nursing shortage research questions

NCSBN Research Projects Significant Nursing Workforce Shortages and Crisis

CHICAGO – Today, NCSBN unveiled its research, titled “Examining the Impact of the COVID-19 Pandemic on Burnout & Stress Among U.S. Nurses,” in a panel titled “Nursing at the Crossroads: A Call to Action” in Washington, D.C. at the National Press Club at 9:30 am EST.

For the first time, the research findings reveal how the nursing workforce was impacted by the pandemic and how many left the workforce in this period, and forecast how many nurses in the U.S. have an intent to leave the workforce. The research also examined the personal and professional characteristics of nurses experiencing heightened workplace burnout and stress due to the COVID-19 pandemic.

The study is considered to be the most comprehensive and only research in existence, uncovering the alarming data points which have far reaching implications for the health care system at large and for patient populations. The research was gathered as part of a biennial nursing workforce study conducted by NCSBN and the National Forum of State Nursing Workforce Centers.

Key findings include:

Approximately 100,000 registered nurses (RNs) left the workforce during the COVID-19 pandemic in the past two years due to stress, burnout and retirements.
Another 610,388 RNs reported an “intent to leave” the workforce by 2027 due to stress, burnout and retirement.
188,962 additional RNs younger than 40 years old reported similar intentions.
Altogether, about one-fifth of RNs nationally are projected to leave the health care workforce.
62% of the sample reported an increase in their workload during the pandemic.
A quarter to half of nurses reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out (45.1%), or at the end of the rope (29.4%) “a few times a week” or “every day.”
These issues were most pronounced with nurses with 10 or fewer years of experience, driving an overall 3.3% decline in the U.S. nursing workforce in the past two years.
Licensed practical/vocational nurses, who generally work in long-term care settings caring for the most vulnerable populations, have seen their ranks decline by 33,811 since the beginning of the pandemic. This trend continues.

Research also suggested that nurses’ workloads and unprecedented levels of burnout during the COVID-19 pandemic played key roles in accelerating these workforce trends and threatening the future of the U.S. nursing workforce, particularly for younger, less experienced RNs. Further, high levels of turnover were seen with the potential for even further declines in a post-pandemic nursing workplace as disruptions in prelicensure nursing programs have also raised concerns about the supply and clinical preparedness of new nurse graduates. Early career data for new entrants into the profession suggest decreased practice and assessment proficiency. Coupled with large declines among nursing support staff, NCSBN calls for significant action to foster a more resilient and safe U.S. nursing workforce moving forward.

“The data is clear: the future of nursing and of the U.S. health care ecosystem is at an urgent crossroads,” said Maryann Alexander, PhD, RN, FAAN, NCSBN Chief Officer of Nursing Regulation. “The pandemic has stressed nurses to leave the workforce and has expedited an intent to leave in the near future, which will become a greater crisis and threaten patient populations if solutions are not enacted immediately. There is an urgent opportunity today for health care systems, policymakers, regulators and academic leaders to coalesce and enact solutions that will spur positive systemic evolution to address these challenges and maximize patient protection in care into the future.”

The research findings and proposed solutions were presented in a panel discussion today at the National Press Club in Washington, D.C.

Panelists included:

Antonia Villarruel, Dean of Nursing at University of Pennsylvania
Gay Landstrom, Senior Vice President and Chief Nursing Officer at Trinity Health System
Congresswoman Lisa Blunt Rochester, U.S. Representative of Delaware
Robyn Begley, CEO of the American Organization for Nursing Leadership and CNO/Sr. VP for the American Hospital Association
Rayna M. Letourneau, Board of Directors, National Forum for State Workforce Centers

A recording of the panel discussion is available on ncsbn.org .

To request interviews with NCSBN or view the entire research, please contact [email protected] or visit ncsbn.org .

Research Methodology: The study examines a subset of the 2022 National Nursing Workforce Study for analysis. Reported trends represent population-based estimates. There were 29,472 registered nurses (including advanced registered nurses [APRN]) and 24,061 licensed practical nurses/vocational nurses across 45 states included.

About NCSBN Empowering and supporting nursing regulators across the world in their mandate to protect the public, NCSBN is an independent, not-for-profit organization. As a global leader in regulatory excellence, NCSBN champions regulatory solutions to borderless health care delivery, agile regulatory systems and nurses practicing to the full scope of their education, experience and expertise. A world leader in test development and administration, NCSBN’s NCLEX® Exams are internationally recognized as the preeminent nursing examinations.

NCSBN’s membership is comprised of the nursing regulatory bodies (NRBs) in the 50 states, the District of Columbia and four U.S. territories. There are five exam user members and 25 associate members that are either NRBs or empowered regulatory authorities from other countries or territories.

The statements and opinions expressed are those of NCSBN and not individual members.

Nursing Shortage Fact Sheet

The U.S. is projected to experience a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age and the need for health care grows. Compounding the problem is the fact that nursing schools across the country are struggling to expand capacity to meet the rising demand for care. The American Association of Colleges of Nursing (AACN) is working with schools, policy makers, nursing organizations, and the media to bring attention to this healthcare concern. AACN is leveraging its resources to shape legislation, identify strategies, and form collaborations to address the shortage.

Download Fact Sheet [PDF]

Current and Projected Shortage Indicators

According to the Bureau of Labor Statistics’ Employment Projections 2022-2032, the Registered Nursing (RN) workforce is expected to expand by 6% over the next decade. The RN workforce is anticipated to grow from 3.1 million in 2022 to 3.3 million in 2032, an increase of 177,440 nurses. The Bureau also projects 193,100 openings for RNs each year through 2032 when nurse retirements and workforce exits are factored into the number of nurses needed in the U.S.
The Advanced Practice Registered Nurse (APRN) workforce, including Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives, is expected to grow much faster than average for all occupations, by 38% from 2022 through 2032, according to the BLS’ Occupational Outlook Handbook. Approximately 29,200 new APRNs, which are prepared in master’s and doctoral programs, will be needed each year through 2032 to meet the rising demand for primary and specialty care.
According to a Health Workforce Analysis published by the Health Resources and Services Administration (HRSA) in November 2022, federal authorities project a shortage of 78,610 full-time RNs in 2025 and a shortage of 63,720 full-time RNs in 2030. The ten states with the largest projected nursing shortage in 2035 are Washington (26%), Georgia (21%), California (18%), Oregon (16%), Michigan (15%), Idaho (15%), Louisiana (13%), North Carolina (13%), New Jersey (12%), and South Carolina (11%). Data for each state may be accessed through HRSA’s Workforce Projections Dashboard .
In April 2022, Dr. David Auerbach and colleagues published a nursing workforce analysis in Health Affairs , which found that total supply of RNs decreased by more than 100,000 from 2020 to 2021 – the largest drop than ever observed over the past four decades. A significant number of nurses leaving the workforce were under the age of 35, and most were employed in hospitals.
The Institute of Medicine in its landmark report on The Future of Nursing called for increasing the number of baccalaureate-prepared nurses in the workforce to at least 80% to enhance patient safety. The current nursing workforce falls short of this recommendation, though more than two-thirds of RNs are educated at the baccalaureate or graduate level. The exact percentage has been reported as 69% by HRSA and 71.7% by the National Council of State Boards of Nursing .
In March 2023, the International Council of Nurses (ICN) released a report calling for the worldwide shortage of nurses to be treated as a global health emergency. The report, titled Recover to Rebuild: Investing in the Nursing Workforce for Health System Effectiveness , details the impact that the pandemic had on the world’s nursing workforce, nurse burnout, and access to care. The authors call for protecting and investing in nurses as key to health system recovery.

Contributing Factors Impacting the Nursing Shortage

Nursing school enrollment is not growing fast enough to meet the projected demand for RN and APRN services.

Though enrollment in entry-level baccalaureate programs in nursing increased by 0.3% in 2023, AACN did report drops in both PhD and master’s nursing programs by 3.1% and 0.9%, respectively. These trends are raising concerns about the capacity of nursing schools to meet the projected demand for nursing services, including the need for more nurse faculty, researchers, and primary care providers.

A shortage of nursing school faculty is restricting nursing program enrollments.

According to AACN’s report on 2023-2024 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing , U.S. nursing schools turned away 65,766 qualified applications (not applicants) from baccalaureate and graduate nursing programs in 2023 due to insufficient number of faculty, clinical sites, classroom space, and clinical preceptors, as well as budget constraints.
According to a Special Survey on Vacant Faculty Positions released by AACN in October 2023, a total of 1,977 full-time faculty vacancies were identified in a survey of 922 nursing schools with baccalaureate and/or graduate programs across the country (84.6% response rate). Besides the vacancies, schools cited the need to create an additional 103 faculty positions to accommodate student demand. The data show a national nurse faculty vacancy rate of 7.8%. Most of the vacancies (79.8%) were faculty positions requiring or preferring a doctoral degree.

A significant segment of the nursing workforce is nearing retirement age.

According to the 2022 National Sample Survey of Registered Nurses , 23% of RNs working in outpatient, ambulatory, and clinical settings have retired or plan to retire over the next 5 years. While hospitals had the lowest share of nurses who have retired or plan to retire over the next 5 years (15.1%), nurses employed in this setting had the lowest levels of job satisfaction.
Published October 4, 2023, by the Journal of the American Medical Association , Dr. Melissa Suran published an article titled Overworked and Understaffed, More Than 1 in 4 US Nurses Say They Plan to Leave the Profession . The author looks at the latest data on nurses’ intent to leave their positions and how burnout and understaffing are impacting the workforce.
In a Health Affairs blog posted in May 2017, Dr. Peter Buerhaus and colleagues project than more than 1 million registered nurses will retire from the workforce by 2030.

Changing demographics signal a need for more nurses to care for our aging population.

The U.S. Census Bureau reported that number of Americans aged 65 and older is projected to increase from 58 million in 2022 to 82 million by 2050 (23% of the population). With larger numbers of older adults, there will be an increased need for geriatric care, including care for individuals with chronic diseases and comorbidities.

Amplified by the pandemic, insufficient staffing is raising the stress level of nurses, impacting job satisfaction, and driving many nurses to leave the profession.

According to data published in Nurse.com’s 2022 Nurse Salary Research Report , 29% of nurses across all license types considering leaving in 2021, compared with 11% in 2020.Among nurses who are considering leaving the profession, higher pay was the most influential motivation to stay, followed by better support for work-life balance and more reasonable workload.
In March 2022, the American Nurses Foundation and the American Nurses Association released the results of its COVID-19 Impact Assessment Survey , which found that 52% of nurses are considering leaving their current position due primarily to insufficient staffing, work negatively affecting health and well-being, and inability to deliver quality care. In addition, 60% of acute care nurses report feeling burnt out, and 75% report feeling stressed, frustrated, and exhausted.
In September 2021, the American Association of Critical-Care Nurses reported survey findings which show 66% of acute care nurses have considered leaving nursing after their experiences during the pandemic.

Impact of Nurse Staffing on Patient Care

Many scientific studies point to the connection between adequate levels of registered nurse staffing and safe patient care.

In November 2021, new research in Nursing Outlook examined Variations in Nursing Baccalaureate Education and 30-day Inpatient Surgical Mortality . Researchers found that having a higher proportion of baccalaureate-prepared nurses (BSN) in hospital settings, regardless of educational pathway, is associated with lower rates of 30-day inpatient surgical mortality. The findings support promoting multiple BSN educational pathways.
In the July 2017 issue of BMJ Quality & Safety , the international journal of healthcare improvement, Dr. Linda Aiken and her colleagues released findings from a study of acute care hospitals in Belgium, England, Finland, Ireland, Spain, and Switzerland, which found that a greater proportion of professional nurses at the bedside is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding assistive personnel without professional nurse qualifications may contribute to preventable deaths, erode care quality, and contribute to nurse shortages.
In a study published in the journal BMJ Quality & Safety in May 2013, researcher Heather L. Tubbs-Cooley and colleagues observed that higher patient loads were associated with higher hospital readmission rates. The study found that when more than four patients were assigned to an RN in pediatric hospitals, the likelihood of hospital readmissions increased significantly.
In the August 2012 issue of the American Journal of Infection Control , Dr. Jeannie Cimiotti and colleagues identified a significant association between high patient-to-nurse ratios and nurse burnout with increased urinary tract and surgical site infections. In this study of Pennsylvania hospitals , the researchers found that increasing a nurse’s patient load by just one patient was associated with higher rates of infection. The authors conclude that reducing nurse burnout can improve both the well-being of nurses and the quality of patient care.
In a study publishing in the April 2011 issue of Medical Care , Dr. Mary Blegen and her colleagues from the University of California, San Francisco found that higher nurse staffing levels were associated with fewer deaths, lower failure-to-rescue incidents, lower rates of infection, and shorter hospital stays.
In March 2011, Dr. Jack Needleman and colleagues published findings in the New England Journal of Medicine , which indicate that insufficient nurse staffing was related to higher patient mortality rates. These researchers analyzed the records of nearly 198,000 admitted patients and 177,000 eight-hour nursing shifts across 43 patient-care units at large academic health centers. The data show that the mortality risk for patients was about 6% higher on units that were understaffed as compared with fully staffed units. In the study titled Nurse Staffing and Inpatient Hospital Mortality , the researchers also found that when a nurse’s workload increases because of high patient turnover, mortality risk also increases.
A growing body of research clearly links baccalaureate-prepared nurses to lower mortality and failure-to-rescue rates. The latest studies published in the journals Health Services Research in August 2008 and the Journal of Nursing Administration in May 2008 confirm the findings of several previous studies which link education level and patient outcomes. Efforts to address the nursing shortage must focus on preparing more baccalaureate-prepared nurses in order to ensure access to safe patient care.
In March 2007, a comprehensive report initiated by the Agency for Healthcare Research and Quality was released on Nursing Staffing and Quality of Patient Care . Through this meta-analysis, the authors found that the shortage of registered nurses, in combination with an increased workload, poses a potential threat to quality. Increases in registered nurse staffing was associated with reductions in hospital-related mortality and failure to rescue as well as reduced length of stays.
A shortage of nurses prepared at the baccalaureate level is affecting health care quality and patient outcomes. In a study published September 24, 2003 , in the Journal of the American Medical Association (JAMA), Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a “substantial survival advantage” if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%.
AACN is committed to working with the higher education and healthcare community to prepare more highly educated nurses in sufficient numbers to meet the needs of the nation’s diverse patient population. To address the nursing shortage, AACN is advocating for federal legislation and increased funding for nursing education ( Title VIII , Future Advancement of Academic Nursing Act ); promoting a post-baccalaureate nurse residency program to aid in nurse retention; encouraging innovation in nursing programs, including the development of fast-track programs (second-degree BSN and MSN programs; baccalaureate to doctoral); and working with partner organizations to highlight careers in nursing, including those requiring graduate level preparation.
Since 2010, AACN has operated NursingCAS, the nation’s centralized application service for nursing education programs that prepare nurses for entry-level and advanced roles. One of the primary reasons for launching NursingCAS was to ensure that all vacant seats in schools of nursing are filled to better meet the nation’s need for RNs, APRNs, and nurse faculty.

Efforts to Address the Nursing Shortage

In June 2022, the National Council of State Legislatures issued a brief profiling different legislative approaches states are using to address the nursing shortage, including adapting scope of practice laws and offering financial incentives for preceptors.
In a report on How To Ease the Nursing Shortage in America released in May 2022, the Center for American Progress calls for bold policies toward solving the nursing shortage to ensure that more patients with access to safe, high-quality nursing services. The report highlights how federal and state policymakers can address the shortage through coordinated planning, action, and investment.
Many statewide initiatives are underway to address both the shortage of RNs and nurse educators. For example, in October 2022, the University of Minnesota and Minnesota State joined forces to create Coalition for Nursing Equity and Excellence, which will work with every school of nursing in the state, healthcare providers, and others to increase enrollment in nurse education programs, expand equity in the nursing workforce, and increase student success. Additional initiatives are also underway in Connecticut , Florida , Louisiana , Missouri , and other states.
Nursing schools are forming strategic partnerships and seeking private support to help expand student capacity. For example, Shenandoah University announced in March 2023 a new collaboration with Valley Health and the Virginia Hospital and Healthcare Association to address the region’s nursing shortage through a program that leverages retiring nurses and simulation to create a sustainable pathway into nursing. See also efforts launched by Idaho State University and Kootenai Health; Illinois College and Memorial Health; Emory University and the Georgia Nursing Leadership Coalition; Washington State University and Providence Health & Services; and the University of Oklahoma and area schools.

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The Real Issues Driving the Nursing Crisis

Our analysis of nurses’ employer reviews reveals the true source of burnout and why nurses are leaving the field. here’s how health care leaders can improve nurse job satisfaction to fight a looming nursing shortage..

Workplace, Teams, & Culture
Talent Management
Organizational Behavior

Health care leaders face a daunting set of challenges — rising costs, the transition to digital health, and shifting payment models, to name just a few. But according to a recent survey from the American College of Healthcare Executives, the No. 1 problem hospital CEOs face is staff shortages and burnout. 1 Ninety percent of the CEOs surveyed cited nursing shortages as a particularly acute pain point.

In 2021, the total number of registered nurses working in the U.S. dropped by the largest amount in 40 years, with younger nurses leading the exodus. 2 By 2025, the U.S. health care system could suffer a shortfall of up to 450,000 nurses, or 20% fewer than the nursing workforce required for patient care. 3

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High levels of job dissatisfaction and burnout are driving nurses from the profession. The COVID-19 pandemic placed tremendous pressure on all health care workers, but dissatisfaction and burnout among nurses have not improved since the pandemic ended. And by some measures, it might be getting worse: In 2021, nearly two-thirds of registered nurses would have encouraged others to become a nurse, but only half said they would recommend nursing as a profession two years later. 4

One of the richest sources of insight on dissatisfaction among nurses is how they describe their job, in their own words, on employment sites like Indeed and Glassdoor. This information is voluminous but difficult to synthesize because most of it takes the form of unstructured free text. To understand the challenges nurses face, we analyzed how 150,000 of them had described their employers in Glassdoor reviews since the beginning of the pandemic. (See “The Research.”) In this article, we share key insights from that analysis and offer advice to health care leaders about how they can address nurses’ most pressing issues.

