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Why Nursing Research Matters

Affiliation.

• 1 Author Affiliation: Director, Magnet Recognition Program®, American Nurses Credentialing Center, Silver Spring, Maryland.
• PMID: 33882548
• DOI: 10.1097/NNA.0000000000001005

Increasingly, nursing research is considered essential to the achievement of high-quality patient care and outcomes. In this month's Magnet® Perspectives column, we examine the origins of nursing research, its role in creating the Magnet Recognition Program®, and why a culture of clinical inquiry matters for nurses. This column explores how Magnet hospitals have built upon the foundation of seminal research to advance contemporary standards that address some of the challenges faced by healthcare organizations around the world. We offer strategies for nursing leaders to develop robust research-oriented programs in their organizations.

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The power of nurses in research: understanding what matters and driving change

The next blog in our series focussing on how research evidence can be implemented into practice, Julie Bayley, Director of the Lincoln Impact Literacy Institute writes about the power of nurses in research and how nurses can support the whole research journey. 

Research is a funny old beast isn’t it? It starts life as a glint in a researcher’s eye, then like a child needs nurturing, shuttling back and forth to events and usually requires constant checking to make sure it’s not doing something stupid.

As someone who spends the majority of their working life on impact – the provable benefits of research outside of the world of academia – it is extraordinarily clear to me how research can make the world better. And as a patient advocate – having chronically and not exactly willingly collected DVTs over the last decade – it’s even more clear how good research and good care together make a difference that matters.

Having had some AMAZING care, nursing strikes me as both an art and a science. A brilliant technical understanding of healthcare processes combined magically with kindness, compassion and care.  Having been hugged by nurses as I cried being separated from my newborn (post DVT), and watching nurses let dad happily talk them through his army photo album as they check on his dementia, I am in no doubt that such compassion is what marks the difference between not just being a patient, but being a person .

One of the oddities about research is how we can so often get the impression that only big and shiny counts. ‘Superpower’ studies such as Randomised Controlled Trials, and multi-national patient cohort studies are amazing, but can mask the breadth of the millions of questions research can explore in endless different ways. Of course we need trials to determine ‘what works’, but we also need research to unveil the stories of those who feel their rarely heard, understand how things work, and connect research to people’s lives.

Research essentially is just the act of questioning in a structured, ethical and transparent way. It might seek to understand things through numbers (quantitative) or words and experiences (qualitative), and may reveal something new or confirm something we already believe. Research is the bedrock of evidence based care, allowing us – either through new (‘primary’) or existing (‘secondary’) data – to explore, understand, confirm or disprove ways patients can be helped. Some of you reading this will be very research active, some of you might think it’s not for you, some may not know where to start, and others may hate the idea altogether. Let’s face it, healthcare is an extremely pressured environment, so why would you add research into an already busy day job? The simple truth is that research gives us a way to add to this care magic, helping to ensure care pathways are the best, safest and most appropriate in every situation.

The pace and scale of research stories can make it easy to presume research is something ‘other people’ do, and whilst there are many brilliant professionals and professions within healthcare, nurses have a unique and phenomenally important place in research in at least three key ways:

• Understanding what matters to patients. A person is far more than their illness, and being so integral to day to day care, nurses have a lens not only on patients’ conditions, but how these interweave with concerns about their life, their livelihood, their loved ones and all else. And it is in this mix that the fuller impact of research can be really understood, way beyond clinical outcome measures, and into what it what matters .
• Understanding how to mobilise and implement new knowledge. Even if new research shows promise, the act of implementing it in a pressured healthcare system can be immensely challenging. Nurses are paramount for understanding – amongst many other things – how patients will engage (or not), what can be integrated into care pathways (or can’t), what unintended consequences could be foreseen and what (if any) added pressures new processes will bring for staff. This depth of insight borne from both experience and expertise is vital to mobilising, translating and otherwise ‘converting’ research promise into reality.
• Driving research . Nurses of course also drive research of all shapes and sizes. Numerous journals, such as BMC Nursing and the Journal of Research in Nursing bear testament to the wealth of research insights driven by nurses, and shared widely to inform practice.

Research isn’t owned by any single profession, or defined by any size. Whatever methods, scale or theories we use, research is the act of understanding, and if nurses aren’t at the heart of understanding the patient experience and the healthcare system, I don’t know who is. So when it comes to research:

• Recognise the value you already bring. You are front and centre in care which gives you a perspective on patient and system need that few others have. Ask yourself, what matters?
• Recognise the sheer breadth of research possibilities, and the million questions it hasn’t yet been used to answer. Ask yourself, what needs to be understood?
• Use – or develop – your skills to do research. Connect with researchers, read up, or just get involved. Ask yourself, how can I make my research mark?

Research is important because people are important. If you’re nearer the research-avoidant than the research-lead end of the spectrum, I’d absolutely urge you to get more involved. Whether you shine a light on problems research could address, critically inform the implementation of research, or do the research yourself….

….from this patient and research impact geek…

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Nurses Deserve Better. So Do Their Patients.

