
care, not currently employed, or retired. These data
were used to evaluate changes in employment status
to understand the extent to which nursing care shortages during the pandemic were likely due to nurses
leaving the profession or hospital practice. This question can only be answered using a sample of all nurses
including those that left hospitals as well as those who
stayed. Nurses employed in hospitals reported their
position (e.g., staff nurse, nurse manager, advanced
practice nurse), and type of unit on which they most
recently worked (e.g., medical
surgical, intensive
care, emergency department). A subset of 40,674 staff
nurses that practiced in hospitals at the time of the
survey (24,114 prepandemic; 16,560 during) was used
to evaluate changes in hospital nurse job outcomes,
work environments, and quality and safety of care.
In contrast to other studies of nurses during the pandemic that mostly relied on convenience sampling, ours
used a sampling frame more likely to yield a representative sample of nurses—state licensure lists of registered
nurses. Also, unlike other surveys, we were able to
aggregate hospital nurses by their employer. The subset
of 40,674 hospital staff nurses in our analytic dataset is
employed by 357 unique hospitals, representing 99% of
acute care hospitals in New York and Illinois. The overall
response rate of all nurses was 18% in the prepandemic
survey and 14% for the survey during the pandemic,
which is within the usual range of response rates for
online surveys. In prior survey research using a similar
survey instrument, we utilized a double-sampling
approach of nonrespondents for evaluating nonresponse
bias and found no significant differences in nursereported measures between main-survey respondents
and nonrespondents (Lasater et al., 2019).
Measures
Burnout was assessed using the emotional exhaustion
subscale of the Maslach Burnout Inventory (Maslach &
Jackson, 1981; Maslach et al., 2001). High burnout was
defined as scores 
27 (Maslach et al., 1997). Job dissatisfaction was a dichotomous variable of “somewhat
2 Nurs Outlook 71 (2023) 101903
dissatisfied” and “very dissatisfied” to a single-item
question asking nurses how satisfied they were overall
with their job (McHugh et al., 2011b). Intent to leave
was measured using nurses’ reports of whether they
planned to be with their current employer for 1 year.
Nurses assessed whether there was enough staff to
provide needed care, whether their overall hospital
work environment was excellent, good, fair, or poor,
and whether there was good teamwork between
nurses and physicians (Sloane et al., 2018).
Nurses rated quality of patient care and the effectiveness of management in their hospitals. Patient care
measures included: overall quality of care, patient safety,
infection prevention, and culture of patient safety. Ratings of the quality of nursing care ranged from
“excellent” to “poor” on a four-point Likert scale. Patient
safety and infection prevention were rated on a scale
(A
F) with grades of C, D, or F considered “unfavorable.”
Culture of patient safety items were drawn from the
Agency for Healthcare Research and Quality (AHRQ)
Hospital Survey on Patient Safety Culture (AHRQ, 2019)
asking nurses to rate on a five-point Likert scale ranging
from “strongly agree” to “strongly disagree” whether
actions of management show patient safety is a top priority, whether nurses feel mistakes are held against
them, and whether nurses feel free to question authority. Nurses indicated whether they were confident (i.e.,
ranging from “very confident” to “not at all confident”
on a four-point Likert scale) that management would act
to resolve problems in patient care that nurses identify.
Nurses indicated whether they agreed with the statement “administration listens and responds to nurses’
concerns” (ranging from “strongly agree” to “strongly
disagree” on a four-point Likert scale).
Data Analysis
First, we show changes in nurse employment from the
prepandemic period to during the pandemic. We then
show percentages of hospital staff nurses reporting
concerns about hospital management and patient care
quality in the two periods, using chi-square statistics
to test the significance of differences across periods.
We show percentages of hospital staff nurses overall
and in different types of units with high burnout, job
dissatisfaction, intent to leave current employer, staffing insufficiency (i.e., not enough staff), work environments that were poor/fair, and not a lot of teamwork
between nurses and physicians.