Health Care Leaders Are Out of Touch

Nurses view their managers as out of touch with the daily realities of patient care. We categorized their comments about managers into nearly 50 leadership traits. The second most frequently cited trait described managers as being unaware of the challenges that nurses struggle with in the workplace. When nurses discussed how managers understood life at the bedside, their comments were negative 9 times out of 10.

Nurses are particularly critical of members of the senior executive team for their disconnectedness. The top team was 10 times more likely than front-line supervisors and middle managers to be criticized for being out of touch. Our results reinforce a separate survey in which nearly half of hospital nurses said they believe management does not listen to their concerns. 5

To address dissatisfaction and burnout, health care leaders must first understand what’s happening at the bedside. This can be challenging, particularly in large health care systems with thousands of nurses working across multiple sites and specialties.

Historically, leaders have struggled to systematically analyze the gold mine of insights into nurses’ frustrations that can be gleaned from their comments in employee surveys or external reviews. Reading, understanding, and analyzing huge volumes of unstructured textual data has simply not been practical. However, recent advances in artificial intelligence make it possible to identify deep patterns in large bodies of text and understand feedback at scale. Leaders can now mine free text to gain a nuanced understanding of the issues driving dissatisfaction and burnout among nurses and use that insight to improve life at work for their nursing staffs. (See “Getting Started With Text Analytics.”)

Identify Relative Strengths and Opportunities Through Benchmarking

Nursing satisfaction varies widely across employers. We identified 200 of the largest health care employers in the United States, including hospitals and health care systems, home health care providers, operators of senior living facilities, and staffing agencies. For each employer, we calculated how highly nurses rated the organization and senior leadership on Glassdoor from the beginning of the COVID-19 pandemic through June 2023. 6

Among large employers, nurses’ Glassdoor ratings ran the gamut from poor (2.6) to nearly perfect (4.9) on a 5-point scale. Nurses’ assessments of how well senior leadership has performed during and after the pandemic were even more varied, ranging from 2.1 to 4.9 on the same 5-point scale. The wide variance in Glassdoor ratings is consistent with a separate survey in which the percentage of dissatisfied nurses ranged from 2% to 48% across 60 U.S. hospitals. 7

Employees of the 200 large health care organizations can use our interactive tool to see how their organization ranks against others. The index is sortable by nurses’ overall ratings, their assessments of the top leadership, and the four most powerful predictors of nurses’ satisfaction: compensation, workload, organizational support, and toxic culture.

Nurses who work for staffing agencies (who are sometimes referred to as travel nurses) are, on average, much more satisfied than other nurses. The five highest-ranked employers in our sample (and six of the top 10) are staffing agencies.

Higher compensation, of course, accounts for part of this difference, but not all of it. We compared how positively nurses working with staffing agencies spoke about 200 topics compared with their counterparts employed by hospitals and health care systems. (See “Staffing Agencies Rate Better on Many Key Factors.”) While compensation was viewed more favorably by agency nurses, issues around solving nurses’ problems and open, honest communication had a larger sentiment gap between the two groups. By focusing on nurses as clients, staffing agencies excel at practices that improve satisfaction beyond simply paying higher wages. Other health care leaders can learn from their example, and we’ll make some concrete recommendations below.

Prioritize Drivers of Job Satisfaction

To understand the drivers of job satisfaction among nurses, we analyzed the free text of all reviews that had been written by the nurses in our sample since the beginning of the COVID-19 pandemic and classified the text into nearly 200 topics. 8 We then clustered topics into two dozen broader themes and used those themes to predict nurses’ overall ratings of their employers. We then compared each theme’s relative importance in predicting ratings. (See “Top and Bottom Predictors of Nurses’ Job Satisfaction.”)

Compensation was the top predictor of satisfaction among nurses reviewing their current employer, which is not surprising, given that inflation eroded the purchasing power of take-home pay during the period we analyzed. The importance of workload, the second-most-important driver, jibes with findings from a separate large-scale survey that found insufficient staffing was the strongest predictor of nurses’ job dissatisfaction, burnout, and intent to quit. 9

Workload and compensation are root causes of the nursing crisis that must be addressed, but they are not the only factors influencing nurses’ job satisfaction. Our analysis surfaced other aspects of the work environment, including toxic culture, organizational support, work schedules, communication, and learning and development opportunities, that leaders can focus on to improve nurses’ work lives.

This analysis also highlights areas that are unlikely to move the needle in improving the workplace experience for nurses. Perks are nice, but they will not compensate for a punishing workload or wages that fail to keep pace with inflation. Highlighting the corporate mission to promote patient health won’t help much either. Nurses already know that their job serves a higher purpose; that’s why most of them became nurses in the first place.

Mine Free Text for Actionable Insights

Many health care organizations rely on annual employee surveys, with dozens of items rated on a 5-point scale and a few open-ended questions tacked on as an afterthought. Faced with a long list of multiple-choice questions, employees are prone to switching to autopilot and assigning similar scores to very different items. The choice of questions constrains what employees can discuss, and there is seldom room to expand on why they chose a particular numeric response.

Open-ended, free-text feedback provides a rich source of nuanced and actionable insights. When nurses can decide which topics to write about, they use their freedom to discuss what matters most to them. Open-ended questions provide nurses with the space to expand on their concerns in their own words, offer crucial context, and propose concrete and actionable fixes to the problems they face. Individual free-text responses can be aggregated into broader themes to prioritize where leaders could focus their attention and limited resources to achieve the largest improvements in nurses’ satisfaction.

While organizational averages are useful, it is important to remember that distinctive subcultures can coexist within the same organization. This is particularly true among large health care systems that have grown through mergers and acquisitions. One national hospital chain, for example, has ratings that range from 1.9 to 3.9 across nearly 50 sites. Rather than relying on organizational averages alone, health care leaders must measure and analyze differences across locations, departments, functions, teams, and individual leaders.

Women, underrepresented minorities, and older employees can also experience organizational culture very differently from other employees. 10 It’s crucial to understand the drivers of job satisfaction and burnout across diverse employee populations.

It’s crucial to understand the drivers of job satisfaction and burnout across diverse employee populations.

Leaders can mine the free text for detailed insights about the most critical pain points for specific groups and tailor their interventions accordingly. Schedules, for example, have a significant impact on nurses’ job satisfaction, but which aspects of scheduling matter most will depend on the specific position. Flexibility in scheduling shifts and the ability to take uninterrupted work breaks is very important for nurses in hospitals and primary care practices, while home health care nurses place a premium on predictable schedules. 11

Nurses’ comments provide a treasure trove of practical suggestions to improve the workplace and patient care. The Glassdoor reviews we studied, for example, include dozens of actionable suggestions for how employers can improve scheduling. Some are easy-to-implement actions, such as using an app to make it easier to pick up or swap shifts, or paying a $20 to $50 bonus to nurses who pick up shifts at the last minute. Others are more systemic changes, like including nurses on a committee established to set schedules or ensuring that employees who receive tuition assistance are able to schedule work around their classes.

Listen to Nurses Who Leave Your Organization

Most organizations limit their surveys to current employees. Exit interviews are administered haphazardly, if at all, and the feedback from former employees is too often dismissed as the rantings of malcontents. But ignoring feedback from former employees is a big mistake.

Interviewing or surveying former employees can surface the reasons for their departure and pinpoint the most effective actions to retain talent. Free of the threat of retaliation, nurses who are leaving (or have left) an organization are more likely to provide candid feedback, even about taboo issues that current employees are reluctant to discuss. By collecting feedback from those who have left, organizations can uncover potential blind spots.

More than one-third of the Glassdoor reviews in our sample were written by former employees and provide insights on what mattered most to nurses who voted with their feet. 12 The bars on the left side of the figure “Top and Bottom Predictors of Nurses’ Job Satisfaction” rank the factors that predict how nurses who quit rank their former employers, and it sheds light on a critical reason nurses might head for the exits.

In an earlier article , we argued that five behavioral attributes — disrespectful, noninclusive, unethical, cutthroat, and abusive — mark an organizational culture as toxic. 13 Among nurses who quit, toxic culture is more than twice as predictive of their overall satisfaction than compensation or workload. The importance of toxic workplaces among nurses who quit is consistent with earlier research that found toxicity to be the strongest predictor of industry-adjusted attrition during the first six months of the Great Resignation. 14

Toxic culture has become more important for nurses in the post-pandemic era. When we compared which factors best predict how nurses rated their employer before and after the pandemic, toxic culture experienced the largest gain in relative importance post-COVID-19 (followed by workload, well-being, and compensation). If your organization suffers from cultural toxicity, another article of ours, “ How to Fix a Toxic Culture ,” presents several evidence-based interventions health care leaders can use to detox their own organization.

Learn From Staffing Agency Practices

As the figure “Staffing Agencies Rate Better on Many Key Factors” shows, nurses are very positive about the processes staffing agencies have in place to resolve problems quickly and efficiently. Of nurses who mentioned the efficiency of staffing agencies’ processes, 75% were positive, compared with 23% expressing positive sentiment for health care systems. For travel nurses, common process issues include onboarding, obtaining required credentials and licenses, contract negotiation, and reimbursement. The best staffing agencies listen to feedback, develop a deep understanding of the typical problems travel nurses face, and optimize their work processes to address these issues.

Many of the pain points encountered by staff nurses will differ from those of agency nurses. Health care systems, home health agencies, and long-term care providers could, however, adopt a similar approach to capture and analyze nurses’ feedback, prioritize the most common and frustrating challenges they face, and work with staff members to address these issues.

Consistently listening to and acting on feedback can also build trust with the nursing staff. Staffing agency nurses are more positive about having the psychological safety to speak up about difficult issues and be heard than are nurses working in hospitals and health care systems.

The benefits of psychological safety are blunted, however, if management is slow to respond to issues that nurses raise. Nurses speak highly of how quickly staffing agencies respond to their questions and concerns. In contrast, nurses frequently complain that other types of employers are slow to respond to emails raising issues, if they get a reply at all. Nurses also place a high value on having multiple channels of communication with their supervisors, including text, email, Facebook, Jabber, and a 24/7 hotline.

Another insight from our research is that nurses value honesty and transparency. They understand the challenges health care faces as well as anyone, and they expect honest communication about what is happening in the organization, how it affects them, and why decisions were made. Triage, a staffing agency and the fourth most highly rated large employer we studied, places honest communication at the center of its value proposition: “We tell it like it is so you won’t be surprised by how it goes.” 15

Health care systems can learn from staffing agencies, but they can also leverage their own distinctive advantages to attract and retain nurses. Nurses in full-time staff positions rate hospitals and health care systems higher than staffing agencies on three important aspects of organizational life: learning and development (including promotion opportunities and reimbursement for training), benefits, and colleagues. Those three factors are among the top 10 predictors of how nurses rate their employers. Health care systems should invest in their comparative advantages and emphasize them when communicating their value proposition to potential and current employees.

Health care systems can learn from staffing agencies, but they can also leverage their own distinctive advantages to attract and retain nurses.

Translate Feedback Into Action to Build Trust

It’s one thing to collect employee feedback, but it’s another to consistently act on those insights. Employees are less likely to surface issues or propose potential solutions if they believe that managers will not act. 16 Worse yet, employees are more likely to quit if they believe that management lacks the power, resources, or interest to make changes based on their suggestions. 17 Nearly half of nurses believe that management will not fix problems that clinical staff members bring to their attention. 18

Organizations need to put in place structures to consistently act on employee feedback. One well-known example is Kaiser Permanente’s unit-based teams (UBTs), which consist of clinical staff members and managers who regularly work together in a specific unit or department. 19 The teams, which meet at least once per month, are responsible for their unit’s performance and are co-led by a manager, a labor representative, and, typically, a clinical staff member.

The UBTs identify opportunities to improve along four dimensions: quality (including patient outcomes), patient service, affordability, and employee experience. The teams use employee feedback to identify and prioritize improvement opportunities. Next, the teams develop and test solutions using best practices and evidence-based methods. Once a solution has been deemed effective, it is implemented across the unit, department, or, in some cases, the entire organization. The UBTs then monitor the impact of these changes in terms of patient outcomes, employee satisfaction, and cost reduction.

Our study of 150,000 reviews written by U.S. nurses since the onset of COVID-19 reveals wide variation in how nurses rate their employers as a whole, and specifically in terms of compensation, workload, toxic culture, and organizational support — the four factors that most shape nurses’ job satisfaction. In our view, this variation offers a message of hope. Despite the structural challenges that all health care organizations face, it is possible to provide an environment where nurses look forward to going to work every day.

Many organizations, including some of the largest employers of nurses, have significant room for improvement. These rankings are not designed to “name and shame” but rather to make health care leaders aware of the magnitude of the gap between their organization’s performance and what is possible when it comes to providing a healthy workplace for nurses. We also hope that the objective data on how health care organizations rank on factors that matter most to nurses can provide their leaders with the impetus to make improvements and the evidence to convince all stakeholders of the urgent need for change.

What leaders should not do is ask nurses to work harder and endure more frustration and stress while failing to understand and address the organizational factors that make life miserable for many of them. Leaders who continue business as usual should not be surprised when staff members quit, workers unionize, and state and federal legislators dictate regulations to protect the interests of nurses.

To improve the work lives of nurses, and indeed all health care workers, leaders must collect and act on their feedback, recognizing that different parts of the organization and different populations will face distinctive challenges and issues. Listening to nurses demonstrates that there are meaningful steps health care leaders can take to fix the nursing crisis. The single most important step is to listen to them in the first place.

About the Authors

Donald Sull ( @culturexinsight ) is a senior lecturer at the MIT Sloan School of Management and a cofounder of CultureX. Charles Sull is a cofounder of CultureX.

1. “ Survey: Workforce Challenges Cited by CEOs as Top Issue Confronting Hospitals in 2022 ,” American College of Healthcare Executives, Feb. 13, 2023, www.ache.org.

2. D.I. Auerbach, P.I. Buerhaus, K. Donelan, et al., “ A Worrisome Drop in the Number of Young Nurses ,” Health Affairs Forefront, April 13, 2022, www.healthaffairs.org.

3. B. Martin, N. Kaminski-Ozturk, C. O’Hara, et al., “ Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses ,” Journal of Nursing Regulation 14, no. 1 (April 2023): 4-12; and G. Berlin, M. Lapointe, M. Murphy, et al., “ Assessing the Lingering Impact of COVID-19 on the Nursing Workforce ,” McKinsey & Co., May 11, 2022, www.mckinsey.com.

4. R.A. Smiley, R.L. Allgeyer, Y. Shobo, et al., “ The 2022 National Nursing Workforce Survey ,” Journal of Nursing Regulation 14, no. 1, sup. 2 (April 2023): S1-S90.

5. L.H. Aiken, K.B. Lasater, D.M. Sloane, et al., “ Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety ,” JAMA Health Forum 4, no. 7 (July 2023): table 2.

6. We selected the largest 200 employers based on the number of U.S. Glassdoor ratings by nurses from April 1, 2020, through June 30, 2023.

7. Aiken et al., “Physician and Nurse Well-Being,” table 1.

8. This methodology is similar to that employed by M. Jura, J. Spetz, and D.-M. Liou in “ Assessing the Job Satisfaction of Registered Nurses Using Sentiment Analysis and Clustering Analysis ,” Medical Care Research and Review 79, no. 4 (August 2022): 585-593.

9. Aiken et al., “Physician and Nurse Well-Being,” table 3.

10. M.A. McCord, D.L. Joseph, L.Y. Dhanani, et al., “ A Meta-Analysis of Sex and Race Differences in Perceived Workplace Mistreatment ,” Journal of Applied Psychology 103, no. 2 (February 2018): 137-163; and K. Aquino and S. Thau, “ Workplace Victimization: Aggression From the Target’s Perspective ,” Annual Review of Psychology 60 (February 2009): 717-741.

11. A. Bergman, H. Song, G. David, et al., “ The Role of Schedule Volatility in Home Health Nursing Turnover ,” Medical Care Research and Review 79, no. 3 (June 2022): 382-393.

12. Nurses quitting (versus being fired) accounted for 96% of all separations from hospitals in 2021. See “ 2021 NSI National Health Care Retention & RN Staffing Report ” (East Petersburg, Pennsylvania: NSI Nursing Solutions, March 2021): 3.

13. D. Sull, C. Sull, W. Cipolli, et al., “ Why Every Leader Needs to Worry About Toxic Culture ,” MIT Sloan Management Review, March 16, 2022, https://sloanreview.mit.edu.

14. D. Sull, C. Sull, and B. Zweig, “ Toxic Culture Is Driving the Great Resignation ,” MIT Sloan Management Review, Jan. 11, 2022, https://sloanreview.mit.edu.

15. “We Tell It Like It Is So You Won’t Be Surprised by How It Goes,” Triage, accessed April 24, 2023, https://triagestaff.com.

16. E.W. Morrison, “ Employee Voice and Silence ,” Annual Review of Organizational Psychology and Organizational Behavior 1 (March 16, 2014): 173-197.

17. E.J. McClean, E.R. Burris, and J.R. Detert, “ When Does Voice Lead to Exit? It Depends on Leadership ,” Academy of Management Journal 56, no. 2 (April 2013): 525-548.

18. Aiken et al., “Physician and Nurse Well-Being,” table 2.

19. “ Unit-Based Team Overview ” and “ UBT Roles ,” Labor Management Partnership, accessed Aug. 30, 2023, www.lmpartnership.org.

i. We ran models for the pre- and post-COVID-19 samples by current employees, former employees, and all employees for a total of six models. The average out-of-sample adjusted R2 across a tenfold validation ranged between 0.29 and 0.39 for all models. A model using structural attributes of employers, including ownership, type of organization (health care system, nursing home, or specialty hospital), and location, however, together explained less than 5% of the variance in how nurses rated their employers. Our analysis of structural attributes included seven ownership types, 17 organizational types, and 50 U.S. states. For the structural model, the average out-of-sample adjusted R2 across a tenfold cross-validation was 4.2%.

Emergency department responses to nursing shortages

Nicole R. Hodgson 1 ,
Richard Kwun 2 ,
Chad Gorbatkin 3 ,
Jeanie Davies 4 &
Jonathan Fisher 4

on behalf of the ACEP Emergency Medicine Practice Committee

International Journal of Emergency Medicine volume 17 , Article number: 51 ( 2024 ) Cite this article

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The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published information regarding recommended interventions for emergency departments (EDs) facing a sudden nursing shortage.

We queried emergency department leaders from the American College of Emergency Physicians to examine the impact of nursing shortages on EDs and to gather real-world interventions employed to mitigate the effects of the shortage.