By Linda H. Aiken

Dr. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Covid-19 pandemic exposed strengths in the nation’s health care system — one of the greatest being our awesome nurses. But it also exposed many weaknesses, foremost among them being chronic nurse understaffing in hospitals , nursing homes and schools .

More nurses died of job-related Covid than any other type of health care worker. The more than 1,140 U.S. nurses who lost their lives in the first year of the pandemic knew the risks to themselves and their families. And yet they stayed in harm’s way. They cared for their fallen co-workers. They went to New York from around the country to fight on the front lines in the first Covid surge. Nurses from Northwell Health in New York returned that support by deploying to the Henry Ford Health System in Detroit in December when a surge occurred there.

We celebrate nurses now. We call them heroes. But if we value their sacrifices and want them to be there when we need them, we must prevent a return to the poor prepandemic working conditions that led to high nurse burnout and turnover rates even before Covid.

As a nurse with extensive clinical experience in hospitals, I found it nearly impossible to guarantee safe, effective and humane care to my patients. And so I established the world’s leading research center on nursing outcomes to understand the causes of nurse understaffing in the United States and abroad and to find solutions to the problem.

The United States has a robust supply of nurses . And there is no evidence that recruits to nursing have been deterred by Covid. To the contrary, applications to nursing schools increased during the pandemic.

Death, Through a Nurse’s Eyes

A short film offering a firsthand perspective of the brutality of the pandemic inside a covid-19 i.c.u..