Finally, we aggregate responses from medical
surgical staff nurses prepandemic to create hospital-level
measures of mean adult medical
surgical patient-tonurse staffing ratios and nurse work environments in
hospitals prior to the pandemic. This aggregation technique resulted in a subset of 239 hospitals, a smaller
number of hospitals than used in the analysis of burnout because some respondents did not provide the
name of their employer which was necessary to calculate staffing levels and work environment quality at
the hospital level. The resulting hospitals consisted of
the following distribution of mean staffing: 39 hospitals had a mean patient-to-nurse staffing ratio of 5 or
fewer patients per nurse in the prepandemic crosssection, 112 hospitals had a mean of more than five
and less than equal to six patients per nurse, and 88
hospitals had more than six patients per nurse on
average. Hospital work environments were categorized by the percentage of medical
surgical staff
nurses who rated their work environment as “poor” or
“fair” in the prepandemic cross-section: 24 hospitals
were categorized as “good” work environments, 128
hospitals had “mixed” work environments, and 87
hospitals had “poor” work environments. Once hospitals were categorized by their prepandemic staffing
and work environments, we use percentages and chisquare statistics to show how nurse outcomes, care
quality and safety, and concerns with management
varied across hospitals during the pandemic based on
their prepandemic patient-to-nurse staffing ratios and
quality of their work environments.
Findings
Figure 1 displays the distribution of actively licensed
registered nurses by employment status prepandemic
and during the pandemic using our entire sample of
nurse respondents whether they were employed or
not; for the employed nurses we considered employment in all settings. Between the two periods there
were no significant changes in employment status
(likelihood ratio chi-square statistic = 7.05 with 4 d.f.,
p = .133 testing the independence of the numbers in
the five employment status categories across two time
points). The percentage of nurses employed in hospitals did not change by more than a fraction of 1% during the pandemic (p = .322). Had large numbers of
nurses left hospitals or health care without being
replaced, we would expect to see decreases in percentages of nurses in hospitals and other health care settings and concomitant increases in numbers of nurses
that were employed in nonhealth care settings or currently unemployed or retired.
Table 1 reports survey results from hospital staff
nurses only. The findings point to lack of confidence in
hospital management prepandemic which worsened
during the pandemic. Over 69% of hospital staff nurses
in the prepandemic period reported a lack of confidence
in hospital management to resolve clinical care problems reported by nurses, and this percentage increased
to almost 78% during the pandemic. Similarly, 47% of
hospital staff nurses in the prepandemic period reported
that administration did not listen or respond to nurses’
concerns which increased to 53% during the pandemic.
Some 48% of nurses prepandemic agreed that the
“actions of management show patient safety is not a top
priority” which rose to 53% during the pandemic. Almost
50% of nurses prepandemic reported feeling that their
mistakes were held against them and 56% reported not
Nurs Outlook 71 (2023) 101903 3
feeling free to question decisions or actions of authority.
Almost 45% of nurses gave their hospitals unfavorable
patient safety grades prepandemic and 47% rated
patient safety unfavorably during the pandemic. A third
of nurses gave their hospitals an unfavorable grade on
infection prevention prepandemic which rose to 36%
during the pandemic. Nurses’ assessments about quality
grew more negative during the pandemic, with higher
percentages of nurses rating their hospitals’ overall quality of care as poor/fair during the pandemic (26%) as
compared to before (20%).
As shown in Table 2, large percentages of hospital
staff nurses before Covid-19 reported high burnout
(48%), job dissatisfaction (27%), intent to leave their
employer (22%), poor/fair work environments (47%),
and not enough staff (57%). These outcomes worsened
or remained high during the pandemic—especially
among nurses working on medical
surgical units,
adult intensive care, and in emergency departments.
The largest increases during the pandemic were in the
percentage of hospital staff nurses reporting there
were not enough staff and the percentage of nurses
Figure 1 – Changes in nurse employment status, prepandemic and during the pandemic.
Notes. Survey data collected by the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. Prepandemic data were collected between December 15, 2019 and February 24, 2020.
Data during the pandemic were collected between April 13, 2021 and June 22, 2021. A chi-square statistic
(L2 = 7.05 with 4 d.f., p = .133) testing the independence of the numbers in the five employment status categories
across two time points is insignificant, indicating no overall change.
