A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic: Implications for action

Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care

BACKGROUND

Hospitals are resurrecting the outdated "team nursing" model of staffing that substitutes lower-wage staff for registered nurses (RNs).

OBJECTIVES

To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers.

RESEARCH DESIGN

Cross-sectional, retrospective.

SUBJECTS

In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019.

MEASURES

Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected.

RESULTS

A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly $3 billion in cost savings annually because of patients requiring longer stays.

CONCLUSIONS

Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40-50 percentage-points-the human and economic consequences of which could be substantial.

Connecting the Health Care Workforce with the Patient Experience

This article is one in a series from Press Ganey-a health care performance improvement organization-that will discuss the many facets of the human experience in health care. Using the latest national data, the series will explore the intersections of safety, reliability, experience, and service, and their impact on engagement, work culture, and nurse-sensitive outcomes. Each installment will be designed as a "deep dive" into the most recent thinking and evidence-based approaches to improvement of the patient experience with a particular focus on practical and implementable tactics in each of the above subject areas.

Diverse perspectives on unit-level nurse staffing ratios in medical-surgical units: A Delphi policy analysis

BACKGROUND

Appropriate staffing is essential to acute care delivery. Staffing ratio policy generates controversy.

PURPOSE

This study examines perspectives on unit-level nurse-to-patient ratio policy in adult medical-surgical units.

METHOD

Delphi methodology uses an invited diverse panel to analyze a policy's effects. Panelists completed iterative surveys about the impact they expect from unit-level ratio policy.

FINDINGS

Panelists demonstrated moderate agreement that the proposed policy could increase staffing levels, decrease patient length of stay, and reduce nurse attrition. Other potential outcomes included reducing staffing in units above the minimum and increasing short-term costs. Panelists agreed that the policy could increase patient safety and nurse satisfaction and did not agree about the effect on long-term cost and innovation. Panelists also anticipated a mostly positive effect on patients and nurses.

DISCUSSION

Policies that set unit-level nurse-to-patient ratios offer a potential strategy to improve medical-surgical staffing. Policy design should consider the range of expected outcomes.

Exploring the relationships between resilience, burnout, work engagement, and intention to leave among nurses in the context of the COVID-19 pandemic: a cross-sectional study

BACKGROUND

Nurses have faced significant personal and professional stressors during the COVID-19 pandemic that have contributed to increased rates of burnout, intention to leave, and poorer work engagement. Resilience has been identified as a critical factor influencing job outcomes; however, the dynamics of this association have not yet been investigated within the context of the Thai workforce. The study objective was to determine the associations between resilience and job outcomes, including burnout, intention to leave, and work engagement among nurses working in Thailand during the COVID-19 pandemic.

METHODS

This cross-sectional study gathered data from a sample of 394 registered nurses employed across 12 hospitals. The research instruments comprised the Connor-Davidson Resilience Scale (CD-RISC), the Maslach Burnout Inventory-Health Services Survey (MBI-HSS), a questionnaire assessing the intention to leave the job, and the Utrecht Work Engagement Scale (UWES). To determine the associations among the measured variables, multivariate logistic regression analyses were conducted.

RESULTS

One-third of nurses experienced emotional exhaustion and depersonalization, and about half experienced reduced personal accomplishment; one-tenth of nurses intended to leave their job. Nurses who exhibited higher levels of resilience were found to have a significantly reduced likelihood of experiencing high emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. Conversely, these nurses were more likely to report higher levels of work engagement than their less resilience.

CONCLUSION

The COVID-19 pandemic offers important lessons learned about promoting the well-being of the nursing workforce and protecting against adverse job outcomes. While we identified resilience as a significant predictor of several nurse outcomes, other work environment factors should be considered. Government and hospital administrations should allocate resources for individual and organizational-level interventions to promote resilience among frontline nurses so that hospitals will be better prepared for the next public health emergency and patient and nurse outcomes can be optimized.