I was looking through the window of a Covid I.C.U. And that’s when I realized I might see someone die. I didn’t even know who she was. But I was filled with immense grief as she edged closer to death by the hour. What I didn’t know yet was that by the time I left just two days later, at least three patients would be dead. The vaccine offers hope, but the sad truth is that the virus continues its brutal slaughter in I.C.U.s like this one in Phoenix, Ariz. The only people allowed in are health care workers. They’re overworked and underpaid in a deluged hospital. I wanted to know what it is like for them now, after a year of witnessing so much death. Eager to show us their daily reality, two nurses wore cameras so that for the first time we could see the I.C.U. through their eyes. “Unless you’re actually in there, you have no idea. Nobody can ever even imagine what goes on in there.” [MUSIC PLAYING] This I.C.U. contains 11 of the hospital’s sickest Covid patients. Most of them are in their 40s and 50s. And they are all on death’s door. It’s an incredibly depressing place. I blurred the patients faces to protect their privacy. But I also worried that blurring would rob them of their humanity. The family of this patient, the one who is rapidly declining, allowed her face to be shown. And they readily told me about her. Her name is Ana Maria Aragon. She’s a school administrator and a 65-year-old grandmother. Sara Reynolds, the nurse in charge of this I.C.U., organized a video call with Ana’s family to give them a chance to be with her just in case she didn’t make it. “It just breaks my heart when I hear families saying goodbye.” You might expect the doctors to be running the show. But it is really the nurses who are providing the vast majority of the care. “We do everything. We give them baths every night.” “Rubbing lotion on their feet.” “Shave the guys’ faces.” “Cleaning somebody up that had a bowel movement. It doesn’t even register as something gross.” “Look, I walk into the room. I say, hey, sounds like you have Covid. And I might order a chest X-ray. I might order blood work. I might order catheters. All that stuff is done by the nurse. I may have spent 10 minutes. The nurse might spend seven or eight hours actually in the room, caring for them. Let’s say there was a day that nurses didn’t come to the hospital. It’s like, why are you even opening?” “Ibuprofen.” 12-hour-plus shifts, isolated in this windowless room, these nurses survive by taking care of each other. “Aww, thank you.” And by finding small doses of levity. [MUSIC - JAMES BAY, “LET IT GO”] “(SINGING) Wrong. Breeze.” “I’m getting older now, and there’s all these new young nurses coming out. And I feel like a mom to all of them. Morgan, she’s got big aspirations. She loves to snowboard, and she’s so smart. And Deb, Deb’s just— she’s funny.” “I tease her all the time. I can tell her to do anything, and she’ll just do it because I think she’s scared of me because I just always say, make sure you have no wrinkles in those sheets.” The patients spend most of their time on their stomachs because it makes it easier to breathe. But the nurses have to turn them often to prevent pressure sores. There was one woman in her 50s who was so critical that this simple procedure risked killing her. “Even just turning them on their side, their blood pressure will drop. Their oxygen levels will drop.” “Her heart had actually stopped the day before. And so the concern was if it was going to make her heart stop again.” “Then come over. Push.” “We were all watching the monitors.” “I felt relieved like, whew, we did it.” Arizona’s a notoriously anti-mask state. And it faced a huge post-holiday surge in Covid cases. In January, the month I was there, Arizona had the highest rate of Covid in the world. As a result, I.C.U.s like this one have too many patients and not enough nurses. “Because they’re so critical, they need continuous monitoring, sometimes just one nurse to one patient with normally what we have is two patients to one nurse. But there definitely are times when we’re super stretched and have to have a three-to-one assignment.” A nurse shortage has plagued hospitals over the past year. To help, traveler nurses have had to fly into hotspots. Others have been forced out of retirement. Especially strained are poorer hospitals like Valleywise, which serves a low-income, predominantly Latino community. “Many of our patients are uninsured. Some of them have Medicaid, which pays something but unfortunately not enough.” This means they simply can’t compete with wealthier hospitals for nurses. “There is a bidding war. The average nurse here, give or take, makes about $35 an hour. Other hospitals, a short mile or two away, might pay them $100.” “We lost a lot of staff because they took the travel contracts. How can you blame them? It’s sometimes a once-in-a-lifetime opportunity to make a lot of money.” “Every single day I’m off, I get a call or a text. ‘Hey, we desperately need help. We need nurses. Can you come in?’” This nursing shortage isn’t just about numbers. “Physically it’s exhausting. We’re just running. We don’t have time to eat or drink or use the restroom.” “They have kids at home, doing online school. And I think, gosh, they haven’t even been able to check on their kids to see how they’re doing.” “My days off, I spend sleeping half the day because you’re exhausted. And eating because we don’t get to eat here often.” Nurses have been proud to be ranked the most trusted profession in America for nearly two decades. But during Covid, many worry they aren’t able to uphold the standards that earned them such respect. “I can’t give the quality of care that I normally would give.” “It’s absolutely dangerous.” “That’s demoralizing because we care. We’re nurses. It’s our DNA.” Ana had been in the hospital for over a month. Her family told me she was born in Mexico. She came to the States 34 years ago, first working in the fields before eventually landing her dream job in education. She’s beloved at her school. Former students often stop her in town and excitedly shout, Miss Anita. She was very cautious about Covid. She demanded her family always wear a mask and yelled at them to stay home. Yet, tragically, she somehow still caught it. “She had been declining over the course of several days. It’s a picture we have seen far too often that we know, this one is going to be coming soon.” Because there is no cure for Covid, the staff can only do so much. Once all the ventilator settings and the medications are maxed out, keeping a patient alive will only do more harm than good. So Ana’s family was forced to make a tough decision. “And I talked to family and let them know that we have offered her, we have given, we have done everything that we can, there’s nothing more that we can do. The family made the decision to move to comfort care.” “If I’m there while someone’s passing, I always hold their hand. I don’t want somebody to die alone. That’s something that brings me peace.” “Thank you.” “Thank you.” “Dance floor is packed. People hugging, holding hands, and almost no one wearing a face mask.” “I think like many health care workers, I’m angry a lot. And my faith in humanity has dwindled.” “How can you think this isn’t a real thing? How can you think that it’s not a big deal?” “Free your face. Free your face.” Arizona Gov. Doug Ducey has advocated for personal responsibility over mask mandates even though he’s been photographed maskless at a gathering and his son posted a video of a crowded dance party. “Even on the outside, they go, I don’t care. I’m not wearing a mask. I’m not getting the vaccine. That’s bullshit. The second they come into the hospital, they want to be saved. Never do they say, ‘I made the decision. I’m accepting this. Don’t do anything, doctor.’” Half a million people in this country have died from Covid. Many have been in I.C.U.s with nurses, not family members holding patients’ hands. “I always wonder, are they still going to be there when I get to work? It’s on my mind when I get home. Are they going to make it through the night? There’s one that I can think of right now.” One patient in his late 50s was so critical that he required constant supervision. Each of his breaths looked painful. “There was one day that he was kind of— he was looking a little bit better. And so he was able to shake his head and smile. And we set up a video call for him. And it was just the sweetest thing ever. I could hear his little grandson— he was probably 4 years old or so. And I saw him on the screen, too. And he was just jumping up and down, so excited. ‘You’re doing it, Grandpa. You’re doing it. We love you. Look at you. You’re getting better.’ It just broke my heart. It broke my heart. He’s one that I don’t think is going to be there when I get back on Sunday.” But I’d already been told something Sara hadn’t. The patient’s family had decided to take him off life support. “Yesterday they did? Oh. And I just think of his little grandson. And ‘you’re doing it, Grandpa. You’re doing it.’” He wasn’t the only patient who didn’t make it. When I went back to the hospital, I noticed that the bed of the patient I’d seen get flipped over was empty. My heart sank. I knew this meant she’d passed away. “What’s sad is when I go back, those beds will be full. They’ll have somebody else there just as sick with another long stretch of a few weeks ahead of them before it’s time for their family to make that decision.” I’d never before seen someone die. And even though I didn’t know these people, witnessing their deaths left me sleepless, exhausted, and depressed. It’s unfathomable to me that these nurses have gone through that every single week, sometimes every single day for an entire year. I assumed the nurses must block out all the deaths to be able to keep going, but they don’t. They grieve every single one. “I’ve always loved being a nurse. It’s what I’ve always wanted to do. And these last couple months, it’s definitely made me question my career choice.” And what makes their situation so tragic is that many of these nurses hide their trauma, leaving them feeling isolated and alone. “We’re the only ones that know what we’re going through. I don’t really want to tell my family about everything because I don’t want them to feel the same emotions that I feel. I don’t want them to know that I carry that burden when it— that it is a lot. I’m Mom. I’m strong. I can do anything. And I don’t want them to see that.” Leadership in the pandemic hasn’t come from elected officials or spiritual guides but from a group that is underpaid, overworked and considered secondary, even in their own workplaces. As so many others have dropped the ball, nurses have worked tirelessly out of the spotlight to save lives, often showing more concern for their patients than for themselves. I worry their trauma will persist long after we re-emerge from hibernation. Covid’s legacy will include a mass PTSD on a scale not felt since World War II. This burden should not be ignored. “Thank you. Thank you. I feel, yeah. And you’re all amazing.” [MUSIC PLAYING]