Table 1 – Hospital Staff Nurses Evaluations of Hospital Management and Patient Care Quality, Prepandemic
and During the Pandemic
Patient Care and Evaluation of Management Prepandemic During Pandemic Changey
Not confident in management resolving clinical care problems 69.4% 77.5% 8.1%***
Administration doesn’t listen or respond to nurses’ concerns 46.8% 52.9% 6.1%***
Actions of management show patient safety is not a top priority 47.7% 53.3% 5.8%***
Feel mistakes are held against them 49.6% 47.1% -2.5%***
Do not feel free to question decisions or actions of authority 56.2% 52.1% -4.1%***
Poor/fair quality of care 19.9% 25.7% 5.8%***
Unfavorable infection prevention grade (C, D, or F) 33.2% 35.6% 2.4%***
Unfavorable patient safety grade (C, D, or F) 44.5% 47.1% 2.6%***
Notes. Survey data collected by the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
*** p < .001
y Prepandemic data were collected between December 15, 2019 and February 24, 2020. Data during the pandemic were collected between April 13, 2021 and June 22, 2021.
4 Nurs Outlook 71 (2023) 101903
reporting job dissatisfaction and high burnout. The
negative impact of the pandemic was not observed in
nurse
physician teamwork which was positive before
the pandemic and improved during the pandemic.
In Table 3 we show how the outcomes and concerns
expressed by hospital staff nurses during the pandemic are associated with mean medical
surgical
patient-to-nurse staffing ratios prepandemic. Percentages of nurses reporting each outcome during the
pandemic are grouped according to reports of their
hospital’s mean medical
surgical staffing in the prepandemic cross-section. Nurses in hospitals in which
the mean number of patients assigned to each nurse
was high prepandemic were more likely to issue unfavorable reports about their own outcomes (e.g., burnout, job dissatisfaction, intent to leave employer),
patient outcomes (e.g., poor quality of care, unfavorable patient safety), and lack confidence in hospital
management during the pandemic.
Similar differences are shown in Table 4, in which
nurses in hospitals with “poor” work environments
in the prepandemic period reported the greatest
concerns with their own wellbeing, patient outcomes,
and lack of confidence in hospital management during
the pandemic.
Discussion
Overall, our findings suggest that the pandemic was
not the root cause but a contributing factor in hospital
nurse recruitment and retention challenges during the
pandemic. Our survey responses from all nurses,
whether working or not before and during the pandemic, do not support the widely held belief that
nurses left health care or hospital practice in large
numbers during the pandemic. The evidence of declining confidence in hospital management along with
high burnout, job dissatisfaction, and intent to leave
before and during the pandemic suggests that nurses
may have been changing employers in higher numbers, including working for supplemental staffing
Table 2 – Hospital Staff Nurse Reports of High Burnout, Job Dissatisfaction, Intent to Leave, Staffing, and
Work Environments, Prepandemic and During the Pandemic
Nurse Reports* Prepandemic During Pandemic Changey
All staff nurses High burnout 48.0% 51.0% 3.0%***
(N = 40,674) Job dissatisfaction 27.2% 30.6% 3.4%***
Intent to leave employer 21.8% 24.7% 2.9%***
Not enough staff 56.9% 67.4% 10.5%***
Poor/fair work environment 46.6% 42.2% -4.4%***
Not a lot of nurse
physician teamwork 18.9% 15.1% -3.8***
Medical
surgical nurses High burnout 54.0% 58.9% 4.8%***
Job dissatisfaction 29.9% 36.3% 6.4%***
(N = 10,743) Intent to leave employer 23.5% 28.0% 4.5%***
Not enough staff 64.9% 75.0% 10.1%***
Poor/fair work environment 46.4% 46.4% 0.0%
Not a lot of nurse
physician teamwork 21.4% 15.8% -5.6%***
Adult intensive care nurses High burnout 50.3% 57.6% 7.3%***
Job dissatisfaction 29.7% 33.9% 4.2%**
(N = 5,429) Intent to leave employer 25.5% 29.2% 3.7%**
Not enough staff 57.4% 73.1% 15.7%***
Poor/fair work environment 49.0% 46.5% -2.5%
Not a lot of nurse
physician teamwork 17.6% 15.2% -2.4%*
Emergency department
nurses (N = 4,515)
High burnout 55.9% 58.1% 2.2%
Job dissatisfaction 31.4% 37.4% 6.0%***
Intent to leave employer 24.7% 28.3% 3.6%*
Not enough staff 63.6% 75.3% 11.7%***
Poor/fair work environment 51.8% 51.9% 0.1%
Not a lot of nurse
physician teamwork 13.9% 12.3% -1.6%
Other nurses High burnout 41.7% 43.9% 2.2%**
(N = 19,987) Job dissatisfaction 23.8% 25.6% 1.8%**
Intent to leave employer 19.0% 21.1% 2.1%***
Not enough staff 50.3% 60.4% 10.1%***
Poor/fair work environment 44.7% 37.0% -7.7%***
Not a lot of nurse
physician teamwork 19.0% 15.3% -3.7%***
Notes. Survey data collected by the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
*p < .05; **p < .01; *** p < .001
y Prepandemic data were collected between December 15, 2019 and February 24, 2020. Data during the pandemic were collected between April 13, 2021 and June 22, 2021.
