COVID pandemic’s effect on nurse staffing confounds linear expectations

Perception: Unprecedented workplace strains caused U.S. nurses to quit in droves during the COVID-19 crisis. Reality: Nurses had been complaining about poor working conditions for years when COVID descended. 

In fact, many or most who left their jobs in the early 2020s—whether for other nursing jobs or entirely new work—were thinking about doing so prior to the pandemic. 

And yet the proportion of nurses who left their primary jobs nearly doubled in 2022 (24%) vs. 2018 (13%).

So maybe COVID’s added burdens were a collective last straw on the overburdened camel’s back. 

Maybe. 

The findings and observations are from research conducted at the University of Michigan and published in the May edition of Medical Care, a journal of the American Public Health Association.

High COVID caseload ‘not associated with employment changes’ 

For the investigation, PhD candidate Charlotte Ahr, RN, MSN, and colleagues conducted a difference-in-difference analysis using data from almost 100,000 nurses in the 2018 (pre-pandemic) and 2022 (pandemic-concurrent) National Sample Survey of Registered Nurses. 

Ahr and co-researchers used the data to build a state-level measure of COVID-19 caseload. This they defined as COVID-19 cases per hospital bed.

They determined high vs. low COVID states based on metrics above versus below the median and used logistic regression models were to estimate the effect of exposure to high COVID-19 caseload (vs. low) and time (2022 vs. 2018) on nurse employment choices across four care settings—inpatient, long-term, outpatient and nonclinical.

The team’s most consequential conclusion: “Exposure to high COVID-19 caseload was not associated with changes in nurses’ employment settings.”

The usual suspects—stress, burnout, workloads 

Their other key findings:

• From 2018 to 2022, the size of the U.S. nursing workforce grew from 3.27 to 3.57 million nurses; however, RN fulltime equivalents (FTEs) increased in outpatient settings and decreased in all other settings. 
   
• In adjusted analyses, nurses were less likely to work in long-term care settings in 2022 than in 2018. Yet those exposed to high COVID-19 caseloads were 0.9% more likely to work in long-term care than those exposed to low COVID-19 caseloads. 
   
• Differences between high versus low COVID-19 caseload exposure were not statistically significant for the likelihood of working in inpatient, outpatient and nonclinical settings.

Further, Ahr and co-researchers found that, across all care settings, the most common reasons for leaving were a stressful work environment, burnout, insufficient staffing and lack of good management. 

These concerns were more common in 2022 than in 2018, especially among nurses working in inpatient and long-term care settings, the study authors report. 

A surprising inversion of expectations  

In a news release from the university, Ahr comments: 

“Because we found the changes in nurse employment weren’t driven by whether states had high COVID caseloads, we explored the reasons that nurses left their jobs. Always rising to the top were stressful work environments, burnout and inadequate staffing.”

Ahr emphasizes that job turnover is not the same as leaving nursing entirely. In the present study, she points out, turnover means nurses left their primary job. 

“They may have moved to another nursing job, changed care settings, reduced their hours, become travel nurses, retired or left nursing temporarily.”

Ahr says the team was surprised to find long-term nurse employment declined less in states with high COVID caseloads than in their low-caseload counterparts. 

The oddity, she offers, “could reflect policy responses, recruitment efforts or local labor-market dynamics rather than a direct positive effect of the pandemic.”