Nevertheless, we find ourselves too often with a shortage of nursing care. Many decades of research reveal two major reasons: First, poor working conditions, including not enough permanent employer-funded positions for nurses in hospitals, nursing homes and schools. And second, the failure of states to enact policies that establish and enforce safe nurse staffing; enable nurses to practice where they are needed, which is often across state borders; and modernize nurse licensing rules so that nurses can use their full education and expertise.

Training more nurses cannot solve these problems. But more responsible management practices in health care, along with better state policies, could.

Not only are states not requiring safe nurse staffing, but individuals also do not have the information and tools they need to pick hospitals and nursing homes based on nurse staffing or to advocate better staffing at their hospitals and nursing homes.

Ninety percent of the public in a recent Harris Poll agreed that hospitals and nursing homes should be required to meet safe nurse staffing standards. But powerful industry stakeholders — such as hospital and nursing home organizations and, often, medical societies — are strongly opposed and usually defeat legislation.

The New York State Legislature is the first in the postpandemic era to fail to approve proposed safe nurse staffing standards for hospitals. The legislature passed a bill that did not require safe nursing ratios, opting instead for internal committees at hospitals to oversee nursing and patient safety. This happened despite compelling evidence that the legislation would have resulted in more than 4,370 fewer deaths and saved more than $720 million over a two-year study period through shorter hospital stays.

What are the solutions? While there are some actions the federal government could take, the states have most of the power because of their licensing authority over occupations and facilities. The hospital and nursing home industries have long failed to police their members to remove the risk of nurse understaffing. So states should set meaningful safe nurse staffing standards, following the example of California, where hospital nurses cannot care for more than five adult patients at a time outside of intensive care. State policies are tremendously influential in health care delivery and deserve greater public attention and advocacy, as they are also ripe for exploitation by special interests.

In states with restrictive nurse licensing rules, many governors used their emergency powers during Covid surges to waive restrictions. If they were not needed during a national medical emergency, why are they needed at all?

Still, the federal government has a role to play: It should require hospitals to report patient-to-nurse staffing ratios on the Medicare Hospital Compare website, because transparency motivates improvement. The federal government could incentivize the states to pass model nurse practice acts.

We need influential champions taking on special interests so that states will make policy changes that are in the public’s interest. AARP is using its clout to advocate nurse-friendly policies. But health insurers and companies such as CVS, Walgreens and Walmart that provide health care have been on the sidelines.

While we long to go back to pre-Covid life, returning to chronic nurse understaffing in hospitals, nursing homes and schools would be a big mistake. We owe nurses and ourselves better health care resources. The so-called nurse shortage has become an excuse for not doing more to make health care safe, effective and patient-centered. State legislators must do their job. Health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.

Linda H. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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An earlier version of this article misstated the status of legislation on nurse staffing standards in New York State. The bill passed without setting minimum nursing ratios; it did not fail to pass.

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Home / Nursing Careers & Specialties / Research Nurse

Research Nurse

What does a research nurse do, becoming a research nurse, where do research nurses work, research nurse salary & employment, helpful organizations, societies, and agencies.

What Is a Research Nurse?

Research nurses conduct scientific research into various aspects of health, including illnesses, treatment plans, pharmaceuticals and healthcare methods, with the ultimate goals of improving healthcare services and patient outcomes. Also known as nurse researchers, research nurses design and implement scientific studies, analyze data and report their findings to other nurses, doctors and medical researchers. A career path that requires an advanced degree and additional training in research methodology and tools, research nurses play a critical role in developing new, potentially life-saving medical treatments and practices.

A highly specialized career path, becoming a nurse researcher requires an advanced degree and training in informatics and research methodology and tools. Often, research nurses enter the field as research assistants or clinical research coordinators. The first step for these individuals, or for any aspiring advanced practice nurse, is to earn a Bachelor of Science in Nursing degree and pass the NCLEX-RN exam. Once a nurse has completed their degree and attained an RN license, the next step in becoming a research nurse is to complete a Master's of Science in Nursing program with a focus on research and writing. MSN-level courses best prepare nurses for a career in research, and usually include coursework in statistics, research for evidence-based practice, design and coordination of clinical trials, and advanced research methodology.

