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Article Contents

Introduction, the current nursing workforce—what do we know, how are shortages calculated and why do shortages of nurses arise, how can nurse shortages be reduced, gap analysis, concluding comment, acknowledgements, conflict of interest statement.

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Global nurse shortages—the facts, the impact and action for change

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Vari M Drennan, Fiona Ross, Global nurse shortages—the facts, the impact and action for change, British Medical Bulletin , Volume 130, Issue 1, June 2019, Pages 25–37, https://doi.org/10.1093/bmb/ldz014

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Nurses comprise half the global health workforce. A nine million shortage estimated in 2014 is predicted to decrease by two million by 2030 but disproportionality effect regions such as Africa. This scoping review investigated: what is known about current nurse workforces and shortages and what can be done to forestall such shortages?

Published documents from international organisations with remits for nursing workforces, published reviews with forward citation and key author searches.

Addressing nurse shortages requires a data informed, country specific model of the routes of supply and demand. It requires evidence informed policy and resource allocation at national, subnational and organisation levels.

The definition in law, type of education, levels and scope of practice of nurses varies between countries raising questions of factors and evidence underpinning such variation. Most policy solutions proposed by international bodies draws on data and research about the medical workforce and applies that to nurses, despite the different demographic profile, the work, the career options, the remuneration and the status.

Demand for nurses is increasing in all countries. Better workforce planning in nursing is crucial to reduce health inequalities and ensure sustainable health systems.

Research is needed on: the nursing workforce in low income countries and in rural and remote areas; on the impact of scope of practice and task-shifting changes; on the impact over time of implementing system wide policies as well as raising the profile of nursing.

Achieving population health, universal health coverage and equitable access to health care is dependent on having a health workforce that is of sufficient capacity, capability and quality to meet epidemiological challenges and changing demand 1 . The World Health Organization (WHO) predicts increased global demand for health and social care staff with the creation of 40 million new jobs by 2030. 2 Professionally educated nurses are numerically the largest professional group in most countries and comprise about half the global healthcare workforce. 2 In 2014, WHO and the World Bank calculated a global shortage of 9 million nurses and midwives. They predicted this will reduce by 2030 to 7.6 million but it will have a disproportionate impact on regions such as Africa. 3 This scoping review 4 addressed the questions: what is known about the current nursing workforce, how are shortages calculated and why do shortages of nurses arise, what can be done to forestall such shortages in a national and global context and where are the evidence gaps?

A scoping review maps out the breadth of issues, identifying areas for policy and research. 4 The review has drawn on the publications of international organizations with remits for health workforce (WHO, Office of Economic Co-operation and Development[OECD]) and nursing (International Council of Nurses [ICN]), reviews concerned with nursing workforce and shortages identified through database searches (SCOPUS, Medline, CINAHL 1-1-2008–1-12-2018) and follow up of cited literature and key authors. The review excluded literature concerned with midwives and nurse-midwifes.

WHO estimated 21 million nurses/midwives 2 globally in 2014, although there are variations in definition and deployment, which we explain later in this section. Despite the 2008 global financial crisis, the number of nurses has grown in many countries 5 . The absolute numbers range from over 3 million nurses in large countries such China, India and the United States to under 5000 in smaller countries such as Guinea, Iceland and Jamaica 3 . Many countries, however, have very little data on the distribution, types or trends of their nursing workforce that contrasts with information held about the medical workforce 2 .

Nurse shortages have to be considered in the context of international variation in health system development, size of the economy, the population size as well as the presence of other key health professionals, the most important of which is medicine. The international variation in ratio of nurses to population and doctors is illustrated in Table 1 .

Examples of variation by country in ratios of nurses to population and to doctors in 2017 or nearest year data available

Data compiled from four OECD sources 5 , – 8 .

The figures in Table 1 , however, mask some fundamental variations as to who counts as a nurse; not all countries have legislation to protect the title and education level of ‘nurse’ 9 . Registered nurse (RN) academic levels also vary; for example, in Europe RN education is at diploma level in seven countries, e.g. Luxembourg, but at degree level in others, e.g. United Kingdom (UK) 10 . Some countries regulate multiple levels of nurse, such as practical nurses and advanced practice nurses. Regulated practical nurses have different names: enrolled nurse (Zambia), licensed practical nurses (US), nurse assistant (Ghana) and nurse associate (UK). Advanced practice roles are those in which RNs, with additional training, undertake diagnostic and treatment roles traditionally the domain of the doctors. Like practical nurses, these are variously named: nurse clinician (Botswana), nurse officer (Lesotho) and nurse practitioner (US). Advanced practice roles and education are not always regulated, for example as in the UK 11 . Some countries also have nurse anaesthetists who are licensed to provide general and regional anaesthesia independently. Countries that have nurse anaesthetists include: Sweden, 12 the US that has over 42 000 13 and Ghana where, regulated by the General Medical Council, there are 14 nurse anaesthetists to every one doctor anaesthesiologist 14 . The scope of practice of nurses also varies. For example, in some countries, RNs have legal authority to prescribe pharmaceutical drugs independently although there are differences as to which nurses (on registration or with additional education) and which classes of drugs 15 . The extent of the scope of practice and advanced practice roles in any country reflects historical and contemporary issues including shortages or mal-distribution of doctors as well as support or otherwise from medical professional bodies.

Four further points are relevant in considering the global nursing workforce and shortages. Firstly, 90% of nurses are women 2 . Even in countries where there have been active programmes to increase the recruitment of men, such as the US, less than 10% are male 16 . Secondly, in most countries the majority of nurses earn less than the average wage of that country 2 . There is some evidence that male nurses on average earn more than female nurses 16 and that nurses from minority ethnic backgrounds earn less and are under-represented in senior grades than those of majority ethnic origin (see for example evidence from the UK 17 ). Thirdly, the majority of nurses are employed within hospitals (see Table 2 ) despite broader international policy aims of strengthening primary care. Lastly, the majority of nurses are salaried employees although in a few countries some practice as independent, self-employed professionals as in the infirmiers liberales in France (see Table 2 ) 18 . Taking into account these similarities and variations in the education, deployment and scope of practice of nurses, we turn now to consider shortages of nurses and the causes.

Nurse employment in different sectors from five exemplar high-income countries in 2018 or nearest year

Data Sources US Bureau of Labor Statistics 19 , Australian Health Workforce 20 , NHS Digital England 21 , Japan Nursing Association 22 , Ministère des Solidarités et de la Santé 23 .

* National Health Service only, ** Infirmiers liberale in primary care.

Calculating shortages

Definitions of ‘shortages’ in workforce are policy contingent and vary between health care systems. Criteria of ‘hard to fill vacancies’ or trends in ‘volume of current vacant posts’ are often used to describe health systems experiencing financial and demand pressures 24 . The latter measure is used currently in the National Health Service (NHS) in the UK and has been reported to have an upward trend over the previous 3 years 25 . A more prosaic definition of national shortages is whether RNs are on a government’s occupation shortage list for inward migration, as they are for Australia 26 and the UK 27 but not for the US 28 , at the time of writing.

In contrast, there are those definitions of shortages that flow from staff planning projections. These calculate any gap between the numbers of nurses required (demand for) against the future number available to work (the supply). One such example is from WHO and the World Bank in which shortages are defined as lower than the minimum number of doctors and nurses per head of population required to achieve population health targets. 3 The targets in this case being 12 of the infectious disease, child and maternal health and non-communicable health specified in the Sustainable Development Goals 3 . Using national data, WHO/World Bank estimated the 7.6 million global shortfall by 2030 with disproportionate impact on Africa and low-income countries. However, many health care systems have other developments beyond minimum targets that create demand for nurses but few have undertaken nurse staffing planning projections at a national level. Only 5 of 31 high-income OECD member countries have modelled their demand for and supply of nurses to 2025. Of the five, four (Australia, Canada, Ireland and UK) predicted shortages and one, the US, predicted a surplus of qualified nurses 29 .

Models of supply of and demand for nurses

WHO offers a system-wide model for the supply and stock of all types of health professionals 2 . We have adapted the model to focus specifically on the supply and availability of qualified nurses (Fig. 1 ). This illustrates the inflows and outflows to the pipeline of supply, to the pool of RNs and to stock of nurses available for employment as nurses. The model applies at national and sub-national levels, where other patterns become more evident such as internal migration from rural to urban areas. All countries face similar problems in the supply of nurses and other health professionals in remote and rural areas 30 . There are some countries, which have an oversupply of nurses, e.g. Philippines as part of ‘export’ model—whereby working age women (often with children) enter other countries as migrants and work in the health system, sending money home to support their families 31 .

Model of the supply of nurses able and willing to participate in a national nurse labour market (adapted from WHO 2 ).

Model of factors increasing and decreasing the demand for nurses.

Shortages occur when demand for nurses outstrips the numbers of nurses available for employment. An overarching factor influencing demand is the economy; for example, vacant nurse posts were frozen following the 2008 global financial crisis in countries such as Iceland 9 and Kenya 32 . Many factors influence the demand for nurses and we offer a model of these in Figure 2 . However, the extent of the demand for nurses is country and time specific. For example, there was increased demand in Thailand in the late eighties when a strong economy was the catalyst for the growth in private hospitals 33 and currently in the US where state legislation specifies the ratio of RNs to in-patients 34 . The volume of internationally educated nurses in a country maybe an indicator of a shortfall against demand or may be the custom and practice for the supply of nurses. For example, the Netherlands has had less than 1% foreign-trained nurses in its workforce consistently over the past 15 years while others such as the UK, Australia and New Zealand have consistently had over 14% in the same period 5 .

What attracts nurses to jobs and why do they leave?

Individual : skills and interests, career plans, caring/family responsibilities, financial responsibilities.

Job characteristics : remuneration, other financial benefits (e.g. health insurance, pension), hours and pattern of working, type and volume of work, physical and/or emotional intensity of work, variety of work, team working, level of responsibility/autonomy, clinical and managerial support, professional support.

Organization : clinical and employer reputation, type (e.g. private, public), size of organization, size of specialties within an organization, infrastructure to support employees (e.g. child care facilities, meal and social facilities), access to professional and career development activities and/or funding for these.

Location : urban, sub-urban, rural, proximity to family and/or other services such as schools for children.

Macro and meso level factors in the home country with the perceived converse in the country of destination : weak economy, political instability and/or civil unrest, unemployment of nurses, low status of nurses, poor working conditions, few opportunities for nurses for career progression.

Personnel level factors : desire for different cultural, life and/or health system experience, perceived opportunity for better financial rewards, perceived opportunity for improved quality of life for family and children, following already established partner or family network in the destination country, opportunity for career advancement and/or education.

Trying to understand why nurses leave and what retains nurses in their jobs has been a perennial question; the first Lancet Commission into shortages of nurses in the UK was published in 1933 39 . Innumerable literature reviews on the subject in the intervening years demonstrate the interlocking range of factors at individual, organizational and the broader socio-economic level 40 . A recent umbrella review of systematic reviews investigating the determinants of nurse turnover (leaving their jobs) in high-income countries reported that most studies focused on ‘individual’ factors influencing ‘intention to leave’, i.e. plans rather than actual leaving 41 . Most of the evidence reported was at the individual level; high levels of stress and burnout, job dissatisfaction and low commitment was associated with intention to leave. The few studies looking at intentions to remain found this had a strong association with good supervisor support 41 . However, there was an absence of studies that considered the interplay of factors at multiple levels (e.g. individual, job characteristics, organizational characteristics and the wider labour market) on actual leaving rates of RNs or on any subgroups, such as those with caring responsibilities 41 . The International Council of Nurses has also noted there is a paucity of evidence that has considered turnover and retention of nurses in low-income countries 42 . We turn now to consider the evidence for action to solve the shortages and mal-distribution.

The WHO calls for greater investment in all human resources for health and advocates for policy attention across the system of production, regulation and employment 2 . Most commentators on nursing shortages make similar arguments that policy attention needs to be paid to all elements (known as policy bundles) and avoid policy making that relies on oversimplified linear thinking. The evidence to support this comes from high- and low-income countries where programmes that focused only on increasing the numbers entering nurse training, have failed to make an impact on increasing numbers entering the workplace or reducing gaps in priority areas with a history of shortages. Subsequent analysis has identified multiple reasons for this failure including: insufficient infrastructure for clinical education, weak regulation of education standards and few posts to apply for, see for example the review from Sub-Saharan African countries 43 . This is not to argue that increasing numbers entering nurse training is inappropriate, but should be seen as one lever among a policy bundle, including for example, retention measures. The UK and the US provide interesting comparisons, in that one (the UK) has reduced nurse training numbers over the past 15 years, has significant numbers of vacancies and plans to rely on internationally trained nurses over the next few years, while the other (the US) has significantly increased nurse graduates over the past 15 years and does not count nursing as a shortage occupation 44 .

Drawing on commentaries and WHO strategic direction statements for strengthening the nursing and midwifery contribution Table 3 describes policy actions to scale up and sustain the nursing workforce at different levels of the health care system.

Exemplars of policy areas to address improved supply, retention and productivity of nurses

The policy solutions have to attend to the demand as well as the supply side, i.e. to increase RN productivity (for example, working to the full extent of their license, task shifting to assistants, using technologies and community health workers) as well as to produce more and retain more RNs. However, documented evaluations of the impact of the implementation of policy bundles on the nursing workforce are rare not least because of the inter-sectoral nature of enactment and the relatively long period between policy decisions, implementation and outcome. Even where there are evaluations of implementation of policy actions to address shortages, such as the WHO strategy for remote and rural areas, these focus on the medical profession not nurses 45 .

At the micro level (organization/service delivery level), good human resource management practices are known to reduce the rates of voluntary turnover in all industries 46 . An umbrella systematic review considered interventions to reduce turnover rates of nurses (i.e. to retain them in their posts) in high-income countries 47 This review found relatively weak evidence for most interventions but there was strong evidence of positive impact for transition programmes and support for newly qualified nurses 47 . There was also evidence that nurse manager leadership styles that were perceived as encouraging work group cohesion were also effective in reducing turnover 47 . Positive working environments are those that not only ensure the nurses well-being but sustain or increase their motivation in their work. There is some evidence that many RNs (like many physicians) in high-income countries consider that they are not working to the full scope of their training and are undertaking work that could be undertaken by others 44 . However, task shifting, shifts in jurisdiction and changes in skill-mixes in teams raises questions of adequate preparation, patient safety and cost effectiveness—all of which require consideration within specific contexts. For example, a growing body of evidence in high-income countries demonstrates a relationship between RN staffing levels and patient safety in acute in-patient hospital settings. Recent research on in-patient hospital care in the UK demonstrates that lower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital and that use of nursing assistants does not compensate for reduced RN staffing 48 . There are significant gaps in evidence for the most effect ways of increasing RN productivity as well as attracting and retaining RNs in the workplace that requires attention to be given to the macro and overarching issues in every health system.

The first major gap is in relation to nursing workforce planning. Workforce planning at a national level is an inexact science and is often absent for nursing, which is in contrast with medical manpower planning. To plan for solutions, you need to understand the scale of the problem, which in the case of nursing, is limited by the significant evidence gaps. For example, at the national level, nursing workforce data is often incomplete and based on historical activity rather than projections. The 2016 WHO resolution on human resources for health urges all countries to have health workforce-related planning mechanisms and has introduced national health workforce accounts with core indicators, including ratio of nurses to population, for annual submission to the WHO Secretariat 1 . However, this could be considered the minimum requirement for benchmarking rather than proactively modelling the future demand for nurses, the availability and supply of nurses and planning to meet the gap or shortfall. This then flags the next gap—the evidence to base the planning decisions on.

The second major gap is the evidence informing policy decisions about interventions that work to attract, equitably distribute, retain and sustain a nursing workforce against the requirements of any health care system. It is noteworthy that the WHO guidance for scaling up and retaining all health care professionals 2 is predominantly evidenced from studies of doctors, thus further emphasizing this gap in the evidence. The demographic profile, status, education, career options and remuneration levels for these two professions are very different and assumptions that evidence from one professionally is automatically applicable and relevant to the other is contestable and at worst misleading.

Overlaying these gaps in knowledge there is an issue, common across many countries as noted by WHO 2 , that the profession of nursing has not been valued and given the policy attention congruent with its scale. Having a weak voice and influence in national and international health workforce policy development has inevitable consequences, which in this context means that fewer levers are available to address shortages and action is slow. At the time of writing, there is a global WHO-sponsored campaign called Nursing Now (2018–20) ( https://www.nursingnow.org/ ) that supports country-specific campaigns and activities to raise the profile of the nursing profession, develop leaders for governments and to make change at a systems level. This is involving nurses in policy making, particularly with regard to increasing and retaining the nursing workforce. The response to, and impact of, these calls for country-specific campaigns is yet to be evaluated.