Emergency Nurses' Reasons for Not Recommending Their Hospital to Clinicians as a Good Place to Work

Importance

Half of emergency nurses report high burnout and intend to leave their job in the next year. Whether emergency nurses would recommend their workplace to other clinicians may be an important indicator of a hospital's ability to recruit clinicians.

Objective

To examine why emergency nurses do not recommend their hospital to other clinicians as a good place to work.

Design, Setting, and Participants

This qualitative study used directed content analysis of open-text responses (n = 142) from the RN4CAST-NY/IL survey of registered nurses licensed in New York and Illinois between April 13 and June 22, 2021. Inductive and deductive analytic approaches guided study theme development informed by the Social Ecological Model. The collected data were analyzed from April to June 2023.

Main Outcomes and Measures

Nurses who answered "probably not" or "definitely not" to the survey question, "Would you recommend your place of employment as a good place to work?" were prompted to provide a rationale in an open-text response.

Results

In this qualitative study of 142 emergency nurses (mean [SD] age, 43.5 [12.5] years; 113 [79.6%] female; mean [SD] experience, 14.0 [12.2] years), 94 (66.2%) were licensed to work in New York and the other 48 (33.8%) in Illinois. Five themes and associated subthemes emerged from the data. Themes conveyed understaffing of nurses and ancillary support (theme 1: unlimited patients with limited support); inadequate responsiveness from unit management to work environment safety concerns (theme 2: unanswered calls for help); perceptions that nurses' licenses were in jeopardy given unsafe working conditions and compromised care quality (theme 3: license always on the line); workplace violence on a patient-to-nurse, clinician-to-nurse, and systems level (theme 4: multidimensional workplace violence); and nurse reports of being undervalued by hospital management and unfulfilled at work in delivering suboptimal care to patients in unsafe working conditions (theme 5: undervalued and unfulfilled).

Conclusions and Relevance

This study found that emergency department nurses did not recommend their workplace to other clinicians as a good place to work because of poor nurse and ancillary staffing, nonresponsive hospital leadership, unsafe working conditions, workplace violence, and a lack of feeling valued. These findings inform aspects of the work environment that employers can address to improve nurse recruitment and retention.

Top Factors in Nurses Ending Health Care Employment Between 2018 and 2021

Importance

The increase in new registered nurses is expected to outpace retirements, yet health care systems continue to struggle with recruiting and retaining nurses.

Objective

To examine the top contributing factors to nurses ending health care employment between 2018 and 2021 in New York and Illinois.

Design, Setting, and Participants

This cross-sectional study analyzed survey data (RN4CAST-NY/IL) from registered nurses in New York and Illinois from April 13 to June 22, 2021. Differences in contributing factors to ending health care employment are described by nurses' age, employment status, and prior setting of employment and through exemplar nurse quotes.

Main Outcomes and Measures

Nurses were asked to select all that apply from a list of contributing factors for ending health care employment, and the percentage of nurse respondents per contributing factor were reported.

Results

A total of 7887 nurses (mean [SD] age, 60.1 [12.9] years; 7372 [93%] female) who recently ended health care employment after a mean (SD) of 30.8 (15.1) years of experience were included in the study. Although planned retirement was the leading factor (3047 [39%]), nurses also cited burnout or emotional exhaustion (2039 [26%]), insufficient staffing (1687 [21%]), and family obligations (1456 [18%]) as other top contributing factors. Among retired nurses, 2022 (41%) ended health care employment for reasons other than planned retirement, including burnout or emotional exhaustion (1099 [22%]) and insufficient staffing (888 [18%]). The age distribution of nurses not employed in health care was similar to that of nurses currently employed in health care, suggesting that a demographically similar, already existing supply of nurses could be attracted back into health care employment.