A typical job posting for a research nurse position would likely include the following qualifications, among others specific to the type of employer and location:

• MSN degree and valid RN license
• Experience conducting clinical research, including enrolling patients in research studies, implementing research protocol and presenting findings
• Excellent attention to detail required in collecting and analyzing data
• Strong written and verbal communication skills for interacting with patients and reporting research findings
• Experience in grant writing a plus

To search and apply for current nurse researcher positions, visit our job boards .

What Are the Education Requirements for Research Nurses?

The majority of nurse researchers have an advanced nursing degree, usually an MSN and occasionally a PhD in Nursing . In addition to earning an RN license, research nurses need to obtain specialized training in informatics, data collection, scientific research and research equipment as well as experience writing grant proposals, research reports and scholarly articles. Earning a PhD is optional for most positions as a research nurse, but might be required to conduct certain types of research.

Are Any Certifications or Credentials Needed?

Aside from a higher nursing degree, such as an MSN or PhD in Nursing, and an active RN license, additional certifications are often not required for work as a research nurse. However, some nurse researcher positions prefer candidates who have earned the Certified Clinical Research Professional (CCRP) certification offered by the Society for Clinical Research Associates . In order to be eligible for this certification, candidates must have a minimum of two years' experience working in clinical research. The Association of Clinical Research Professionals also offers several certifications in clinical research, including the Clinical Research Associate Certification, the Clinical Research Coordinator Certification and the Association of Clinical Research Professionals – Certified Professional Credential. These certifications have varying eligibility requirements but generally include a number of hours of professional experience in clinical research and an active RN license.

Nurse researchers work in a variety of settings, including:

• Medical research organizations
• Research laboratories
• Universities
• Pharmaceutical companies

A research nurse studies various aspects of the healthcare industry with the ultimate goal of improving patient outcomes. Nurse researchers have specialized knowledge of informatics, scientific research and data collection and analysis, in addition to their standard nursing training and RN license. Nurse researchers often design their own studies, secure funding, implement their research and collect and analyze their findings. They may also assist in the recruitment of study participants and provide direct patient care for participants while conducting their research. Once a research project has been completed, nurse researchers report their findings to other nurses, doctors and medical researchers through written articles, research reports and/or industry speaking opportunities.

What Are the Roles and Duties of a Research Nurse?

• Design and implement research studies
• Observe patient care of treatment or procedures, and collect and analyze data, including managing databases
• Report findings of research, which may include presenting findings at industry conferences, meetings and other speaking engagements
• Write grant applications to secure funding for studies
• Write articles and research reports in nursing or medical professional journals or other publications
• Assist in the recruitment of participants for studies and provide direct patient care for participants

The Society of Clinical Research Associates reported a median salary for research nurses of $72,009 in their SoCRA 2015 Salary Survey , one of the highest-paying nursing specializations in the field. Salary levels for nurse researchers can vary based on the type of employer, geographic location and the nurse's education and experience level. Healthcare research is a growing field, so the career outlook is bright for RNs interested in pursuing an advanced degree and a career in research.

• National Institute of Nursing Research
• Council for the Advancement of Nursing Science
• International Association of Clinical Research Nurses
• Nurse Researcher Magazine

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How to bridge the experience gap by supporting nurses of all tenures

From baby boomers to Gen Zers, the question of how the four generations comprising today’s workforce 1 Elka Torpey, “Millennials in the labor force, projected 2019‒29,” US Bureau of Labor Statistics, November 2020. can best work together gets a lot of attention. Personal and professional experiences, levels of training, employer expectations, and career outlook can vary across generations. In nursing, tenure is a particularly nuanced factor that adds complexity to the discussion on workforce dynamics and may be one of the more definitive features of employee experience and, ultimately, retention.

About the authors

As healthcare organizations and other stakeholders refine their strategies for bolstering the nursing workforce, it is critical to incorporate the nuanced needs and preferences of nurses at different stages of their careers. To this end, we surveyed 5,772 nurses across tenures in October 2023 as part of an ongoing research collaboration between the American Nurses Foundation (the Foundation) and McKinsey (see sidebar, “About the research collaboration between the American Nurses Foundation and McKinsey”). The survey results provide insights into opportunities to bridge the experience gap and support nurses across their career continuum.

The survey analyzed three specific nurse cohorts: early-tenure nurses (less than five years of nursing experience), midtenure nurses (five to less than 21 years), and most-tenured nurses (21 or more years). When notable differences were reported within these cohorts, the specific tenure range was also noted.

About the research collaboration between the American Nurses Foundation and McKinsey

The American Nurses Foundation (the Foundation) is a national research, educational, and philanthropic affiliate of the American Nurses Association committed to advancing the nursing profession by serving as a thought leader, catalyst for action, convener, and funding conduit. The Foundation and McKinsey have partnered to assess and report on trends related to the nursing profession. A foundational part of this effort is jointly publishing novel insights related to supporting nurses throughout their careers. The first publication from the research partnership, “ Understanding and prioritizing nurses’ mental health and well-being ,” was based on a survey conducted in April and May 2023. 1 “ Understanding and prioritizing nurses’ mental health and well-being ,” McKinsey, November 6, 2023.