Nurs Outlook 71 (2023) 101903 5
agencies, which contributed to a perception of more
nurses leaving clinical care than can be documented.
Our findings confirmed among hospital nurses that
high nurse burnout, job dissatisfaction, intent to leave
hospital employer, and lack of confidence in hospital
management predated the pandemic. Immediately
prior to Covid-19, 48% of hospital nurses in our study
experienced high burnout; more than a year into the
pandemic, the percentage of high burnout went up
only 3% to 51%. The high rates of nurse burnout during
the pandemic appear to be largely a consequence of
high burnout prior to the pandemic. Addressing
the root causes of high nurse burnout and hospital job
dissatisfaction before the pandemic is critical to
achieving a stable, qualified hospital nurse workforce
going forward.
Importantly, our results show that hospital nurse
understaffing and poor work environments prior to
the Covid-19 emergency were associated with unfavorable outcomes during the pandemic. Before Covid19, 57% of hospital staff nurses said there were too few
nurses to care for patients which increased to 67% during the pandemic. Almost half of nurses (47%) rated
their hospital work environments as “poor” or “fair”
prepandemic; during the pandemic 42% rated their
work environments unfavorably. High nurse burnout,
job dissatisfaction, and intent to leave were worse during the pandemic in hospitals that were poorly staffed
Table 3 – Hospital Staff Nurse Reports of Job Outcomes, Patient Care Quality, and Hospital Management Support During the Pandemic are Associated with Patient-to-Nurse Staffing Ratios Prepandemic
Percent of Nurses Reporting Various Outcomes
During Pandemic
Hospital Mean Medical
Surgical Patients Per Nurse Prepandemic*
5
N = 39
>5 and 6
N = 112
>6
N = 88
High burnout 48.7% 52.0% 53.4%
Dissatisfied with job 25.1% 32.1% 35.0%
Intent to leave employer 21.5% 24.3% 26.7%
Not confident in management resolving
clinical care problems
72.0% 77.5% 82.1%
Actions of management show patient safety
is not a top priority
45.1% 55.0% 58.5%
Administration doesn’t listen or respond
to nurses’ concerns
44.0% 53.9% 58.2%
Unfavorable patient safety grade (C, D, or F) 33.9% 46.7% 54.6%
Unfavorable infection prevention grade (C, D, or F) 27.0% 33.8% 41.8%
Poor/fair quality of care 15.7% 24.7% 33.0%
Not a lot of teamwork between nurses and physicians 12.6% 13.7% 18.0%
Notes. Survey data collected by Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
* Chi-square tests reveal that the differences in each of the reported outcomes between the three categories (defined by the
hospital mean medical
surgical patients per nurse prepandemic) are significant at the p < .01 level of confidence.