Conclusions and Relevance

In this cross-sectional study, nurses primarily ended health care employment due to systemic features of their employer. Reducing and preventing burnout, improving nurse staffing levels, and supporting nurses' work-life balance (eg, childcare needs, weekday schedules, and shorter shift lengths) are within the scope of employers and may improve nurse retention.

It's Time! The Path for Nursing Reimbursement Reform

Since the COVID-19 pandemic, nurses and nurse leaders are increasingly vocal about chronic understaffing and the impact the staffing crisis continues to have on nurses' well-being and patient outcomes. The American Nurses Association's Nurse Staffing Task Force addressed the importance of staffing standards as a critically needed step toward improving patient and population health outcomes. Against the backdrop of ongoing nursing shortages, hospital leaders have been hesitant to embrace staffing ratios, expressing concerns about their ability to hire and retain sufficient nursing staff, as operational revenue margins remain thin and nursing labor is costly. This article explicates structural issues within the current nursing reimbursement model that harms hospitals' business case for investments in nurse staffing and work environments. We argue that nurses must advocate for nursing reimbursement reform to increase the nursing workforce and improve nurse staffing and work environments. Such reform is necessary to support sustained hospital investments, financial philosophies, and approaches to meaningfully address and improve nurse staffing.

A theoretical framework for Acute Care Nurse Stress Appraisal: Application of the transactional model of stress and coping

AIM

To develop a framework for understanding the stress appraisal process among acute care nurses during the COVID-19 pandemic.

DESIGN

A secondary analysis of open-ended responses from a cross-sectional survey of 3030 frontline, acute care nurses in New Jersey and the effect of burnout during the COVID-19 pandemic.

METHODS

Lazarus and Folkman's transactional model of stress and coping guided the study. Thematic analysis was used to analyse 1607 open-ended responses.

RESULTS

Nine themes emerged during the secondary appraisal of stress. Five themes contributed to distress and burnout including (1) high patient acuity with scarce resources, (2) constantly changing policies with inconsistent messaging, (3) insufficient PPE, (4) unprepared pandemic planning and (5) feeling undervalued. Four themes led to eustress and contributed to post-traumatic growth including (1) team nursing to ensure sufficient resource allocation, (2) open channels of communication, (3) sense- of-duty and (4) personal strength from new possibilities.

CONCLUSION

The COVID-19 pandemic was a traumatic event for patients and the nursing workforce. Internal and external demands placed on acute care nurses increased burnout, however, a subset of nurses with adequate support experienced personal growth.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Beyond mental health interventions for acute care nurses, organizational interventions such as reevaluation of emergency action plans to optimize resource allocation, and work environment strategies such as improved communication and decision-making transparency are necessary.

IMPACT

To better understand how frontline acute care nurses experienced stress during COVID-19, a data-informed framework was developed that included a primary and secondary appraisal of stress. Themes contributing to distress and burnout were identified, and themes leading to eustress and post-traumatic growth were also identified. These findings can assist nurse leaders in optimizing strategies to reduce burnout and promote post-traumatic growth in the post-COVID years.

REPORTING METHOD

No patient or public contribution.

Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study

BACKGROUND

There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19.

RESEARCH QUESTION

Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19?

STUDY DESIGN AND METHODS

We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods.

RESULTS

In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period.

INTERPRETATION

Among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.

Emergency Nurses' Well-Being in Magnet Hospitals and Recommendations for Improvements in Work Environments: A Multicenter Cross-Sectional Observational Study

INTRODUCTION

This study aimed to determine the well-being outcomes and quality of work environment among emergency nurses compared with inpatient nurses working in Magnet hospitals and identify recommendations in emergency department work environments that hold promise for enhancing emergency nurses' well-being.

METHODS

This is a cross-sectional analysis of multicenter survey data collected in 2021 from 11,743 nurses practicing in 60 United States Magnet hospitals. Nurses report on burnout, job dissatisfaction, intent to leave, work environment, and recommendations to improve well-being.