This is the second publication from the research partnership and is based on a survey of 5,772 nurses across the United States, conducted in October 2023. The intent of this new research is to better understand surveyed nurses’ experiences, needs, preferences, and career intentions.

As part of the research, we asked nurses to share how much nursing experience they had based on these categories: less than two years, two to four, five to ten, 11 to 20, 21 to 30, 31 to 40, 41 to 50, and more than 50 years. Respondents were provided a disclaimer prior to completing the survey that results would be anonymous and shared only in aggregate. All survey questions were based on the experiences of the individual professional. All questions were also optional for survey respondents; therefore, the number of responses may vary by question. Additionally, publicly shared examples, tools, and healthcare systems referenced in this article are representative of actions that stakeholders are taking to address workforce challenges.

Across all experience levels, intent to leave the bedside remains high for surveyed nurses. About 30 percent of survey respondents indicated they were at least somewhat likely to leave their positions in the next six months. This is particularly acute in the early-tenure population, where a greater proportion of surveyed nurses reported considering leaving (about 45 percent) compared with midtenure (31 percent) and most-tenured nurses (27 percent).

The early-tenure population is particularly important to retain as more experienced nurses reach retirement age. Supporting and retaining midtenure and most-tenured nurses is also crucial given the critical role they play in teaching and mentoring those newer to the profession. In fact, finding creative ways to enable not only nurses nearing retirement but also those already retired to participate in direct patient care activities or coaching could help fill part of the experience void—and this cohort appears open to doing so if their needs and preferences were met.

We asked nurses who indicated they were currently or previously retired what would make them consider returning to clinical nursing. Of the 179 survey respondents, 45 percent reported that having the ability to set their own schedule would make them consider returning to clinical nursing, 34 percent wanted the ability to serve as an educator, and 31 percent wanted the ability to mentor nurses. Surveyed nurses across tenures indicated that there is a need to enact structures that would enable more robust onboarding and training for new nurses, promote team building, and create safe working environments through policies designed to prevent incivility and bullying.

Understanding the common needs of the nursing workforce as well as unique tenure-specific qualities can help hospital leaders find tangible ways to create collaborative and sustainable environments that would benefit nurses across the entirety of their careers. In this article, we explore how a positive team environment, across and between all tenures, can promote well-being and holistic employee health.

How the work environment can affect nurses

It’s no surprise that a team environment can substantially affect both health and burnout. Positive team characteristics, such as a sense of belonging, psychological safety, opportunities to learn and grow, and coworker support, were among the top indicators of an employee’s holistic health, according to a global survey  conducted by the McKinsey Health Institute (MHI) across industries last year. 2 Jacqueline Brassey, Brad Herbig, Barbara Jeffery, and Drew Ungerman, “ Reframing employee health: Moving beyond burnout to holistic health ,” McKinsey Health Institute, November 2, 2023. Negative team characteristics, such as toxic workplace behavior and interpersonal conflict, were strongly linked with burnout.

MHI’s findings were reflected in the sentiments of early-tenure nurses in our survey. These respondents indicated that they were looking for a work environment where they felt supported and could learn from more-tenured nurses, but reported sometimes experiencing a negative environment, which can contribute to burnout. While in our May 2023 survey, nurses overall reported that they were indeed feeling burned out and that their mental health was suffering , nurses with less than five years of experience more often reported lower satisfaction with their roles, greater intent to leave their roles, and experiencing burnout. 3 “ Understanding and prioritizing nurses’ mental health and well-being ,” McKinsey, November 6, 2023.

In our October 2023 survey, we examined how negative sentiments after working a shift may be affecting nurses’ intent to leave. We asked nurses to select an adjective or sentiment for how they felt after they finished working a shift with each nursing tenure, including their peer group. When we compared intent to leave with the sentiments each nurse shared, there was a positive correlation between those who reported more negative sentiments and those who reported a greater intent to leave. This is particularly salient for stakeholders, as it provides a glimpse into how culture and team dynamics may affect nurses and their likelihood to stay in their current roles.

Nurses’ sentiments about working with those of different tenures

To better understand the overall nursing experience, it is important to evaluate each tenure, including the unique needs, preferences, and experiences of the nurses in each tenure, as well as where there is common ground among tenures. Not surprisingly, we found some distinct nuances to each group’s professional experience but also many commonalities to build upon.

Our joint research highlighted that nurses’ experiences working with different tenures may affect how they feel at the end of their shifts (Exhibit 1)—even though nurses are likely to tell you there is no such thing as a typical shift or day for them.

Surveyed nurses were asked to select the top sentiments they felt after working a shift. Early-tenure nurses more often reported feeling supported by midtenure nurses (29 percent) than feeling supported by most-tenured nurses (17 percent). Early-tenure nurses also more often said that they felt frustrated by their most-tenured colleagues (12 percent), compared with midtenure nurses (8 percent). Additionally, early-tenure nurses more often reported feeling intimidated by most-tenured nurses (12 percent) than by their midtenure coworkers (2 percent).