This review has demonstrated that that the nature and size of the professionally qualified nurse workforce is shaped by the societal context of individual countries—political choices that influence decisions about resource allocation to health systems, demographics (labour market pressures on working age, particularly of women), image of nursing and its positional power in relation to medicine, demands for care/health and social inequalities. Understanding nursing shortages and acting on them requires attention to the gaps in knowledge and evidence but also the wider societal context of nursing.

This review was undertaken without external funding.

The authors have no potential conflicts of interest.

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NCSBN Research Projects Significant Nursing Workforce Shortages and Crisis

CHICAGO – Today, NCSBN unveiled its research, titled “Examining the Impact of the COVID-19 Pandemic on Burnout & Stress Among U.S. Nurses,” in a panel titled “Nursing at the Crossroads: A Call to Action” in Washington, D.C. at the National Press Club at 9:30 am EST.

For the first time, the research findings reveal how the nursing workforce was impacted by the pandemic and how many left the workforce in this period, and forecast how many nurses in the U.S. have an intent to leave the workforce. The research also examined the personal and professional characteristics of nurses experiencing heightened workplace burnout and stress due to the COVID-19 pandemic.

The study is considered to be the most comprehensive and only research in existence, uncovering the alarming data points which have far reaching implications for the health care system at large and for patient populations. The research was gathered as part of a biennial nursing workforce study conducted by NCSBN and the National Forum of State Nursing Workforce Centers.

Key findings include:

• Approximately 100,000 registered nurses (RNs) left the workforce during the COVID-19 pandemic in the past two years due to stress, burnout and retirements.
• Another 610,388 RNs reported an “intent to leave” the workforce by 2027 due to stress, burnout and retirement.
• 188,962 additional RNs younger than 40 years old reported similar intentions.
• Altogether, about one-fifth of RNs nationally are projected to leave the health care workforce.
• 62% of the sample reported an increase in their workload during the pandemic.
• A quarter to half of nurses reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out (45.1%), or at the end of the rope (29.4%) “a few times a week” or “every day.”
• These issues were most pronounced with nurses with 10 or fewer years of experience, driving an overall 3.3% decline in the U.S. nursing workforce in the past two years.
• Licensed practical/vocational nurses, who generally work in long-term care settings caring for the most vulnerable populations, have seen their ranks decline by 33,811 since the beginning of the pandemic. This trend continues.

Research also suggested that nurses’ workloads and unprecedented levels of burnout during the COVID-19 pandemic played key roles in accelerating these workforce trends and threatening the future of the U.S. nursing workforce, particularly for younger, less experienced RNs. Further, high levels of turnover were seen with the potential for even further declines in a post-pandemic nursing workplace as disruptions in prelicensure nursing programs have also raised concerns about the supply and clinical preparedness of new nurse graduates. Early career data for new entrants into the profession suggest decreased practice and assessment proficiency. Coupled with large declines among nursing support staff, NCSBN calls for significant action to foster a more resilient and safe U.S. nursing workforce moving forward.

“The data is clear: the future of nursing and of the U.S. health care ecosystem is at an urgent crossroads,” said Maryann Alexander, PhD, RN, FAAN, NCSBN Chief Officer of Nursing Regulation. “The pandemic has stressed nurses to leave the workforce and has expedited an intent to leave in the near future, which will become a greater crisis and threaten patient populations if solutions are not enacted immediately. There is an urgent opportunity today for health care systems, policymakers, regulators and academic leaders to coalesce and enact solutions that will spur positive systemic evolution to address these challenges and maximize patient protection in care into the future.”

The research findings and proposed solutions were presented in a panel discussion today at the National Press Club in Washington, D.C.

Panelists included:

• Antonia Villarruel, Dean of Nursing at University of Pennsylvania
• Gay Landstrom, Senior Vice President and Chief Nursing Officer at Trinity Health System
• Congresswoman Lisa Blunt Rochester, U.S. Representative of Delaware
• Robyn Begley, CEO of the American Organization for Nursing Leadership and CNO/Sr. VP for the American Hospital Association
• Rayna M. Letourneau, Board of Directors, National Forum for State Workforce Centers

A recording of the panel discussion is available on ncsbn.org .

To request interviews with NCSBN or view the entire research, please contact [email protected] or visit ncsbn.org .

Research Methodology: The study examines a subset of the 2022 National Nursing Workforce Study for analysis. Reported trends represent population-based estimates. There were 29,472 registered nurses (including advanced registered nurses [APRN]) and 24,061 licensed practical nurses/vocational nurses across 45 states included.

About NCSBN Empowering and supporting nursing regulators across the world in their mandate to protect the public, NCSBN is an independent, not-for-profit organization. As a global leader in regulatory excellence, NCSBN champions regulatory solutions to borderless health care delivery, agile regulatory systems and nurses practicing to the full scope of their education, experience and expertise. A world leader in test development and administration, NCSBN’s NCLEX® Exams are internationally recognized as the preeminent nursing examinations.

NCSBN’s membership is comprised of the nursing regulatory bodies (NRBs) in the 50 states, the District of Columbia and four U.S. territories. There are five exam user members and 25 associate members that are either NRBs or empowered regulatory authorities from other countries or territories.

The statements and opinions expressed are those of NCSBN and not individual members.

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RN Shortages Negatively Impact Patient Safety

• PMID: 30801322
• DOI: 10.1097/01.NAJ.0000554040.98991.23

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Nearly a third of nurses nationwide say they are likely to leave the profession

Jaclyn Diaz

Miriala Gonzalez, a registered nurse in Miami, carries a monkeypox vaccine. A new survey highlights major concerns from nurses nationwide regarding future staffing levels in hospitals. Joe Raedle/Getty Images hide caption

Miriala Gonzalez, a registered nurse in Miami, carries a monkeypox vaccine. A new survey highlights major concerns from nurses nationwide regarding future staffing levels in hospitals.

Close to a third of nurses nationwide say they are likely to leave the profession for another career due to the COVID-19 pandemic, a new survey from AMN Healthcare shows.

This level is up at least seven points since 2021. And the survey found that the ongoing shortage of nurses is likely to continue for years to come.

About 94% of nurses who responded to the AMN Healthcare survey said that there was a severe or moderate shortage of nurses in their area, with half saying the shortage was severe. And around 89% of registered nurses (RNs) said the nursing shortage is worse than five years ago.

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The economics of america's nurse shortage.

Nurses aren't optimistic about the future, either. At least 80% of those surveyed expect that to get much worse in another five years, the report shows.

Unions representing nurses have long warned about the problem facing the profession, said National Nurses United President Deborah Burger and President of SEIU Healthcare 1199NW Jane Hopkins. Both women are also RNs.

"It's a critical moment in our time for nurses. The country needs nurses. We are very short and we are feeling very worried about the future of their work," Hopkins said.

Nurses, other healthcare workers and members of the Service Employees International Union rally for better staffing levels at West Hills Hospital on January 12, 2023 in West Hills, California. Araya Doheny/Getty Images for SEIU hide caption

Nurses, other healthcare workers and members of the Service Employees International Union rally for better staffing levels at West Hills Hospital on January 12, 2023 in West Hills, California.

The COVID-19 pandemic certainly exacerbated problems, but short staffing was an issue even before then, Burger and Hopkins said.

"The staffing crisis didn't just happen. It's been around for years. Unions have been sounding the alarm that organizations were putting profits before patients," Hopkins said. Employers "had cut staffing so bad, that there was no room for flexibility."

She said she hears from members that they rarely have time to eat lunch or use the bathroom during their shifts.

Low staffing has a dangerous trickle-down effect, Burger said. It leads to a heavier workload, more stress and burnout for the remaining staff, as well as a negative impact to patient care.

The AMN Healthcare survey findings indicated younger generations of nurses were also less satisfied with their jobs compared to their older counterparts.

Shots - Health News

The u.s. needs more nurses, but nursing schools don't have enough slots.

But even before the pandemic, the younger generation had signaled they were done with nursing, Hopkins said. "First and second year nurses were leaving the profession at a higher rate because it's not what they expected. This escalated during the pandemic," she said.

Across generations, a higher percentage of nurses also reported dealing with a greater deal of stress at their job than in previous years, the survey said. Four in five nurses experience high levels of stress at work — an increase of 16 points from 2021.

Similarly, a higher level of nurses reported feeling emotionally drained from the 2021 survey — up at least 15% in two years (62% to 77%).

One source of that stress? Nurses are also experiencing an increasing level workplace violence in the hospitals, Burger said.

"Nurses don't feel safe in many of the hospitals around the country. And we've heard horrendous stories. That also gets tied back into short staffing," she said.

Nurses have been fighting for better working conditions

This discontent among staff has deeper implications for hospitals and other organizations across the country.

In January, around 7,000 nurses in New York went on strike over a contract dispute with hospitals in the city. The nurses were looking for higher wages and better working conditions. This strike forced several hospitals to divert patients elsewhere.

NYC nurses are on strike, but the problems they face are seen nationwide

For Health Care Workers, The Pandemic Is Fueling Renewed Interest In Unions

Vox reported in January that nurses and other healthcare workers have frequently gone on strike in recent years. In 2022, eight of the 25 work stoppages involving 1,000 or more workers in the U.S. were done by nurses.

National Nurses United has issued a number of its own reports and surveys about the current state of the profession, which have come to similar conclusions to the AMN survey. The union has lobbied Congress hard to pass legislation that address staffing ratios and improve workplace safety provisions .

The AMN Healthcare survey similarly recommended that health care providers create safer working environments and broader regulatory changes to make meaningful differences.

Burger was more direct.

"Stop studying it and start actually legislating. Congress knows that they need to do something," Burger said.

"It's concerning that there's a lot of hand wringing," she said, but nothing is being done.

The U.S. Nursing Shortage: A State-by-State Breakdown

• Nursing shortages continue to affect every state, especially in the southwestern U.S.
• A lack of educators, more nurses leaving the workforce, and the rising demand for healthcare is driving the shortage.
• These factors combine to create a cycle, with overwork leading to more burnout.

The nursing shortage in the U.S. is still a concern. A lack of nurse educators keeps nursing schools from being able to admit enough students to address the shortfall. A shortage of nurses means more burnout and more nurses choosing to leave the profession, contributing to the shortage.

In addition, the aging of Baby Boomers means that more nurses are retiring at a time when an aging population has a greater need for healthcare providers. The COVID-19 pandemic exacerbated the nursing shortage. Learn more about the nursing shortage by state and what legislators are doing to address it.

To best understand the shortage on a national scale, we gathered the most recent available data on the number of registered nurses employed in each state from the U.S. Bureau of Labor Statistics (BLS). We then compared these figures to state population estimates to illustrate the nursing shortage on a state-by-state basis. The table below provides a ranking of states, starting with those with the lowest nurse-to-state population ratios.

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Local Nurse Employment vs. National Nurse Employment

Major cities with higher populations tend to always need more nurses, with most city hospitals offering many open positions. According to data from the BLS , the following five states have the lowest local concentrations of nurse employment vs. national nurse employment:

• Utah (0.68 location quotient)
• District of Columbia (0.82 location quotient)
• Nevada (0.82 location quotient)
• Idaho (0.83 location quotient)
• Texas (0.86 location quotient)

Metropolitan areas tend to maintain the highest location quotients of local nurse employment to national nurse employment:

• Bloomsburg Berwick, Pennsylvania (3.14 location quotient)
• Morgantown, West Virginia (2.90 location quotient)
• Rochester, Minnesota (2.77 location quotient)
• Ann Arbor, Michigan (2.37 location quotient)
• Iowa City, Iowa (2.26 location quotient)

From the BLS data: The location quotient is the ratio of the area concentration of occupational employment to the national average concentration. A location quotient greater than one indicates the occupation has a higher share of employment than average, and a location quotient less than one indicates the occupation is less prevalent in the area than average.

Larger cities tend to suffer more from nursing shortages due to higher population densities. Simply put, there needs to be more new nurses entering the field to properly manage the volume of people who need healthcare within most large cities.

Factors Contributing to the National Nursing Shortage

According to StatPearls there are many factors contributing to the national nursing shortage, including:

• Lack of educators and schooling: Nursing school enrollment hasn’t kept up with projected demand. There’s also a need for more nursing school instructors. Without enough teachers, thousands of people interested in joining the nursing workforce are unable to do so without degrees.
• High turnover: For years, nurse turnover has climbed at a steady rate. In some cases, nursing graduates quickly enter the workforce and find that the profession is not what they anticipated. In other scenarios, nurses may work for a while, experience burnout, and leave the profession.
• An aging workforce: The rate of retirement for nurses is growing rapidly, as over half of the RN workforce is currently over 50 years old .

State legislators are addressing the nursing shortage . Hospitals and schools are also taking action to combat the nursing shortage and prevent a future deficit.

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What is the nursing shortage, why is there a nursing shortage.

• Is the Nursing Shortage Getting Worse?

How Do We Solve the Nursing Shortage?

The nursing shortage is a growing problem in the United States, with the   U.S. Bureau of Labor Statistics (BLS) projecting that a 6% growth rate in the demand for registered nurses will result in a need for 3.3 million nurses by 2031. But, how much of that will need will actually be met?

Unfortunately, the Covid-19 pandemic has only exacerbated this issue as front-line nurses feel the strain of increased workloads and decreased staffing levels. This has led to higher rates of nurse burnout due to long hours and high-stress levels.

The nursing shortage is impacting the care that nurses are able to provide for patients and stretching their ability to cope with having to do more work with less help. 

But why is there a nursing shortage? And can anything be done about it? Keep reading to learn about the causes and possible solutions of the nursing shortage based on findings from our own 2023 State of Nursing report and other findings from the AACN. 

>> Download the 2023 State of Nursing Report

According to the American Association of Colleges of Nursing (AACN) , the nursing shortage is a chronic and escalating problem created by several interrelated factors:

• Nursing school enrollment not keeping up with the demand for nurses
• Shortage of nurse faculty restricting nursing school enrollments
• A large number of nurses are retiring or approaching retirement
• Increase in the aging population and therefore nursing services
• Insufficient staffing causes nurses to leave the profession

Interestingly, many of the top reasons nurses cited as causes of the nursing shortage are not included in the AACN’s list.  When asked “What do you think are the primary causes of the nursing shortage?” these were the most popular responses from the 2023 State of Nursing survey:

• Nurses are burned out - 74%
• Poor working conditions - 58%
• Inadequate pay for nurses - 57%
• Lack of appreciation for nurses - 34%

The greater number of patients due to an aging population, changes to the medicare/healthcare system, and lack of nursing school educators/faculty got the least amount of responses from nurses. Indicating that, while these systemic factors may be contributing to the overall nursing shortage, that’s not what nurses are feeling on a day-to-day basis, and not what’s ultimately prompting many nurses to think about leaving the bedside, or even the profession altogether.

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Is the Nursing Shortage Getting Worse? 

While a nursing shortage has existed for decades, 91% of nurses believe the nursing shortage is getting worse. Other reports support this as well.

For example, a 2022 report by  McKinsey consulting and advisory firm warns that the “nursing shortage will become dire by 2025” due to a projected shortage of 200,000 to 450,000 nurses—roughly 10% to 20% of the nurses required to provide all patient care.

Already some nurses describe having to “ration care” due to inadequate nurse-patient ratios so they can focus on keeping patients “alive”, often at the expense of meeting patients’ other basic needs such as helping them with a much-needed bath.

When asked “What do you think would make the biggest impact on the nursing shortage” 71% of nurses replied that improved staffing ratios would have the biggest impact, followed by better pay (64%) and better working conditions (41%).  

But ultimately, addressing the nursing shortage will require a multi-faceted approach that includes both short-term solutions to improve nurses' daily lives and long-term strategies to address the underlying issues. 

1. Increasing Funding to Improve Nurse-Patient Ratios and Retain Nurses 

Hospitals and healthcare facilities need to start listening to nurses if they want to retain them and improving staffing ratios was the number one factor that nurses thought could positively impact the nursing shortage. 

New York state nurses described “abysmal working conditions” as they went on strike in January 2023 but were told “There’s no money in the budget” to improve working conditions and ensure safe nursing staff levels. Hospital administrators and those that control the purse strings of healthcare facility budgets need to reevaluate their budget priorities if they want to retain and attract nurses and protect patients.