RESULTS

Emergency nurses are significantly more likely to report high burnout (P = .04), job dissatisfaction (P < .001), and intent to leave (P < .001) than inpatient nurses working in the same Magnet hospitals. Emergency nurses are significantly more likely to report insufficient staffing (P = .001), an unfavorable work environment (P < .001), and lack confidence that management will act to resolve problems in patient care (P < .001) but did report significantly better working relationships with physicians (P < .001) than their inpatient counterparts. The 2 greatest recommendations to improve well-being included improving nurse staffing (91.4%) and the ability to take uninterrupted breaks (86.7%); the lowest-ranked recommendations were employing more advanced practice providers (25.9%) and appointing a wellness champion (21.2%).

DISCUSSION

High burnout and other adverse nurse outcomes are common among emergency nurses in Magnet hospitals. Modifiable features of ED work environments including inadequate nurse staffing, inability of nurses to take uninterrupted breaks, and lack of responsiveness of management to persistent problems in patient care warrant high priority attention by Magnet hospital leaders.

Left Without Being Seen: Nurse Work Environment and Timely Outcomes in New York and Illinois Emergency Departments

INTRODUCTION

This study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay.

METHODS

Cross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved.

RESULTS

"Mixed" work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while "poor" work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from "poor" to "better," depending on annual patient volumes.

DISCUSSION

Hospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study

BACKGROUND

High rates of medical device alarms in hospitals are a well-documented threat to patient safety. Little is known about organisational features that may be associated with nurses' experience of alarm burden.

AIMS

To evaluate the association between nurse-reported alarm burden, appraisals of patient safety, quality of care and hospital characteristics.

METHODS

Secondary analysis of cross-sectional survey data from 3986 hospital-based direct-care registered nurses in 213 acute care hospitals in New York and Illinois, USA. We evaluated associations of alarm burden with appraisals of patient safety and quality of care and hospital characteristics (work environment, staffing adequacy, size, teaching status) using χ2 tests.

RESULTS

The majority of respondents reported feeling overwhelmed by alarms (83%), delaying their response to alarms because they were unable to step away from another patient/task (76%), and experiencing situations where a patient needed urgent attention but no one responded to an alarm (55%). Nurses on medical-surgical units reported these experiences at higher rates than nurses working in intensive care units (p<0.001). Alarm burden items were significantly associated with poorer nurse-reported patient safety, quality of care, staffing and work environment. Findings were most pronounced for situations where a patient needed urgent attention but no one responded to the alarm, which was frequently/occasionally experienced by 72% of those who rated their hospital's safety as poor versus 38% good, p<0.001; 80% who rated overall quality of care poor/fair versus 46% good/excellent, p<0.001 and 65% from poor work environments versus 42% from good work environments, p<0.001.

CONCLUSION

Most nurses reported feeling overwhelmed by medical device alarms, and our findings suggest that alarm burden may be more pronounced in hospitals with unfavourable working conditions and suboptimal quality and safety. Because this was a cross-sectional study, further research is needed to explore causal relationships and the role of modifiable systems factors in reducing alarm burden.

Perceived Work Environment, Educational Status, Staffing Levels, and Work Outcomes in Long-Term Care Settings During COVID-19

OBJECTIVES

Coronavirus disease (COVID-19) has severely affected older residents in long-term care (LTC) settings. However, care workers' perceptions of their work environment and potential impact on their work outcomes during the pandemic is not well known. This study examined associations between care staff's perceived work environment, educational status, and facility staffing levels and work outcomes of care staff in LTC settings during the COVID-19 pandemic.

DESIGN

This study employed a cross-sectional, observational, correlational design.

SETTING AND PARTICIPANTS

A total of 207 care staff were conveniently recruited from 30 LTC settings in South Korea.

