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

Introduction

The Surgeon General (2022) recently issued a public advisory declaring health care clinician burnout to be an urgent public health issue in need of immediate action. The American Hospital Association (AHA) in a March 1, 2022, letter to Congress proclaimed workforce challenges a national emergency that demanded immediate attention (AHA, 2022). There is little doubt that many hospitals failed to perform well during the Covid-19 emergency (Fleisher et al., 2022; Joint Commission, 2021). Bloodstream infections, which had declined 31% in the 5 years preceding the pandemic increased 28% in the pandemic's first months (Patel et al., 2021) with similar disappointing trends in other infections, falls, and pressure ulcers (AHRQ, 2021; Rosenthal et al., 2022). The AHA's proposed solutions to the nursing care shortage included increasing the national supply of nurses, recruiting nurses from abroad, addressing clinicians’ “behavioral health needs,” and investigating anticompetitive behavior of travel nurse agencies. Are these the highest priority solutions to the problems of hospitals not being able to recruit and retain enough nurses? Our study of hospital nurses in a large, repeated cross-sectional study before and during the pandemic adds a new perspective on where to look for solutions to the shortage of hospital nursing care.

The solutions may have been in plain sight for two decades. In 2002, two landmark studies (Aiken et al., 2002; Needleman et al., 2002) documented significant associations between hospital patient-to-nurse workloads and patient mortality and nurse burnout. Each one patient increase in nurses’ workloads was associated with a 7% increase in the odds of risk-adjusted patient mortality, a 23% increase in the odds of high nurse burnout, and a 15% increase in the odds of nurse job dissatisfaction (Aiken et al., 2002). A large body of research (Aiken et al., 2018; Lake et al., 2019; Lasater et al., 2021c; Lu et al., 2012; Sloane et al., 2018; Wynendaele et al., 2019) confirms the association of hospital nurse staffing and work environments with patient outcomes and nurse retention.

The only major policy response to chronic hospital nurse understaffing and poor work environments in 20 years has been the implementation in 2004 of a mandated minimum nurse staffing requirement in hospitals throughout California (Aiken et al., 2010; McHugh et al., 2011a, 2012). The unfunded mandate resulted in patients in California hospitals currently receiving, on average, 2 to 3 more hours a day of registered nurse care than patients in other states (Dierkes et al., 2021). Similar safe nurse staffing legislation has been considered in other states but despite research estimating improved patient outcomes and cost savings (Lasater et al., 2021a, 2021b), no other states have implemented minimum hospital nurse staffing requirements.