2. Paying Higher Salaries to All Nurses, Particularly to Recruit and Retain Nursing Faculty

As we saw above, 64% of nurses believe that better pay would help lessen the nursing shortage. When we asked nurses how they felt about their current pay, 75% of nurses said they felt underpaid. 

In addition, a major reason for the shortage of nursing faculty is low salaries. While the average salary of an advanced nurse practitioner with a master’s degree is $120,680 , master’s prepared nursing faculty were paid just $87,325/year in 2022. 

With the average nursing faculty salary being $33,372/year less than what nurses earn in clinical and private-sectors positions, it’s hard to attract and retain faculty. Therefore, nursing faculty salaries need to be increased substantially if nursing schools want to attract and retain faculty.

3. Better Working Conditions

Being able to do things like take breaks and feeling that they’re able to turn down extra shifts may seem like basics that all nurses should be getting, but our survey shows that they are not. 72% of nurses don’t have adequate backup, 53% of nurses are unable to take sick days, and 36% feel that they can’t turn down extra shifts at work. 

4. Providing Funding for More Master’s and Doctoral Nursing Student Enrollments 

According to the AACN, “Master’s and doctoral programs in nursing are not producing a large enough pool of potential nurse educators to meet the demand.” 

For example, although enrollment in entry-level baccalaureate nursing programs increased by 3.3% in 2021, enrollment in master’s and PhD nursing programs dropped by 7% and 3.8%, respectively. 

Therefore, more funding and recruitment need to be directed at graduate-level nursing programs to help prepare more nursing faculty and create more advanced practice nurses.

5. Designing Nursing Positions That Offer Better Work-Life Balance

And finally, nurse leaders need to start creating nursing positions that allow nurses to have a better work-life balance if they want to attract and retain nurses in these positions. 

The high levels of nurse burnout and chronic stress in nursing are simply unacceptable and cannot continue if the nursing shortage is to be significantly reduced.  81% of nurses said they’ve felt burnt out in the past year, according to our survey. 

Nurses will continue to leave the profession and their jobs in search of a more manageable lifestyle and less stressful work.

By making a commitment to listen to nurses and implement these changes, policymakers, facility administrators, and nurse leaders can reverse this nursing shortage and ensure that our healthcare system has enough nurses to meet the needs of patients now and into the future.

Leona Werezak BSN, MN, RN is the Director of Business Development at NCLEX Education. She began her nursing career in a small rural hospital in northern Canada where she worked as a new staff nurse doing everything from helping deliver babies to medevacing critically ill patients. Learning much from her patients and colleagues at the bedside for 15 years, she also taught in baccalaureate nursing programs for almost 20 years as a nursing adjunct faculty member (yes! Some of those years she did both!). As a freelance writer online, she writes content for nursing schools and colleges, healthcare and medical businesses, as well as various nursing sites.

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Facing 'critical' staff shortages, nurses in these states work the most hours at long-term care facilities

Facing ‘critical’ staff shortages, nurses in these states work the most hours at long-term care facilities

A nurse holding an elderly man’s hand on his cane.

Unlike hospital and outpatient care settings, where staffing has returned to or surpassed levels seen prior to the COVID-19 pandemic, nursing home staffing continues to experience shortages. A quarter of all nursing homes in the United States in recent years reported  “critical” staff shortages amid growing demand from an aging population for long-term health care.

To better explore the working conditions of registered nurses in nursing homes, Vivian Health examined payroll data compiled by the Centers for Medicare & Medicaid Services to see where RNs in long-term care facilities work the longest shifts. The data represents the average daily hours worked during the first three months of 2024, the latest data available.

Workforce capacity in nursing homes, already in decline before COVID-19, was further exacerbated by the pandemic, according to the 2023 “National Healthcare Quality and Disparities Report” from the Agency for Healthcare Research and Quality. Surges of various COVID-19 variants, including Alpha, Delta, and Omicron, coincided with worsening staff shortages. That crisis has only deepened: There were 8.4% fewer nursing and residential care workers employed in January 2023 than in January 2020, according to the AHRQ.

Factors outside COVID also contribute to critical staffing shortages in long-term care facilities. Burnout among nursing home care workers plays a key role in driving staffing challenges. Occupational hazards, long working shifts, exposure to violence, low salaries, and high workloads have all been shown to correlate with high levels of burnout among long-term care facility nurses.

When nurses experiencing burnout opt for less stressful health care settings, staffing shortages grow—along with the responsibilities of remaining nursing home workers. In this vicious cycle, nearly half of new nurses report working overtime , and more than 1 in 10 nurses reported holding a second job. Newly licensed nurses, like experienced nurses, predominantly work 12-hour shifts, plus voluntary and mandatory overtime. Newly licensed nurses are also more likely to be scheduled for less desirable time slots , such as night shifts.

The combination of long shifts, holding multiple jobs, and working undesirable hours can accelerate burnout for early career nurses working in nursing homes: a dangerous outcome for an already limited workforce.

RNs in Alaska and Utah work the longest shifts

A map showing the average number of hours registered nurses worked in nursing homes in 2024.

Workplace data from the Centers for Medicare & Medicaid Services shows that nurses working in Alaska, Utah, Nevada, Montana, and Kentucky average the longest shifts among nurses in the United States.

Alaska, where nurses work an average of 11.9-hour shifts, faces a severe nursing shortage. There are more than 1,500 reported registered nurse vacancies, a figure expected to exceed 5,000 vacancies by 2030. A new bill signed into law in July 2024 seeks to address the nursing shortage in Alaska, citing long waits for nursing licensure that deter people from pursuing a nursing career or renewing their licenses.

Utah’s nursing shortage—nurses here work 11.77 hours per shift on average—is additionally impacted by an aging nursing population: Almost 1 in 5 Utah nurses is approaching retirement age . States that have large rural areas, such as Nevada, Montana, and Kentucky, also face significant challenges in part due to an uneven distribution of workers concentrated in urban and metropolitan areas.

Long work shifts and staffing shortages can lead to burnout, distress, and illness among nurses—but they also tend to lower the quality of care patients receive . Nurses working longer shifts may experience increased fatigue, which can lead to errors that impact patient safety and experience. Staffing shortages have even been associated with increases in patient mortality rates.

New staffing requirements issued in April 2024 aim to address overburdened worker schedules and staff shortages , but most nursing homes are not currently equipped to meet the new standards. The American Health Care Association notes that 4 out of 5 nursing homes cannot meet the requirement to have nurses on staff 24/7. When all new requirements are combined, just 6% of operating long-term care facilities can currently achieve them.

With these challenges, nursing homes are limiting admissions and are concerned about closures. AHCA reports that 66% of long-term care facilities are concerned that if workforce challenges persist, they may have to permanently close . This prospect could be devastating for thousands of residents, families, and staff.

Story editing by Nicole Caldwell. Additional editing by Kelly Glass. Copy editing by Tim Bruns. 

This story originally appeared on Vivian Health and was produced and distributed in partnership with Stacker Studio.

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• Open access
• Published: 28 August 2024

The design, implementation, and evaluation of a blended (in-person and virtual) Clinical Competency Examination for final-year nursing students

• Rita Mojtahedzadeh 1 ,
• Tahereh Toulabi 2 , 3 &
• Aeen Mohammadi 1  

BMC Medical Education volume  24 , Article number:  936 ( 2024 ) Cite this article

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Introduction

Studies have reported different results of evaluation methods of clinical competency tests. Therefore, this study aimed to design, implement, and evaluate a blended (in-person and virtual) Competency Examination for final-year Nursing Students.

This interventional study was conducted in two semesters of 2020–2021 using an educational action research method in the nursing and midwifery faculty. Thirteen faculty members and 84 final-year nursing students were included in the study using a census method. Eight programs and related activities were designed and conducted during the examination process. Students completed the Spielberger Anxiety Inventory before the examination, and both faculty members and students completed the Acceptance and Satisfaction questionnaire.

The results of the analysis of focused group discussions and reflections indicated that the virtual CCE was not capable of adequately assessing clinical skills. Therefore, it was decided that the CCE for final-year nursing students would be conducted using a blended method. The activities required for performing the examination were designed and implemented based on action plans. Anxiety and satisfaction were also evaluated as outcomes of the study. There was no statistically significant difference in overt, covert, and overall anxiety scores between the in-person and virtual sections of the examination ( p  > 0.05). The mean (SD) acceptance and satisfaction scores for students in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97), respectively, out of 30 points, in which there was a significant increase in the in-person section compared to the other sections. ( p  = 0.008). The mean acceptance and satisfaction scores for faculty members were 30.31 (4.47) in the virtual, 29.86 (3.94) in the in-person, and 30.00 (4.16) out of 33 in the blended, and there was no significant difference between the three sections ( p  = 0.864).

Evaluating nursing students’ clinical competency using a blended method was implemented and solved the problem of students’ graduation. Therefore, it is suggested that the blended method be used instead of traditional in-person or entirely virtual exams in epidemics or based on conditions, facilities, and human resources. Also, the use of patient simulation, virtual reality, and the development of necessary virtual and in-person training infrastructure for students is recommended for future research. Furthermore, considering that the acceptance of traditional in-person exams among students is higher, it is necessary to develop virtual teaching strategies.

Peer Review reports

The primary mission of the nursing profession is to educate competent, capable, and qualified nurses with the necessary knowledge and skills to provide quality nursing care to preserve and improve the community’s health [ 1 ]. Clinical education is one of the most essential and fundamental components of nursing education, in which students gain clinical experience by interacting with actual patients and addressing real problems. Therefore, assessing clinical skills is very challenging. The main goal of educational evaluation is to improve, ensure, and enhance the quality of the academic program. In this regard, evaluating learners’ performance is one of the critical and sensitive aspects of the teaching and learning process. It is considered one of the fundamental elements of the educational program [ 2 ]. The study area is educational evaluation.

Various methods are used to evaluate nursing students. The Objective Structured Clinical Examination (OSCE) is a valid and reliable method for assessing clinical competence [ 1 , 2 ]. In the last twenty years, the use of OSCE has increased significantly in evaluating medical and paramedical students to overcome the limitations of traditional practical evaluation systems [ 3 , 4 ]. The advantages of this method include providing rapid feedback, uniformity for all examinees, and providing conditions close to reality. However, the time-consuming nature and the need for a lot of personnel and equipment are some disadvantages of OSCE [ 5 , 6 ]. Additionally, some studies have shown that this method is anxiety-provoking for some students and, due to time constraints, being observed by the evaluator and other factors can cause dissatisfaction among students [ 7 , 8 ].

However, some studies have also reported that this method is not only not associated with high levels of stress among students [ 9 ] but also has higher satisfaction than traditional evaluation methods [ 4 ]. In addition, during the COVID-19 pandemic, problems such as overcrowding and student quarantine during the exam have arisen. Therefore, reducing time and costs, eliminating or reducing the tiring quarantine time, optimizing the exam, utilizing all facilities for simulating the clinical environment, using innovative methods for conducting the exam, reducing stress, increasing satisfaction, and ultimately preventing the transmission of COVID-19 are significant problems that need to be further investigated.

Studies show that using virtual space as an alternative solution is strongly felt [ 10 , 11 , 12 ]. In the fall of 2009, following the outbreak of H1N1, educational classes in the United States were held virtually [ 13 ]. Also, in 2005, during Hurricane Katrina, 27 universities in the Gulf of Texas used emergency virtual education and evaluation [ 14 ].

One of the challenges faced by healthcare providers in Iran, like most countries in the world, especially during the COVID-19 outbreak, was the shortage of nursing staff [ 15 , 16 ]. Also, in evaluating and conducting CCE for final-year students and subsequent job seekers in the Clinical Skills Center, problems such as student overcrowding and the need for quarantine during the implementation of OSCE existed. This problem has been reported not only for us but also in other countries [ 17 ]. The intelligent use of technology can solve many of these problems. Therefore, almost all educational institutions have quickly started changing their policies’ paradigms to introduce online teaching and evaluation methods [ 18 , 19 ].

During the COVID-19 pandemic, for the first time, this exam was held virtually in our school. However, feedback from professors and students and the experiences of researchers have shown that the virtual exam can only partially evaluate clinical and practical skills in some stations, such as basic skills, resuscitation, and pediatrics [ 20 ].

Additionally, using OSCE in skills assessment facilitates the evaluation of psychological-motor knowledge and attitudes and helps identify strengths and weaknesses [ 21 ]. Clinical competency is a combination of theoretical knowledge and clinical skills. Therefore, using an effective blended method focusing on the quality and safety of healthcare that measures students’ clinical skills and theoretical expertise more accurately in both in-person and virtual environments is essential. The participation of students, professors, managers, education and training staff, and the Clinical Skills Center was necessary to achieve this important and inevitable goal. Therefore, the Clinical Competency Examination (CCE) for nursing students in our nursing and midwifery school was held in the form of an educational action research process to design, implement, and evaluate a blended method. Implementing this process during the COVID-19 pandemic, when it was impossible to hold an utterly in-person exam, helped improve the quality of the exam and address its limitations and weaknesses while providing the necessary evaluation for students.

The innovation of this research lies in evaluating the clinical competency of final-year nursing students using a blended method that focuses on clinical and practical aspects. In the searches conducted, only a few studies have been done on virtual exams and simulations, and a similar study using a blended method was not found.

The research investigates the scientific and clinical abilities of nursing students through the clinical competency exam. This exam, traditionally administered in person, is a crucial milestone for final-year nursing students, marking their readiness for graduation. However, the unforeseen circumstances of the COVID-19 pandemic and the resulting restrictions rendered in-person exams impractical in 2020. This necessitated a swift and significant transition to an online format, a decision that has profound implications for the future of nursing education. While the adoption of online assessment was a necessary step to ensure student graduation and address the nursing workforce shortage during the pandemic, it was not without its challenges. The accurate assessment of clinical skills, such as dressing and CPR, proved to be a significant hurdle. This underscored the urgent need for a change in the exam format, prompting a deeper exploration of innovative solutions.

To address these problems, the research was conducted collaboratively with stakeholders, considering the context and necessity for change in exam administration. Employing an Action Research (AR) approach, a blend of online and in-person exam modalities was adopted. Necessary changes were implemented through a cyclic process involving problem identification, program design, implementation, reflection, and continuous evaluation.

The research began by posing the following questions:

What are the problems of conducting the CCE for final-year nursing students during COVID-19?

How can these problems be addressed?

What are the solutions and suggestions from the involved stakeholders?

How can the CCE be designed, implemented, and evaluated?

What is the impact of exam type on student anxiety and satisfaction?

These questions guided the research in exploring the complexities of administering the CCE amidst the COVID-19 pandemic and in devising practical solutions to ensure the validity and reliability of the assessment while meeting stakeholders’ needs.

Materials and methods

Research setting, expert panel members, job analysis, and role delineation.

This action research was conducted at the Nursing and Midwifery School of Lorestan University of Medical Sciences, with a history of approximately 40 years. The school accommodates 500 undergraduate and graduate nursing students across six specialized fields, with 84 students enrolled in their final year of undergraduate studies. Additionally, the school employs 26 full-time faculty members in nursing education departments.

An expert panel was assembled, consisting of faculty members specializing in various areas, including medical-surgical nursing, psychiatric nursing, community health nursing, pediatric nursing, and intensive care nursing. The panel also included educational department managers and the examination department supervisor. Through focused group discussions, the panel identified and examined issues regarding the exam format, and members proposed various solutions. Subsequently, after analyzing the proposed solutions and drawing upon the panel members’ experiences, specific roles for each member were delineated.

Sampling and participant selection

Given the nature of the research, purposive sampling was employed, ensuring that all individuals involved in the design, implementation, and evaluation of the exam participated in this study.

The participants in this study included final-year nursing students, faculty members, clinical skills center experts, the dean of the school, the educational deputy, group managers, and the exam department head. However, in the outcome evaluation phase, 13 faculty members participated in-person and virtually (26 times), and 84 final-year nursing students enrolled in the study using a census method in two semesters of 2020–2021 completed the questionnaires, including 37 females and 47 males. In addition, three male and ten female faculty members participated in this study; of this number, 2 were instructors, and 11 were assistant professors.

Data collection tools

In order to enhance the validity and credibility of the study and thoroughly examine the results, this study utilized a triangulation method consisting of demographic information, focus group discussions, the Spielberger Anxiety Scale questionnaire, and an Acceptance and Satisfaction Questionnaire.

Demographic information

A questionnaire was used to gather demographic information from both students and faculty members. For students, this included age, gender, and place of residence, while for faculty members, it included age, gender, field of study, and employment status.