Most respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing left without being seen rates (90.9%). ED leaders reported a range of interventions, including operational flow changes, utilizing alternative staff to fill nurse roles, recruitment of new nurses, and retention strategies for existing nurses. They employed temporary and permanent pay increases as well as efforts to improve the ED work environment and techniques to hire new nurses from atypical pipelines.

We report a patchwork of solutions ED leaders utilized which may have variable efficacy among different EDs; personalization is essential when selecting interventions during a sudden nursing shortage.

Introduction

Cyclical nursing shortages, both global and localized to the United States of America, existed prior to the COVID-19 pandemic [ 1 ]. The COVID-19 pandemic led to a worsening shortage [ 2 ]; the 2022 National Council of State Boards of Nursing’s National Nursing Workforce Survey revealed a loss of 100,000 registered nurses (RNs) and 34,000 licensed practical and vocational nurses (LPNs/LVNs) due to the pandemic between 2020–2022, with an alarming 28% of nurses planning to retire within the next 5 years [ 3 ]. Nursing shortages, especially in emergency medicine (EM), where nurses face significant burnout rates [ 4 ], are predicted to worsen.

Worsening nursing staff levels correspond with worsening patient satisfaction [ 5 ], deterioration of operational metrics [ 6 ], and increasing patient mortality [ 7 ]. Despite this, literature searches by our American College of Emergency Physicians’ (ACEP) Emergency Medicine Practice Committee (EMPC) revealed a lack of published interventions for emergency departments (EDs) facing a sudden nursing shortage.

We queried national ED leaders to examine the impact of nursing shortages and to obtain information regarding interventions employed to mitigate the effects of these shortages.

We gathered information via an electronic collection tool (Appendix 1 ) from the ACEP Medical Directors ( N = 450) and EMPC ( N = 75) listservs to examine the impact of the nursing shortage on EDs and to collect novel solutions and approaches in an open-ended format. Although the listservs mostly consist of physician leaders, a small number of ACEP administrators as well as resident, medical student, physician assistant, and nurse practitioner representatives serve on the committees and are included in the counts. The Mayo Clinic Institutional Review Board provided an exemption from full review. We performed basic statistical analyses for multiple-choice responses (counts, percentages). For free-text responses, one author (NRH) performed content analysis combining similar responses into categories with counts (Appendix 2 ).

We present demographics from our 66 respondents in Table 1 . All worked in hospital EDs except one, who worked at a freestanding ED.

We report multiple-choice responses in Table 2 .

We report free-text response summaries in Appendix 2 with numbers of respondents noted as (x#). We describe key results from free-text responses below.

When queried regarding ED interventions to reduce demands on nurse/technician staff or to increase capacity of nurse/technician staff or supply of other ancillary services, ED leaders commonly repurposed higher-paid staff for ED RN roles, such as physicians administering medications, placing intravenous (IV) lines, and discharging patients. Conversely, some respondents utilized lesser-paid workers including paramedics, emergency medical technicians (EMTs), LPNs, non-emergency RNs, and patient care technician staff to perform basic RN duties such as IV access, blood draws, and administering medications, within the scope of what state regulations allowed. One ED placed a scribe in triage to replace the triage RN, although the respondent clarified that although scribes recorded vitals and chief complaints, they couldn’t perform Emergency Severity Index (ESI) scores. Another ED used virtual mental health sitters instead of physical RNs for patients requiring monitoring for behavioral concerns. ED leaders attempted to decrease RN work requirements by decreasing documentation burden, decreasing discharge vitals requirements, and changing IV drip medications to oral, IV push, or intramuscular routes. Operational changes to decrease the impact of RN shortages included employing a physician-in-triage (PIT) or teletriage model alongside lobby-based care such as formal vertical care spaces with chairs for administration of IV medications or dedicated areas for physician waiting room (WR) evaluations, lab draws, and discharges. Two ED leaders reported closing ED sections due to lack of RNs.

We asked what changes were made to maintain patient safety during RN shortages, and respondents highlighted above-mentioned interventions along with attempts to obtain new RN staff. Several mentioned operational changes implemented for patient safety, such as vertical flow, PIT, and assigning more RNs to the enlarging waiting room pool. Two new interventions mentioned in response to this question included calling patients ESI 1/2/3 who left without being seen (LWBS) and increasing physician order entry requirements (for example, decreasing use of verbal orders).

Although some ED leaders reported their systems employed no strategies to retain existing nurses, several described RN retention efforts. Many focused on improving RN pay either through temporary (retention or shift/incentive bonuses, internal higher-paid travel programs, time-limited rate increases to match travelers) or longer-lasting (increasing RN base/hourly rates or creating an RN clinical pay ladder or RVU model) improvements. Some described non-financial interventions including improvements in the work environment such as a twice daily physician-led “medical minute” educational huddle, promoting a team environment, and improving nurse-patient ratios.

Attempts at recruitment of new staff mainly focused on financial-related incentives such as sign-on bonuses, pay increases, referral bonuses, and RN tuition reimbursement. However, some ED leaders increased the ED RN pipeline by hiring new graduates and international RNs, creation of or increasing enrollment in an RN ED residency or hospital-affiliated RN school, hiring RN students as externs, cross-training non-ED RNs, and creation of internal traveler programs.

Most respondents (98.5%) reported nursing shortages, with 83.3% describing prolonged shortages lasting more than 12 months, with negative impacts such as misses/near-misses (93.9%) and increasing LWBS (90.9%). The shortage impacts both the ED as well as inpatient nurse availability, with 90.9% of respondents attesting that inpatient shortages contributed to boarding in the ED. Most respondents used travel nurses (92.4%), which can be costly to hospital systems, dissatisfying for employed RNs, and potentially harmful to patient safety [ 8 ].

Published literature lacks recommendations for best practices during ED RN shortages. Some hospital systems tried to mitigate the crisis through nurse retention efforts and attempts at hiring new nurses, often by improving reimbursement, which may be beyond the abilities of hospital systems or, depending on employment model, outside the purview of ED directors. Some created RN educational programs such as ED RN residencies or student rotations; however, those solutions take time and may not be beneficial in an acute crisis. Similarly, cross-training RNs for float pools or internal traveler programs takes initial investment. Previous publications support boosting retention by improving the workplace environment and enhancing support systems for ED RNs [ 9 ]; our survey respondents reported implementing a physician-led “medical minute” and promoting a team atmosphere. Building RN mentoring programs and implementing other changes to improve the ED environment may be rapidly accessible by an ED director working closely with nurse leadership and may improve retention rates.

Additional interventions included use of alternative staff to offload RN duties. ED directors should consider individual aspects of their EDs and state regulations prior to experimenting with these changes, as some options considered beneficial at one hospital were not felt to be helpful at others. The practice parameters of alternative staff replacing RNs must be clearly established to be successful in the ED. Though lesser-trained than RNs for emergency medicine departmental work, paramedics completing the National Standard Paramedic Curriculum meet or exceed 90% of knowledge, skills and competencies for Certified Emergency Nurse and Critical Care Registered Nurse board certification [ 10 ]. Non-traditional staff in triage may increase wait times and LWBS rates [ 11 ], although when incorporated into the ED as complementary team members, EMTs and LPNs have helped decrease length of stay (LOS) [ 12 ].

Multiple respondents reported operational changes to improve flow and strive for safe care, which may include accelerated diagnostic pathways, fast track, team triage, and technological enhancements of existing processes, alongside alternative space utilization for clinical care. Although suboptimal, the WR may be the only space available to initiate care [ 13 , 14 ]. WR assessments do not overcome nurse-driven rate-limiting steps but can facilitate diagnostic and therapeutic actions not requiring time-intensive bedside tasks. WR care overlaps with dedicated PIT models, which in certain circumstances can identify and accelerate rate-limiting steps such as advanced imaging or time-sensitive treatment such as early antibiotics or thrombolytics. The rise of WR care may be a symptom of unsafe and overcrowded department conditions, but when used strategically if physician and nurse staffing permits, it can decompress bottlenecks and provide a secondary layer of safety when the department and triage are overrun [ 13 ].

Our study is small and therefore suffers limitations. Response and selection bias may impact our results, as we did experience a low response rate (12.6%). Our study was designed to obtain ED physician leader responses and therefore lacks the perspective of RN leadership. There is a possibility of the same hospital system responding multiple times, as several physicians from the same institution could be contained within the listservs; however, this appears unlikely due to variation in responses. Although our sample size was low, we believe the description of interventions employed will benefit ED directors facing acute nursing shortages. We are unable to isolate the individual impact of each intervention due to our study format and the fact that EDs typically employed combinations of interventions; our report may serve as a launching pad for future research but is only a beginning.

ED leaders reported a variety of interventions, typically employing multiple methods simultaneously; departmental factors should be considered when selecting interventions at the individual ED level. Future research should investigate the impact of isolated interventions to delineate the most beneficial strategies.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Emergency departments

Registered nurses

Licensed practical and vocational nurses

Emergency medicine

American College of Emergency Physicians

Intravenous

Emergency Severity Index

Physician-in-triage

Waiting room

Left without being seen

Length of stay

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Nicole R. Hodgson

Department of Emergency Medicine, Swedish Medical Center, Issaquah, WA, USA

Richard Kwun

Department of Emergency Medicine, Madigan Army Medical Center, JBLM, Lakewood, WA, USA

Chad Gorbatkin

American College of Emergency Physicians, Irving, TX, USA

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Conceptualization (NRH, RK, CG, JD, JF), data collection (NRH, JD, JF), critical review and evaluation (NRH, RK, CG, JD, JF), primary authorship of the paper (NRH, RK, CG), review and editing of the paper (NRH, RK, CG, JD, JF), study supervision (NRH, JD, JF).

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Correspondence to Nicole R. Hodgson .

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Hodgson, N.R., Kwun, R., Gorbatkin, C. et al. Emergency department responses to nursing shortages. Int J Emerg Med 17 , 51 (2024). https://doi.org/10.1186/s12245-024-00628-y

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Table of Contents
Volume 29 - 2024
Number 2: May 2024
Today’s Nursing Shortage

Overview and Summary: Today’s Nursing Shortage: Workforce Considerations

ORCID ID: 0000-0001-6259-8501

Dr. Speroni is a research infrastructure and process expert who uniquely integrates organizational missions with research goals to facilitate evidence-informed practice of nursing, ultimately to advance the practice of nursing, including patient outcomes and work environment.

She has nearly 40 years of experience in biomedical research and hospital consultation, including hospital-based research, nursing excellence, serving on Institutional Review Boards, university teaching, presenting research processes and research findings nationally and internationally, and authoring research/healthcare related publications.

As a nurse from a generation ‘ a while back ’ you can only hope that in the future there will be enough Registered Nurses (RNs) to fulfil a complex and diverse nursing workforce, both in the United States and abroad. All nurses will need to continue to innovate our profession of nursing, to provide quality evidence-based care while simultaneously working in a ‘healthy’ environment.

The nursing shortage has waxed and waned since the dawn of nursing. Accordingly, nursing leaders have implemented a variety of best practices to attract and retain RNs. One of the most effective practices has been for hospitals to achieve nursing excellence requirements per the American Nurses Credentialing Center Magnet® Recognition Program. ( [ANCC], 2021 ). Hospitals with Magnet designation have transformational leaders who structurally empower their RNs and interprofessional teams to have exemplary professional practice. They generate new knowledge, innovations, and improvements. Their enculturated structures and processes are grounded in empirical outcomes that demonstrate nursing excellence.

This OJIN topic focuses on contemporary issues in the nursing workforce, for which one of the biggest swirling in the center is a lack of enough RNs to deliver nursing excellence! Attracting and retaining nurses is problematic. The nursing shortage can be attributed to many factors, including pandemic challenges, burn-out/compassion fatigue, unhealthy work environments, pay rates variances (e.g., staff versus travelers), staffing constraints, management issues, nurses retiring, nurses leaving the profession early, and not enough academic nurse educators adequately compensated to enable university nursing programs to accept all of the qualified baccalaureate nursing program candidates. This topic addresses many of these factors, with new research findings as well. The topic also focuses on mitigating issues surrounding nursing shortage, ranging from policy and administrative implications to how to have more supportive work environments for retaining nurses.

Longyear and colleagues, in their article, “ The Contingent Nursing Workforce during Covid-19: Implications for Policy and Administration ,” provide a review of the significant supply issues and operating challenges in hospital labor markets, noting travel contingent worker dynamics. Highlighted is the need for health system leaders, public health professionals and policymakers, working together to manage the interplay of competing labor market dynamics (e.g., hospital workers and travel workers). The authors summarize recommendations and opportunities for policy and administration and discuss both short- and long-term policy implications. They also underscore the need to implement evidence-based policy and administrative solutions.

The second article, “ Addressing the Shortage of Academic Nurse Educators: Enlisting Public and Business Sectors as Advocates ,” by Lee and colleagues addresses the shortage of academic nurse educators. In this qualitative study, researchers focused on public and business sector advocates. Themes identified support the need for continued partnerships within the profession of nursing so we may continue to serve the public sustainably in the future.

The article by Leep-Lazar and Stimpfel, “ Factors Associated with Intent to Stay at Current Nursing Job During the COVID-19 Pandemic ,” describes a cross-sectional survey design of over 600 working nurses. The authors aimed to identify individual and work-related factors which predict intent to stay in current nursing job in one year, including the psychosocial health and contextual pandemic factors. They highlight key factors needed for a healthy work environment, including psychosocial support.

Chicca and Hubbard addressed the need for more literature on healthy nurse-to-nurse relationships as nurses transition into new clinical specialties. In the article, “ Supporting Healthy Nurse-to-Nurse Relationships as Experienced Nurses Transition to New Clinical Specialties ,“ the authors review experienced nurse challenges and healthy relationship strategies during transition into new settings.

“ Distressed But Not Deterred: Nurses Reveal Solutions to the Nursing Shortage in the Aftermath of a Pandemic ,“ by White and Godsey, employed survey research of over 800 Kentucky nurses during the pandemic nursing shortage. The authors aimed to identify perceived contributors to the nursing shortage and the supportive actions that could be taken to alleviate them. They provide nurse recommendations to effectively retain and recruit nurses in the pandemic aftermath.

Author Tate conducted qualitative research to address why RNs leave the profession in the first two years. The author aimed to identify the reasons that novice nurses leave from the perspective of those who have actually departed. In the article, “ Nurses Leaving the Profession in the First Two Years: A Qualitative Study ,“ she describes emerging themes and potential interventions to retain nurses.

The journal editors invite you to share your response to this OJIN topic addressing workforce considerations for today’s nursing shortage either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Karen Gabel Speroni, PhD, RN, BSN, MHSA Email: [email protected] ORCID ID: 0000-0001-6259-8501

American Nurses Credentialing Center. (2021). 2023 Magnet® application manual . Silver Spring, MD: American Nurses Credentialing Center.

May 31, 2024

DOI : 10.3912/OJIN.Vol29No02ManOS

https://doi.org/10.3912/OJIN.Vol29No02ManOS

Citation: Speroni, K.G., (May 31, 2024) "Overview and Summary: Today’s Nursing Shortage: Workforce Considerations" OJIN: The Online Journal of Issues in Nursing Vol. 29, No. 2, Overview and Summary.

Nursing Shortage Solutions for the Future

Written by: applied nursing research editorial team • may 19, 2024.

The nursing profession has long stood as a pillar of healthcare systems worldwide. Nurses act as the backbone, offering compassionate care, executing vital medical tasks, and serving as the bridge between patients and doctors. Despite their essential role, a looming crisis threatens healthcare: the nursing shortage. In this article, we delve deep into understanding the nursing shortage, its implications, and why it is a pressing concern for all of us.

What is the nursing shortage?

A nursing shortage refers to a situation where the demand for registered nurses (RNs) and other nursing roles exceeds the supply—locally, nationally, or globally. This deficit isn’t a new phenomenon. In fact, sporadic shortages have been recorded over the decades. However, the current and impending scarcity is unparalleled in its reach and potential impact.

There are two types of shortages to consider:

Global shortages: These are broad in nature, affecting many countries simultaneously. Factors like global health crises, universal trends in education, and collective shifts in population age can contribute.

Regional shortages: These can be isolated to specific areas, often exacerbated by unique local factors. For instance, rural areas might suffer more due to the lack of educational institutions or attractive job opportunities.

Why is the nursing shortage important?

The implications of a nursing shortage reverberate throughout the entire healthcare system:

Impact on Patient Care and Safety: An inadequate number of nurses can lead to oversights in patient care. With fewer hands on deck, essential tasks like monitoring patients, administering medication, and responding to emergencies can be delayed or overlooked.

Economic Implications: Hospitals and healthcare systems face financial strain due to overtime costs, the need for temporary staffing, and potential lawsuits arising from medical oversights or mistakes. Additionally, a stretched-thin staff may lead to longer hospital stays for patients, further increasing costs.

Effects on Current Nursing Staff: Nurses working in understaffed facilities face significant stress. Their shifts become longer, their patient loads increase, and their chances of burnout skyrocket. This not only affects their mental and physical health but can also lead to higher turnover rates, exacerbating the shortage.

Future of Healthcare: In the longer term, a persistent nursing shortage can diminish the quality of healthcare. Prospective medical procedures or treatments might be delayed or canceled due to lack of staff. Moreover, as the frontline caregivers, nurses offer valuable insights into patient care optimization. A shortage means fewer voices to champion patient needs or to innovate in care delivery.

Challenges surrounding the nursing shortage

The nursing shortage isn’t merely an issue of insufficient recruitment. It’s a multifaceted challenge, with roots in various areas:

Rising Demand Due to an Aging Population

As the global population ages, there’s an increased demand for healthcare services. Elderly individuals often have complex medical needs, necessitating more frequent and specialized care. This increased demand strains an already under-resourced nursing workforce.

Burnout and High Turnover Rates

Nursing, while rewarding, is also emotionally and physically taxing. Long hours, the emotional toll of patient care, and the high-stress nature of the job can lead to burnout. This results in nurses leaving the profession or seeking less demanding roles.

Educational Bottlenecks

Nursing education institutions are grappling with their challenges, including a shortage of faculty and limited classroom space. This restricts the number of students they can admit, despite a growing list of qualified applicants.