Despite these negative sentiments, however, about 75 percent of early-tenure nurse respondents reported that they agreed or strongly agreed that they enjoyed working with most-tenured nurses. More than 80 percent reported that they viewed most-tenured nurses as “a great resource to learn from” (Exhibit 2). These sentiments were consistent across early-tenure nurses with less than two years of experience and those with more than two years but less than five years of experience.

These two early-tenure nurse subsets differed, however, when reflecting on shifts with midtenure colleagues, most evidently on whether midtenure nurses “have the time and capacity to train and coach them.” About 25 percent of those with less than two years of experience reported that they disagreed or strongly disagreed, compared with about 11 percent of nurses with more than two years but less than five years of experience.

Midtenure and most-tenured nurses were fairly aligned with each other in terms of how they felt about working with early-tenure nurses. Midtenure and most-tenured nurses reported feeling hopeful, like a leader, and respected. Yet they also noted being exhausted and concerned after a shift with early-tenure nurses. In fact, only half of most-tenured and midtenure nurses reported that they got enough support from early-tenure nurses.

This response may indicate that midtenure nurses feel that early-tenure nurses entering the workforce require more support than they can provide (for example, if they are managing more complex patients while also training new joiners). Nonetheless, about 75 percent of both midtenure and most-tenured nurse respondents shared that they enjoyed working with early-tenure nurses (Exhibit 3). Greater than 70 percent of midtenure and most-tenured nurses said they felt energized or personally fulfilled by supporting early-tenure nurses in learning and developing, but more than 33 percent reported that they didn’t have the time or capacity to train or coach others.

Actions to improve collaborative work across tenures

To address the unique challenges facing each tenure and strengthen retention, it is imperative for organizations to evaluate how and where to deploy resources that best match the needs of nurses across their career continuum. To identify tactical, actionable solutions, organizations need a better understanding of what initiatives nurses think could improve the experience of a multitenure workforce and how to create environments that are more collaborative. We also looked at additional cross-cutting strategies for recruitment and retention, such as flexibility.

Ultimately, the interventions an organization chooses will depend on the makeup of its staff and the organization’s goals for its nursing pipeline. However, by using the preferences that the nurses in our survey shared, there are three potential avenues that organizations can consider.

Enhance flexibility for all

Providing schedule flexibility could be helpful not only for nurses who are currently practicing but also to potentially bring back retired nurses. Nearly a third of respondents reported that their employers didn’t offer any type of shift flexibility. Among those who worked at places offering some schedule flexibility, more than 30 percent of early-tenure nurses reported feeling neutral to very dissatisfied with the available options, and 25 percent of midtenure and most-tenured nurses reported the same.

We asked nurses to select all the flexible-schedule options that mattered the most to them (Exhibit 4). Across all tenures, nurses expressed a desire for self-scheduling (for example, everyone gets to select the days and shifts they work for the entirety of the published schedule). This was particularly important for early-tenure nurses, with 46 percent selecting this as an important scheduling option. Additionally, all nurses wanted their employers to offer variable and flexible shift lengths (for example, four, six, eight, ten, and 12 hours). Among early-tenure nurses, 36 percent selected this as a desired scheduling option, while 32 percent of midtenure nurses chose this option. Early-tenure nurses also requested flexible and variable start times (for example, 7:00 a.m., 8:00 p.m., et cetera), while midtenure and most-tenured nurses opted for hybrid working options.

Some organizations have started utilizing technology to support flexible scheduling options. For example, Providence partnered with healthcare platform CareRev to provide unclaimed shifts to nurses or care providers in nontraditional increments, such as 9:00 a.m. to 2:00 p.m., which could then free up nurses to perform daytime activities such as dropping off and picking up their kids from school. 4 “Flexible staffing models cut costs, attract workers,” Becker’s Hospital Review , January 2, 2024. Similarly, SSM Health partnered with the app ShiftMed to offer open shifts to its workforce. The partnership gave SSM Health the opportunity to pilot flexible shift options, start times, and roles and allowed them to fill more than 85 percent of their 25,000 posted shifts per quarter. 5 “How on-demand staffing benefited SSM Health,” Becker’s Hospital Review , December 28, 2023.

The exodus from the workforce of the many nurses nearing retirement age 6 Nursing workforce fact sheet, American Association of Colleges of Nursing, updated July 2023. may mean the loss of decades of expertise and institutional knowledge. Some organizations have implemented programs that provide flexibility and schedule relief to these most-tenured preretirement nurses. Indeed, being able to set their own schedule was the top response among the 1,640 respondents who identified as eligible for retirement, with 46 percent sharing that this would encourage them to consider delaying their retirement. And 45 percent of nurses who were currently or previously retired indicated that this would make them consider rejoining the workforce.