Focus group discussion

Multiple focused group discussions were conducted with the participation of professors, administrators, experts, and students. These discussions were held through various platforms such as WhatsApp Skype, and in-person meetings while adhering to health protocols. The researcher guided the talks toward the research objectives and raised fundamental questions, such as describing the strengths and weaknesses of the previous exam, determining how to conduct the CCE considering the COVID-19 situation, deciding on virtual and in-person stations, specifying the evaluation checklists for stations, and explaining the weighting and scoring of each station.

Spielberger anxiety scale questionnaire

This study used the Spielberger Anxiety Questionnaire to measure students’ overt and covert anxiety levels. This questionnaire is an internationally standardized tool known as the STAI questionnaire that measures both overt (state) and covert (trait) anxiety [ 22 ]. The state anxiety scale (Form Y-1 of STAI) comprises twenty statements that assess the individual’s feelings at the moment of responding. The trait anxiety scale (Form Y-2 of STAI) also includes twenty statements that measure individuals’ general and typical feelings. The scores of each of the two scales ranged from 20 to 80 in the current study. The reliability coefficient of the test for the apparent and hidden anxiety scales, based on Cronbach’s alpha, was confirmed to be 0.9084 and 0.9025, respectively [ 23 , 24 ]. Furthermore, in the present study, Cronbach’s alpha value for the total anxiety questionnaire, overt anxiety, and covert anxiety scales were 0.935, 0.921, and 0.760, respectively.

Acceptance and satisfaction questionnaire

The Acceptability and Satisfaction Questionnaire for Clinical Competency Test was developed by Farajpour et al. (2012). The student questionnaire consists of ten questions, and the professor questionnaire consists of eleven questions, using a four-point Likert scale. Experts have confirmed the validity of these questionnaires, and their Cronbach’s alpha coefficients have been determined to be 0.85 and 0.87 for the professor and student questionnaires, respectively [ 6 ]. In the current study, ten medical education experts also confirmed the validity of the questionnaires. Regarding internal reliability, Cronbach’s alpha coefficients for the student satisfaction questionnaire for both virtual and in-person sections were 0.76 and 0.87, respectively. The professor satisfaction questionnaires were 0.84 and 0.87, respectively. An online platform was used to collect data for the virtual exam.

Data analysis and rigor of study

Qualitative data analysis was conducted using the method proposed by Graneheim and Lundman. Additionally, the criteria established by Lincoln and Guba (1985) were employed to confirm the rigor and validity of the data, including credibility, transferability, dependability, and confirmability [ 26 ].

In this research, data synthesis was performed by combining the collected data with various tools and methods. The findings of this study were reviewed and confirmed by participants, supervisors, mentors, and experts in qualitative research, reflecting their opinions on the alignment of findings with their experiences and perspectives on clinical competence examinations. Therefore, the member check method was used to validate credibility.

Moreover, efforts were made in this study to provide a comprehensive description of the research steps, create a suitable context for implementation, assess the views of others, and ensure the transferability of the results.

Furthermore, researchers’ interest in identifying and describing problems, reflecting, designing, implementing, and evaluating clinical competence examinations, along with the engagement of stakeholders in these examinations, was ensured by the researchers’ long-term engagement of over 25 years with the environment and stakeholders, seeking their opinions and considering their ideas and views. These factors contributed to ensuring confirmability.

In this research, by reflecting the results to the participants and making revisions by the researchers, problem clarification and solution presentation, design, implementation, and evaluation of operational programs with stakeholder participation and continuous presence were attempted to prevent biases, assumptions, and research hypotheses, and to confirm dependability.

Data analysis was performed using SPSS version 21, and descriptive statistical tests (absolute and relative frequency, mean, and standard deviation) and inferential tests (paired t-test, independent t-test, and analysis of variance) were used. The significance level was set at 0.05. Parametric tests were used based on the normality of the data according to the Kolmogorov-Smirnov statistical test.

Given that conducting the CCE for final-year nursing students required the active participation of managers, faculty members, staff, and students, and to answer the research question “How can the CCE for final-year nursing students be conducted?” and achieve the research objective of “designing, implementing, and evaluating the clinical competency exam,” the action research method was employed.

The present study was conducted based on the Dickens & Watkins model. There are four primary stages (Fig.  1 ) in the cyclical action research process: reflect, plan, act, observe, and then reflect to continue through the cycle [ 27 ].

The cyclical process of action research [ 27 ]

Stage 1: Reflection

Identification of the problem.

According to the educational regulations, final semester nursing students must complete the clinical competency exam. However, due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person was not feasible.

This exam was conducted virtually at our institution. However, based on the reflections from experts, researchers have found that virtual exams can only partially assess clinical and practical skills in certain stations, such as basic skills, resuscitation, and pediatrics. Furthermore, utilizing Objective Structured Clinical Examination (OSCE) in skills assessment facilitates the evaluation of psychomotor skills, knowledge, and attitudes, aiding in identifying strengths and weaknesses.

P3, “Due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person is not feasible.”

Stage 2: Planning

Based on the reflections gathered from the participants, the exam was designed using a blended approach (combining in-person and virtual components) as per the schedule outlined in Fig.  2 . All planned activities for the blended CCE for final-year nursing students were executed over two semesters.

P5, “Taking the exam virtually might seem easier for us and the students, but in my opinion, it’s not realistic. For instance, performing wound dressing or airway management is very practical, and it’s not possible to assess students with a virtual scenario. We need to see them in person.”

P6"I believe it’s better to conduct those activities that are highly practical in person, but for those involving communication skills like report writing, professional ethics, etc., we can opt for virtual assessment.”

Design and implementation of the blended CCE

Stage 3: Act

Cce implementation steps.

The CCE was conducted based on the flowchart in Fig.  3 and the following steps:

Steps for conducting the CCE for final-year nursing students using a blended method

Step 1: Designing the framework for conducting the blended Clinical Competency Examination

The panelists were guided to design the blended exam in focused group sessions and virtual panels based on the ADDIE (Analysis, Design, Development, Implementation, Evaluation) model [ 28 ]. Initially, needs assessment and opinion polling were conducted, followed by the operational planning of the exam, including the design of the blueprint table (Table  1 ), determination of station types (in-person or virtual), designing question stems in the form of scenarios, creating checklists and station procedure guides by expert panel groups based on participant analysis, and the development of exam implementation guidelines with participant input [ 27 ]. The design, execution, and evaluation were as follows:

In-person and virtual meetings with professors were held to determine the exam schedule, deadlines for submitting checklists, decision-making regarding the virtual or in-person nature of stations based on the type of skill (practical, communication), and presenting problems and solutions. Based on the decisions, primary skill stations, as well as cardiac and pediatric resuscitation stations, were held in person. In contrast, virtual stations for health, nursing ethics, nursing reports, nursing diagnosis, physical examinations, and psychiatric nursing were held.

News about the exam was communicated to students through the college website and text messages. Then, an online orientation session was held on Skype with students regarding the need assessment of pre-exam educational workshops, virtual and in-person exam standards, how to use exam software, how to conduct virtual exams, explaining the necessary infrastructure for participating in the exam by students, completing anxiety and satisfaction questionnaires, rules and regulations, how to deal with rejected individuals, and exam testing and Q&A. Additionally, a pre-exam in-person orientation session was held.

To inform students about the entire educational process, the resources and educational content recommended by the professors, including PDF files, photos and videos, instructions, and links, were shared through a virtual group on the social media messenger, and scientific information was also, questions were asked and answered through this platform.

Correspondence and necessary coordination were made with the university clinical skills center to conduct in-person workshops and exams.

Following the Test-centered approach, the Angoff Modified method [ 29 , 30 ] was used to determine the scoring criteria for each station by panelists tasked with assigning scores.

Additionally, in establishing standards for this blended CCE for fourth-year nursing students, for whom graduation was a prerequisite, the panelists, as experienced clinical educators familiar with the performance and future roles of these students and the assessment method of the blended exam, were involved [ 29 , 30 ](Table 1 ).

Step 2: Preparing the necessary infrastructure for conducting the exam

Software infrastructure.

The pre- and post-virtual exam questions, scenarios, and questionnaires were uploaded using online software.

The exam was conducted on a trial basis in multiple sessions with the participation of several faculty members, and any issues were addressed. Students were authenticated to enter the exam environment via email and personal information verification. The questions for each station were designed and entered into the software by the respective station instructors and the examination coordinator, who facilitated the exam. The questions were formatted as clinical scenarios, images, descriptive questions, and multiple-choice questions, emphasizing the clinical and practical aspects. This software had various features for administering different types of exams and various question formats, including multiple-choice, descriptive, scenario-based, image-based, video-based, matching, Excel output, and graphical and descriptive statistical analyses. It also had automatic questionnaire completion, notification emails, score addition to questionnaires, prevention of multiple answer submissions, and the ability to upload files up to 4 gigabytes. Student authentication was based on national identification numbers and student IDs, serving as user IDs and passwords. Students could enter the exam environment using their email and multi-level personal information verification. If the information did not match, individuals could not access the exam environment.

Checklists and questionnaires

A student list was prepared, and checklists for the in-person exam and anxiety and satisfaction questionnaires were reproduced.

Empowerment workshops for professors and education staff

Educational needs of faculty members and academic staff include conducting clinical competency exams using the OSCE method; simulating and evaluating OSCE exams; designing standardized questions, checklists, and scenarios; innovative approaches in clinical evaluations; designing physical spaces and setting up stations; and assessing ethics and professional commitment in clinical competency exams.

Student empowerment programs

According to the students’ needs assessment results, in-person workshops on cardiopulmonary resuscitation and airway management and online workshops were held on health, pediatrics, cardiopulmonary resuscitation, ethics, nursing diagnosis, and report writing through Skype messenger. In addition, vaccination notes, psychiatric nursing, and educational files on clinical examinations and basic skills were recorded by instructors and made available to students via virtual groups.

Step 3: CCE implementation

The CCE was held in two parts, in-person and virtual.

In-person exam

The OSCE method was used for this section of the exam. The basic skills station exam included dressing and injections, and the CPR and pediatrics stations were conducted in person. The students were divided into two groups of 21 each semester, and the exam was held in two shifts. While adhering to quarantine protocols, the students performed the procedures for seven minutes at each station, and instructors evaluated them using a checklist. An additional minute was allotted for transitioning to the next station.

Virtual exam

The professional ethics, nursing diagnosis, nursing report, health, psychiatric nursing, and physical examination stations were conducted virtually after the in-person exam. This exam was made available to students via a primary and a secondary link in a virtual space at the scheduled time. Students were first verified, and after the specified time elapsed, the ability to respond to inactive questions and submitted answers was sent. During the exam, full support was provided by the examination center.

The examination coordinator conducted the entire virtual exam process. The exam results were announced 48 h after the exam. A passing grade was considered to be a score higher than 60% in all stations. Students who failed in various stations were given the opportunity for remediation based on faculty feedback, either through additional study or participation in educational workshops. Subsequent exams were held one week apart from the initial exam. It was stipulated that students who failed in more than half of the stations would be evaluated in the following semester. If they failed in more than three sessions at a station, a decision would be made by the faculty’s educational council. However, no students met these situations.

Step 4: Evaluation

The evaluation of the exam was conducted by examiners using a checklist, and the results were announced as pass or fail.

Stage 4: Observation / evaluation

In this study, both process and outcome evaluations were conducted:

Process evaluation

All programs and activities implemented during the test design and administration process were evaluated in the process evaluation. This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups.

Sample reflections received from faculty members, managers, experts, and students through group discussions and social messaging platforms after the changes:

P7: “The implementation of the blended virtual exam, in the conditions of the COVID-19 crisis where the possibility of holding in-person exams was not fully available, in my opinion, was able to improve the quality of exam administration and address the limitations and weaknesses of the exam entirely virtually.”

P5: “In my opinion, this blended method was able to better evaluate students in terms of clinical readiness for entering clinical practice.”

Outcomes evaluation

The study outcomes were student anxiety, student acceptance and satisfaction, and faculty acceptance and satisfaction. Before the start of the in-person and virtual exams, the Spielberger Anxiety Questionnaire was provided to students. Additionally, immediately after the exam, students and instructors completed the acceptance and satisfaction questionnaire for the relevant section. After the exam, students and instructors completed the acceptance and satisfaction questionnaire again for the entire exam process, including feasibility, satisfaction with its implementation, and educational impact.

Design framework and implementation for the blended Clinical Competency Examination

The exam was planned using a blended method (part in-person, part virtual) according to the Fig.  2 schedule, and all planned programs for the blended CCE for final-year nursing students were implemented in two semesters.

Evaluation results

In this study, 84 final-year nursing students participated, including 37 females (44.05%) and 47 males (55.95%). Among them, 28 (33.3%) were dormitory residents, and 56 (66.7%) were non-dormitory residents.

In this study, both process and outcome evaluations were conducted.

All programs and activities implemented during the test design and administration process were evaluated in the process evaluation (Table  2 ). This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups on social media.

Anxiety and satisfaction were examined and evaluated as study outcomes, and the results are presented below.

The paired t-test results in Table  3 showed no statistically significant difference in overt anxiety ( p  = 0.56), covert anxiety ( p  = 0.13), and total anxiety scores ( p  = 0.167) between the in-person and virtual sections before the blended Clinical Competency Examination.

However, the mean (SD) of overt anxiety in persons in males and females was 49.27 (11.16) and 43.63 (13.60), respectively, and this difference was statistically significant ( p  = 0.03). Also, the mean (SD) of overt virtual anxiety in males and females was 45.70 (11.88) and 51.00 (9.51), respectively, and this difference was statistically significant ( p  = 0.03). However, there was no significant difference between males and females regarding covert anxiety in the person ( p  = 0.94) and virtual ( p  = 0.60) sections. In addition, the highest percentage of overt anxiety was apparent in the virtual section among women (15.40%) and the in-person section among men (21.28%) and was prevalent at a moderate to high level.

According to Table  4 , One-way analysis of variance showed a significant difference between the virtual, in-person, and blended sections in terms of acceptance and satisfaction scores.

The results of the One-way analysis of variance showed that the mean (SD) acceptance and satisfaction scores of nursing students of the CCE in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97) out of 30, respectively. There was a significant difference between the three sections ( p  = 0.008).

In addition, 3 (7.23%) male and 10 (76.3%) female faculty members participated in this study; of this number, 2 (15.38%) were instructors, and 11 (84.62%) were assistant professors. Moreover, they were between 29 and 50 years old, with a mean (SD) of 41.37 (6.27). Furthermore, they had 4 to 20 years of work experience with a mean and standard deviation of 13.22(4.43).

The results of the analysis of variance showed that the mean (SD) acceptance and satisfaction scores of faculty members of the CCE in virtual, in-person, and blended sections were 30.31 (4.47), 29.86 (3.94), and 30.00 (4.16) out of 33, respectively. There was no significant difference between the three sections ( p  = 0.864).

This action research study showed that the blended CCE for nursing students is feasible and, depending on the conditions and objectives, evaluation stations can be designed and implemented virtually or in person.

The blended exam, combining in-person and virtual elements, managed to address some of the weaknesses of entirely virtual exams conducted in previous terms due to the COVID-19 pandemic. Given the pandemic conditions, the possibility of performing all in-person stations was not feasible due to the risk of students and evaluators contracting the virus, as well as the need for prolonged quarantine. Additionally, to meet the staffing needs of hospitals, nursing students needed to graduate. By implementing the blended exam idea and conducting in-person evaluations at clinical stations, the assessment of nursing students’ clinical competence was brought closer to reality compared to the entirely virtual method.

Furthermore, the need for human resources, station setup costs, and time spent was less than the entirely in-person method. Therefore, in pandemics or conditions where sufficient financial resources and human resources are not available, the blended approach can be utilized.

Additionally, the evaluation results showed that students’ total and overt anxiety in both virtual and in-person sections of the blended CCE did not differ significantly. However, the overt anxiety of female students in the virtual section and male students in the in-person section was considerably higher. Nevertheless, students’ covert anxiety related to personal characteristics did not differ in virtual and in-person exam sections. However, students’ acceptance and satisfaction in the in-person section were higher than in the virtual and blended sections, with a significant difference. The acceptance and satisfaction of faculty members from the CCE in in-person, virtual, and blended sections were the same and relatively high.

A blended CCE nursing competency exam was not found in the literature review. However, recent studies, especially during the COVID-19 pandemic, have designed and implemented this exam using virtual OSCE. Previously, the CCE was held in-person or through traditional OSCE methods.