Economic Challenges

In some regions, the compensation for nursing roles isn’t commensurate with the demands of the job. When alternative professions offer better pay, benefits, or work-life balance, nursing can lose its appeal to potential recruits.

Migration Patterns

The migration of nurses from low-income to high-income countries, or from rural to urban areas, further aggravates localized shortages. While migration can offer individual nurses better opportunities, it can also drain resources from already vulnerable areas.

Solutions for the nursing shortage

Addressing the nursing shortage requires a multi-pronged approach, tailored to the unique challenges presented:

Increasing Educational Opportunities:

Partnering with Colleges: Establishing partnerships with colleges and universities can create fast-track nursing programs, enabling students to enter the workforce more rapidly.

Online and Distance Learning: Digital platforms can accommodate more students, bypassing the traditional limitations of physical space. This also allows students from remote areas to access quality education.

Financial Incentives:

Scholarships and Loan Forgiveness: Offering financial aid can incentivize students to choose nursing as a career and help them graduate without burdensome debt.

Competitive Pay and Benefits: Reviewing and restructuring compensation packages can make nursing roles more attractive, retaining current staff and attracting new recruits.

Creating a Supportive Work Environment:

Reducing Nurse-to-Patient Ratios: Fewer patients per nurse can significantly reduce workload, ensuring patients get quality care while reducing nurse burnout.

Professional Development: Offering opportunities for career advancement, training, and mentorship can motivate nurses and improve job satisfaction.

Addressing Burnout: Implementing mental health support, wellness programs, and flexible scheduling can help nurses manage the demands of their roles.

Nursing shortage outlook

While the current situation paints a grim picture, understanding the future landscape of the nursing shortage is vital for proactive planning:

Predictions for the Future: Forecasts suggest that unless significant measures are taken, the nursing shortage will continue to grow over the next two decades.

Potential Shifts: Global events, such as pandemics or economic downturns, can either exacerbate or temporarily alleviate shortages. For instance, economic crises might see more individuals turning to nursing as a stable profession, but this can be offset by the increased healthcare demands during such periods.

Technological Advancements: Innovations in healthcare technology, such as AI-driven diagnostics or robotic assistance, might reduce some of the demand on nurses. However, the human touch and expertise that nurses provide will remain irreplaceable.

Nursing Shortage FAQ

As the nursing shortage continues to be a topic of concern, several frequently asked questions arise that help shed light on its intricacies.

Q: How severe is the current nursing shortage?

The severity varies by region, but many parts of the world, particularly in the West, face acute shortages. The World Health Organization (WHO) estimates a global deficit of nearly six million nurses, making it a pressing issue on a global scale.

Q: Why can’t we just train more nurses?

While training more nurses sounds like a straightforward solution, there are underlying challenges. First, nursing schools often face faculty shortages, limiting their ability to admit more students. Second, nursing is a demanding profession, both physically and emotionally. Not everyone interested in healthcare chooses or is suited for nursing, making recruitment a challenge.

Q: Are there countries unaffected by the nursing shortage?

Most countries experience some level of nursing shortage, but the severity varies. Some nations have mitigated the issue through targeted policies, international recruitment, or offering better incentives for nursing professionals. However, no country is entirely immune.

Q: What are the health risks associated with a nursing shortage?

A shortage can lead to compromised patient care, increased risk of medical errors, longer hospital stays, and overall strain on the healthcare system. It also leads to increased stress and burnout among the existing nursing staff, potentially impacting their own health and well-being.

Q: How do nursing shortages affect other medical professionals?

The entire healthcare system is interconnected. A shortage of nurses increases the workload on other professionals, from doctors to medical technicians. It can cause delays in treatment, diagnosis, and overall patient care.

Q: Are there any positive side effects of a nursing shortage?

While the effects of a nursing shortage are primarily negative, it does bring attention to systemic issues within the healthcare system. This increased attention can lead to policy changes, innovations in training, and heightened public awareness about the value of nurses.

The nursing shortage is more than a staffing issue; it’s a complex, multifaceted challenge that touches every corner of the healthcare system. From the well-being of individual patients to the overall efficacy of global health initiatives, the role of nurses is paramount. Addressing the nursing shortage requires collaborative efforts from governments, institutions, communities, and the nurses themselves.

While the road ahead is fraught with challenges, there’s also room for hope. The spotlight on the nursing shortage has led to innovations in education, technology, and healthcare policy. By continuing to prioritize the well-being and professional development of nurses, we not only ensure their rightful place in the healthcare ecosystem but also uphold the highest standards of patient care. The future of global health hinges on the steps we take today to value and support our nursing professionals.

May 19, 2024 May 19, 2024

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The Nursing Shortage Explained

What is the nursing shortage, why is there a nursing shortage.

Is the Nursing Shortage Getting Worse?

How Do We Solve the Nursing Shortage?

The nursing shortage is a growing problem in the United States, with the U.S. Bureau of Labor Statistics (BLS) projecting that a 6% growth rate in the demand for registered nurses will result in a need for 3.3 million nurses by 2031. But, how much of that will need will actually be met?

Unfortunately, the Covid-19 pandemic has only exacerbated this issue as front-line nurses feel the strain of increased workloads and decreased staffing levels. This has led to higher rates of nurse burnout due to long hours and high-stress levels.

The nursing shortage is impacting the care that nurses are able to provide for patients and stretching their ability to cope with having to do more work with less help.

But why is there a nursing shortage? And can anything be done about it? Keep reading to learn about the causes and possible solutions of the nursing shortage based on findings from our own 2023 State of Nursing report and other findings from the AACN.

>> Download the 2023 State of Nursing Report

According to the American Association of Colleges of Nursing (AACN) , the nursing shortage is a chronic and escalating problem created by several interrelated factors:

Nursing school enrollment not keeping up with the demand for nurses
Shortage of nurse faculty restricting nursing school enrollments
A large number of nurses are retiring or approaching retirement
Increase in the aging population and therefore nursing services
Insufficient staffing causes nurses to leave the profession

Interestingly, many of the top reasons nurses cited as causes of the nursing shortage are not included in the AACN’s list. When asked “What do you think are the primary causes of the nursing shortage?” these were the most popular responses from the 2023 State of Nursing survey:

Nurses are burned out - 74%
Poor working conditions - 58%
Inadequate pay for nurses - 57%
Lack of appreciation for nurses - 34%

The greater number of patients due to an aging population, changes to the medicare/healthcare system, and lack of nursing school educators/faculty got the least amount of responses from nurses. Indicating that, while these systemic factors may be contributing to the overall nursing shortage, that’s not what nurses are feeling on a day-to-day basis, and not what’s ultimately prompting many nurses to think about leaving the bedside, or even the profession altogether.

chart showing nurses feelings about their current job

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Is the Nursing Shortage Getting Worse?

While a nursing shortage has existed for decades, 91% of nurses believe the nursing shortage is getting worse. Other reports support this as well.

For example, a 2022 report by McKinsey consulting and advisory firm warns that the “nursing shortage will become dire by 2025” due to a projected shortage of 200,000 to 450,000 nurses—roughly 10% to 20% of the nurses required to provide all patient care.

Already some nurses describe having to “ration care” due to inadequate nurse-patient ratios so they can focus on keeping patients “alive”, often at the expense of meeting patients’ other basic needs such as helping them with a much-needed bath.

When asked “What do you think would make the biggest impact on the nursing shortage” 71% of nurses replied that improved staffing ratios would have the biggest impact, followed by better pay (64%) and better working conditions (41%).

chart showing the factors nurses think would have the biggest impact on the nursing shortage

But ultimately, addressing the nursing shortage will require a multi-faceted approach that includes both short-term solutions to improve nurses' daily lives and long-term strategies to address the underlying issues.

1. Increasing Funding to Improve Nurse-Patient Ratios and Retain Nurses

Hospitals and healthcare facilities need to start listening to nurses if they want to retain them and improving staffing ratios was the number one factor that nurses thought could positively impact the nursing shortage.

New York state nurses described “abysmal working conditions” as they went on strike in January 2023 but were told “There’s no money in the budget” to improve working conditions and ensure safe nursing staff levels. Hospital administrators and those that control the purse strings of healthcare facility budgets need to reevaluate their budget priorities if they want to retain and attract nurses and protect patients.

2. Paying Higher Salaries to All Nurses, Particularly to Recruit and Retain Nursing Faculty

As we saw above, 64% of nurses believe that better pay would help lessen the nursing shortage. When we asked nurses how they felt about their current pay, 75% of nurses said they felt underpaid.

In addition, a major reason for the shortage of nursing faculty is low salaries. While the average salary of an advanced nurse practitioner with a master’s degree is $120,680 , master’s prepared nursing faculty were paid just $87,325/year in 2022.

With the average nursing faculty salary being $33,372/year less than what nurses earn in clinical and private-sectors positions, it’s hard to attract and retain faculty. Therefore, nursing faculty salaries need to be increased substantially if nursing schools want to attract and retain faculty.

3. Better Working Conditions

Being able to do things like take breaks and feeling that they’re able to turn down extra shifts may seem like basics that all nurses should be getting, but our survey shows that they are not. 72% of nurses don’t have adequate backup, 53% of nurses are unable to take sick days, and 36% feel that they can’t turn down extra shifts at work.

4. Providing Funding for More Master’s and Doctoral Nursing Student Enrollments

According to the AACN, “Master’s and doctoral programs in nursing are not producing a large enough pool of potential nurse educators to meet the demand.”

For example, although enrollment in entry-level baccalaureate nursing programs increased by 3.3% in 2021, enrollment in master’s and PhD nursing programs dropped by 7% and 3.8%, respectively.

Therefore, more funding and recruitment need to be directed at graduate-level nursing programs to help prepare more nursing faculty and create more advanced practice nurses.

5. Designing Nursing Positions That Offer Better Work-Life Balance

And finally, nurse leaders need to start creating nursing positions that allow nurses to have a better work-life balance if they want to attract and retain nurses in these positions.

The high levels of nurse burnout and chronic stress in nursing are simply unacceptable and cannot continue if the nursing shortage is to be significantly reduced. 81% of nurses said they’ve felt burnt out in the past year, according to our survey.

Nurses will continue to leave the profession and their jobs in search of a more manageable lifestyle and less stressful work.

By making a commitment to listen to nurses and implement these changes, policymakers, facility administrators, and nurse leaders can reverse this nursing shortage and ensure that our healthcare system has enough nurses to meet the needs of patients now and into the future.

Leona Werezak BSN, MN, RN is the Director of Business Development at NCLEX Education. She began her nursing career in a small rural hospital in northern Canada where she worked as a new staff nurse doing everything from helping deliver babies to medevacing critically ill patients. Learning much from her patients and colleagues at the bedside for 15 years, she also taught in baccalaureate nursing programs for almost 20 years as a nursing adjunct faculty member (yes! Some of those years she did both!). As a freelance writer online, she writes content for nursing schools and colleges, healthcare and medical businesses, as well as various nursing sites.

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Post-Pandemic Nursing Shortage Affecting Aspiring Nurses

Nurses are a critical part of the healthcare system. During the COVID-19 pandemic , many saw how much nurses contribute to the care and protection of patients.

What has also become evident is a growing nursing shortage. COVID-19 has highlighted the gaps in healthcare and created an increasing demand for bedside nurses. In the United States, it is projected that 1.1 million nurses are needed to replace retiring nurses by 2022. Globally, the need is closer to 13 million.

The shortage has pros and cons for nursing students. One pro is being able to find a job quickly after graduation. A key disadvantage, though, is that nursing programs have fewer openings. For students, this means acceptance into a program may be more challenging.

The nursing shortage has many consequences. First, let’s address a few frequently asked questions before diving into what it may mean for prospective nurses.

Frequently Asked Questions on the Nursing Shortage

It’s important to correct some misconceptions about what has caused the shortage and how it might affect healthcare. Identifying the challenges the nursing workforce faces may help with potential post-pandemic nursing solutions.

What Is Causing the Nursing Shortage?

To ensure hospitals are fully staffed, we must identify why there is a nursing shortage . Professional nursing organizations and published studies have identified the following factors:

Aging population: An aging population has strained the workforce. Older adults typically have more than one chronic disease . Many illnesses that were once terminal are now considered chronic.
Aging workforce: Nurses are also reaching retirement age. At the start of the pandemic, some nurses retired, and others were given an early retirement package , increasing the shortage.
Nurse burnout: The consequences of nurse burnout on patient care may be severe. Data show that high workload, low staffing, and long shifts are triggers.
Family obligations: The majority of nurses are women. According to the U.S. Bureau of Labor Statistics (BLS), 12.6% of working nurses are men. Villanova University reports 20% of its incoming nursing students in 2021 are men. With the lack of family care benefits, a high number of women nurses who are also working parents may cut back or leave the profession to raise their families.
Nursing educators: There’s a major bottleneck in nurse teaching . A shortage of nursing faculty limits the students a program can accept. Retirement, moving into the private sector, and a lack of incentives to become nurse educators affect the faculty shortage.

What Is the Current Status of the Nursing Shortage?

According to the American Nurses Association (ANA), more jobs will be available in nursing in 2022 than in any other profession. This shortage will have a significant impact on patient care. The BLS projects a 9% job growth rate for registered nurses (RNs) from 2020-2030, slightly higher than average.

The Department of Health and Human Services estimates at least seven U.S. states have the most severe nursing shortages. These include:

South Carolina

Even before 2020, there were statewide initiatives to address the shortage of bedside nurses and nurse educators .

What Does the Nursing Shortage Mean for Healthcare?

Several key factors affect staffing needs . These include the level of patient illness, patient number, and staff skills and expertise (seasoned nurses versus new graduates). Patient outcomes are affected by staffing shortages. High nurse-to-patient ratios can lead to medication errors and higher morbidity and mortality rates.

Data also show that a patient’s risk of infection increased by 15% when the unit was understaffed. Higher nurse-to-patient ratios can also increase readmission rates in the pediatric population.

Staffing shortages, paired with a global pandemic, can increase nurse burnout and patient dissatisfaction. A staffing shortage also impacts the hospital’s level of reimbursement . Though the pandemic created a massive need for more nurses, it also reduced funding for hospitals, resulting in staff layoffs .

At the pandemic’s start, hospitals canceled elective surgeries to prioritize COVID-19 patients. Many non-COVID patients avoided hospitals. This led to decreased hospital funding and administrations furloughing nursing staff, further contributing to staffing shortages.

The Nursing Shortage on a Global Scale

Nursing shortages are not limited to the U.S. The International Council of Nurses (ICN) Policy Brief published in 2020 shows that 27.9 million nurses were working worldwide. However, the ICN estimates there was a shortfall of 5.9 million nurses.

Unfortunately, 89% of the shortages were in low- and lower-middle-income countries. Additionally, 17% of nurses expect to retire by 2030. The report shows that 4.7 million nurses are needed to maintain the current workforce. To address the global nursing shortage, 10.6 million more nurses must replace retiring nurses. (This 10.6 million estimate doesn’t take into account the loss from COVID-19.)

Retirement is only one of the challenges. Each factor contributing to the nursing shortage must be addressed to help fill the gap.

Global Impacts of COVID-19 on the Nursing Shortage

COVID-19 has not only highlighted disparities in healthcare but further contributed to the nursing shortage. In 2020, healthcare professionals used technology to provide care for people at home such as telehealth nursing . While this helped expand the reach of healthcare, it cannot replace the care of a bedside nurse.

Some countries have encouraged retired nurses to return as a volunteer nurse or reinstate their licence to help relieve the nursing shortage. Some have even mandated inactive nurses back to the bedside.

An ICN survey found that nearly 90% of national nurses’ associations were concerned that heavy workloads, burnout, and stress were factors for the growing nursing shortages. Nurses were either retiring or moving into the private sector where stress was lower.

Infection rates and deaths are also contributing factors to the nursing shortage. Because of their close contact with patients severely ill with COVID-19, millions of nurses have also been infected. Nearly 3,000 deaths have been recorded in 60 countries. In the U.S., after 12 months, there were 3,561 deaths of healthcare workers ; 32%, or 1,136, were nurses.

The ICN estimates that as a result of all contributing factors up to 13 million nurses are needed to fill the gap.

COVID-19 Is Increasing Nurse Burnout

No job or career is stress free. Every decision a nurse makes may impact the lives of their patients.

COVID-19 has added to this stress. The ICN expects the added burden will increase burnout and post-traumatic stress disorder, which “could have potentially significant detrimental effects, especially on the nursing workforce.”

Nurse burnout is a mental, physical, and emotional state of exhaustion, often triggered by work-related stressors. Nurses who experience burnout initially feel detached and disengaged. As the condition progresses, they may begin to use food, drugs, or alcohol to cope. Some nurses have physical symptoms, such as headaches or stomach problems.

Nurse burnout can lead to health conditions like insomnia, heart disease, high blood pressure, and Type 2 diabetes. Burned-out nurses risk providing low-quality care, leading to mistakes and even death. One study from Marshall University found that when nurses took care of more than four patients in a shift, there was a higher correlation of burnout and a 7% increase in mortality for each additional patient.

An online survey found a key contributor to burnout during COVID-19 was a decreased feeling of well-being. The survey also evaluated staff resilience, or “the ability to cope with and adapt positively to adversity.” Several factors were associated with decreased well-being, including a low measure of resilience, feeling personal protective equipment was inadequate, and believing the workload had increased.

A study from India found that the higher a nurse’s resilience, the lower the risk of burnout. The ICN report expresses significant concern over the burden that COVID-19 had placed on the healthcare system, writing:

— “In January this year, ICN raised significant concerns about the mass trauma that is being experienced by nurses during COVID-19 pandemic, and the medium to long term effects that trauma will have on the nursing workforce. These issues and risks combined do not bode well for long-term nurse retention in an already overstretched and vulnerable workforce. The COVID-19 pandemic has the potential to increase the number of nurses reaching the point of burnout, and increase the number leaving the profession, which could have a damaging impact as early as in the second half of 2021.”

Hostile Working Conditions Fueled by COVID-19

During the COVID-19 pandemic, nurses faced spikes in workplace physical violence and verbal abuse as patients’ families felt helpless with sick loved ones in the hospital.

One study researched nurses’ experiences with workplace violence. The researchers used an online survey of RNs working in hospitals to calculate the frequency of physical violence and verbal abuse from February to June 2020. The purpose was to help describe the type of violence that nurses may be experiencing during the pandemic.