Table 4 – Hospital Staff Nurse Reports of Job Outcomes, Patient Care Quality, and Hospital Management Support During the Pandemic Are Associated With Nurse Work Environments Prepandemic
Percent of Nurses Reporting Various Outcomes During Pandemic Hospital Nurse Work Environment Prepandemic*
Good
N = 24
Mixed
N = 128
Poor
N = 87
High burnout 42.1% 51.3% 55.7%
Dissatisfied with job 19.9% 29.9% 37.8%
Intent to leave employer 19.7% 23.8% 26.9%
Not confident in management resolving clinical care problems 63.1% 76.4% 84.7%
Actions of management show patient safety is not a top priority 35.5% 51.6% 64.3%
Administration doesn’t listen or respond to nurses’ concerns 36.3% 49.8% 63.9%
Unfavorable patient safety grade (C, D, or F) 24.6% 42.1% 60.6%
Unfavorable infection prevention grade (C, D, or F) 17.3% 29.9% 48.4%
Poor/fair quality of care 9.4% 21.9% 36.0%
Not a lot of teamwork between nurses and physicians 9.8% 12.9% 19.3%
Notes. Survey data collected by Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
* Chi-square tests reveal that the differences in each of the reported outcomes between the three categories (defined by the
percentage of nurses who rated their hospital work environment as “poor” or “fair” prepandemic) are significant at the p <
.001 level of confidence.
6 Nurs Outlook 71 (2023) 101903
before the pandemic and/or had unfavorable work
environments before the pandemic. The proportion of
hospital staff nurses during the pandemic intending to
leave their employer was significantly higher in hospitals with the worst nurse staffing and poorest work
environments in the prepandemic period suggesting
that both chronic understaffing and subpar work environments dually threaten nurse retention.
Also, nurses’ negative appraisals of quality of care
and patient safety during the pandemic were substantially worse in hospitals in which nurses cared for
more patients each before the pandemic. For example,
33% of nurses in hospitals where mean prepandemic
medical
surgical staffing was more than six patients
per nurse reported poor/fair quality of care during the
pandemic, compared with half that many, only 16% of
nurses, in hospitals where the mean prepandemic
staffing was 5 or fewer patients per nurse.
Before the pandemic, an astounding 70% of hospital
staff nurses lacked confidence in management in their
employing organization to resolve clinical care problems identified by nurses, and close to half of nurses
reported their employer did not listen or respond to
their concerns. Nurses’ negative appraisals of hospital
management increased further during the pandemic
when nurse layoffs and furloughs were common.
Almost half of nurses reported prepandemic that the
actions of hospital management show patient safety is
not a top priority which increased to 53% during the
pandemic. Also, both before and during the pandemic
nearly half of nurses reported they feel like mistakes
are held against them and they do not feel free to question decisions and actions of authority-disturbing evidence of the failure of hospital management to
embrace the basic tenets of keeping patients safe. The
recent case (Kalman & Norman, 2022) of a hospital
nurse being fired by her hospital and convicted of
criminally negligent homicide for a medication error
reportedly associated with a system failure adds further distress to a burned out and discouraged nurse
workforce and is a real-world example of why nurses
lack confidence in management and lack loyalty to
their employing hospitals.
One finding to be celebrated is that nurses reported
that nurse
physician relations were good prior to the
pandemic and even improved some during the pandemic. Interprofessional relationships and interdisciplinary teamwork among clinicians seem strong, in
contrast to the substantial lack of confidence nurses
have in hospital management.
Study Strengths and Limitations
While the timing of our surveys is unique in having a
baseline immediately before the Covid-19 pandemic
and a second survey during the pandemic, we have
measures at only two points in time, so caution is warranted in making causal inferences. Our survey is
unique among others available in that nurses were
invited to participate from a sampling frame
consisting of all licensed registered nurses in two large
states as compared to convenience samples. Also,
nurses are linked to their place of employment providing a unique perspective on nursing practice within
individual hospitals. Survey response rates are not
optimal although not out of line with recent experience with large online surveys. Our previous research
shows that nonresponders do not rate nursing care
differently from those that do respond, and that nonresponse is not a factor that influences the kind of outcomes we are studying (Lasater et al., 2019). Nurses
who did not report their hospital name were somewhat more likely to report more negatively about their
hospitals’ quality; however, in most cases the differences were not statistically significant. Some may consider nurse reports of patient care quality as subjective
but our previously published research shows that
nurse reports of quality and safety of care are highly
predictive of objectively measured patient outcomes
including mortality, failure to rescue, and patient satisfaction (McHugh & Stimpfel, 2012). Finally, the pandemic has continued for a year after our “during the
pandemic” survey so it is possible that conditions have
changed further over time.