During the COVID-19 pandemic, nursing schools worldwide faced difficulties administering clinical competency exams for students. The virtual simulation was used to evaluate clinical competency and develop nursing students’ clinical skills in the United States, including standard videos, home videos, and clinical scenarios. Additionally, an online virtual simulation program was designed to assess the clinical competency of senior nursing students in Hong Kong as a potential alternative to traditional clinical training [ 31 ].

A traditional in-person OSCE was also redesigned and developed through a virtual conferencing platform for nursing students at the University of Texas Medical Branch in Galveston. Survey findings showed that most professors and students considered virtual OSCE a highly effective tool for evaluating communication skills, obtaining a medical history, making differential diagnoses, and managing patients. However, professors noted that evaluating examination techniques in a virtual environment is challenging [ 32 ].

However, Biranvand reported that less than half of the nursing students believed the in-person OSCE was stressful [ 33 ]. At the same time, the results of another study showed that 96.2% of nursing students perceived the exam as anxiety-provoking [ 1 ]. Students believe that the stress of this exam is primarily related to exam time, complexity, and the execution of techniques, as well as confusion about exam methods [ 7 ]. In contrast to previous research results, in a study conducted in Egypt, 75% of students reported that the OSCE method has less stress than other examination methods [ 9 ]. However, there has yet to be a consensus across studies on the causes and extent of anxiety-provoking in the OSCE exam. In a study, the researchers found that in addition to the factors mentioned above, the evaluator’s presence could also be a cause of stress [ 34 ]. Another survey study showed that students perceived the OSCE method as more stressful than the traditional method, mainly due to the large number of stations, exam items, and time constraints [ 7 ]. Another study in Egypt, which designed two stages of the OSCE exam for 75 nursing students, found that 65.6% of students reported that the second stage exam was stressful due to the problem-solving station. In contrast, only 38.9% of participants considered the first-stage exam stressful [ 35 ]. Given that various studies have reported anxiety as one of the disadvantages of the OSCE exam, in this study, one of the outcomes evaluated was the anxiety of final-year nursing students. There was no significant difference in total anxiety and overt anxiety between students in the in-person and virtual sections of the blended Clinical Competency Examination. The overt anxiety was higher in male students in the in-person part and female students in the virtual section, which may be due to their personality traits, but further research is needed to confirm this. Moreover, since students’ total and overt anxiety in the in-person and virtual sections of the exam are the same in resource and workforce shortages or pandemics, the blended CCE is suggested as a suitable alternative to the traditional OSCE test. However, for generalization of the results, it is recommended that future studies consider three intervention groups, where all OSCE stations are conducted virtually in the first group, in-person in the second group, and a blend of in-person and virtual in the third group. Furthermore, the results of the study by Rafati et al. showed that the use of the OSCE clinical competency exam using the OSCE method is acceptable, valid, and reliable for assessing nursing skills, as 50% of the students were delighted, and 34.6% were relatively satisfied with the OSCE clinical competency exam. Additionally, 57.7% of the students believed the exam revealed learning weaknesses [ 1 ]. Another survey study showed that despite higher anxiety about the OSCE exam, students thought that this exam provides equal opportunities for everyone, is less complicated than the traditional method, and encourages the active participation of students [ 7 ]. In another study on maternal and infant care, 95% of the students believed the traditional exam only evaluates memory or practical skills. In contrast, the OSCE exam assesses knowledge, understanding, cognitive and analytical skills, communication, and emotional skills. They believed that explicit evaluation goals, appropriate implementation guidelines, appropriate scheduling, wearing uniforms, equipping the workroom, evaluating many skills, and providing fast feedback are among the advantages of this exam [ 36 ]. Moreover, in a survey study, most students were satisfied with the clinical environment offered by the OSCE CCE using the OSCE method, which is close to reality and involves a hypothetical patient in necessary situations that increase work safety. On the other hand, factors such as the scheduling of stations and time constraints have led to dissatisfaction among students [ 37 ].

Furthermore, another study showed that virtual simulations effectively improve students’ skills in tracheostomy suctioning, triage concepts, evaluation, life-saving interventions, clinical reasoning skills, clinical judgment skills, intravenous catheterization skills, role-based nursing care, individual readiness, critical thinking, reducing anxiety levels, and increasing confidence in the laboratory, clinical nursing education, interactive communication, and health evaluation skills. In addition to knowledge and skills, new findings indicate that virtual simulations can increase confidence, change attitudes and behaviors, and be an innovative, flexible, and hopeful approach for new nurses and nursing students [ 38 ].

Various studies have evaluated the satisfaction of students and faculty members with the OSCE Clinical Competency Examination. In this study, one of the evaluated outcomes was the acceptability and satisfaction of students and faculty members with implementing the CCE in blended, virtual, and in-person sections, which was relatively high and consistent with other studies. One crucial factor that influenced the satisfaction of this study was the provision of virtual justification sessions for students and coordination sessions with faculty members. Social messaging groups were formed through virtual and in-person communication, instructions were explained, expectations and tasks were clarified, and questions were answered. Students and faculty members could access the required information with minimal presence in medical education centers and time and cost constraints. Moreover, with the blended evaluation, the researcher’s communication with participants was more accessible. The written guidelines and uploaded educational content of the workshops enabled students to save the desired topics and review them later if needed. Students had easy access to scientific and up-to-date information, and the application of social messengers and Skype allowed for sending photos and videos, conducting workshops, and questions and answering questions. However, the clinical workshops and examinations were held in-person to ensure accuracy. The virtual part of the examination was conducted through online software, and questions focused on each station’s clinical and practical aspects. Students answered various questions, including multiple-choice, descriptive, scenario, picture, and puzzle questions, within a specified time. The blended examination evaluated clinical competency and did not delay these individuals’ entry into the job market. Moreover, during the severe human resource shortage faced by the healthcare system, the examination allowed several nurses to enter the country’s healthcare system. The blended examination can substitute in-person examination in pandemic and non-pandemic situations, saving facilities, equipment, and human resources. The results of this study can also serve as a model to guide other nursing departments that require appropriate planning and arrangements for Conducting Clinical Competency Examinations in blended formats. This examination can also be developed to evaluate students’ clinical performance.

One of the practical limitations of the study was the possibility that participants might need to complete the questionnaires accurately or be concerned about losing marks. Therefore, in a virtual session before the in-person exam, the objectives and importance of the study were explained. Participants were assured that it would not affect their evaluation and that they should not worry about losing marks. Additionally, active participation from all nursing students, faculty members, and staff was necessary for implementing this plan, achieved through prior coordination, virtual meetings, virtual group formation, and continuous reflection of results, creating the motivation for continued collaboration and participation.

Among other limitations of this study included the use of the Spielberger Anxiety Questionnaire to measure students’ anxiety. It is suggested that future studies use a dedicated anxiety questionnaire designed explicitly for pre-exam anxiety measurement. Another limitation of the current research was its implementation in nursing and midwifery faculty. Therefore, it is recommended that similar studies be conducted in nursing and midwifery faculties of other universities, as well as in related fields, and over multiple consecutive semesters. Additionally, for more precise effectiveness assessment, intervention studies in three separate virtual, in-person, and hybrid groups using electronic checklists are proposed. Furthermore, it is recommended that students be evaluated in terms of other dimensions and variables such as awareness, clinical skill acquisition, self-confidence, and self-efficacy.

Conducting in-person Clinical Competency Examination (CCE) during critical situations, such as the COVID-19 pandemic, is challenging. Instead of virtual exams, blended evaluation is a feasible approach to overcome the shortages of virtual ones and closely mimic in-person scenarios. Using a blended method in pandemics or resource shortages, it is possible to design, implement, and evaluate stations that evaluate basic and advanced clinical skills in in-person section, as well as stations that focus on communication, reporting, nursing diagnosis, professional ethics, mental health, and community health based on scenarios in a virtual section, and replace traditional OSCE exams. Furthermore, the use of patient simulators, virtual reality, virtual practice, and the development of virtual and in-person training infrastructure to improve the quality of clinical education and evaluation and obtain the necessary clinical competencies for students is recommended. Also, since few studies have been conducted using the blended method, it is suggested that future research be conducted in three intervention groups, over longer semesters, based on clinical evaluation models and influential on other outcomes such as awareness and clinical skill acquisition self-efficacy, confidence, obtained grades, and estimation of material and human resources costs. This approach reduced the need for physical space for in-person exams, ensuring participant quarantine and health safety with higher quality. Additionally, a more accurate assessment of nursing students’ practical abilities was achieved compared to a solely virtual exam.

Data availability

The datasets generated and analyzed during the current study are available on request from the corresponding author.

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Acknowledgements

We want to thank the Research and Technology deputy of Smart University of Medical Sciences, Tehran, Iran, the faculty members, staff, and officials of the School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran, and all individuals who participated in this study.

All steps of the study, including study design and data collection, analysis, interpretation, and manuscript drafting, were supported by the Deputy of Research of Smart University of Medical Sciences.

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RM. Participating in study design, accrual of study participants, review of the manuscript, and critical revisions for important intellectual content. TT : The investigator; participated in study design, data collection, accrual of study participants, and writing and reviewing the manuscript. AM: Participating in study design, data analysis, accrual of study participants, and reviewing the manuscript. All authors read and approved the final version of the manuscript.

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This action research was conducted following the participatory method. All methods were performed according to the relevant guidelines and regulations in the Declaration of Helsinki (ethics approval and consent to participate). The study’s aims and procedures were explained to all participants, and necessary assurance was given to them for the anonymity and confidentiality of their information. The results were continuously provided as feedback to the participants. Informed consent (explaining the goals and methods of the study) was obtained from participants. The Smart University of Medical Sciences Ethics Committee approved the study protocol (IR.VUMS.REC.1400.011).

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Mojtahedzadeh, R., Toulabi, T. & Mohammadi, A. The design, implementation, and evaluation of a blended (in-person and virtual) Clinical Competency Examination for final-year nursing students. BMC Med Educ 24 , 936 (2024). https://doi.org/10.1186/s12909-024-05935-9

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Nursing Workforce Challenges in the Postpandemic World

The United States and the rest of the world continue to grapple with the COVID-19 pandemic. Considering that nurses make up the largest segment of the U.S. healthcare workforce, they are essential to the country’s collective pandemic response. Nurses are the primary source of direct care to persons infected by COVID-19, including historically marginalized populations, and the ongoing demands placed on nurses are leading to unprecedented stress, burnout, and uncertainty about their profession. Even before the pandemic, healthcare settings were chronically understaffed and nurses were burnt out. According to a prepandemic analysis, a shortfall of more than 150,000 registered nurses was anticipated by 2020 ( Zhang et al., 2018 ). The pandemic has exacerbated the labor shortage well beyond prior forecasts, stressing an already fragile U.S. healthcare system and potentially contributing to worse patient outcomes and wider health inequities.

A 2021 integrative review examining the pre- and post-COVID-19 pandemic literature on nursing turnover found that since the pandemic’s onset, there has been a significant increase in nurse turnover intention ( Falatah, 2021 ). A 16-study synthesis of nurse burnout literature during the pandemic found high levels of emotional exhaustion and depersonalization, as well as reduced feelings of personal accomplishment ( Galanis et al., 2021 ). The same study also identified risk factors for burnout, including decreased social support, working in hospitals with inadequate and insufficient material and human resources, and increased workload ( Galanis et al., 2021 ).

The staggeringly high turnover across America’s working population due to the COVID-19 pandemic has been referred to as the “Great Resignation” ( Gahdhi & Robison, 2021 ). In addition to record-high resignations and unfilled positions, an analysis by Gallup found employee engagement—rather than an industry, role, or pay issue—to be the major risk factor for resignation ( Gahdhi & Robison, 2021 ). From September 2019 to March 2021, the proportion of U.S. employees “actively disengaged” (looking for a job or watching for opportunities) increased from 69% to 74% ( Gahdhi & Robison, 2021 ).

Studies suggest that nursing is particularly susceptible to the Great Resignation. An American Nurses Foundation (2022) survey of nearly 12,000 nurses conducted in January 2022 found that 60% of respondents younger than 35 years reported experiencing an extremely stressful, violent, or traumatic event resulting from COVID-19, and 89% reported that their organization was experiencing a staffing shortage. More than one-half of respondents felt undervalued, and nearly one quarter reported that they intended to leave their positions in the next 6 months.

Concerned about these trends, the AcademyHealth Interdisciplinary Research Group on Nursing Issues (IRGNI) has devoted its energy to supporting the development of health services research that examines the nursing workforce, shapes our understanding of the practice environment, and evaluates the workforce needs of the postpandemic world in both hospital and community settings. The collection of abstracts presented at this year’s IRGNI conference reflects this commitment. Many of these abstracts address the adverse effects of the pandemic on nurses. Stimpfel, for example, describes the impact of the first 6 months of the pandemic on nurses’ psychological health and reports high rates of depression, anxiety, and insomnia. In the study by Montgomery and Patrician, the researchers show that stress during the pandemic contributed to high rates of burnout. Similarly, Pogue et al. found that during COVID-19, registered nurses, compared to physicians and advanced practice providers, reported the highest levels of burnout, job dissatisfaction, stress, and intent to leave.

These abstracts reinforce the importance of a supportive work environment for achieving nurses’ well-being, improving patient outcomes, and reducing health inequities. Townley et al., for example, found that poorly rated primary care nurse practitioner work environments contributed to high rates of hospitalization for dually-eligible adults with chronic conditions. In a systematic review of 12 research articles, Rosenbaum and Lake reported a strong association between hospital nursing resources, such as Magnet designation, nurse staffing, and the nurse work environment, and patient satisfaction based on the Hospital Consumer Assessment of Healthcare Providers and Systems survey.

Taken together, these works call for “rebooting” the practice environment to offset the adverse effects of the pandemic on nurses and their patients, and the nursing workforce must be prepared for the postpandemic world. Investments in the practice environment may help to offset the adverse effects of the pandemic on nurses and their patients. We believe that this will require innovative models of nurse-led care; reimagined nursing-sensitive performance measures; new and sustained efforts for promoting diversity, equity, and inclusion; payment policies that reflect nurses’ value; as well as innovative organizational and institutional approaches that enable flexibility and recognize nurses’ contributions. The IRGNI looks to its members and other nursing health services researchers to open lines of inquiry that inform these new directions and improve healthcare delivery for all Americans.

We thank the contributors for their trailblazing work, and we look forward to witnessing and contributing to the innovations in practice environments to come.

A Mixed Methods Study of Individual and Work Factors Associated With Psychosocial Health of Registered Nurses During the COVID-19 Pandemic

Author: Amy Witkoski Stimpfel, PhD, RN

Research Objective: To describe the initial influence of the COVID-19 pandemic on U.S. nurses’ psychosocial health, and to identify factors associated with poor psychosocial health outcomes.

Study Design: We conducted an exploratory, descriptive study with a convergent mixed methods design (QUAN + qual) in which the quantitative data were prioritized and qualitative data were used to explain and augment findings. The quantitative data were captured in a survey of nurses’ work environments, COVID-19–related experiences, and psychosocial health outcomes using REDCap, a secure cloud-based platform. We developed separate multivariable logistic regression models for 3 psychosocial health outcomes using the Patient Health Questionnaire (PHQ-9), which is a 9-item survey measuring depressive symptom severity; the Generalized Anxiety Disorder (GAD-7) tool, which measures anxiety using 7 items; and the Insomnia Severity Index (ISI), which measures insomnia symptoms with 7 items. Qualitative data were captured in individual semi-structured interviews conducted through audio-only Zoom meetings. An interview guide based on the conceptual framework that guided this study (Work, Stress, and Health) consisted of a series of theoretically derived open-ended questions and probes. We used content analysis to process and analyze qualitative data. To integrate the quantitative and qualitative data, we used joint analysis displays.

Population Studied: Participants were recruited from June to August 2020, which was an early period of the pandemic in the United States. To capture a range of geographic locations and pandemic intensity, we used multiple sources, including regional professional nursing organization membership list servs, NIOSH (National Institute for Occupational Safety and Health) Education and Research Centers, and social media platforms. Eligibility criteria included (a) being a registered nurse, (b) currently working in the, United States, and, (c) having at least 6 months of work experience since initial nursing licensure. We administered surveys ( N = 629) and conducted semi-structured interviews ( N = 34) among a subset of nurses working across healthcare settings in 18 states.