They found 44.4% nurses reported physical violence and 67.8% reported verbal abuse. The rate of violence was higher in nurses caring for COVID-19 patients than in nurses who did not care for COVID-19 patients. The researchers recommend that hospital administrators recognize nurses’ increased risk of workplace violence and the urgent need to carry out preventive strategies.

Another data sampling of nurses working in Iran found similar results. Researchers measured “incivility” in nurses working in seven training hospitals. Some nurses reported that patients’ families were uncooperative because of their lack of knowledge of healthcare practices. Once educated, their behavior seemed to change.

The interviews also revealed that emotional and physical abuse has increased during the pandemic, elevating an already stressful environment.

What the Shortage Means for Future Nurses

It might appear as if the shortage opens the field for nursing graduates to find a job right after school. However, there is good and bad news. Job opportunities will differ depending on the geographical area.

Many states with significant shortages have rural areas where it may be difficult to attract experienced, skilled nurses. Job opportunities may also depend on experience and skill level.

The Shortage Impacts Nurse Working Conditions

Nursing shortages have a high impact on working environments, patient outcomes, and the long-term health of nurses, leading to longer shifts and higher nurse-to-patient ratios. This shortage increases stress, fatigue, and the risk of injury to nurses. It can also reduce patient care.

Another effect of understaffing is nurses quitting because of heavy workloads and the stress of caring for dying patients. According to one estimate in 2018, the cost of turnover per nurse was $44,000.

The shortage of nurses also depends on the nursing specialty . Higher shortages are measured in labor and delivery, critical care nursing, geriatric nursing, and nurse educators.

Before the pandemic, the nursing shortage’s most significant factors were aging, burnout, wage disparities, and regional needs.

Some Regions Have Higher Demand for Nurses Than Others

The fastest growth potential are in the West and Mountain regions of the U.S. Some experts anticipate slower growth in the Northeast and Midwest regions. This aligns with the U.S. Health and Human Services’ list of states with the largest nursing shortage gap. As the population ages, there will also be growth potential in areas with high retirement populations . This includes Florida, California, and Texas.

Despite regional differences, the BLS estimates the overall growth rate for nurse practitioners to be an outstanding 52% from 2020-2030. This is much faster than the average job growth rate. While there continues to be a shortage of bedside nurses, the BLS estimates the growth rate for RNs to be 9% during the same decade, just above average. This may be a result of challenges faced in nursing education.

Interest in Nursing School Increases, but Applicants Are Turned Away

The pandemic seemed to inspire a career in nursing. According to a study from the American Association of Colleges of Nursing (AACN), student applications surged. Enrollment to bachelor of science in nursing (BSN), master of science in nursing (MSN), and doctoral nursing programs in fall 2020 increased.

While the interest was high, 80,521 qualified applicants could not be admitted. They included:

66,274 who applied to BSN programs
1,376 to RN-to-BSN programs
8,987 to MSN degree programs
3,884 to doctoral programs

Applicants were not accepted primarily because of a shortage of teaching faculty and clinical sites for nursing students.

According to AACN , nursing schools turned away 80,407 qualified applicants in 2019 for some of the same reasons like a shortage of clinical and classroom space. Another report identified a shortage of 1,637 educators in 892 nursing schools. Many of the empty faculty positions required or preferred a doctoral degree.

There Are Global Initiatives to Increase the Nursing Workforce

The ICN has encouraged national nurses’ associations and governments to address the nursing shortage. According to their estimates, 74% of associations have reported that their countries are committed to addressing the problem, and 54% are addressing the need to retain working nurses.

Nursing associations have recorded a 20% increase in the number of nurses who left the profession in 2020. This raises concerns about the emotional and physical trauma experienced by nurses during the pandemic and increases the expected nursing shortage gap.

Additionally, there will continue to be a 3-4 year gap in the nursing shortage before new graduates are ready to enter the field. During this period, national nursing associations worry that the added workload and stress will increase the number of experienced nurses who leave.

Changes Need to Be Made to Ensure On-the-Job Safety for Nurses

The stories of front-line nurses caring for COVID-19 patients have inspired many to apply to nursing programs and join a career that focuses on the care and protection of others. To close this shortage gap, the ICN has made several suggestions:

Protect the safety and well-being of the current and future nursing staff
Provide psychosocial support to bedside nursing staff
Commit time and finances to long-term strategies that increase the number of nurses in the workplace
Invest in the recruitment, retention, education, and training of nurses
Improve wages and working conditions so local nurses do not leave for high-income countries
Prioritize fair pay for all nurses

Nurses Can Advocate for Changes Too

Nurses need to advocate for changes at the local and federal levels. To that end, ANA has developed an activist toolkit with action plans nurses can use to support for their profession.

ANA offers one-click options of writing to legislators to encourage change or thank them for their efforts. Top federal priorities include the opioid epidemic, workplace violence, safe staffing, and health system transformation. Nurses can learn more about each effort through the site.

The Post-Pandemic Future Remains Uncertain

The future of the nursing shortage is uncertain. Higher than expected numbers of nurses are leaving the profession from:

Rising stress that triggers burnout
Physical and verbal abuse in the workplace

There is a massive increase in job growth for nurses and nurse practitioners, so nursing jobs are and will continue to be abundant. Although the pandemic has inspired many to apply to nursing programs, many schools do not have the clinical sites or faculty to accommodate applicants.

If you are experiencing the symptoms of burnout, don’t wait until the situation is so bad you must quit. Instead, take these self-care steps for nurses and avoid getting burned out.

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Nursing Workforce Challenges in the Postpandemic World

The United States and the rest of the world continue to grapple with the COVID-19 pandemic. Considering that nurses make up the largest segment of the U.S. healthcare workforce, they are essential to the country’s collective pandemic response. Nurses are the primary source of direct care to persons infected by COVID-19, including historically marginalized populations, and the ongoing demands placed on nurses are leading to unprecedented stress, burnout, and uncertainty about their profession. Even before the pandemic, healthcare settings were chronically understaffed and nurses were burnt out. According to a prepandemic analysis, a shortfall of more than 150,000 registered nurses was anticipated by 2020 ( Zhang et al., 2018 ). The pandemic has exacerbated the labor shortage well beyond prior forecasts, stressing an already fragile U.S. healthcare system and potentially contributing to worse patient outcomes and wider health inequities.

A 2021 integrative review examining the pre- and post-COVID-19 pandemic literature on nursing turnover found that since the pandemic’s onset, there has been a significant increase in nurse turnover intention ( Falatah, 2021 ). A 16-study synthesis of nurse burnout literature during the pandemic found high levels of emotional exhaustion and depersonalization, as well as reduced feelings of personal accomplishment ( Galanis et al., 2021 ). The same study also identified risk factors for burnout, including decreased social support, working in hospitals with inadequate and insufficient material and human resources, and increased workload ( Galanis et al., 2021 ).

The staggeringly high turnover across America’s working population due to the COVID-19 pandemic has been referred to as the “Great Resignation” ( Gahdhi & Robison, 2021 ). In addition to record-high resignations and unfilled positions, an analysis by Gallup found employee engagement—rather than an industry, role, or pay issue—to be the major risk factor for resignation ( Gahdhi & Robison, 2021 ). From September 2019 to March 2021, the proportion of U.S. employees “actively disengaged” (looking for a job or watching for opportunities) increased from 69% to 74% ( Gahdhi & Robison, 2021 ).

Studies suggest that nursing is particularly susceptible to the Great Resignation. An American Nurses Foundation (2022) survey of nearly 12,000 nurses conducted in January 2022 found that 60% of respondents younger than 35 years reported experiencing an extremely stressful, violent, or traumatic event resulting from COVID-19, and 89% reported that their organization was experiencing a staffing shortage. More than one-half of respondents felt undervalued, and nearly one quarter reported that they intended to leave their positions in the next 6 months.

Concerned about these trends, the AcademyHealth Interdisciplinary Research Group on Nursing Issues (IRGNI) has devoted its energy to supporting the development of health services research that examines the nursing workforce, shapes our understanding of the practice environment, and evaluates the workforce needs of the postpandemic world in both hospital and community settings. The collection of abstracts presented at this year’s IRGNI conference reflects this commitment. Many of these abstracts address the adverse effects of the pandemic on nurses. Stimpfel, for example, describes the impact of the first 6 months of the pandemic on nurses’ psychological health and reports high rates of depression, anxiety, and insomnia. In the study by Montgomery and Patrician, the researchers show that stress during the pandemic contributed to high rates of burnout. Similarly, Pogue et al. found that during COVID-19, registered nurses, compared to physicians and advanced practice providers, reported the highest levels of burnout, job dissatisfaction, stress, and intent to leave.

These abstracts reinforce the importance of a supportive work environment for achieving nurses’ well-being, improving patient outcomes, and reducing health inequities. Townley et al., for example, found that poorly rated primary care nurse practitioner work environments contributed to high rates of hospitalization for dually-eligible adults with chronic conditions. In a systematic review of 12 research articles, Rosenbaum and Lake reported a strong association between hospital nursing resources, such as Magnet designation, nurse staffing, and the nurse work environment, and patient satisfaction based on the Hospital Consumer Assessment of Healthcare Providers and Systems survey.

Taken together, these works call for “rebooting” the practice environment to offset the adverse effects of the pandemic on nurses and their patients, and the nursing workforce must be prepared for the postpandemic world. Investments in the practice environment may help to offset the adverse effects of the pandemic on nurses and their patients. We believe that this will require innovative models of nurse-led care; reimagined nursing-sensitive performance measures; new and sustained efforts for promoting diversity, equity, and inclusion; payment policies that reflect nurses’ value; as well as innovative organizational and institutional approaches that enable flexibility and recognize nurses’ contributions. The IRGNI looks to its members and other nursing health services researchers to open lines of inquiry that inform these new directions and improve healthcare delivery for all Americans.

We thank the contributors for their trailblazing work, and we look forward to witnessing and contributing to the innovations in practice environments to come.

A Mixed Methods Study of Individual and Work Factors Associated With Psychosocial Health of Registered Nurses During the COVID-19 Pandemic

Author: Amy Witkoski Stimpfel, PhD, RN

Research Objective: To describe the initial influence of the COVID-19 pandemic on U.S. nurses’ psychosocial health, and to identify factors associated with poor psychosocial health outcomes.

Study Design: We conducted an exploratory, descriptive study with a convergent mixed methods design (QUAN + qual) in which the quantitative data were prioritized and qualitative data were used to explain and augment findings. The quantitative data were captured in a survey of nurses’ work environments, COVID-19–related experiences, and psychosocial health outcomes using REDCap, a secure cloud-based platform. We developed separate multivariable logistic regression models for 3 psychosocial health outcomes using the Patient Health Questionnaire (PHQ-9), which is a 9-item survey measuring depressive symptom severity; the Generalized Anxiety Disorder (GAD-7) tool, which measures anxiety using 7 items; and the Insomnia Severity Index (ISI), which measures insomnia symptoms with 7 items. Qualitative data were captured in individual semi-structured interviews conducted through audio-only Zoom meetings. An interview guide based on the conceptual framework that guided this study (Work, Stress, and Health) consisted of a series of theoretically derived open-ended questions and probes. We used content analysis to process and analyze qualitative data. To integrate the quantitative and qualitative data, we used joint analysis displays.

Population Studied: Participants were recruited from June to August 2020, which was an early period of the pandemic in the United States. To capture a range of geographic locations and pandemic intensity, we used multiple sources, including regional professional nursing organization membership list servs, NIOSH (National Institute for Occupational Safety and Health) Education and Research Centers, and social media platforms. Eligibility criteria included (a) being a registered nurse, (b) currently working in the, United States, and, (c) having at least 6 months of work experience since initial nursing licensure. We administered surveys ( N = 629) and conducted semi-structured interviews ( N = 34) among a subset of nurses working across healthcare settings in 18 states.

Principal Findings: Nurses reported high rates of depressive symptoms (22%), anxiety (52%), and insomnia (55%). The only work or COVID-19–related variable that predicted poor outcomes across all three multivariable logistic regression models was shorter total sleep time before work, i.e., 5 hours of sleep or less. The integrated analysis found that disturbances to sleep were both a contributing factor to, and an outcome of, poor psychosocial health status. Throughout the individual interviews, participants described sleep as “the biggest issue I’ve had” with a mix of anxiety and insomnia co-occurring. For example, one participant said, “I had the anxiety and the constant racing of thoughts and that kind of kept me up and that didn’t let me fall asleep as well.” Anxiety and rumination about their working conditions—extreme stress, understaffing, redeployment into a COVID-19 unit, rationing/lack of personal protective equipment, high mortality—lead to difficulty initiating or maintaining sleep.

Conclusions: Nurses working during the onset of the COVID-19 pandemic faced severe work stressors affecting their psychosocial health status. Immediate attention as well as long-term follow-up are warranted for this priority workforce.

Implications for Policy or Practice: Healthcare leaders are responsible for ensuring that evidence-based interventions are being implemented within their organizations to promote and restore the psychosocial health and well-being of the nursing workforce.

Nursing Data in Large, Federal Government-Sponsored, Health-Related Surveys and Datasets: A Mapping Review

Authors: Ann Annis, PhD, MPH, RN; Crista Reaves, PhD, RN; Jessica Sender; and Sherry Bumpus, PhD, FNP-BC

Research Objective: Nursing faculty conducting research and scholarship face competing priorities, time constraints, and limited resources. Secondary big data from national databases offer new opportunities to address important issues that influence the nation’s health. However, navigating these sources can be challenging. Furthermore, the extent to which these data sources include information related to nursing practice is not known. We aimed to review and summarize a comprehensive list of federally-sponsored sources of healthcare data and determine the inclusion of nursing-sensitive data.

Study Design: We conducted a systematic mapping review of federal sources of healthcare data available for researchers. An iterative process of data collection, coding, and review was undertaken. The primary measure of interest was the availability of nursing-inclusive data. Additional key measures included the overview and purpose of the data, population of interest and sampling design, methodology of data collection, type and description of data, and cost to obtain data. Convergent synthesis analysis was used to aggregate findings.

Population Studied: We included federal government entities that collected health-related data on populations, patients, individuals, healthcare providers, or systems. We searched their websites for publicly available datasets. Data sources with active data collection within the previous 10 years, and those that collected health-related data on populations, individuals, healthcare providers, or systems were included. Among 91 data sources identified, 58 met final inclusion criteria.

Principal Findings: The 58 data sources belonged to nine government entities, with the majority (28%) managed by the Centers for Disease Control and Prevention. The primary population of interest for most sources (71%) was individuals or patients; fewer sources focused on providers (26%) and health systems (24%). More than half ( n = 34, 59%) included some data elements on healthcare providers, which included nurses. However, few ( n = 13, 22%) distinguished nurses from other healthcare providers. Data related to nurses were generally buried within measures that were nonspecific for type of provider, which prevents the calculation of metrics that directly reflect nursing practice.

Conclusions: National data sources represent a valuable resource of big data that provide insight into the nation’s health, healthcare system, and workforce. These secondary data are a feasible, cost-efficient means by which to investigate important health issues relevant to nurses. However, despite the diverse collection of nationally representative datasets available to researchers, we found that the inclusion of nursing-specific data is uncommon. More than half of the data sources we reviewed contained information on providers, yet few collected data that would permit nursing-specific analyses.

Implications for Policy or Practice: Nurses and advanced practice nurses deliver a large proportion of care in the, United States, but federal data sources do not adequately measure the role of nurses in healthcare delivery. The current drive toward value-based care requires the attribution of providers’ care to patient outcomes. However, without more granular data on providers, we are unable to produce measures that accurately reflect nursing contributions in healthcare. Our findings highlight the importance of building the capacity of big data sources to incorporate nursing-specific data, which are needed to inform policies that guide provider practice.

Better NP Practice Environments Reduce Disparities in Hospitalizations Among Dually Eligible Patients With Chronic Ambulatory Care Sensitive Conditions

Authors: Jacqueline Nikpour Townley, PhD, RN; Heather Brom, PhD, APRN; Aleigha Mason, BSN, RN; Jesse Chittams, MS; Lusine Poghosyan, PhD, MPH, RN, FAAN; and J. Margo Brooks Carthon, PhD, APRN, FAAN

Research Objective: Adults eligible for both Medicare and Medicaid, known as dually eligible patients, experience significant health disparities, including twice as many hospitalizations, significant unmet health-related social needs, and higher rates of chronic ambulatory care sensitive conditions (ACSCs), such as coronary artery disease (CAD) and diabetes, compared to Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually eligible patients, as NPs are increasingly providing primary care management of ACSCs and are more likely than physicians to accept Medicaid. However, NPs often work in unsupportive clinical practice environments marked by strained relationships with administrators, a lack of independent practice and support, and limited professional visibility, limiting their ability to optimally meet patients’ needs. The purpose of this study was to examine the association between the NP primary care practice environment and disparities in all-cause hospitalizations between dually eligible and Medicare-only patients with ACSCs.

Study Design: Secondary cross-sectional survey methodology was employed to collect data from primary care NPs across 460 practices in four states (Pennsylvania, New, Jersey, California, and Florida) in 2015. The Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), which contains 4 subscales with high internal consistency reliability, was used to measure NP practice environment. Practice environments with all 4 mean subscale scores above the median were classified as “good.” Those with 2–3 subscales above the median were classified as “mixed” practice environments, and those with 0–1 subscales above the median were classified as “poor.” Survey data were linked to Medicare claims files through a practice identifier available in the SK&A OneKey database. Multilevel regression models accounting for patient and practice characteristics were employed, followed by pairwise comparisons to compare disparities in all-cause hospitalizations between dually eligible patients and Medicare-only patients within good, mixed, and poor NP practice environments.

Population Studied: A total of 165,200 patients (14.9% dually eligible patients and 85.1% Medicare-only beneficiaries) were included across 460 practices. Patients had an International Classifications of Diseases, 10th edition, Clinical Modification, code for CAD or diabetes as one of their top five diagnoses.

Principal Findings: The majority of patients (58.1% dually eligible, 60.1% Medicare only) received care in poor practice environments (χ 2 = 157.8, p < .001). After adjusting for patient and practice characteristics, dually eligible patients had 50% higher odds overall of being hospitalized compared to Medicare-only patients (OR 1.51, 95% CI: 1.41–1.62). Dually eligible patients in poor practice environments had the highest adjusted odds of being hospitalized compared to their Medicare-only counterparts (OR 1.51, 95% CI: 1.41–1.62). In mixed practice environments, dually eligible patients had approximately 44% higher odds of a hospitalization (OR 1.44, 95% CI: 1.23–1.67), whereas in the best practice environments, dually eligible patients had approximately 29% higher odds (OR 1.29, 95% CI: 1.14–1.45, p < .001).

