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Chronic hospital nurse understaffing meets COVID-19: an observational study
  1. Karen B Lasater1,2,
  2. Linda H Aiken1,2,
  3. Douglas M Sloane1,
  4. Rachel French1,2,
  5. Brendan Martin3,
  6. Kyrani Reneau3,
  7. Maryann Alexander3,
  8. Matthew D McHugh1,2
  1. 1Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
  3. 3National Council of State Boards of Nursing, Chicago, Illinois, USA
  1. Correspondence to Dr Karen B Lasater, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA; karenbl{at}


Introduction Efforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public’s health. Despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one US state (California) sets patient-to-nurse staffing standards. To inform staffing legislation actively under consideration in two other US states (New York, Illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. Coincidentally, data collection occurred just prior to the COVID-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing.

Methods Survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout.

Results Mean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in New York City. Over half the nurses in both states experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units.

Conclusions Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health. Such risks could be addressed by safe nurse staffing policies currently under consideration.

  • health policy
  • health services research
  • nurses
  • patient safety

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  • Funding National Council of State Boards of Nursing; National Institute of Nursing Research (grant number: R01NR014855); Leonard Davis Institute of Health Economics.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. US Nurse survey data: These data were collected under the NCSBN grant (KBL, principal investigator) for purposes of improving nurse and patient outcomes and were granted a certificate of confidentiality through the National Institutes of Health/Department of Health and Human Services as per section 301(d) of the Public Health Service Act 42 USC 241(d).

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