Principal Findings: Nurses reported high rates of depressive symptoms (22%), anxiety (52%), and insomnia (55%). The only work or COVID-19–related variable that predicted poor outcomes across all three multivariable logistic regression models was shorter total sleep time before work, i.e., 5 hours of sleep or less. The integrated analysis found that disturbances to sleep were both a contributing factor to, and an outcome of, poor psychosocial health status. Throughout the individual interviews, participants described sleep as “the biggest issue I’ve had” with a mix of anxiety and insomnia co-occurring. For example, one participant said, “I had the anxiety and the constant racing of thoughts and that kind of kept me up and that didn’t let me fall asleep as well.” Anxiety and rumination about their working conditions—extreme stress, understaffing, redeployment into a COVID-19 unit, rationing/lack of personal protective equipment, high mortality—lead to difficulty initiating or maintaining sleep.

Conclusions: Nurses working during the onset of the COVID-19 pandemic faced severe work stressors affecting their psychosocial health status. Immediate attention as well as long-term follow-up are warranted for this priority workforce.

Implications for Policy or Practice: Healthcare leaders are responsible for ensuring that evidence-based interventions are being implemented within their organizations to promote and restore the psychosocial health and well-being of the nursing workforce.

Nursing Data in Large, Federal Government-Sponsored, Health-Related Surveys and Datasets: A Mapping Review

Authors: Ann Annis, PhD, MPH, RN; Crista Reaves, PhD, RN; Jessica Sender; and Sherry Bumpus, PhD, FNP-BC

Research Objective: Nursing faculty conducting research and scholarship face competing priorities, time constraints, and limited resources. Secondary big data from national databases offer new opportunities to address important issues that influence the nation’s health. However, navigating these sources can be challenging. Furthermore, the extent to which these data sources include information related to nursing practice is not known. We aimed to review and summarize a comprehensive list of federally-sponsored sources of healthcare data and determine the inclusion of nursing-sensitive data.

Study Design: We conducted a systematic mapping review of federal sources of healthcare data available for researchers. An iterative process of data collection, coding, and review was undertaken. The primary measure of interest was the availability of nursing-inclusive data. Additional key measures included the overview and purpose of the data, population of interest and sampling design, methodology of data collection, type and description of data, and cost to obtain data. Convergent synthesis analysis was used to aggregate findings.

Population Studied: We included federal government entities that collected health-related data on populations, patients, individuals, healthcare providers, or systems. We searched their websites for publicly available datasets. Data sources with active data collection within the previous 10 years, and those that collected health-related data on populations, individuals, healthcare providers, or systems were included. Among 91 data sources identified, 58 met final inclusion criteria.

Principal Findings: The 58 data sources belonged to nine government entities, with the majority (28%) managed by the Centers for Disease Control and Prevention. The primary population of interest for most sources (71%) was individuals or patients; fewer sources focused on providers (26%) and health systems (24%). More than half ( n = 34, 59%) included some data elements on healthcare providers, which included nurses. However, few ( n = 13, 22%) distinguished nurses from other healthcare providers. Data related to nurses were generally buried within measures that were nonspecific for type of provider, which prevents the calculation of metrics that directly reflect nursing practice.

Conclusions: National data sources represent a valuable resource of big data that provide insight into the nation’s health, healthcare system, and workforce. These secondary data are a feasible, cost-efficient means by which to investigate important health issues relevant to nurses. However, despite the diverse collection of nationally representative datasets available to researchers, we found that the inclusion of nursing-specific data is uncommon. More than half of the data sources we reviewed contained information on providers, yet few collected data that would permit nursing-specific analyses.

Implications for Policy or Practice: Nurses and advanced practice nurses deliver a large proportion of care in the, United States, but federal data sources do not adequately measure the role of nurses in healthcare delivery. The current drive toward value-based care requires the attribution of providers’ care to patient outcomes. However, without more granular data on providers, we are unable to produce measures that accurately reflect nursing contributions in healthcare. Our findings highlight the importance of building the capacity of big data sources to incorporate nursing-specific data, which are needed to inform policies that guide provider practice.

Better NP Practice Environments Reduce Disparities in Hospitalizations Among Dually Eligible Patients With Chronic Ambulatory Care Sensitive Conditions

Authors: Jacqueline Nikpour Townley, PhD, RN; Heather Brom, PhD, APRN; Aleigha Mason, BSN, RN; Jesse Chittams, MS; Lusine Poghosyan, PhD, MPH, RN, FAAN; and J. Margo Brooks Carthon, PhD, APRN, FAAN

Research Objective: Adults eligible for both Medicare and Medicaid, known as dually eligible patients, experience significant health disparities, including twice as many hospitalizations, significant unmet health-related social needs, and higher rates of chronic ambulatory care sensitive conditions (ACSCs), such as coronary artery disease (CAD) and diabetes, compared to Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually eligible patients, as NPs are increasingly providing primary care management of ACSCs and are more likely than physicians to accept Medicaid. However, NPs often work in unsupportive clinical practice environments marked by strained relationships with administrators, a lack of independent practice and support, and limited professional visibility, limiting their ability to optimally meet patients’ needs. The purpose of this study was to examine the association between the NP primary care practice environment and disparities in all-cause hospitalizations between dually eligible and Medicare-only patients with ACSCs.

Study Design: Secondary cross-sectional survey methodology was employed to collect data from primary care NPs across 460 practices in four states (Pennsylvania, New, Jersey, California, and Florida) in 2015. The Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ), which contains 4 subscales with high internal consistency reliability, was used to measure NP practice environment. Practice environments with all 4 mean subscale scores above the median were classified as “good.” Those with 2–3 subscales above the median were classified as “mixed” practice environments, and those with 0–1 subscales above the median were classified as “poor.” Survey data were linked to Medicare claims files through a practice identifier available in the SK&A OneKey database. Multilevel regression models accounting for patient and practice characteristics were employed, followed by pairwise comparisons to compare disparities in all-cause hospitalizations between dually eligible patients and Medicare-only patients within good, mixed, and poor NP practice environments.

Population Studied: A total of 165,200 patients (14.9% dually eligible patients and 85.1% Medicare-only beneficiaries) were included across 460 practices. Patients had an International Classifications of Diseases, 10th edition, Clinical Modification, code for CAD or diabetes as one of their top five diagnoses.

Principal Findings: The majority of patients (58.1% dually eligible, 60.1% Medicare only) received care in poor practice environments (χ 2 = 157.8, p < .001). After adjusting for patient and practice characteristics, dually eligible patients had 50% higher odds overall of being hospitalized compared to Medicare-only patients (OR 1.51, 95% CI: 1.41–1.62). Dually eligible patients in poor practice environments had the highest adjusted odds of being hospitalized compared to their Medicare-only counterparts (OR 1.51, 95% CI: 1.41–1.62). In mixed practice environments, dually eligible patients had approximately 44% higher odds of a hospitalization (OR 1.44, 95% CI: 1.23–1.67), whereas in the best practice environments, dually eligible patients had approximately 29% higher odds (OR 1.29, 95% CI: 1.14–1.45, p < .001).

Conclusions: Improving NPs’ clinical practice environment in primary care may sizably reduce disparities in hospitalizations for dually eligible patients. However, even in the best practice environments, critical disparities in hospitalizations remain.

Implications for Policy or Practice: As policymakers look to improve outcomes and reduce costs among dually eligible patients, addressing a modifiable aspect of care delivery in NPs’ clinical practice environment is a key opportunity to reduce hospitalization disparities. Further efforts are needed to address remaining disparities by understanding and meeting patients’ health-related social needs.

Understanding Relationships Between Health Access Literacy, Health Self-Efficacy, Emotional Well-being, and Meaningful Engagement With the Children’s Mental Health System During the COVID-19 Pandemic.

Authors: Suzanne Courtwright, PhD, MSN, NP, NEA-BC, and Jacqueline Jones, PhD, RN, FAAN

Research Objective: Access to adolescent mental health services is limited, leading the Children’s Hospital Association to advocate on behalf of children and teens with a written letter to leaders of the, United States Senate and House of Representatives on January 27, 2022, to invest in the pediatric mental health workforce. The COVID-19 pandemic is exacerbating the growing mental health crisis in the country’s pediatric and adolescent population. In October 2021, the Children’s Hospital Association joined the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry and declared a national emergency in children’s mental health, as rates of anxiety, depression, and hospitalizations for suicide attempts and self-harm have risen more than 50% from prepandemic levels. Teens with chronic conditions have 4.3 greater odds of suicidal ideation and completion than their peers, and nearly 1 in 4 teens has a chronic condition. Understanding how adolescents with chronic conditions access, utilize, and engage with the children’s mental health system is necessary to better inform allocation of investments in mental healthcare delivery models for this vulnerable but growing population. The purpose of this study is to understand how health access literacy, health self-efficacy, and emotional well-being influence meaningful engagement with the children’s mental health system during the COVID-19 pandemic.

Study Design: A convergent mixed methods design utilizing path analysis of factor variables integrated with analysis of qualitative data using interpretive phenomenology was used.

Population Studied: Adolescents aged 10–21 years with chronic conditions, defined as requiring ongoing treatment for more than 1 year, were included.

Principal Findings: Preliminary findings indicate that adolescents with chronic conditions do not access healthcare for mental help until “it gets really bad.” Establishing trust over time is an important factor for this population. For those who tried to access services, non-White participants reported more challenges to access mental health services than their White peers.

Conclusion: The preliminary results of this study highlight opportunities to improve health equity by investing in mental health resources across both micro- and macro-level systems of care.

Implications for Policy or Practice: Improving health equity for teen mental health services may begin with placing interdisciplinary providers in micro-level proximity to teens, such as in schools and community-based programs, to optimize opportunities for trusting relationships to develop. Psychiatric mental health nurse practitioners, pediatric nurse practitioners, nurse coaches, community health nurses, school nurses, and public health nurses are well poised to provide easier access to school- and community-level preventive mental health education, and services. Removing policy barriers to advanced practice in densely populated states such as New, Jersey and the northeast will only advance efforts to optimize access to care.

Complementing ICD Codes With Nurses’ EHR Documentation Can Improve the Identification of Patients With Predisposing Factors of Iatrogenic Conditions

Authors: Sarah E. Ser, MS; Urszula A. Snigurska, BSN, RN; Mattia Prosperi, PhD, MEng; Ragnhildur I. Bjarnadottir, PhD, MPH, RN; and Robert J. Lucero, PhD, MPH, RN, FAAN

Research Objective: Accurate identification of patients with predisposing factors of iatrogenic conditions is a prerequisite for implementation of targeted prevention interventions. The International Classification of Diseases (ICD) codes are frequently used as proxies for a patient’s health status. However, ICD codes are unlikely to reflect a patient’s complete hospital experience. This results in an underutilization of potentially significant clinical information, including nursing assessment data, which could be used to develop valid outcome measures as well as accurate prognostic models for point-of-care decision support. Nursing assessment data may complement ICD codes in the overall characterization of a patient’s hospital experience. This study explored complementing ICD codes with electronic health record (EHR) nursing assessment data to operationalize dysuria, a factor associated with several iatrogenic conditions.

Study Design: We conducted a descriptive observational analysis of data from an ongoing retrospective study on predictors of iatrogenic conditions. Data were extracted from the University of Florida (UF)’s Integrated Data Repository. We developed an operational definition of dysuria using ICD codes from the 9th (ICD-9) and 10th (ICD-10) editions and EHR nursing assessment data. We compared the number of patients with dysuria based on ICD codes to those captured by our operational definition.

Population Studied: Observations included 135,739 patients admitted to one of 21 medical and/or surgical nursing units of an academic medical center hospital between 2012 and 2018.

Principal Findings: Based on ICD codes and EHR nursing assessment data, we created the following operational definition of dysuria: ICD-9 Code: 788.1 (or) ICD-10 Code: R30.0 (or) ICD-10 Code: R30.9 (or) nurses’ documentation of “burning” under “genitourinary symptoms” in at least one of the simple or complex Assessment flowsheets. A total of 3,637 patients with dysuria were identified by our new operational definition, and 198 were identified with both ICD codes and nursing assessment data. Four and one-half times as many patients experienced dysuria based on the combination of ICD codes with nursing assessment data compared to only ICD codes.

Conclusions: We demonstrated that complementing ICD codes with nurses’ documentation of dysuria captured patients who would not have been identified using only ICD codes. These findings could have practical and methodological implications for understanding dysuria during hospitalization; our analysis indicates that use of nursing assessment and other nursing data should be further explored. We highlighted only one of the many possibilities for identifying patients with risk factors of iatrogenic conditions using nurse-generated data. In addition to the simple and complex assessment flowsheets, there are other flowsheets in which nurses document patients’ data, which can be used to complement ICD codes and other coded data. Additionally, although we used only structured data to formulate our operational definition of dysuria, nurses’ narrative notes can contain rich contextual information, which is not typically documented in structured fields of EHRs but may be necessary for accurate outcomes measurement and case identification.

Implications for Policy or Practice: Relying exclusively on ICD codes to identify patients with certain conditions can introduce coding bias. Nursing assessments and other sources of clinical EHR documentation data may provide a source of direct clinical information to address the bias found when using ICD codes.

Understanding Crisis Needs Among Family Caregivers of Patients in Critical Care: A Qualitative Analysis

Authors: Amanda C. Blok, PhD, MSN, RN, PHCNS-BC; Thomas S. Valley, MD, MSc; Lauren E. Weston, MPH; Jacquelyn Miller, MA; Kyra Lipman, BS; and Sarah L. Krein, PhD, RN

Research Objective: To understand met or unmet needs of family caregivers in crisis during a critical care hospitalization and examine differences by anxiety level to help inform family-centered intervention design.

Study Design: We conducted a qualitative content analysis of 40 semi-structured interviews of family caregivers of mechanically ventilated patients to understand their experiences with critical care. We specifically identified needs of family caregivers in crisis—informational and emotional processing, social support, and self-care—and factors that may influence these needs using nursing theoretical models for family management of conditions. Next, we used the Hospital Anxiety and Depression Scale (HADS) administered at the time of interview to measure anxiety and divided the sample into three groups by HADS: anxiety ( n = 15), borderline anxiety ( n = 11), and low anxiety ( n = 14). We examined similarities and differences in family member experiences and needs among the three groups.

Population Studied: Family caregivers of patients hospitalized in critical care.

Principal Findings: Most family caregivers were adult children (32%), followed by spouses (22%), parents (15%), siblings (15%), and other family (15%). Crisis needs were present in all anxiety groups, but there were differences in the extent and specifics of their needs by anxiety level. For informational processing, family caregivers with anxiety described challenges understanding medical decisions made by the clinical team, often waiting for healthcare providers to initiate conversations, while family caregivers with low anxiety valued detailed information from staff and tried to prepare other family members to prevent distress. For emotional processing, family caregivers with anxiety reported fear, a sense of responsibility to protect other family members from fear, and a preoccupation with day-to-day events that inhibited processing their emotions, whereas those with borderline and low anxiety noted that other family members and prior experiences helped them deal with their emotions. For social support, more than half of caregivers with anxiety expressed strained relationships in their social support network or felt alone, whereas those with borderline and low anxiety did not describe experiencing relationship strain. Faith communities were identified as a source of support by all anxiety groups, although the added emotional and financial support from these communities appeared more prominent among those with borderline and low anxiety. For self-care, family caregivers with anxiety reported that worry impinged on their sleep and self-care, whereas family caregivers with low anxiety prioritized sleep and self-care. Caregivers with low and borderline anxiety were better able to care for themselves due to tangible support from other family members.

Conclusions: Family caregivers of critical care patients experience crisis needs during the hospitalization, although the specific needs appear to differ by family caregiver anxiety level. Our detailed understanding of caregiver experiences can inform intervention components that address these crisis needs during a patient’s critical care hospitalization.

Implications for Policy or Practice: Critical care nurses spend the most time at the bedside with family caregivers of critical care patients. Developing interventions that address the crisis needs of family caregivers may help family caregivers to engage with nurses and further enhance the care delivery process.

COVID-Related Stressors, Burnout, Turnover Intention, and Resilience Among Nurse Leaders During the Pandemic

Authors: Aoyjai P. Montgomery, PhD, BSN, and Patricia A. Patrician, PhD, RN, FAAN

Research Objective: Even before the COVID-19 outbreak, at least one of every 10 nurses worldwide was suffering from high burnout, which contributed to high turnover rates. With the COVID-19 pandemic, anecdotal reports of overwork, burnout, and even suicide of healthcare professionals is being shared in the news and on social media. The pandemic introduced new stressors to nurse leaders, such as managing the complex staffing situation (staff shortages, reassigning nurses to cover COVID-19 units, limited bed capacity, high patient acuities, shortage of personal protective equipment), while supporting their staff nurses. Since COVID-19 began, there has been research concerning COVID-related stressors, burnout, turnover intention, and resilience among nursing staff but not among nurse leaders. Therefore, this study aimed to examine the COVID-related stressors that are most significantly related to burnout and turnover intention, investigate how resilience impacts burnout and turnover intention, and explore strategies that nurse leaders are using during this pandemic to maintain resiliency.