Conclusions: Improving NPs’ clinical practice environment in primary care may sizably reduce disparities in hospitalizations for dually eligible patients. However, even in the best practice environments, critical disparities in hospitalizations remain.

Implications for Policy or Practice: As policymakers look to improve outcomes and reduce costs among dually eligible patients, addressing a modifiable aspect of care delivery in NPs’ clinical practice environment is a key opportunity to reduce hospitalization disparities. Further efforts are needed to address remaining disparities by understanding and meeting patients’ health-related social needs.

Understanding Relationships Between Health Access Literacy, Health Self-Efficacy, Emotional Well-being, and Meaningful Engagement With the Children’s Mental Health System During the COVID-19 Pandemic.

Authors: Suzanne Courtwright, PhD, MSN, NP, NEA-BC, and Jacqueline Jones, PhD, RN, FAAN

Research Objective: Access to adolescent mental health services is limited, leading the Children’s Hospital Association to advocate on behalf of children and teens with a written letter to leaders of the, United States Senate and House of Representatives on January 27, 2022, to invest in the pediatric mental health workforce. The COVID-19 pandemic is exacerbating the growing mental health crisis in the country’s pediatric and adolescent population. In October 2021, the Children’s Hospital Association joined the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry and declared a national emergency in children’s mental health, as rates of anxiety, depression, and hospitalizations for suicide attempts and self-harm have risen more than 50% from prepandemic levels. Teens with chronic conditions have 4.3 greater odds of suicidal ideation and completion than their peers, and nearly 1 in 4 teens has a chronic condition. Understanding how adolescents with chronic conditions access, utilize, and engage with the children’s mental health system is necessary to better inform allocation of investments in mental healthcare delivery models for this vulnerable but growing population. The purpose of this study is to understand how health access literacy, health self-efficacy, and emotional well-being influence meaningful engagement with the children’s mental health system during the COVID-19 pandemic.

Study Design: A convergent mixed methods design utilizing path analysis of factor variables integrated with analysis of qualitative data using interpretive phenomenology was used.

Population Studied: Adolescents aged 10–21 years with chronic conditions, defined as requiring ongoing treatment for more than 1 year, were included.

Principal Findings: Preliminary findings indicate that adolescents with chronic conditions do not access healthcare for mental help until “it gets really bad.” Establishing trust over time is an important factor for this population. For those who tried to access services, non-White participants reported more challenges to access mental health services than their White peers.

Conclusion: The preliminary results of this study highlight opportunities to improve health equity by investing in mental health resources across both micro- and macro-level systems of care.

Implications for Policy or Practice: Improving health equity for teen mental health services may begin with placing interdisciplinary providers in micro-level proximity to teens, such as in schools and community-based programs, to optimize opportunities for trusting relationships to develop. Psychiatric mental health nurse practitioners, pediatric nurse practitioners, nurse coaches, community health nurses, school nurses, and public health nurses are well poised to provide easier access to school- and community-level preventive mental health education, and services. Removing policy barriers to advanced practice in densely populated states such as New, Jersey and the northeast will only advance efforts to optimize access to care.

Complementing ICD Codes With Nurses’ EHR Documentation Can Improve the Identification of Patients With Predisposing Factors of Iatrogenic Conditions

Authors: Sarah E. Ser, MS; Urszula A. Snigurska, BSN, RN; Mattia Prosperi, PhD, MEng; Ragnhildur I. Bjarnadottir, PhD, MPH, RN; and Robert J. Lucero, PhD, MPH, RN, FAAN

Research Objective: Accurate identification of patients with predisposing factors of iatrogenic conditions is a prerequisite for implementation of targeted prevention interventions. The International Classification of Diseases (ICD) codes are frequently used as proxies for a patient’s health status. However, ICD codes are unlikely to reflect a patient’s complete hospital experience. This results in an underutilization of potentially significant clinical information, including nursing assessment data, which could be used to develop valid outcome measures as well as accurate prognostic models for point-of-care decision support. Nursing assessment data may complement ICD codes in the overall characterization of a patient’s hospital experience. This study explored complementing ICD codes with electronic health record (EHR) nursing assessment data to operationalize dysuria, a factor associated with several iatrogenic conditions.

Study Design: We conducted a descriptive observational analysis of data from an ongoing retrospective study on predictors of iatrogenic conditions. Data were extracted from the University of Florida (UF)’s Integrated Data Repository. We developed an operational definition of dysuria using ICD codes from the 9th (ICD-9) and 10th (ICD-10) editions and EHR nursing assessment data. We compared the number of patients with dysuria based on ICD codes to those captured by our operational definition.

Population Studied: Observations included 135,739 patients admitted to one of 21 medical and/or surgical nursing units of an academic medical center hospital between 2012 and 2018.

Principal Findings: Based on ICD codes and EHR nursing assessment data, we created the following operational definition of dysuria: ICD-9 Code: 788.1 (or) ICD-10 Code: R30.0 (or) ICD-10 Code: R30.9 (or) nurses’ documentation of “burning” under “genitourinary symptoms” in at least one of the simple or complex Assessment flowsheets. A total of 3,637 patients with dysuria were identified by our new operational definition, and 198 were identified with both ICD codes and nursing assessment data. Four and one-half times as many patients experienced dysuria based on the combination of ICD codes with nursing assessment data compared to only ICD codes.

Conclusions: We demonstrated that complementing ICD codes with nurses’ documentation of dysuria captured patients who would not have been identified using only ICD codes. These findings could have practical and methodological implications for understanding dysuria during hospitalization; our analysis indicates that use of nursing assessment and other nursing data should be further explored. We highlighted only one of the many possibilities for identifying patients with risk factors of iatrogenic conditions using nurse-generated data. In addition to the simple and complex assessment flowsheets, there are other flowsheets in which nurses document patients’ data, which can be used to complement ICD codes and other coded data. Additionally, although we used only structured data to formulate our operational definition of dysuria, nurses’ narrative notes can contain rich contextual information, which is not typically documented in structured fields of EHRs but may be necessary for accurate outcomes measurement and case identification.

Implications for Policy or Practice: Relying exclusively on ICD codes to identify patients with certain conditions can introduce coding bias. Nursing assessments and other sources of clinical EHR documentation data may provide a source of direct clinical information to address the bias found when using ICD codes.

Understanding Crisis Needs Among Family Caregivers of Patients in Critical Care: A Qualitative Analysis

Authors: Amanda C. Blok, PhD, MSN, RN, PHCNS-BC; Thomas S. Valley, MD, MSc; Lauren E. Weston, MPH; Jacquelyn Miller, MA; Kyra Lipman, BS; and Sarah L. Krein, PhD, RN

Research Objective: To understand met or unmet needs of family caregivers in crisis during a critical care hospitalization and examine differences by anxiety level to help inform family-centered intervention design.

Study Design: We conducted a qualitative content analysis of 40 semi-structured interviews of family caregivers of mechanically ventilated patients to understand their experiences with critical care. We specifically identified needs of family caregivers in crisis—informational and emotional processing, social support, and self-care—and factors that may influence these needs using nursing theoretical models for family management of conditions. Next, we used the Hospital Anxiety and Depression Scale (HADS) administered at the time of interview to measure anxiety and divided the sample into three groups by HADS: anxiety ( n = 15), borderline anxiety ( n = 11), and low anxiety ( n = 14). We examined similarities and differences in family member experiences and needs among the three groups.

Population Studied: Family caregivers of patients hospitalized in critical care.

Principal Findings: Most family caregivers were adult children (32%), followed by spouses (22%), parents (15%), siblings (15%), and other family (15%). Crisis needs were present in all anxiety groups, but there were differences in the extent and specifics of their needs by anxiety level. For informational processing, family caregivers with anxiety described challenges understanding medical decisions made by the clinical team, often waiting for healthcare providers to initiate conversations, while family caregivers with low anxiety valued detailed information from staff and tried to prepare other family members to prevent distress. For emotional processing, family caregivers with anxiety reported fear, a sense of responsibility to protect other family members from fear, and a preoccupation with day-to-day events that inhibited processing their emotions, whereas those with borderline and low anxiety noted that other family members and prior experiences helped them deal with their emotions. For social support, more than half of caregivers with anxiety expressed strained relationships in their social support network or felt alone, whereas those with borderline and low anxiety did not describe experiencing relationship strain. Faith communities were identified as a source of support by all anxiety groups, although the added emotional and financial support from these communities appeared more prominent among those with borderline and low anxiety. For self-care, family caregivers with anxiety reported that worry impinged on their sleep and self-care, whereas family caregivers with low anxiety prioritized sleep and self-care. Caregivers with low and borderline anxiety were better able to care for themselves due to tangible support from other family members.

Conclusions: Family caregivers of critical care patients experience crisis needs during the hospitalization, although the specific needs appear to differ by family caregiver anxiety level. Our detailed understanding of caregiver experiences can inform intervention components that address these crisis needs during a patient’s critical care hospitalization.

Implications for Policy or Practice: Critical care nurses spend the most time at the bedside with family caregivers of critical care patients. Developing interventions that address the crisis needs of family caregivers may help family caregivers to engage with nurses and further enhance the care delivery process.

COVID-Related Stressors, Burnout, Turnover Intention, and Resilience Among Nurse Leaders During the Pandemic

Authors: Aoyjai P. Montgomery, PhD, BSN, and Patricia A. Patrician, PhD, RN, FAAN

Research Objective: Even before the COVID-19 outbreak, at least one of every 10 nurses worldwide was suffering from high burnout, which contributed to high turnover rates. With the COVID-19 pandemic, anecdotal reports of overwork, burnout, and even suicide of healthcare professionals is being shared in the news and on social media. The pandemic introduced new stressors to nurse leaders, such as managing the complex staffing situation (staff shortages, reassigning nurses to cover COVID-19 units, limited bed capacity, high patient acuities, shortage of personal protective equipment), while supporting their staff nurses. Since COVID-19 began, there has been research concerning COVID-related stressors, burnout, turnover intention, and resilience among nursing staff but not among nurse leaders. Therefore, this study aimed to examine the COVID-related stressors that are most significantly related to burnout and turnover intention, investigate how resilience impacts burnout and turnover intention, and explore strategies that nurse leaders are using during this pandemic to maintain resiliency.

Study Design: This descriptive, cross-sectional study employed an electronic survey of several instruments to measure COVID-related stressors (COVID-related Stress Scales [CSS]), burnout (Copenhagen Burnout Inventory [CBI]), turnover intention (a single item), and resilience (Connor-Davidson Resilience Scale [CD-RISC-25]) among nurse leaders. The survey also included open-ended questions that were analyzed qualitatively.

Population Studied: In September 2021, 57 nurse leaders who worked in Birmingham, Alabama, hospitals, including nurse managers, directors of nursing, and other nurses who are in administrative roles, responded to the survey.

Principal Findings: The average respondent had 10.7 years of nurse leader experience, had a graduate degree (67%), and worked as nurse managers (42%) or nursing directors (37%). The CSS was positively related to all three burnout subscales (Personal, Work-Related, Client-Related Burnout) ( r = .27 to .40, p < .05) but not significantly related to intent to leave ( r = 0.17, p = .20). Resiliency was negatively related to all subscales of burnout ( r = -.53 to -.59), p < .01) and intent to leave ( r = -.32, p < .05) but not significantly related to COVID-19 stress ( r = -.07 to -.20, p > .05). The top three resiliency strategies that nurse leaders used were (a) prayer and faith, (b) social support, and (c) self-care (e.g., taking a break, exercising, promoting good nutrition). The top three recommendations that nurse leaders had for other nurse leaders were (a) disconnect/take time off, (b) positive and creative thinking, (c) self-care (e.g., exercising, resting, and stress relief).

Conclusions: Among nurse leaders, COVID-19 stress impacts burnout but does not affect resiliency and intent to leave. Nurse leaders who had higher resiliency seemed to have lower burnout and were less likely to leave their positions.

Implications for Policy or Practice: The findings of this study provide baseline data to inform the development of actionable interventions to prevent or at least reduce burnout and turnover intention. Furthermore, the resiliency strategies and recommendations from these nurse leaders should be disseminated to other nurse leaders to help them reduce burnout and turnover intention.

The Association Between Hospital Nursing Resources and Patient Satisfaction Using the HCAHPS Survey: A Systematic Review

Authors: Kathleen E. Fitzpatrick Rosenbaum, BSN, RN, NICU-RNC, CCRN; and Eileen T. Lake, PhD, RN, FAAN

Research Objective: Identifying factors that influence patient satisfaction has become a priority for healthcare system managers. The Centers for Medicare and Medicaid Services implemented Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys to evaluate hospitals and incentivize them to improve patient satisfaction. Survey results are linked to hospital Medicare reimbursements, making high scores of particular interest to hospital managers and to healthcare consumers. The purpose of this systematic review was to synthesize the literature reporting the association between nursing resources (nurse education, nurse staffing, the nurse work environment, and Magnet designation) and HCAHPS scores. Our goals were to provide managers with evidence to inform their decisions and identify gaps for researchers to address.

Study Design: A systematic review was conducted searching the CINAHL and MEDLINE databases. Key terms were searched using headings and text phrases related to educational preparation, nurse work environment and nurse staffing, and Magnet designation. Chain searching was applied, and the Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide was used to grade the evidence. Effect sizes were measured by regression coefficients when available.

Population Studied: Our inclusion criteria were (a) a nursing resource as an independent variable, (b) HCAHPS scores as a dependent variable, (c) a cross-sectional study design, and (d) U.S. empirical data published in a scientific journal. Studies meeting these criteria and published between 2006 and 2021 were examined.

Principal Findings: Twelve articles met inclusion criteria. Among these articles, 7 focused on magnet designation, 3 on nurse staffing, 2 on the nurse work environment, and 0 on nurses’ education. All but 2 studies included global HCAHPS measures. In addition, 8 studies included HCAHPS composite measures. The samples of hospitals ranged from 110 to 3,026. The years represented in the data encompassed 2005 to 2018. In 11 of the 12 studies, nursing resources were significantly associated with HCAHPS scores. Magnet designation exhibited the largest effect size of 6.33. Nurse staffing showed the most variation across studies with the largest effect size related to an additional hour of nursing care per patient day or an additional patient per nurse. Coefficients ranged between -0.24 and -1.44. Nurse staffing results showed that for every one additional patient a nurse cared for, there was a 1.44% decrease in the percentage of patients giving high ratings for willingness to recommend. The nurse work environment had a positive association with patient satisfaction; effect sizes ranged from 3.15 to 6.08, with patients much more likely to give high ratings to hospitals classified as having favorable nurse work environments.

Conclusions: For hospital managers eager to improve patient satisfaction, understanding which organizational factors are associated with patient satisfaction is of interest. Nursing resources were shown to be a lever toward high HCAHPS scores. Additional research is needed to identify the association between nurse education and HCAHPS scores.

Implications for Policy or Practice: It would behoove managers to invest in nursing resources to improve patient satisfaction and achieve high-value care. Administration should support managers’ endeavors to improve nurse staffing, foster a positive nurse work environment, and develop Magnet-like qualities.

The Association Between Nursing Home IT Maturity and UTI Among Long-Term Residents

Authors: Catherine C. Cohen, PhD, RN; Kimberly Powell, PhD, RN; Andrew W. Dick; Patricia W. Stone, PhD, RN, FAAN; and Gregory L. Alexander, PhD, RN, FAAN, FACMI

Research Objective: Urinary tract infections (UTIs) are the most common infections among nursing home (NH) residents. Improving UTI prevention and management in NHs is included in key antibiotic stewardship and infection control and prevention initiatives. NH information technology (IT) maturity (i.e., technological capability, extent to which systems are used, and degree to which different systems are integrated) could impact NHs’ ability to prevent and manage UTIs through improved integration and communication of data from multiple sources. This study aimed to explore the relationship between specific aspects of IT maturity and odds of UTI among long-stay NH residents.

Study Design: We conducted a repeated cross-sectional study combining three nationally representative data sources: (a) four annual surveys measuring IT maturity, (b) Minimum Data Set (MDS) 3.0 assessments measuring resident characteristics, and (c) Certification and Survey Provider Enhanced Reporting data identifying facility characteristics. Nonadmission MDS assessments completed within 90 days of IT survey completion were matched to survey data, including nine scales of IT maturity including three healthcare domains (resident care, clinical support, and administrative activities) and three dimensions (IT capabilities, extent of IT use, and degree of IT integration with internal/external stakeholders). The outcome was a binary indicator of UTI, which is recorded according to evidence-based criteria that includes clinical symptoms. Descriptive statistics were examined. Bivariate and multivariate regressions using NH fixed effects were conducted controlling for resident and NH characteristics. We varied assumptions to test robustness of our results.

Population Studied: Assessments of long-term residents aged 65 + years from a random sample of Medicare-certified U.S. NHs over 4 consecutive years (2013–2017) were included.

Principal Findings: Our sample included 816 NHs. These NHs had 219,730 regular NH resident assessments within 90 days of a survey, representing 80,322 unique long-term NH residents. Of these assessments, 4.1% recorded a UTI. In the multivariate analyses, maturity of administrative IT capabilities was associated with lower odds of UTI (adjusted OR 0.906, 95% CI: 0.843, 0.973). No components of this domain/dimension were individually associated with UTI, nor were any other IT maturity dimension/domain scores. These results were robust in all sensitivity analyses.

Conclusion: To our knowledge, this study was the first to determine a link between NHs’ IT maturity and health outcomes at the resident-assessment level. The finding that administrative IT capabilities are associated with decreased odds of UTI was additionally robust given healthcare facilities with better documentation systems may experience measurement bias as they are more likely to record health outcomes, such as UTI.

Implications for Policy and/or Practice: This work is timely and relevant to policy decisions at facility and public health levels, as it could shape utilization of IT in NHs. This work supports the need to include use of health IT in publicly reported national datasets. Consistent reporting of IT maturity in NHs could clarify ongoing impacts of important legislative actions such as the 21st Century Cures Act, which was enacted to accelerate the effective use of IT to support better access to healthcare information.

