The ongoing investigation into hospital staff practices has revealed significant issues that have been exacerbated by the COVID-19 pandemic. A recent study by the University of Pennsylvania highlights the severe burnout experienced by nurses, which has been linked to long-standing inadequate staffing policies.
This extensive survey, conducted by the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research (CHOPR), involved over 70,000 registered nurses in New York and Illinois. The study, titled “A Repeated Cross-Sectional Study of Nurses Immediately Before and During the COVID-19 Pandemic: Implications for Action,” provides a detailed look at the dire working conditions faced by nurses both before and during the pandemic.
Lead author Linda Aiken, PhD, RN, FAAN, emphasized that returning to pre-pandemic conditions will not resolve the ongoing disruptions in hospital care. Aiken, a Professor of Nursing and Sociology and the Founding Director of CHOPR, called for transformational improvements in nurse staffing and clinical work environments to stabilize the workforce and ensure safe patient care.
The survey asked nurses about their working conditions, staffing adequacy, administrative policies, patient outcomes, infection prevention practices, and management’s commitment to patient safety. The findings, while not surprising to hospital insiders, may shock the general public who have viewed healthcare facilities as heroic during the pandemic.
Before the pandemic, 69% of nurses lacked confidence in hospital management to address clinical care issues. This figure rose to 78% during the pandemic. Additionally, 48% of nurses felt that patient safety was not a top priority for management before the pandemic, increasing to 58% during the crisis.
Staffing issues were also highlighted, with 64.9% of medical-surgical nurses reporting insufficient staffing before the pandemic, which increased to 75% during the pandemic. High burnout rates were evident, with 54% of medical-surgical nurses experiencing burnout pre-pandemic, rising to 58.9% during the pandemic.
The research team concluded that the high rates of nurse burnout during the pandemic were largely due to pre-existing burnout. Addressing the root causes of nurse burnout and job dissatisfaction is crucial for achieving a stable and qualified hospital nurse workforce.
These findings come shortly after U.S. Surgeon General Vice Admiral Vivek Murthy issued a special advisory warning that burnout has reached crisis levels across the U.S. healthcare workforce. Burnout among health workers has harmful consequences for patient care and safety, including decreased provider-patient interaction, increased medical errors, and hospital-acquired infections.
One of the primary drivers of nurse burnout is the chronic stress caused by patient overload. When a nurse has too many patients, they cannot provide the necessary care or perform effective patient surveillance, leading to poor patient outcomes. The nurse-to-patient staffing ratio is a critical issue, although many patients are unaware of its importance.
Over the past 20 years, more than 100 studies have confirmed the link between inadequate nurse-to-patient staffing levels and poor patient outcomes, including unnecessary deaths. Safe nurse staffing standards, such as those established by law in California, mandate that nurses in adult medical-surgical units care for no more than five patients at a time. However, many hospitals across the country set higher nurse-to-patient workloads to reduce costs, which can have serious consequences.
A landmark 2002 study by a Penn Nursing CHOPR team found that in hospitals with high nurse-to-patient ratios, each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue. Each additional patient per nurse also increased the odds of nurse burnout by 23% and job dissatisfaction by 15%.
Recent studies by LDI Senior Fellow Margo Brooks Carthon have shown that inadequate nurse-to-patient staffing ratios also increase racial disparities in patient outcomes. Minorities, who already experience worse hospital outcomes due to structural racism and chronic diseases, are further disadvantaged by reduced nursing attention.
Despite various state programs addressing nurse staffing issues, the only major policy response that has significantly improved patient care quality is California’s law mandating minimum nurse staffing requirements. This law has resulted in California hospital patients receiving an average of 2-3 more hours per day of registered nursing care.
In Pennsylvania, a political battle over a potential state law mandating nurse staffing minimums is currently underway. Despite majority support among legislators, the measure has been stalled in the Republican-controlled House Health Committee. The state’s hospital association and healthcare unions are actively lobbying for and against the proposal.
Following the 2022 election, Democrats have gained leverage in the Pennsylvania Legislature, potentially opening new opportunities for the safe nurse staffing bill to progress toward becoming law.
Linda Aiken stressed the urgency of the situation, stating that millions of patients are currently receiving care in hospitals with too few nurses, leading to unnecessary deaths and poor outcomes. The public’s gratitude toward nurses during the pandemic has not translated into advocacy and policy actions to ensure adequate nurse staffing for safe and effective care.