Study Design: This descriptive, cross-sectional study employed an electronic survey of several instruments to measure COVID-related stressors (COVID-related Stress Scales [CSS]), burnout (Copenhagen Burnout Inventory [CBI]), turnover intention (a single item), and resilience (Connor-Davidson Resilience Scale [CD-RISC-25]) among nurse leaders. The survey also included open-ended questions that were analyzed qualitatively.

Population Studied: In September 2021, 57 nurse leaders who worked in Birmingham, Alabama, hospitals, including nurse managers, directors of nursing, and other nurses who are in administrative roles, responded to the survey.

Principal Findings: The average respondent had 10.7 years of nurse leader experience, had a graduate degree (67%), and worked as nurse managers (42%) or nursing directors (37%). The CSS was positively related to all three burnout subscales (Personal, Work-Related, Client-Related Burnout) ( r = .27 to .40, p < .05) but not significantly related to intent to leave ( r = 0.17, p = .20). Resiliency was negatively related to all subscales of burnout ( r = -.53 to -.59), p < .01) and intent to leave ( r = -.32, p < .05) but not significantly related to COVID-19 stress ( r = -.07 to -.20, p > .05). The top three resiliency strategies that nurse leaders used were (a) prayer and faith, (b) social support, and (c) self-care (e.g., taking a break, exercising, promoting good nutrition). The top three recommendations that nurse leaders had for other nurse leaders were (a) disconnect/take time off, (b) positive and creative thinking, (c) self-care (e.g., exercising, resting, and stress relief).

Conclusions: Among nurse leaders, COVID-19 stress impacts burnout but does not affect resiliency and intent to leave. Nurse leaders who had higher resiliency seemed to have lower burnout and were less likely to leave their positions.

Implications for Policy or Practice: The findings of this study provide baseline data to inform the development of actionable interventions to prevent or at least reduce burnout and turnover intention. Furthermore, the resiliency strategies and recommendations from these nurse leaders should be disseminated to other nurse leaders to help them reduce burnout and turnover intention.

The Association Between Hospital Nursing Resources and Patient Satisfaction Using the HCAHPS Survey: A Systematic Review

Authors: Kathleen E. Fitzpatrick Rosenbaum, BSN, RN, NICU-RNC, CCRN; and Eileen T. Lake, PhD, RN, FAAN

Research Objective: Identifying factors that influence patient satisfaction has become a priority for healthcare system managers. The Centers for Medicare and Medicaid Services implemented Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys to evaluate hospitals and incentivize them to improve patient satisfaction. Survey results are linked to hospital Medicare reimbursements, making high scores of particular interest to hospital managers and to healthcare consumers. The purpose of this systematic review was to synthesize the literature reporting the association between nursing resources (nurse education, nurse staffing, the nurse work environment, and Magnet designation) and HCAHPS scores. Our goals were to provide managers with evidence to inform their decisions and identify gaps for researchers to address.

Study Design: A systematic review was conducted searching the CINAHL and MEDLINE databases. Key terms were searched using headings and text phrases related to educational preparation, nurse work environment and nurse staffing, and Magnet designation. Chain searching was applied, and the Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide was used to grade the evidence. Effect sizes were measured by regression coefficients when available.

Population Studied: Our inclusion criteria were (a) a nursing resource as an independent variable, (b) HCAHPS scores as a dependent variable, (c) a cross-sectional study design, and (d) U.S. empirical data published in a scientific journal. Studies meeting these criteria and published between 2006 and 2021 were examined.

Principal Findings: Twelve articles met inclusion criteria. Among these articles, 7 focused on magnet designation, 3 on nurse staffing, 2 on the nurse work environment, and 0 on nurses’ education. All but 2 studies included global HCAHPS measures. In addition, 8 studies included HCAHPS composite measures. The samples of hospitals ranged from 110 to 3,026. The years represented in the data encompassed 2005 to 2018. In 11 of the 12 studies, nursing resources were significantly associated with HCAHPS scores. Magnet designation exhibited the largest effect size of 6.33. Nurse staffing showed the most variation across studies with the largest effect size related to an additional hour of nursing care per patient day or an additional patient per nurse. Coefficients ranged between -0.24 and -1.44. Nurse staffing results showed that for every one additional patient a nurse cared for, there was a 1.44% decrease in the percentage of patients giving high ratings for willingness to recommend. The nurse work environment had a positive association with patient satisfaction; effect sizes ranged from 3.15 to 6.08, with patients much more likely to give high ratings to hospitals classified as having favorable nurse work environments.

Conclusions: For hospital managers eager to improve patient satisfaction, understanding which organizational factors are associated with patient satisfaction is of interest. Nursing resources were shown to be a lever toward high HCAHPS scores. Additional research is needed to identify the association between nurse education and HCAHPS scores.

Implications for Policy or Practice: It would behoove managers to invest in nursing resources to improve patient satisfaction and achieve high-value care. Administration should support managers’ endeavors to improve nurse staffing, foster a positive nurse work environment, and develop Magnet-like qualities.

The Association Between Nursing Home IT Maturity and UTI Among Long-Term Residents

Authors: Catherine C. Cohen, PhD, RN; Kimberly Powell, PhD, RN; Andrew W. Dick; Patricia W. Stone, PhD, RN, FAAN; and Gregory L. Alexander, PhD, RN, FAAN, FACMI

Research Objective: Urinary tract infections (UTIs) are the most common infections among nursing home (NH) residents. Improving UTI prevention and management in NHs is included in key antibiotic stewardship and infection control and prevention initiatives. NH information technology (IT) maturity (i.e., technological capability, extent to which systems are used, and degree to which different systems are integrated) could impact NHs’ ability to prevent and manage UTIs through improved integration and communication of data from multiple sources. This study aimed to explore the relationship between specific aspects of IT maturity and odds of UTI among long-stay NH residents.

Study Design: We conducted a repeated cross-sectional study combining three nationally representative data sources: (a) four annual surveys measuring IT maturity, (b) Minimum Data Set (MDS) 3.0 assessments measuring resident characteristics, and (c) Certification and Survey Provider Enhanced Reporting data identifying facility characteristics. Nonadmission MDS assessments completed within 90 days of IT survey completion were matched to survey data, including nine scales of IT maturity including three healthcare domains (resident care, clinical support, and administrative activities) and three dimensions (IT capabilities, extent of IT use, and degree of IT integration with internal/external stakeholders). The outcome was a binary indicator of UTI, which is recorded according to evidence-based criteria that includes clinical symptoms. Descriptive statistics were examined. Bivariate and multivariate regressions using NH fixed effects were conducted controlling for resident and NH characteristics. We varied assumptions to test robustness of our results.

Population Studied: Assessments of long-term residents aged 65 + years from a random sample of Medicare-certified U.S. NHs over 4 consecutive years (2013–2017) were included.

Principal Findings: Our sample included 816 NHs. These NHs had 219,730 regular NH resident assessments within 90 days of a survey, representing 80,322 unique long-term NH residents. Of these assessments, 4.1% recorded a UTI. In the multivariate analyses, maturity of administrative IT capabilities was associated with lower odds of UTI (adjusted OR 0.906, 95% CI: 0.843, 0.973). No components of this domain/dimension were individually associated with UTI, nor were any other IT maturity dimension/domain scores. These results were robust in all sensitivity analyses.

Conclusion: To our knowledge, this study was the first to determine a link between NHs’ IT maturity and health outcomes at the resident-assessment level. The finding that administrative IT capabilities are associated with decreased odds of UTI was additionally robust given healthcare facilities with better documentation systems may experience measurement bias as they are more likely to record health outcomes, such as UTI.

Implications for Policy and/or Practice: This work is timely and relevant to policy decisions at facility and public health levels, as it could shape utilization of IT in NHs. This work supports the need to include use of health IT in publicly reported national datasets. Consistent reporting of IT maturity in NHs could clarify ongoing impacts of important legislative actions such as the 21st Century Cures Act, which was enacted to accelerate the effective use of IT to support better access to healthcare information.

Nurses Insight and Psychological Reaction Toward a COVID-19 Outbreak in Bangladesh

Authors: Shanzida Khatun, PhD, MSc, RN; Fahima Khatun; Md. Shariful Islam; Khaleda Akter; and Md. Abdul Latif

Research Objective: To explore nurses’ insights and psychological reactions toward a COVID-19 outbreak in Bangladesh.

Study Design and Setting: Both the qualitative and quantitative aspects of this study were conducted at 54 settings from primary level to tertiary level hospitals.

Population Studied: A total of 800 nurses participated in the quantitative portion of the study, which used the Z-score formula, and 28 nurses participated in the qualitative portion, which used focus group discussion.

Principal Findings: The mean age of nurses was around 34 years. The mean (SD) knowledge score was 15.33 (2.60); perception, 7.41 (1.62); and Depression, Anxiety, and Stress Scale, 43.73 (30.95). Regression analysis showed that knowledge, perception, length of service, working experience at a COVID-19 ward, information from media, personal protective equipment supply, hand hygiene supply, and feeling of confidence in taking care of COVID-19 patients together explained 25% of the variance in the psychological reaction toward the COVID-19 outbreak. Five themes emerged from the focus group discussion, including “challenges for nurses of working [at] COVID-19 hospital,” “fear of becoming infected and infecting the family members,” “stress due to new context and heavy workloads,” inappropriate knowledge of wearing personal protective equipment, and lack of adequate training for nurses regarding COVID-19.

Conclusions: Further study is needed to identify the factors influencing nurses’ psychological reactions toward the COVID-19 outbreak. In addition, an intervention study will help nurses to increase their knowledge and perception of the pandemic and will help to decrease nurses’ psychological problems and increase coping related to the pandemic.

Implications for Policy or Practice: The findings of this study provide baseline information to policymakers to develop a strategy on nursing management for COVID-19 patients. This also contributes to design training programs for nurses during the outbreak.

Clarifying Nurse Practitioner Integration

Authors: Joshua Porat-Dahlerbruch, PhD, RN; Lusine Poghosyan, PhD, MPH, RN, FAAN; Nancy Blumenthal, DNP; Shoshana Ratz, MSc, RN; and Moriah Ellen, MBA, PhD

Research Objectives: Globally, healthcare systems are facing care provider shortages. These shortages are due to growing populations with increasingly complex healthcare needs, and physician supply alone cannot meet demands. These workforce needs across the world require innovative solutions. Many nations have introduced the nurse practitioner (NP) role to diminish workforce shortages. NPs bring a holistic scope of practice, which has been found to be well suited to address complex care needs. Research has shown that NPs provide safe and effective care. However, the ability to produce these results relies on successfully integrating NPs into all levels of the healthcare system. Despite the rich literature, to our knowledge, the “NP integration” concept has never been synthesized and defined. “NP integration” is described inconsistently and lacks elucidation. Without a definition of the concept, NP integration cannot be researched consistently. High-level evidence requires synthesis of findings researching the same concept. Research, therefore, cannot be synthesized to create a theory or a model to guide NP integration, which is critical for policymakers and stakeholders. This concept analysis aims to define and operationalize the concept of NP integration for research and to provide a basis for which theory on NP integration can be deduced and policy can be easily understood from the literature.

Study Design: The Walker and Avant (2019) concept analysis method was used.

Study Population: We included full-text articles, government reports, conference presentations, and abstracts, yielding 200 publications. After removing duplicates and abstract screening, 78 publications remained.

Principal Findings: Defining attributes of NP integration include process, achievable goal, introduction of the role, incorporation into organizational care models, challenging traditional ideologies, ability to function, provide high care quality, and improve outcomes, sustainability, and health system transformation. We identified facilitators and barriers affecting NP integration and multiple healthcare system levels at which NP integration occurs—macro, meso, and micro. We identified antecedents and consequences of NP integration. We synthesized findings to create an NP integration conceptual model. The analysis resulted in an operational definition of NP integration: A multilevel process of incorporating NPs into the healthcare system so that they can function to the full extent of their scope and contribute to patient, health system, and population needs.

Conclusions: This is the first research to synthesize NP integration literature to provide an operational definition and conceptual model. Moreover, most literature refers to macro (system-wide) or meso (organizational) level integration. We identified a new dimension—micro—which refers to individual interactions of NPs with other NPs, patients, physicians, nurses, and staff. NP integration is a complex process acting on multiple levels in the healthcare system. Policy intervention at all three levels is likely critical for NP integration.

Implications for Policy or Practice: These findings provide an operational definition so that research on NP integration can be conducted consistently. This research can be a basis for developing research tools assessing NP integration progress that stakeholders and policymakers can use to understand where policy intervention is necessary to improve NP integration.

Nurse Work Patterns in Long-Term Care: A Time-Motion Analysis

Authors: Yu Jin Kang, PhD, MPH, RN; Jeannie P. Cimiotti, PhD, RN, FAAN; and Karen A. Monsen, PhD, RN, FAMIA, FNAP, FAAN

Research Objective: It is well known that nurses working in the long-term care sector are short staffed and under a tremendous amount of pressure to complete nursing care in a timely manner. Multitasking is expected of these nurses, such as performing nursing tasks while communicating, but extensive multitasking should be minimized to avoid potential adverse events. Little is known about how these nurses might multitask in an effort to complete essential nursing care. The purpose of this study was to examine the workflow of licensed nurses in a skilled nursing facility and to determine how they might multitask to complete nursing care.

Study Design: An observational time-motion study was conducted at a 250-bed skilled nursing facility located in the southeastern United States. A web-based time capture application, TimeCaT, was used to collect data from September 2019 to March 2020. TimeCaT was customized to include 57 validated nursing activities based on the Omaha System. This method allowed for the collection of time-stamped workflow data that included communication and tasks—data that were not mutually exclusive. Observed nurse workflow was analyzed using χ 2 statistics and visualized with a heatmap.

Population Studied: Registered nurses (RNs, n = 4) and licensed practical nurses (LPNs, n = 7) who worked on short-term care (STC) and long-term care (LTC) units or provided wound care were included in the study. All participating nurses were full-time clinicians except one nurse who was supplied by a supplemental staffing agency. On average, one nurse was responsible for the care of 12 residents.

Principal Findings: There were 5,306 observations of multitasking episodes—an average of 35 multitasking episodes per hour. The majority of multitasking episodes occurred during care supervision (81%) and medication regimen (33%). Forty-eight percent of the episodes were related to the medication regimen among STC and LTC nurses, where communication with residents and other care team members and documentation occurred while nurses prepared medications (17%) and where communication with residents, including medication instruction, occurred while nurses administered medications (11%). A larger percentage of LTC nurses multitasked medication regimen activities when compared to STC nurses (55% vs 39%, p < 0.001) and in the morning when compared to afternoon and evening (57% vs 39% vs 48%, p < 0.001). Overall, a larger percentage of LPNs multitasked medication regimen activities when compared to RNs (51% vs 46%, p < 0.001).

Conclusions: Nurses frequently multitask during the preparation and administration of medications in a skilled nursing facility. Research is warranted to better understand the complexity of medication regimens and the factors that contribute to multitasking practice patterns. Furthermore, it is imperative that we determine whether multitasking practice patterns increase the cognitive workload of nurses and the likelihood of medication errors in skilled nursing facilities.

Implications for Policy or Practice: Healthcare administrators and policymakers should be mindful of the fact that nurses often multitask in skilled nursing facilities. This calls for policies that monitor nurse practice patterns in the long-term care sector and provide suggestions for improvement when necessary. If not, we risk the possibility of short- and long-term sequela associated with these questionable workflow patterns.

Linking Patient Safety Climate With Missed Nursing Care in Labor and Birth Units: Findings From the LaborRNs Survey

Authors: Jie Zhong, MSN; Kathleen Rice Simpson, PhD, RNC, FAAN; Joanne Spetz, PhD; Jason Fletcher, PhD; Caryl L. Gay, PhD; Gay L. Landstrom, PhD, RN, NEA-BC; and Audrey Lyndon, PhD, RNC, FAAN

Research Objective: Inpatient labor and birth settings are specialty care units with limited evidence regarding nursing care quality. Missed nursing care has been used to indicate nursing care quality in medical-surgical, intensive, and pediatric care settings. An emerging body of evidence suggests that features inherent in a better culture of safety, such as aligned organizational priorities, attention to workload, and team communication, are associated with less missed nursing care in general. The aim of this study was to explore patient safety climate and its association with the outcome of missed nursing care in labor and birth units.