Nurses Insight and Psychological Reaction Toward a COVID-19 Outbreak in Bangladesh

Authors: Shanzida Khatun, PhD, MSc, RN; Fahima Khatun; Md. Shariful Islam; Khaleda Akter; and Md. Abdul Latif

Research Objective: To explore nurses’ insights and psychological reactions toward a COVID-19 outbreak in Bangladesh.

Study Design and Setting: Both the qualitative and quantitative aspects of this study were conducted at 54 settings from primary level to tertiary level hospitals.

Population Studied: A total of 800 nurses participated in the quantitative portion of the study, which used the Z-score formula, and 28 nurses participated in the qualitative portion, which used focus group discussion.

Principal Findings: The mean age of nurses was around 34 years. The mean (SD) knowledge score was 15.33 (2.60); perception, 7.41 (1.62); and Depression, Anxiety, and Stress Scale, 43.73 (30.95). Regression analysis showed that knowledge, perception, length of service, working experience at a COVID-19 ward, information from media, personal protective equipment supply, hand hygiene supply, and feeling of confidence in taking care of COVID-19 patients together explained 25% of the variance in the psychological reaction toward the COVID-19 outbreak. Five themes emerged from the focus group discussion, including “challenges for nurses of working [at] COVID-19 hospital,” “fear of becoming infected and infecting the family members,” “stress due to new context and heavy workloads,” inappropriate knowledge of wearing personal protective equipment, and lack of adequate training for nurses regarding COVID-19.

Conclusions: Further study is needed to identify the factors influencing nurses’ psychological reactions toward the COVID-19 outbreak. In addition, an intervention study will help nurses to increase their knowledge and perception of the pandemic and will help to decrease nurses’ psychological problems and increase coping related to the pandemic.

Implications for Policy or Practice: The findings of this study provide baseline information to policymakers to develop a strategy on nursing management for COVID-19 patients. This also contributes to design training programs for nurses during the outbreak.

Clarifying Nurse Practitioner Integration

Authors: Joshua Porat-Dahlerbruch, PhD, RN; Lusine Poghosyan, PhD, MPH, RN, FAAN; Nancy Blumenthal, DNP; Shoshana Ratz, MSc, RN; and Moriah Ellen, MBA, PhD

Research Objectives: Globally, healthcare systems are facing care provider shortages. These shortages are due to growing populations with increasingly complex healthcare needs, and physician supply alone cannot meet demands. These workforce needs across the world require innovative solutions. Many nations have introduced the nurse practitioner (NP) role to diminish workforce shortages. NPs bring a holistic scope of practice, which has been found to be well suited to address complex care needs. Research has shown that NPs provide safe and effective care. However, the ability to produce these results relies on successfully integrating NPs into all levels of the healthcare system. Despite the rich literature, to our knowledge, the “NP integration” concept has never been synthesized and defined. “NP integration” is described inconsistently and lacks elucidation. Without a definition of the concept, NP integration cannot be researched consistently. High-level evidence requires synthesis of findings researching the same concept. Research, therefore, cannot be synthesized to create a theory or a model to guide NP integration, which is critical for policymakers and stakeholders. This concept analysis aims to define and operationalize the concept of NP integration for research and to provide a basis for which theory on NP integration can be deduced and policy can be easily understood from the literature.

Study Design: The Walker and Avant (2019) concept analysis method was used.

Study Population: We included full-text articles, government reports, conference presentations, and abstracts, yielding 200 publications. After removing duplicates and abstract screening, 78 publications remained.

Principal Findings: Defining attributes of NP integration include process, achievable goal, introduction of the role, incorporation into organizational care models, challenging traditional ideologies, ability to function, provide high care quality, and improve outcomes, sustainability, and health system transformation. We identified facilitators and barriers affecting NP integration and multiple healthcare system levels at which NP integration occurs—macro, meso, and micro. We identified antecedents and consequences of NP integration. We synthesized findings to create an NP integration conceptual model. The analysis resulted in an operational definition of NP integration: A multilevel process of incorporating NPs into the healthcare system so that they can function to the full extent of their scope and contribute to patient, health system, and population needs.

Conclusions: This is the first research to synthesize NP integration literature to provide an operational definition and conceptual model. Moreover, most literature refers to macro (system-wide) or meso (organizational) level integration. We identified a new dimension—micro—which refers to individual interactions of NPs with other NPs, patients, physicians, nurses, and staff. NP integration is a complex process acting on multiple levels in the healthcare system. Policy intervention at all three levels is likely critical for NP integration.

Implications for Policy or Practice: These findings provide an operational definition so that research on NP integration can be conducted consistently. This research can be a basis for developing research tools assessing NP integration progress that stakeholders and policymakers can use to understand where policy intervention is necessary to improve NP integration.

Nurse Work Patterns in Long-Term Care: A Time-Motion Analysis

Authors: Yu Jin Kang, PhD, MPH, RN; Jeannie P. Cimiotti, PhD, RN, FAAN; and Karen A. Monsen, PhD, RN, FAMIA, FNAP, FAAN

Research Objective: It is well known that nurses working in the long-term care sector are short staffed and under a tremendous amount of pressure to complete nursing care in a timely manner. Multitasking is expected of these nurses, such as performing nursing tasks while communicating, but extensive multitasking should be minimized to avoid potential adverse events. Little is known about how these nurses might multitask in an effort to complete essential nursing care. The purpose of this study was to examine the workflow of licensed nurses in a skilled nursing facility and to determine how they might multitask to complete nursing care.

Study Design: An observational time-motion study was conducted at a 250-bed skilled nursing facility located in the southeastern United States. A web-based time capture application, TimeCaT, was used to collect data from September 2019 to March 2020. TimeCaT was customized to include 57 validated nursing activities based on the Omaha System. This method allowed for the collection of time-stamped workflow data that included communication and tasks—data that were not mutually exclusive. Observed nurse workflow was analyzed using χ 2 statistics and visualized with a heatmap.

Population Studied: Registered nurses (RNs, n = 4) and licensed practical nurses (LPNs, n = 7) who worked on short-term care (STC) and long-term care (LTC) units or provided wound care were included in the study. All participating nurses were full-time clinicians except one nurse who was supplied by a supplemental staffing agency. On average, one nurse was responsible for the care of 12 residents.

Principal Findings: There were 5,306 observations of multitasking episodes—an average of 35 multitasking episodes per hour. The majority of multitasking episodes occurred during care supervision (81%) and medication regimen (33%). Forty-eight percent of the episodes were related to the medication regimen among STC and LTC nurses, where communication with residents and other care team members and documentation occurred while nurses prepared medications (17%) and where communication with residents, including medication instruction, occurred while nurses administered medications (11%). A larger percentage of LTC nurses multitasked medication regimen activities when compared to STC nurses (55% vs 39%, p < 0.001) and in the morning when compared to afternoon and evening (57% vs 39% vs 48%, p < 0.001). Overall, a larger percentage of LPNs multitasked medication regimen activities when compared to RNs (51% vs 46%, p < 0.001).

Conclusions: Nurses frequently multitask during the preparation and administration of medications in a skilled nursing facility. Research is warranted to better understand the complexity of medication regimens and the factors that contribute to multitasking practice patterns. Furthermore, it is imperative that we determine whether multitasking practice patterns increase the cognitive workload of nurses and the likelihood of medication errors in skilled nursing facilities.

Implications for Policy or Practice: Healthcare administrators and policymakers should be mindful of the fact that nurses often multitask in skilled nursing facilities. This calls for policies that monitor nurse practice patterns in the long-term care sector and provide suggestions for improvement when necessary. If not, we risk the possibility of short- and long-term sequela associated with these questionable workflow patterns.

Linking Patient Safety Climate With Missed Nursing Care in Labor and Birth Units: Findings From the LaborRNs Survey

Authors: Jie Zhong, MSN; Kathleen Rice Simpson, PhD, RNC, FAAN; Joanne Spetz, PhD; Jason Fletcher, PhD; Caryl L. Gay, PhD; Gay L. Landstrom, PhD, RN, NEA-BC; and Audrey Lyndon, PhD, RNC, FAAN

Research Objective: Inpatient labor and birth settings are specialty care units with limited evidence regarding nursing care quality. Missed nursing care has been used to indicate nursing care quality in medical-surgical, intensive, and pediatric care settings. An emerging body of evidence suggests that features inherent in a better culture of safety, such as aligned organizational priorities, attention to workload, and team communication, are associated with less missed nursing care in general. The aim of this study was to explore patient safety climate and its association with the outcome of missed nursing care in labor and birth units.

Study Design and Population Studied: We recruited nurse respondents for this cross-sectional study in the United States via email distribution of an electronic survey between February 2018 and July 2019. Hospitals with labor and birth units were recruited from states with projected availability of 2018 State Inpatient Data. All registered nurses working in labor and birth units in the targeted hospitals were eligible. Measures included the Safety Climate Subscale from the Safety Attitudes Questionnaire, the Perinatal MISSCARE Survey, and nurse characteristics. The mean of individual nurse Safety Climate Subscale questions was used to measure nurses’ perception of the unit safety climate on a scale of 1–5, with a higher score indicating a better climate. The Perinatal MISSCARE Survey uses 25 items to assess the frequency at which required aspects of nursing care are delayed, unfinished, or completely missed on the respondent’s unit. The sum of missed aspects of care ranged from 0–25, with a higher score indicating more missed care. We used Kruskal-Wallis tests for bivariate analysis followed by mixed-effects linear regression models to estimate the relationships between patient safety climate and missed nursing care while accounting for clustering of nurses within hospitals.

Principal Findings: The response rate was 35%, resulting in a sample of 3,429 labor and birth registered nurses from 255 hospitals. A majority of respondents (65.7%) reported a perception of good safety climate in their units, with a mean (SD) score of 4.12 (0.73). The mean (SD) number of aspects of care occasionally, frequently, or always missed on their units was 11.04 (6.99). The adjusted mixed-effects model identified a significant association between better nurse-perceived safety climate and less missed care (-2.65; 95% CI: -2.97 to -2.34) after controlling for age and years of experience as a labor nurse. The estimates indicated each one unit increase of the mean score of nurse-perceived safety climate was associated with 2.65 fewer missed essential aspects of perinatal nursing care.

Conclusion and Implications for Policy or Practice: Our findings suggest that improving safety climate may promote nursing care quality during labor and birth through decreasing missed nursing care. Conversely, it is also possible that strategies to reduce missed care, such as staffing improvements, may improve safety climate. Safety strategies such as promoting open communication, ensuring nonpunitive response to error, incorporating perinatal safety nurses, and ongoing learning from safety events may decrease missed care in daily nursing activities.

Emergency Nursing Workforce Burnout and Job Turnover in the United States: A National Sample Survey Analysis

Authors: Allison A. Norful, PhD, RN, ANP-BC, FAAN; Kenrick Cato, PhD, RN, FAAN; Bernard P. Chang, PhD, MD; Taryn Amberson, MPH, RN, CEN, NHDP-BC; and Jessica Castner, PhD, RN, FAEN, FAAN

Research Objective: Burnout, especially in registered nurses working in emergency departments, has substantially jeopardized the nursing workforce supply and the ability to meet demands for care. Past research documenting the prevalence of burnout among emergency nurses have been limited by small sample sizes and local sampling approaches as they have been unable to capture the diversity of clinical, geographic, and demographic characteristics at a national level. Few studies have examined turnover in nurses who have left their job or are not currently working, resulting in the potential for healthy worker or survivor bias. The aims of our study were to (a) test differences in reasons for turnover or not currently working between emergency nurses and other registered nurses and (b) ascertain factors associated with burnout as a reason for turnover or not currently working among emergency nurses.

Study Design: We conducted a secondary analysis of the National Sample Survey for Registered Nurses publicly available from Health Resources and Services Administration. We excluded advanced practice nurses and respondents who were not working due to retirement. Demographic and work characteristics (e.g., sex, age, race and ethnicity, marital status, highest degree, years of experience, hours worked per week, household income, and degree enrollment) were extracted. Next, we extracted responses to 6 survey items permitting the identification of nurses who were not currently working or who recently left their position (within 2 years) and their reasons for turnover (22 response options, including “burnout”). Design weights were applied using the jackknife estimation procedure. Data were analyzed using descriptive statistics, χ 2 test, t test, unadjusted and adjusted logistic regression applying design sampling weights, and controlling for potential individual and work characteristic confounders.

Population Studied: Nationally representative sample of registered nurses (weighted N = 3,001,283) from the 50 United States and the District of Columbia. Analysis included 1,266 emergency nurses (weighted N = 217,706) and 18,589 nurses (weighted N = 2,786,879) in other settings.

Principal Findings: Seven job turnover reasons were endorsed by emergency nurses and significantly higher than reasons provided by other nurses: Insufficient staffing (11.1%, p = .011); physical demands (5.1%, p = 0.44); patient population (4.3%, p < .001); better pay elsewhere (11.5%, p = .001); career advancement/promotion (9.6%, p = .007); length of commute (5.1%, p = .012); and relocation (5%, p = .006). Increasing age and years of experience were significantly associated with decreased odds of burnout in adjusted models. Being female was associated with decreased odds of burnout when controlling for insufficient staffing, scheduling, and stressful work environment.

Conclusions: Several modifiable factors, such as insufficient staffing and better pay elsewhere, appear to be associated with job turnover. Further research should account for gender and age to better understand and mitigate burnout. Ongoing research is essential to identify priorities for risk detection and for future national-level nursing workforce policies and interventions.

Implications for Policy or Practice: Given the critical need of the emergency nursing workforce, this study provides evidence for preventive intervention and policy at the national level. Interventions to reduce burnout and job turnover may include enhancing work environments (e.g., sufficient staffing), increasing pay, and investing in the physical and psychological health of nurses. Practice and policy efforts aimed at precursors of nursing burnout as modifiable targets to reduce turnover may improve career longevity, well-being, and workforce retention.

The Impact of Pre–COVID-19 Nursing Home Infection Prevention and Control Policies on COVID- 19 Deaths

Authors: Jung A Kang, MSN, RN, AGACNP-BC, AGCNS-BC; Patricia Stone, PhD, RN, FAAN, CIC; and Andrew Dick, PhD

Research Objective: Nursing home (NH) residents have been disproportionally suffering from the COVID-19 pandemic. Therefore, it is essential to have a comprehensive NH Infection Prevention and Control (IPC) program to prevent potential infectious disease outbreaks. However, it is not known how NH IPC programs have impacted COVID-19 deaths. Therefore, the goal of this study was to examine the relationship between pre–COVID-19 NH IPC programs/policies and COVID-19 resident deaths.

Study Design: This retrospective study used publicly available data from the Centers for Disease Control and Prevention’s Long-Term Care Facility COVID-19 Module and USA Facts county-level COVID-19 data linked to a national survey of NHs in 2018. The survey included questions about NH IPC programs such as having infection preventionists certified in infection control (CIC) and outbreak preparedness policies. We used 10-week periods to separately assess the impact of NH IPC programs on the weekly resident COVID-19 deaths per 1,000 residents between May 24, 2020 and May 30, 2021. We then estimated multivariable regression models to examine the association between NH IPC programs and COVID-19 deaths controlling for facility-level characteristics and county-level COVID-19 death intensity.

Population Studied: A total of 857 NHs located in 489 counties were identified and included in this analysis. Approximately 7.5% of NHs had the infection preventionist certified in infection control. Among the outbreak preparedness policies, instructing infected staff to stay home was most common in NHs (92.4%), and use of rapid diagnostic methods for case detection was least common (49.9%).

Principal Findings: In the multivariable models, during the December 2020 peak period, NHs with CIC infection preventionists had 4.9 fewer weekly COVID-19 deaths per 1,000 residents compared to the NHs without CIC infection preventionists (β = -4.9, SE = 1.1, p < .0001). Use of rapid diagnostic methods for case detection was also associated with lower weekly COVID-19 deaths during the peak period (β = -1.25, SE = 0.43, p = .004). Cohorting infected residents together was negatively associated with weekly COVID-19 deaths during the off-peak periods (β = -2.7, SE = 0.5, p < .0001). On the other hand, instructing infected staff to stay home and closing to new admits were associated with higher weekly COVID-19 deaths, particularly during the peak periods (β = 1.03, SE = 0.52, p = .047; and β = 3.16, SE = 0.94, p = .001 respectively).

Conclusions: Most of the IPC programs had different impacts on COVID-19 deaths depending on the stage of COVID-19. The lower rate of COVID-19 deaths in NHs with CIC infection preventionists persisted throughout the pandemic periods. We also found that the use of rapid diagnostic methods for case detection was protective against COVID-19 deaths during the peak period, as was cohorting infected residents together during the off-peak period.

Implications for Policy or Practice: This study provides evidence-based policy recommendations to clinicians and policymakers to prevent future infectious disease crises in NHs. Aligning with the Centers for Disease Control and Prevention’s recommendation regarding infection preventionists, assigning one or more full-time infection preventionist with training in infection control in NHs is recommended.

U.S. Clinician Well-being Study: A Descriptive Analysis of the Work Environment and Clinician Well-being

Authors: Colleen A. Pogue, PhD, RN; Linda H. Aiken, PhD, RN, FAAN, FRCN; Kathleen F. Rosenbaum, BSN, RN, NICU-RNC, CCRN; Maura E. Dougherty, BSN, CRNA; and Matthew D. McHugh, PhD, JD, MPH, RN, FAAN

Research Objective: To determine factors associated with interdisciplinary clinician mental health and well-being in hospitals during COVID-19.

Study Design: This cross-sectional study utilized primary data collected through an electronic survey sent via hospital emails to identified clinicians between February 2021 and July 2021. Clinicians provided detailed information regarding clinician well-being (i.e., mental health, burnout, and job satisfaction) and quality of work environment (e.g., workload, autonomy, work-life balance, and interdisciplinary teamwork). Data were aggregated at the hospital level.

Population Studied: An interdisciplinary group of registered nurses (RNs) ( n = 15,738), advanced practice registered nurses and physician assistants (advanced practice providers [APPs]) ( n = 2,662), and physicians ( n = 5,336) were surveyed. Surveyed clinicians had to be working in an inpatient or ED setting. Data were collected from 60 different Magnet hospitals across the United States.

