The pandemic was not the “root cause” of hospitals’ problems recruiting and retaining nurses but, rather, a “contributing factor,” said the authors of a cross-sectional study of registered nurses in two states.
High levels of nurse burnout, job dissatisfaction, and intent to leave their employer predated the pandemic, reported Linda Aiken, PhD, RN, founding director at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia, and colleagues.
“The pandemic didn’t cause [these problems],” Aiken told MedPage Today. “These things were really bad before COVID, and they got a little bit worse.”
The study underscores the need for policies to prevent chronic understaffing of nurses in hospitals, Aiken’s group wrote in their paper in Nursing Outlook.
“The main takeaway is that better staffed hospitals before the pandemic had better outcomes during it, and continue to have better outcomes as time goes on,” Aiken said.
Prior to the pandemic, 57% of hospital staff nurses said there were too few nurses to care for patients; that number grew to 67% during the pandemic.
However, the high proportion of nurses who reported burnout grew only 3 percentage points after more than 1 year of the pandemic (51% vs 48% prior to the pandemic).
Nor was there “evidence that large numbers of nurses left healthcare or hospital practice in the first 18 months of the pandemic,” the researchers found. Comparing pre-pandemic survey data with data collected during the pandemic, the share of nurses employed in hospitals did not differ by more than a fraction of 1% (43.9% vs 43.7%, P=0.322).
“All this business of people throwing up their arms and saying ‘There are not nurses to hire because they’ve all left’ [is] not really true,” she said.
While there has been a lot of “disruption” and many nurses have changed employers, “leaving your employer is not the same as leaving the field of patient care or even leaving hospitals,” Aiken stressed.
In addition, the share of nurses reporting they were “not confident in management resolving clinical care problems” grew during the pandemic from 69.4% to 77.5% (P<0.001), rates Aiken called shocking.
“You could see that it would be very demoralizing if three-quarters of all the nurses that you work with have absolutely no confidence that top management is setting a priority on the things that you are really invested in as a clinician,” she said.
“This is at the heart of the burnout, and the job dissatisfaction and all of the turnover in hospitals,” Aiken suggested.
Additionally, the group found that nurses with lower patient-to-nurse staffing ratios prior to the pandemic had lower rates of a range of negative outlooks during the pandemic. Nurses with a pre-pandemic patient-to-nurse ratio of five or less were less likely to endorse the following compared with those who had a ratio of six or more:
- Job dissatisfaction (25.1% vs 35%)
- Unfavorable patient safety grades (33.9% vs 54.6% )
- Poor or fair quality of care (15.7% vs 33.0%)
- Administration doesn’t listen or respond to nurses’ concerns (44% vs 58.2%)
That “deep chasm” in confidence in hospital management might have been due to furloughs and layoffs of nurses during the pandemic, leading to a loss of confidence that hospitals really had patients’ interests at heart, Aiken suggested.
“As nurses lose their sense of loyalty to an individual hospital that just creates this sort of revolving door where people keep going on to the next best offer,” Aiken said.
Unless they can bridge that gap in confidence, hospitals won’t succeed in bringing nurses back, she added.
One silver lining was a finding of “very good” relations between doctors and nurses, Aiken said. The share of nurses reporting that there is “not a lot of nurse-physician teamwork” actually declined during the pandemic from 18.9% to 15.1%.
The findings imply that fixing hospitals’ nursing care shortages might take “committing more of their budget to employing full time nurses and improving their work environment,” Aiken said, which might be achieved by engaging more clinicians in decision-making, offering more flexible scheduling and committing to developing their workforce.
“Everybody wants the nurse with 10 years of ICU experience when they come in the door,” Aiken said, but “successful organizations develop their own work forces and invest in young people and help them to become experts over time and then create policies to retain them.”
Policy levers like nursing staffing standards are also important to consider, she added, pointing to the success of California’s implementation of staffing ratios some 20 years ago.
“But no other state has been able to do it since,” she said, because of strong resistance from the hospital industry.
Instead of relying on states, Aiken suggested looking to the federal government for support. Medicare, for instance, could make staffing levels more transparent by requiring all hospitals that participate in the program to publicly report their nursing ratios on the Hospital Compare website or simply mandate minimum nurse staffing standards, she suggested.
Methodology and Limitations
The cross-sectional study was based on surveys of 151,335 registered nurses in New York and Illinois, including a subset of 40,674 staff nurses working at 357 hospitals, representing 99% of all facilities in those states.
Data were collected via an online survey during the prepandemic period from Dec. 16, 2019, to Feb. 24, 2020, and during the pandemic from April 13, 2021, to June 22, 2021.
All registered nurses with active licenses in New York and Illinois were invited to take the survey. Approximately 81,263 nurses participated pre-pandemic and 70,072 participated during the pandemic, for response rates of 18% and 14%, respectively.
Respondents were asked whether they were currently employed in a healthcare position at a hospital, employed in a healthcare position but not in a hospital, employed but not in healthcare, not currently employed, or retired.
Because the study measures were conducted at only two points in time, the authors warned against drawing causal inferences. The survey response rates were also “not optimal” they wrote, although “not out of line” with other large online surveys.
Other limitations were that the pandemic-era surveys might not have been representative of the entire pandemic, with further changes possible since the time of completion, and the number of overlapping respondents who participated in both rounds of surveys was unknown.
The study was supported by the National Council on State Boards of Nursing, the National Institute of Nursing Research, NIH, and the Agency for Healthcare Research and Quality.
The authors reported no conflicts of interest.
Source Reference: Aiken, LH et al “A repeated cross-sectional study of nurses immediately before and during the Covid-19 pandemic: Implications for action” Nursing Outlook 2022; DOI:10.1016/j.outlook.2022.11.007.