Implications for Policy
The most common suggestion for addressing the present shortage of nursing care in hospitals is to increase
the national supply of nurses, although evidence does
not suggest this strategy will be effective. The numbers
of US educated nurses graduating annually has been
steadily increasing for decades even during the pandemic and currently over 185,000 new nurses enter the
workforce each year (National Council of State Boards
of Nursing, 2021). In 2017, the National Center for
Health Workforce Analysis (U.S. Department of Health
and Human Services, 2017) projected a national registered nurse excess of about 8% by 2030. There is little
association between increases in the national supply
of nurses and hospital patient-to-nurse ratios. Immediately before the pandemic, after a decade that added
a million registered nurses to the national supply,
mean patient-to-nurse staffing ratios varied widely
across hospitals in New York and Illinois from a low of
4.3 patients per nurse in adult medical and surgical
inpatient units to a high of 10.5 patients per nurse
(Lasater et al., 2021c). This lack of an association
between supply and hospital nursing care shortage is
also shown at the state-level where RNs per 1,000 population vary substantially. California, the only state
with mandated nurse staffing ratios, has among the
fewest nurses with 9.25 RNs per 1,000 population while
Massachusetts, a state with 16.04 RNs per 1,000, turned
down legislation setting minimum hospital nurse
staffing standards because of fears of nurse shortages.
The shortage of nursing care in hospitals is largely
the result of chronic nurse understaffing by design.
Focusing policy attention primarily on substantial and
rapid increases in the supply of nurses diverts
Nurs Outlook 71 (2023) 101903 7
attention from more promising solutions to the
chronic shortage of nursing care in hospitals as well as
in other settings such as nursing homes and schools
where the number of budgeted positions for nurses is
the problem that needs a solution. Also, policies to
rapidly increase RN supply could undermine national
nurse workforce goals by attracting new poor-quality
nursing schools with unfavorable graduation rates
and a proliferation of programs that do not produce
nurses with bachelor’s degrees as recommended by
the National Academy of Medicine (Institute of Medicine, 2011).
Fifteen states currently address hospital nurse staffing in law (de Cordova et al., 2019a, 2019b). However,
only in California where minimum nurse staffing is
mandated is there an association between state legislation and improved nurse staffing (Han et al., 2021).
California implemented minimum required hospital
nurse staffing almost 20 years ago with positive results
(Aiken et al., 2010; Dierkes et al., 2021). Significant
improvements in nurse staffing were achieved in California safety-net hospitals, one of the few observed
improvements in nurse staffing in minority serving
hospitals since the passage of Medicare and Medicaid
(McHugh et al., 2012). Hospitals that staffed better
than the minimum required before the law did not
decrease their staffing to the minimum, thus demonstrating that safe nurse staffing standards do not
require “one size to fit all,” a slogan used liberally by
opponents of safe nurse staffing standards. And other
negative unintended consequences such as hospital or
emergency department closures due to staffing legislation were not observed (McHugh et al., 2011a). Recent
research in other states has shown that pending staffing legislation is in the public’s interest because of the
substantial variation in patient-to-nurse ratios across
hospitals within states which is associated with higher
deaths as well as higher costs due to longer stays and
more readmissions (Lasater et al., 2021a, 2021b).
There is no evidence that mandated nurse staffing
committees, the most prevalent form of state nurse
staffing legislation, have any impact on improved
staffing (Han et al., 2021). While state legislation to
require public reporting of hospital nurse staffing has
not shown much impact (de Cordova et al., 2019b;
Han et al., 2021) the Medicare Hospital Compare website is more visible and accessible to the public than
state reports of staffing but currently does not report
on hospital nurse staffing. Remedying this important
omission could make hospital nurse staffing more
transparent to the public and motivate improvements.
A concern by opponents of legislating minimum hospital staffing requirements is the risk of creating a
short-term nurse shortage at state or local levels that
could disrupt health services. The Nurse Licensure
Compact, which has been passed in 39 US states and
territories, addresses that risk by allowing nurses to
practice in any Compact state. The Compact offers the
advantage of comprehensive vetting of nurses’ qualifications and avoiding delays in issuing state-based
licenses (Alexander et al., 2021). Nurse employers
should advocate for its passage given the substantial
delays in processing RN licenses that have worsened
during Covid, and slow onboarding of newly hired
nurses (Fast, 2022).