Principal Findings: Overall, findings of high clinician burnout (30%–44%), job dissatisfaction (12%–22%), and likelihood of leaving the job (23%–41%) were consistent across clinician groups and highest among nurses. A quarter of nurses experienced clinical levels of anxiety. Overall burnout levels varied widely across Magnet hospitals (25%–65%). Clinicians reported having high levels of stress at work (40%–53%) and having very little joy (7%–14%) with nurses reporting the highest levels of stress and the least joy. One-third of nurses rated their work environment as poor/fair. The quality of the work environment varied considerably across all Magnet hospitals, with as few as 5% and up to as many as 65% of hospital clinicians reporting that their work environment was poor/fair. More than half of all nurses (54%) felt there were not enough nurses to care for patients. There was less concern regarding nurse staffing among physicians and APPs, with 71% of physicians and 63% of APPs feeling that there were enough nurses to care for patients. Physicians reported high frustration with electronic health records (61%) and poor work-life balance (32%). APPs experience of well-being and perceptions of their work environment overlapped with both physicians and nurses. All clinicians stated the importance of being heard and supported by the administration and having a shared vision and values with the administration. Nearly 95% of clinicians reported good interdisciplinary working relationships and high levels of teamwork. Clinicians also rated the effectiveness of interventions to improve well-being. Across all clinicians, the most effective interventions were those that allow them time and resources to provide clinical care (e.g., improve nurse staffing levels, have breaks without interruption, reduce time spent on documentation, increase control over scheduling). There was clear agreement across clinicians on interventions they felt would not be as effective in improving well-being (e.g., resilience training, meditation rooms, wellness champion/committee).

Conclusions: Clinician burnout was high, and the quality of the work environment varied considerably across Magnet hospitals.

Implications for Policy or Practice: Opportunities to improve the work environment through empirically informed interventions are necessary to improve clinician well-being. Data suggest variation in the effectiveness of well-being interventions by clinician group, which should be taken into consideration during the development and implementation of such interventions.

The Association Between Primary Care Work Environments and Missed Opportunities for Emotional Healthcare

Authors: Eleanor Turi, BSN, RN, CCRN; Amelia Schlak, PhD, RN; Jianfang Liu, PhD; and Lusine Poghosyan, PhD, MPH, RN, FAAN

Research Objective: Nurse practitioners (NPs) are key to improving primary care delivery as they represent the fastest growing segment of the primary care workforce. Yet, poor nursing working conditions (i.e., hostile working relations, low autonomy, lack of support, and inadequate professional visibility) often challenge NP care delivery and have been linked with lower quality of care and adverse patient outcomes. These poor conditions also lead NPs to prioritize acute care needs of patients and ignore other needs such as addressing patients’ emotional well-being, which is an important and often overlooked area of health. We investigated the relationship between NP work environment and missed care around patients’ emotional health.

Study Design: This was a secondary analysis of cross-sectional survey data from 2017. The survey asked primary care NPs to complete the Errors of Care Omission Survey (EoCOS) to determine whether NPs missed opportunities for care and the NP Primary Care Organizational Climate Questionnaire (NP-PCOCQ) to assess the NP work environment. We examined the association between the NP-PCOCQ subscales (i.e., independent practice and support [IPS], NP-administrative relations [NP-AR], professional visibility [PV], and NP-physician relations [NP-PR]) and an aggregate measure of the EoCOS describing NP ability to address patients’ emotional health (EH-EoCOS; 3 items related to addressing emotional concerns of patients, discussing patients’ emotional well-being, and providing emotional support when making treatment decisions) using multilevel mixed-effects linear regression models. Higher scores on the NP-PCOCQ and the EH-EoCOS indicate a favorable work environment and that patients’ emotional health is addressed, respectively. We controlled for NP demographics and practice features.

Population Studied: A total of 397 primary care NPs in New York State across 377 primary care practices were included.

Principal Findings: In the bivariate model, higher IPS scores were positively associated with a higher EH-EoCOS score that neared statistical significance; for every 1 unit increase in IPS score, EH-EoCOS increased by 0.30 ( p = 0.059). After adjusting for NP demographics and practice features, there was a positive association between IPS score and EH-EoCOS, again that neared statistical significance (β = 0.29, p = 0.077). NP-AR (β = 0.11, p = 0.285), PV (β = 0.10, p = 0.370), and NP-PR (β = 0.22, p = 0.106) subscales were not significantly associated with EH-EoCOS.

Conclusions: Our findings suggest that NP ability to address patients’ emotional health needs is, in part, driven by the level of support for NP independent practice.

Implications for Policy or Practice: Lack of support for NP independent practice may prevent NPs from addressing patients’ emotional health, which could lead to future mental health complications among patients. NPs are uniquely prepared to deliver emotional healthcare because of their nursing education, which is grounded in holistic, person-centered care. Practices employing NPs should ensure that NPs have access to ancillary staff and support for care management to deliver care to patients. Practices should also allow NPs to manage patients independently, practicing to the full scope of their education and licensure.

Conflicts of Interest: Dr. Ghazal is a postdoctoral research fellow supported by NIH-NCI T32CA236621. Dr. Nikpour Townley is a postdoctoral fellow supported by NIH-NINR T32NR007104. Dr. Pogue is a postdoctoral fellow supported by NIH-NINR T32NR007104. Dr. Riman is a postdoctoral fellow supported by NIH-NHLBI T32HL007820. Dr. Schlak is a postdoctoral fellow supported by NIH-NINR CER2 T32NR014205.

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Should California community colleges offer bachelor’s degrees in nursing? Universities say no

Understanding the nursing shortages

Even as the state may not have an industry-wide nursing shortage by 2027, there are still stubborn sub-shortages.

While California has seen the number of nursing education program slots grow by 3,000 between 2018 and 2023 , virtually all of that was at private nonprofit and for-profit campuses . Available slots at the more affordable public colleges and universities have remained flat.

There are regional differences, too, with California’s Central Valley and the Central Coast lacking enough nursing program slots to meet demand. “Those would be the regions that I would point to as having the biggest challenges,” said Joanne Spetz, a researcher at UC San Francisco who studies the state’s nursing sector and co-wrote the projections report

Yet another micro-shortage stems from the fact that more hospitals prefer — or require — hiring nurses with bachelor’s degrees . That makes sense: Several academic studies concluded that hospitals that increased their share of nurses with bachelor’s degrees saw lower rates of patient death and shorter hospital stays .

And an overall shortage may still persist past 2027 due to “high rates of burnout” that “may lead to greater turnover and departures from nursing,” the projections report said.

What the two bills will do

Enter the two bills the Legislature passed last week.

Will they lead to more registered nurses? Speaking of his bill in July, Roth said no. But it would help produce more nurses with bachelor’s degrees — which more hospitals say they want, he said.

The bill authors — as well as their community college and hospital backers — say some community colleges should be allowed to issue bachelor’s degrees in nursing for other reasons, too.

Students who live too far from a California State University or University of California nursing program could enroll at a community college and avoid long commutes to the public universities or much more expensive private colleges . There are more than 70 community colleges in California that offer associate degrees in nursing and 21 public universities — mostly through the Cal State system — that award bachelor’s degrees in nursing . And while some universities offer online programs, not every student has fast-enough internet or enough computing power at home, Roth told lawmakers .

Students with associate and bachelor’s degrees take the same licensure exam. Typically a bachelor’s degree in nursing requires about 30 more units of coursework, which takes about a year to complete.

An overall shortage may still persist past 2027 due to “high rates of burnout” that “may lead to greater turnover and departures from nursing.” UC San Francisco projections report

Both bills seek to form pilot programs that each allow just 10 community college districts — out of the state’s 73 — to offer bachelor’s degrees in nursing.

But they vary in other ways. Soria’s bill places an emphasis on pilots in the Central Valley , which has a chronic nursing shortage. Roth’s bill is aimed at the whole state, though it would focus on the Central Valley and other regions by prioritizing pilot programs in underserved communities. Both would require the Legislative Analyst’s Office to evaluate the pilots, but Roth’s bill would have the pilot programs last until 2034 while under Soria’s bill the programs would run until 2031.

Roth’s bill requires colleges in the pilot to have national accreditation, which can take several years to accomplish. Soria’s bill doesn’t specify that. Still, 28 community colleges already have national accreditation, according to a July legislative bill analysis.

Learn more about legislators mentioned in this story.

Josh Newman

Democrat, State Senate, District 29 (Fullerton)

Richard Roth

Democrat, State Senate, District 31 (Riverside)

Esmeralda Soria

Democrat, State Assembly, District 27 (Merced)

The differences raise questions about how Gov. Gavin Newsom may reconcile the two bills.

That’s one reason why the California Community Colleges Chancellor’s Office is “recommending the governor sign SB 895” over Soria’s bill, wrote Melissa Villarin, a spokesperson for the California Community Colleges Chancellor’s Office, in an email Wednesday. She also noted that either bill getting Newsom’s signature would be a “major victory.”

The chancellor’s office prefers Roth’s bill because it was sponsored by statewide groups close to the central office, including the Community College League of California, which represents community college administrators and trustees. Roth’s legislation is also a “bill where more attention and efforts (in terms of negotiating amendments) have been focused throughout the legislative process,” she wrote.

Why Cal State opposes bachelors degrees at community colleges

Both bills are creating a panic for Cal State leadership and the system’s nursing programs. There’s the fear that the community colleges will eat Cal State’s enrollment lunch by offering bachelor’s degrees that are cheaper than what Cal States charge.

Roth’s bill “will siphon off the students” who’d “otherwise come to a CSU nursing degree program,” said Rehman Attar , director of health care workforce development at the Cal States, during a July legislative hearing. He said the same about Soria’s bill .

Forming new bachelor’s programs at community colleges is expensive, he argued. Cal State’s online bachelor’s programs and the system’s fast-track bachelor’s degree programs with 37 existing community colleges can meet the bills’ goals, he said in an interview. More of these partnership programs are pending, he added .

California’s health care workers are burning out. These universities want to help.

There’s also a philosophical battle brewing over the distinct roles of each higher education segment in California. For decades, the state’s 1960 Master Plan for Higher Education stipulated that the community colleges offer certificates and associate degrees; Cal States chiefly provide bachelor’s degrees and master’s degrees; and the UCs focus on research by offering bachelor’s, master’s and doctoral degrees.

But in recent years, the Legislature has permitted the community colleges to award bachelor’s degrees, with the proviso that those degrees don’t duplicate the degrees already offered at Cal States. Both systems have fought over the practicalities of that détente , but the bills proposed by Roth and Soria would knowingly blow up that public policy peace by allowing the community colleges to offer the same nursing bachelor’s degrees the Cal States already provide.

“Our overall opposition is, of course, we’re opposed to duplication,” Attar said in an interview. Both bills received wide bipartisan support. However, a few Democrats — who have a supermajority in the Legislature — expressed reservations about the emerging mission creep of the community colleges.

Among those is Sen. Josh Newman, a Democrat from Fullerton who is chair of the Senate’s education committee. During a hearing on Soria’s bill , he said that the master plan assumed a “division of labor, if you will, between the segments. And largely because of geographical and workforce needs, we’re seeing that erode. I believe that is problematic.”

Roth’s bill would also create new layers of pricing. It would cap tuition for the pilot nursing bachelor’s degrees to be no more expensive than other community college courses — $46 a unit — wrote Villarin.

“The only way to pursue a bachelor’s degree, if you’re in some of those communities, is to either do an online program, some of which are excellent and some of which are not so good, or to relocate to do a bachelor’s degree.” Joanne Spetz, researcher at UCSF

Existing bachelor’s degrees at community colleges have tuition charges that are capped at $10,560, excluding course and campus fees, so Roth’s bill would make a nursing bachelor’s roughly half that. Meanwhile, Cal State systemwide tuition, excluding fees, is now more than $6,000 a year and will grow by 5% annually through 2028-29 .

Spetz of UC San Francisco said the lack of public bachelor’s degree programs in nursing is a real barrier to Californians in remote parts of the state where there’s no nearby university.

“The only way to pursue a bachelor’s degree, if you’re in some of those communities, is to either do an online program, some of which are excellent and some of which are not so good, or to relocate to do a bachelor’s degree, which just seems kind of silly and isn’t possible for many people,” she said.

She’d recommend limiting the pilot programs to community colleges that are particularly far from a public university with a nursing program. “I think having a distance threshold and really focusing on regions where there is not a public bachelor’s degree opportunity for folks …is a reasonable thing to test.”

Tired of the waiting lists for California’s public universities, nursing students increasingly turn to expensive private programs

California needs thousands of nurses, but leaders can’t agree on how to fill jobs

Mikhail zinshteyn higher education reporter.

Mikhail Zinshteyn reports on higher education for CalMatters. His coverage tackles state legislation, financial aid, labor issues, student demands, campus housing and college affordability. His work on... More by Mikhail Zinshteyn

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Strategies to Overcome the Nursing Shortage
Nursing shortage: Nursing shortage is the struggle to expand capacity to meet the. rising supply and demand for nursing workforce nationally (Mee, 2014). Registered nurses (RNs): RNs provide and coordinate patient care, educate. patients and the public about various health conditions, and provide advice and emotional.
The Nursing Shortage and Work Expectations Are in Critical Condition
Working conditions have worsened for many nurses and health care professionals across the globe during the COVID-19 pandemic. 1-3 During the Omicron wave, the US Department of Health and Human Services has reported critical staffing shortages in 24% of US hospitals, 4 and military medical personnel have been deployed to assist hospitals in at least 8 states. 5 As I write this editorial in ...
The Real Issues Driving the Nursing Crisis
In 2021, the total number of registered nurses working in the U.S. dropped by the largest amount in 40 years, with younger nurses leading the exodus. 2 By 2025, the U.S. health care system could suffer a shortfall of up to 450,000 nurses, or 20% fewer than the nursing workforce required for patient care. 3.
Emergency department responses to nursing shortages
The COVID-19 pandemic exacerbated the nursing shortage, which is predicted to continue to worsen with significant numbers of nurses planning to retire within the next 5 years. There remains a lack of published information regarding recommended interventions for emergency departments (EDs) facing a sudden nursing shortage. We queried emergency department leaders from the American College of ...
Overview and Summary: Today's Nursing Shortage: Workforce
"Distressed But Not Deterred: Nurses Reveal Solutions to the Nursing Shortage in the Aftermath of a Pandemic," by White and Godsey, employed survey research of over 800 Kentucky nurses during the pandemic nursing shortage. The authors aimed to identify perceived contributors to the nursing shortage and the supportive actions that could be ...
Nursing Shortage Solutions for the Future
A nursing shortage refers to a situation where the demand for registered nurses (RNs) and other nursing roles exceeds the supply—locally, nationally, or globally. This deficit isn't a new phenomenon. In fact, sporadic shortages have been recorded over the decades. However, the current and impending scarcity is unparalleled in its reach and ...
The Nursing Shortage Explained
In addition, a major reason for the shortage of nursing faculty is low salaries. While the average salary of an advanced nurse practitioner with a master's degree is $120,680, master's prepared nursing faculty were paid just $87,325/year in 2022. With the average nursing faculty salary being $33,372/year less than what nurses earn in ...
Building a strategy for the recruitment and retention of nurses in
The global nursing shortage is a critical issue in healthcare. In this brief contemporary issue, we will present insights originating from a quality improvement project. The project included the planning and execution of a comprehensive strategy designed to recruit and retain nurses.
Relevant factors affecting nurse staffing: a qualitative study from the
From the perspective of nursing managers, this study explores the related factors affecting the allocation of nurses through descriptive qualitative research, explores the specific challenges, pressures and needs of nurses in their work, and reveals the deep causes of the shortage of nurses from multiple levels and directions, rather than just ...
Registered nurses' perceptions on the factors affecting nursing
Conclusion. This study has identify factors affected shortage of current nursing workforce and the impact it has on registered nurses. Broad themes and sub-themes were identified which highlighted the impact of nursing shortage to registered nurses and the effects on their performance which includes stress or moral distress from work overload and lengthy hours shift which impact the nurses ...
Nursing faculty shortage in the U.S.: Has a pandemic compounded an
The issue of nursing faculty shortages predates the Covid-19 pandemic, but the pandemic has added new weight to this reality. For example, the pandemic has forced much of nursing education to an online, virtual format. Luckett (2020) reports that at the start of the pandemic, nearly 70% of nursing faculty had not previously taught online. An ...
A systematic review study on the factors affecting shortage of nursing
The studies published from 1 January 2010 to 31 August 2021 and in English language were examined and included from peer-reviewed journals, published books and WHO reports with full text available that were related to the nursing workforce shortage and were suitable to support the current research study.
Strategies To Combat The Nursing Shortage
6 Innovative Ways Top Nursing Executives Are Surviving the Nursing Shortage. There are six proven strategies to increase nurse retention. These strategies include: Listening to nurses' concerns. Prioritizing workplace culture. Adjusting protocol to meet nurses' needs. Increasing diversity and representation in nursing.
Why Is There A Nursing Shortage?
The U.S. faces a nursing shortage due to an aging population and retiring nurses, creating abundant opportunities for nurses nationwide. The need for nurses aligns with all-time highs in increased demand for healthcare. The American Nurses Association estimates that more than a million new nurses need to join the workforce over the next few ...
Post-Pandemic Nursing Shortage Affecting Aspiring Nurses
Nursing shortages have a high impact on working environments, patient outcomes, and the long-term health of nurses, leading to longer shifts and higher nurse-to-patient ratios. This shortage increases stress, fatigue, and the risk of injury to nurses. It can also reduce patient care.
PDF A systematic review study on the factors affecting shortage of nursing
The impact of 2021 nursing workforce shortage is a huge challenge globally and is affect - ing more than one billion people, especially vulnerable populations such as women and children who badly needed the quality health- care services (Aluko et al.,; Marć et al., 2019 2019). The inadequate supply of nurses has notably created many negative ...
Nursing Workforce Challenges in the Postpandemic World
A Mixed Methods Study of Individual and Work Factors Associated With Psychosocial Health of Registered Nurses During the COVID-19 Pandemic. Author: Amy Witkoski Stimpfel, PhD, RN Research Objective: To describe the initial influence of the COVID-19 pandemic on U.S. nurses' psychosocial health, and to identify factors associated with poor psychosocial health outcomes.
Should CA community colleges offer bachelor's degrees in nursing
Even as the state may not have an industry-wide nursing shortage by 2027, there are still stubborn sub-shortages. While California has seen the number of nursing education program slots grow by 3,000 between 2018 and 2023, virtually all of that was at private nonprofit and for-profit campuses. Available slots at the more affordable public ...