METHODS

The perceived work environment, educational status of care staff, and facility staffing levels (ie, beds-to-registered nurse [RN] and beds-to-nursing assistant [NA] or care worker ratios), as well as their work outcomes (ie, general and COVID-19 specific outcomes) were collected using questionnaires. Multivariable binary logistic regressions were conducted, controlling for the characteristics of care staff (ie, age, sex, occupation, and career length) and facilities (ie, location, bed size, ownership, and residents' disease and care profiles).

RESULTS

Approximately 45% of the participants were either NAs or care workers, and 38% were RNs. More than half (53.14%) perceived their work environment to be good. LTC staff who perceived their work environment to be poor were more likely to be dissatisfied with their work [odds ratio (OR) 20.88), experience high burnout (OR 8.63), intend to leave the facility within a year (OR 5.00), and experience increased overtime work (OR 3.58) and work-life imbalance (OR 1.93) due to COVID-19.

CONCLUSIONS AND IMPLICATIONS

LTC work environments should be improved and government-led initiatives for ensuring such improvements should be implemented to enable a better response to future public health crises and maintain the quality of care for and safety of residents in LTC settings.

The association of the emergency department work environment on patient care and nurse job outcomes

Objective

To determine the association between emergency nurses' work environments and patient care quality and safety, and nurse burnout, intent to leave, and job dissatisfaction.

Methods

Cross-sectional study of 221 hospitals in New York and Illinois informed by surveys from 746 emergency nurses and 6932 inpatient nurses with linked data on hospital characteristics from American Hospital Association Annual Hospital Survey. The RN4CAST-NY/IL study surveyed all registered nurses in New York and Illinois between April and June 2021 about patient safety, care quality, burnout, intent to leave, and job dissatisfaction and aggregated their responses to specific hospitals where they practiced. Work environment quality was measured using the abbreviated Practice Environment Scale of the Nursing Work Index. Generalized estimating equations were used to determine the relationship between emergency nurses' work environments on patient care and nurse job outcomes.

Results

A total of 58% of emergency nurses reported high burnout, 39% reported job dissatisfaction, and 27% indicated intent to leave their job in the next year. Nurses in hospitals with good (vs mixed) or mixed (vs poor) emergency work environments were less likely to report unfavorable patient care quality and hospital safety grades, and were less likely to experience high burnout, job dissatisfaction, and intentions to leave the job, by factors ranging from odds ratio (OR) 0.21 (95% confidence interval [CI], 0.16-0.29) to OR 0.46 (95% CI, 0.34-0.61).

Conclusions

Given the complex and high stakes nature of emergency nursing care, leaders should place a high priority on organizational solutions targeting improved nurse staffing and work environments to advance better patient and clinician outcomes.

Earnings, job satisfaction, and turnover of nurse practitioners across employment settings

Nurse practitioners (NPs) are an important part of the health care workforce. However, little information is available on NP earnings, job satisfaction, or turnover. National survey data from 2018 offer a pre-COVID-19 baseline for ongoing NP workforce monitoring. We found evidence that NPs earned approximately $92 500 annually, ranging from $82 800 in long-term care to $95 600 in hospital settings. Wages increased with tenure in the workforce and varied considerably by geography. Approximately 1 in 5 NPs switched jobs annually, with some net in-flow to ambulatory settings. Both NPs who left their position or considered leaving reported better pay and benefits, burnout, management role, stressful work environment, career advancement, and inadequate staffing as the primary explanations. These findings were augmented by analysis of 2012-2022 Bureau of Labor Statistics data that illustrated substantial growth in the NP workforce. Improving NP job satisfaction has the direct benefit of supporting a critical and growing segment of the health workforce; it has the additional benefit of reducing job turnover and the associated costs, potentially increasing earnings for NPs. Policies that improve working conditions for NPs in different employment settings will not just increase immediate job satisfaction but also ideally strengthen the longer-term labor market to improve patient outcomes.

Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety

Importance

Disruptions in the hospital clinical workforce threaten quality and safety of care and retention of health professionals. It is important to understand which interventions would be well received by clinicians to address the factors associated with turnover.

Objectives

To determine well-being and turnover rates of physicians and nurses in hospital practice, and to identify actionable factors associated with adverse clinician outcomes, patient safety, and clinicians' preferences for interventions.

Design, Setting, and Participants

This was a cross-sectional multicenter survey study conducted in 2021 with 21 050 physicians and nurses at 60 nationally distributed US Magnet hospitals. Respondents described their mental health and well-being, associations between modifiable work environment factors and physician and nurse burnout, mental health, hospital staff turnover, and patient safety. Data were analyzed from February 21, 2022, to March 28, 2023.

Main Outcomes and Measures

Clinician outcomes (burnout, job dissatisfaction, intent to leave, turnover), well-being (depression, anxiety, work-life balance, health), patient safety, resources and work environment adequacy, and clinicians' preferences for interventions to improve their well-being.

Results

The study sample comprised responses from 15 738 nurses (mean [SD] age, 38.4 [11.7] years; 10 887 (69%) women; 8404 [53%] White individuals) practicing in 60 hospitals, and 5312 physicians (mean [SD] age, 44.7 [12.0] years; 2362 [45%] men; 2768 [52%] White individuals) practicing in 53 of the same hospitals, with an average of 100 physicians and 262 nurses per hospital and an overall clinician response rate of 26%. High burnout was common among hospital physicians (32%) and nurses (47%). Nurse burnout was associated with higher turnover of both nurses and physicians. Many physicians (12%) and nurses (26%) rated their hospitals unfavorably on patient safety, reported having too few nurses (28% and 54%, respectively), reported having a poor work environment (20% and 34%, respectively), and lacked confidence in management (42% and 46%, respectively). Fewer than 10% of clinicians described their workplace as joyful. Both physicians and nurses rated management interventions to improve care delivery as more important to their mental health and well-being than interventions directed at improving clinicians' mental health. Improving nurse staffing was ranked highest among interventions (87% of nurses and 45% of physicians).

Conclusions and Relevance

This cross-sectional survey study of physicians and nurses practicing in US Magnet hospitals found that hospitals characterized as having too few nurses and unfavorable work environments had higher rates of clinician burnout, turnover, and unfavorable patient safety ratings. Clinicians wanted action by management to address insufficient nurse staffing, insufficient clinician control over workload, and poor work environments; they were less interested in wellness programs and resilience training.

Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses

Background

The COVID-19 pandemic has amplified long-standing issues of burnout and stress among the U.S. nursing workforce, renewing concerns of projected staffing shortages. Understanding how these issues affect nurses’ intent to leave the profession is critical to accurate workforce modeling.

Purpose

To identify the personal and professional characteristics of nurses experiencing heightened workplace burnout and stress.

Methods

We used a subset of data from the 2022 National Nursing Workforce Survey for analysis. Binary logistic regression models and natural language processing were used to determine the significance of observed trends.

Results

Data from a total of 29,472 registered nurses (including advanced practice registered nurses) and 24,061 licensed practical nurses/licensed vocational nurses across 45 states were included in this analysis. More than half of the sample (62%) reported an increase in their workload during the COVID-19 pandemic. Similarly high proportions reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out (45.1%), or at the end of their rope (29.4%) “a few times a week” or “every day.” These issues were most pronounced among nurses with 10 or fewer years of experience, driving an overall 3.3% decline in the U.S. nursing workforce during the past 2 years.

Conclusion

High workloads and unprecedented levels of burnout during the COVID-19 pandemic have stressed the U.S. nursing workforce, particularly younger, less experienced RNs. These factors have already resulted in high levels of turnover with the potential for further declines. Coupled with disruptions to prelicensure nursing education and comparable declines among nursing support staff, this report calls for significant policy interventions to foster a more resilient and safe U.S. nursing workforce moving forward.