A recent Harris poll showed 90% of the public surveyed favored requiring safe nurse staffing standards
in hospitals and nursing homes (NursesEverywhere, 2020). Given the strong headwinds from deep
pocket special interests opposed to states establishing
hospital minimum nurse staffing requirements, federal options should be pursued. The most promising
federal option is to establish minimum safe nurse
staffing standards for hospitals as a condition of participation in Medicare (Aiken & Fagin, 2022). There is
precedent in Medicare nurse staffing requirements for
nursing homes, even though the current staffing standard there is too low to produce safe care. Medicare
conditions of participation have previously been used
to solve vexing problems including the desegregation
of hospitals and the implementation of the employee
Covid-19 vaccine mandate in hospitals that was
upheld by the Supreme Court. Similar policy intervention is warranted to require hospitals participating in
Medicare to meet evidence-based nurse staffing standards to ensure safe care for the public and to reduce
outcomes disparities in understaffed minority serving
hospitals.
Further explication of Medicare’s value-based purchasing policies to create a visible funding stream for
professional nurses, as is common for other health
professionals, is promising as a potentially cost neutral strategy to explicitly reward hospitals and other
providers for employing enough nurses to provide safe
care of high quality. Evidence-based nurse staffing has
been shown to reduce length of stay, readmissions,
and never events such as health care-acquired infections that save lives and avoid pain and suffering as
well as saving Medicare money (Lasater et al., 2021a;
Yakusheva et al., 2020).
Implications for Practice
Interventions for improving subpar work environments are not codified in policy, but rather in administrative decision-making about how to structure and
operate complex organizations. One example of an
evidence-based organizational intervention that has
been shown to improve nurse work environments is
the American Nurses Credentialing Center Magnet
Recognition Program (Kutney-Lee et al., 2015). The
Magnet program offers an actionable blueprint for
how organizations can transform culture to enhance
clinician wellbeing and patient care outcomes. Organizations committed to improving their work environments and attracting and retaining registered nurses
may find success in following the organizational principles, such as structural empowerment and engagement of clinicians in decision-making, characteristic
of Magnet hospitals.
8 Nurs Outlook 71 (2023) 101903
Conclusion
Chronic nurse understaffing and poor work environments in hospitals that existed prior to the Covid-19
pandemic and worsened during it are the major
explanations for why many hospitals cannot hire and
keep enough nurses even though Covid-19 hospitalizations have dropped. Without fundamental improvements in hospital nurse staffing and work
environments, the shortage of nursing care in hospitals will not likely abate even after the Covid-19 pandemic has run its course. Increasing the supply of
nurses through short-term emergency measures is
unlikely to solve the problem. Hospitals need to hire
more permanent registered nurses, provide more
favorable work environments, and earn back the confidence of nurses that quality and safety of patient care
are institutional priorities. Because most hospitals
have not implemented substantial improvements in
either staffing or work environments over the past
decade (Aiken et al., 2018; Sloane et al., 2018), policymakers should mandate hospitals to meet minimum
safe nurse staffing standards. A continuation of
chronic nurse understaffing and unacceptable working
conditions in hospitals will not restore the public’s or
nurses’ confidence in hospitals.
Authors’ Contributions
L.H.A.: Conceptualization, funding, data collection, writing, interpretation of results, policy implications; D.M.S.:
Study design, analysis, interpretation of findings, writing; M.D.M.: Conceptualization, funding, data collection,
interpretation of results, policy implications; C.A.P.: Conceptualization, interpretation of findings, writing, manuscript review; K.B.L.: Conceptualization, funding, data
collection, analysis, writing, policy implications.
Acknowledgments
This research was supported by the National Council
on State Boards of Nursing, the National Institute of
Nursing Research, National Institutes of Health
(R01NR014855 and T32NR00714), and Agency for
Healthcare Research and Quality (R01HS028978
Lasater). The authors thank Timothy Cheney for analytic assistance and the tens of thousands of nurses
who responded to our survey during challenging
times.
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