Study Design and Population Studied: We recruited nurse respondents for this cross-sectional study in the United States via email distribution of an electronic survey between February 2018 and July 2019. Hospitals with labor and birth units were recruited from states with projected availability of 2018 State Inpatient Data. All registered nurses working in labor and birth units in the targeted hospitals were eligible. Measures included the Safety Climate Subscale from the Safety Attitudes Questionnaire, the Perinatal MISSCARE Survey, and nurse characteristics. The mean of individual nurse Safety Climate Subscale questions was used to measure nurses’ perception of the unit safety climate on a scale of 1–5, with a higher score indicating a better climate. The Perinatal MISSCARE Survey uses 25 items to assess the frequency at which required aspects of nursing care are delayed, unfinished, or completely missed on the respondent’s unit. The sum of missed aspects of care ranged from 0–25, with a higher score indicating more missed care. We used Kruskal-Wallis tests for bivariate analysis followed by mixed-effects linear regression models to estimate the relationships between patient safety climate and missed nursing care while accounting for clustering of nurses within hospitals.

Principal Findings: The response rate was 35%, resulting in a sample of 3,429 labor and birth registered nurses from 255 hospitals. A majority of respondents (65.7%) reported a perception of good safety climate in their units, with a mean (SD) score of 4.12 (0.73). The mean (SD) number of aspects of care occasionally, frequently, or always missed on their units was 11.04 (6.99). The adjusted mixed-effects model identified a significant association between better nurse-perceived safety climate and less missed care (-2.65; 95% CI: -2.97 to -2.34) after controlling for age and years of experience as a labor nurse. The estimates indicated each one unit increase of the mean score of nurse-perceived safety climate was associated with 2.65 fewer missed essential aspects of perinatal nursing care.

Conclusion and Implications for Policy or Practice: Our findings suggest that improving safety climate may promote nursing care quality during labor and birth through decreasing missed nursing care. Conversely, it is also possible that strategies to reduce missed care, such as staffing improvements, may improve safety climate. Safety strategies such as promoting open communication, ensuring nonpunitive response to error, incorporating perinatal safety nurses, and ongoing learning from safety events may decrease missed care in daily nursing activities.

Emergency Nursing Workforce Burnout and Job Turnover in the United States: A National Sample Survey Analysis

Authors: Allison A. Norful, PhD, RN, ANP-BC, FAAN; Kenrick Cato, PhD, RN, FAAN; Bernard P. Chang, PhD, MD; Taryn Amberson, MPH, RN, CEN, NHDP-BC; and Jessica Castner, PhD, RN, FAEN, FAAN

Research Objective: Burnout, especially in registered nurses working in emergency departments, has substantially jeopardized the nursing workforce supply and the ability to meet demands for care. Past research documenting the prevalence of burnout among emergency nurses have been limited by small sample sizes and local sampling approaches as they have been unable to capture the diversity of clinical, geographic, and demographic characteristics at a national level. Few studies have examined turnover in nurses who have left their job or are not currently working, resulting in the potential for healthy worker or survivor bias. The aims of our study were to (a) test differences in reasons for turnover or not currently working between emergency nurses and other registered nurses and (b) ascertain factors associated with burnout as a reason for turnover or not currently working among emergency nurses.

Study Design: We conducted a secondary analysis of the National Sample Survey for Registered Nurses publicly available from Health Resources and Services Administration. We excluded advanced practice nurses and respondents who were not working due to retirement. Demographic and work characteristics (e.g., sex, age, race and ethnicity, marital status, highest degree, years of experience, hours worked per week, household income, and degree enrollment) were extracted. Next, we extracted responses to 6 survey items permitting the identification of nurses who were not currently working or who recently left their position (within 2 years) and their reasons for turnover (22 response options, including “burnout”). Design weights were applied using the jackknife estimation procedure. Data were analyzed using descriptive statistics, χ 2 test, t test, unadjusted and adjusted logistic regression applying design sampling weights, and controlling for potential individual and work characteristic confounders.

Population Studied: Nationally representative sample of registered nurses (weighted N = 3,001,283) from the 50 United States and the District of Columbia. Analysis included 1,266 emergency nurses (weighted N = 217,706) and 18,589 nurses (weighted N = 2,786,879) in other settings.

Principal Findings: Seven job turnover reasons were endorsed by emergency nurses and significantly higher than reasons provided by other nurses: Insufficient staffing (11.1%, p = .011); physical demands (5.1%, p = 0.44); patient population (4.3%, p < .001); better pay elsewhere (11.5%, p = .001); career advancement/promotion (9.6%, p = .007); length of commute (5.1%, p = .012); and relocation (5%, p = .006). Increasing age and years of experience were significantly associated with decreased odds of burnout in adjusted models. Being female was associated with decreased odds of burnout when controlling for insufficient staffing, scheduling, and stressful work environment.

Conclusions: Several modifiable factors, such as insufficient staffing and better pay elsewhere, appear to be associated with job turnover. Further research should account for gender and age to better understand and mitigate burnout. Ongoing research is essential to identify priorities for risk detection and for future national-level nursing workforce policies and interventions.

Implications for Policy or Practice: Given the critical need of the emergency nursing workforce, this study provides evidence for preventive intervention and policy at the national level. Interventions to reduce burnout and job turnover may include enhancing work environments (e.g., sufficient staffing), increasing pay, and investing in the physical and psychological health of nurses. Practice and policy efforts aimed at precursors of nursing burnout as modifiable targets to reduce turnover may improve career longevity, well-being, and workforce retention.

The Impact of Pre–COVID-19 Nursing Home Infection Prevention and Control Policies on COVID- 19 Deaths

Authors: Jung A Kang, MSN, RN, AGACNP-BC, AGCNS-BC; Patricia Stone, PhD, RN, FAAN, CIC; and Andrew Dick, PhD

Research Objective: Nursing home (NH) residents have been disproportionally suffering from the COVID-19 pandemic. Therefore, it is essential to have a comprehensive NH Infection Prevention and Control (IPC) program to prevent potential infectious disease outbreaks. However, it is not known how NH IPC programs have impacted COVID-19 deaths. Therefore, the goal of this study was to examine the relationship between pre–COVID-19 NH IPC programs/policies and COVID-19 resident deaths.

Study Design: This retrospective study used publicly available data from the Centers for Disease Control and Prevention’s Long-Term Care Facility COVID-19 Module and USA Facts county-level COVID-19 data linked to a national survey of NHs in 2018. The survey included questions about NH IPC programs such as having infection preventionists certified in infection control (CIC) and outbreak preparedness policies. We used 10-week periods to separately assess the impact of NH IPC programs on the weekly resident COVID-19 deaths per 1,000 residents between May 24, 2020 and May 30, 2021. We then estimated multivariable regression models to examine the association between NH IPC programs and COVID-19 deaths controlling for facility-level characteristics and county-level COVID-19 death intensity.

Population Studied: A total of 857 NHs located in 489 counties were identified and included in this analysis. Approximately 7.5% of NHs had the infection preventionist certified in infection control. Among the outbreak preparedness policies, instructing infected staff to stay home was most common in NHs (92.4%), and use of rapid diagnostic methods for case detection was least common (49.9%).

Principal Findings: In the multivariable models, during the December 2020 peak period, NHs with CIC infection preventionists had 4.9 fewer weekly COVID-19 deaths per 1,000 residents compared to the NHs without CIC infection preventionists (β = -4.9, SE = 1.1, p < .0001). Use of rapid diagnostic methods for case detection was also associated with lower weekly COVID-19 deaths during the peak period (β = -1.25, SE = 0.43, p = .004). Cohorting infected residents together was negatively associated with weekly COVID-19 deaths during the off-peak periods (β = -2.7, SE = 0.5, p < .0001). On the other hand, instructing infected staff to stay home and closing to new admits were associated with higher weekly COVID-19 deaths, particularly during the peak periods (β = 1.03, SE = 0.52, p = .047; and β = 3.16, SE = 0.94, p = .001 respectively).

Conclusions: Most of the IPC programs had different impacts on COVID-19 deaths depending on the stage of COVID-19. The lower rate of COVID-19 deaths in NHs with CIC infection preventionists persisted throughout the pandemic periods. We also found that the use of rapid diagnostic methods for case detection was protective against COVID-19 deaths during the peak period, as was cohorting infected residents together during the off-peak period.

Implications for Policy or Practice: This study provides evidence-based policy recommendations to clinicians and policymakers to prevent future infectious disease crises in NHs. Aligning with the Centers for Disease Control and Prevention’s recommendation regarding infection preventionists, assigning one or more full-time infection preventionist with training in infection control in NHs is recommended.

U.S. Clinician Well-being Study: A Descriptive Analysis of the Work Environment and Clinician Well-being

Authors: Colleen A. Pogue, PhD, RN; Linda H. Aiken, PhD, RN, FAAN, FRCN; Kathleen F. Rosenbaum, BSN, RN, NICU-RNC, CCRN; Maura E. Dougherty, BSN, CRNA; and Matthew D. McHugh, PhD, JD, MPH, RN, FAAN

Research Objective: To determine factors associated with interdisciplinary clinician mental health and well-being in hospitals during COVID-19.

Study Design: This cross-sectional study utilized primary data collected through an electronic survey sent via hospital emails to identified clinicians between February 2021 and July 2021. Clinicians provided detailed information regarding clinician well-being (i.e., mental health, burnout, and job satisfaction) and quality of work environment (e.g., workload, autonomy, work-life balance, and interdisciplinary teamwork). Data were aggregated at the hospital level.

Population Studied: An interdisciplinary group of registered nurses (RNs) ( n = 15,738), advanced practice registered nurses and physician assistants (advanced practice providers [APPs]) ( n = 2,662), and physicians ( n = 5,336) were surveyed. Surveyed clinicians had to be working in an inpatient or ED setting. Data were collected from 60 different Magnet hospitals across the United States.

Principal Findings: Overall, findings of high clinician burnout (30%–44%), job dissatisfaction (12%–22%), and likelihood of leaving the job (23%–41%) were consistent across clinician groups and highest among nurses. A quarter of nurses experienced clinical levels of anxiety. Overall burnout levels varied widely across Magnet hospitals (25%–65%). Clinicians reported having high levels of stress at work (40%–53%) and having very little joy (7%–14%) with nurses reporting the highest levels of stress and the least joy. One-third of nurses rated their work environment as poor/fair. The quality of the work environment varied considerably across all Magnet hospitals, with as few as 5% and up to as many as 65% of hospital clinicians reporting that their work environment was poor/fair. More than half of all nurses (54%) felt there were not enough nurses to care for patients. There was less concern regarding nurse staffing among physicians and APPs, with 71% of physicians and 63% of APPs feeling that there were enough nurses to care for patients. Physicians reported high frustration with electronic health records (61%) and poor work-life balance (32%). APPs experience of well-being and perceptions of their work environment overlapped with both physicians and nurses. All clinicians stated the importance of being heard and supported by the administration and having a shared vision and values with the administration. Nearly 95% of clinicians reported good interdisciplinary working relationships and high levels of teamwork. Clinicians also rated the effectiveness of interventions to improve well-being. Across all clinicians, the most effective interventions were those that allow them time and resources to provide clinical care (e.g., improve nurse staffing levels, have breaks without interruption, reduce time spent on documentation, increase control over scheduling). There was clear agreement across clinicians on interventions they felt would not be as effective in improving well-being (e.g., resilience training, meditation rooms, wellness champion/committee).

Conclusions: Clinician burnout was high, and the quality of the work environment varied considerably across Magnet hospitals.

Implications for Policy or Practice: Opportunities to improve the work environment through empirically informed interventions are necessary to improve clinician well-being. Data suggest variation in the effectiveness of well-being interventions by clinician group, which should be taken into consideration during the development and implementation of such interventions.

The Association Between Primary Care Work Environments and Missed Opportunities for Emotional Healthcare

Authors: Eleanor Turi, BSN, RN, CCRN; Amelia Schlak, PhD, RN; Jianfang Liu, PhD; and Lusine Poghosyan, PhD, MPH, RN, FAAN

Research Objective: Nurse practitioners (NPs) are key to improving primary care delivery as they represent the fastest growing segment of the primary care workforce. Yet, poor nursing working conditions (i.e., hostile working relations, low autonomy, lack of support, and inadequate professional visibility) often challenge NP care delivery and have been linked with lower quality of care and adverse patient outcomes. These poor conditions also lead NPs to prioritize acute care needs of patients and ignore other needs such as addressing patients’ emotional well-being, which is an important and often overlooked area of health. We investigated the relationship between NP work environment and missed care around patients’ emotional health.

Study Design: This was a secondary analysis of cross-sectional survey data from 2017. The survey asked primary care NPs to complete the Errors of Care Omission Survey (EoCOS) to determine whether NPs missed opportunities for care and the NP Primary Care Organizational Climate Questionnaire (NP-PCOCQ) to assess the NP work environment. We examined the association between the NP-PCOCQ subscales (i.e., independent practice and support [IPS], NP-administrative relations [NP-AR], professional visibility [PV], and NP-physician relations [NP-PR]) and an aggregate measure of the EoCOS describing NP ability to address patients’ emotional health (EH-EoCOS; 3 items related to addressing emotional concerns of patients, discussing patients’ emotional well-being, and providing emotional support when making treatment decisions) using multilevel mixed-effects linear regression models. Higher scores on the NP-PCOCQ and the EH-EoCOS indicate a favorable work environment and that patients’ emotional health is addressed, respectively. We controlled for NP demographics and practice features.

Population Studied: A total of 397 primary care NPs in New York State across 377 primary care practices were included.

Principal Findings: In the bivariate model, higher IPS scores were positively associated with a higher EH-EoCOS score that neared statistical significance; for every 1 unit increase in IPS score, EH-EoCOS increased by 0.30 ( p = 0.059). After adjusting for NP demographics and practice features, there was a positive association between IPS score and EH-EoCOS, again that neared statistical significance (β = 0.29, p = 0.077). NP-AR (β = 0.11, p = 0.285), PV (β = 0.10, p = 0.370), and NP-PR (β = 0.22, p = 0.106) subscales were not significantly associated with EH-EoCOS.

Conclusions: Our findings suggest that NP ability to address patients’ emotional health needs is, in part, driven by the level of support for NP independent practice.

Implications for Policy or Practice: Lack of support for NP independent practice may prevent NPs from addressing patients’ emotional health, which could lead to future mental health complications among patients. NPs are uniquely prepared to deliver emotional healthcare because of their nursing education, which is grounded in holistic, person-centered care. Practices employing NPs should ensure that NPs have access to ancillary staff and support for care management to deliver care to patients. Practices should also allow NPs to manage patients independently, practicing to the full scope of their education and licensure.

Conflicts of Interest: Dr. Ghazal is a postdoctoral research fellow supported by NIH-NCI T32CA236621. Dr. Nikpour Townley is a postdoctoral fellow supported by NIH-NINR T32NR007104. Dr. Pogue is a postdoctoral fellow supported by NIH-NINR T32NR007104. Dr. Riman is a postdoctoral fellow supported by NIH-NHLBI T32HL007820. Dr. Schlak is a postdoctoral fellow supported by NIH-NINR CER2 T32NR014205.

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Qualitative Research on Mindfulness Interventions for Staff Nurses

A review of the literature.

Lemke, Johanna MA, BSN, RN, NEA-BC; Evanson, Tracy A. PhD, RN, PHNA-BC

Author Affiliations: Regional Director of Nursing (Lemke), Advocate Health, Charlotte, North Carolina; Professor (Dr Evanson), University of North Dakota, Grand Forks.

The authors declare no conflicts of interest.

Correspondence: Lemke, Northern Plains Center for Behavioral Research, Room 380H, Stop 9025, College of Nursing & Professional Disciplines, University of North Dakota, Grand Forks, ND 58202 ( [email protected] ).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.jonajournal.com ).

Complexity, workforce shortages, and escalating stressors in the healthcare setting have led to increased turnover and burnout of nursing staff. Mindfulness has been demonstrated to offer a variety of benefits to nurses. This article summarizes the qualitative research on the experience of mindfulness training and practice with the goal of providing evidence-based recommendations for nurse leaders on how to design and implement effective and well-adopted mindfulness programs.

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