Examples of organizations that have focused on bringing nurses back to their organizations by using flexibility include Henry Ford Health and Northwestern Memorial HealthCare. Henry Ford Health focused on outreach to nurses who left the workforce during the COVID-19 pandemic. It offered flexible opportunities, including internal travel nurse programs and weekend-only options. This strategy resulted in about 25 percent of nurses returning to the organization. 7 Mackenzie Bean and Erica Carbajal, “How Henry Ford rehired 25% of nurses who left during the pandemic,” Becker’s Hospital Review , February 15, 2023. Similarly, Northwestern Memorial HealthCare concentrated on opportunities it called “knowledge worker” roles, which may be less physically demanding than a bedside position and allow nurses to participate in its innovative nursing models, including remote intensive care unit care and virtual nursing. 8 Mackenzie Bean and Erica Carbajal, “How Henry Ford rehired 25% of nurses who left during the pandemic,”  Becker’s Hospital Review , February 15, 2023.

Bolster mentorship opportunities

Asking nurses how they felt after working a shift revealed a road map of what they need, as well as the barriers they encounter when nurses don’t have the time or resources to follow this plan. Early-tenure nurses indicated they wanted to learn from their midtenure and most-tenured coworkers, with 18 percent ranking formal mentorship programs as a top initiative to support a positive work environment. About 72 percent of midtenure and most-tenured nurses shared that they felt energized and fulfilled when they could teach and coach their early-tenure colleagues. However, only about 60 percent of midtenure and most-tenured nurses shared that they had adequate time or capacity to coach and teach. This can lead to sentiments of confusion, burnout, intimidation, and frustration.

Although many nurses are already feeling stretched and mentally exhausted, there may be a key group of nurses with the expertise, bandwidth, and desire to support onboarding and mentoring programs. We asked nurses who had not yet retired to select the top three things that their employers could do for them to consider staying in their role. While the ability to set their own schedule was the top response (46 percent), 27 percent reported that being able to work as a nurse educator or in a virtual-nurse capacity would be attractive.

Among nurses who have retired or were previously retired, similar sentiments were shared (Exhibit 5). More than 30 percent reported that being able to serve as an educator or focus on mentoring newer nurses would be enough to make them consider rejoining the workforce.

As a growing number of nurses reach retirement age, organizations have an opportunity to create roles that honor the expertise of these often more-tenured nurses while promoting a work environment that is collaborative and positive for early-tenure nurses. Facilities within the Mass General Brigham healthcare system piloted a formal mentoring program in which early-tenure nurses meet every two weeks for three months with more-tenured nurses. The organization considers this to be paid educational time. Reviews from the pilot show that job satisfaction increased for both new and experienced nurses. 9 “New nurse mentorship program provides ongoing connections, deepens professional investment,” Cooley Dickinson Health Care, April 15, 2022. Similarly, the AARP Center for Health Equity through Nursing is recruiting working and retired nurses for its mentorship program, which is focused on nursing students in underrepresented communities, as part of its Campaign for Action focused on health equity. 10 “Help wanted: Nurse mentors for a more diverse nurse workforce,” Campaign for Action, April 11, 2023.

In addition, adequate support for new graduates entering the workforce was indicated as the number-one contributor toward a positive work environment among all three tenure cohorts. For example, the Practice Transition Accreditation Program, an evidence-based accredited registered nurse residency and fellowship program created by the American Nurses Credentialing Center (ANCC), demonstrated an 85.3 percent retention over 12 months, compared with the industry average of 71.3 percent. 11 “ANCC PTAP accredited programs: Data gathered from PTAP accredited RN programs Oct. 2022–Sept. 2023,” American Nurses Credentialing Center; ANCC is a subsidiary of the American Nurses Association (ANA), while McKinsey’s partner for this research, American Nurses Foundation, is ANA’s research, education, and charitable affiliate.

Promote team building and safe spaces

Personal working styles in any work environment can vary greatly depending on the individual; however, in healthcare specifically, teams should work cohesively and collaboratively. When surveyed nurses were asked to choose the top three most important factors for creating a collaborative working environment, nurses across all tenures selected team building as a top initiative.

Healthcare organizations may not need to look far to find processes to support better collaboration and understanding among team members. Many organizations use after-action reviews following patient safety events to assess and reflect on what went well and what needs to be improved to prevent such future incidents. 12 Catherine Hogan et al., “Effect of after action review on safety culture and second victim experience and its implementation in an Irish hospital: A mixed methods study protocol,” PLoS One , 2021, Volume 16, Issue 11. Additionally, it may be beneficial for departments to conduct more frequent check-ins, huddles, and team-building exercises to give nurses and health professionals an opportunity to share experiences and establish norms for their working culture. Often conducted at the beginning of shifts, huddles may also allow departments to set up working models and provide a platform for staff to get to know one another more informally, which can build trust and professional collaboration.

Another example initiative that could help build a more supportive environment is the Schwartz Rounds program. It was established as a contrast to traditional patient rounding, which tends to focus on patient needs and barriers to care. Instead, the Schwartz Rounds program offers healthcare providers time and space to discuss the social and emotional issues they face while caring for patients and families. The benefits include improved teamwork, better interdisciplinary communication, and a greater appreciation for different roles and disciplines, as well as a decrease in feelings of stress and isolation.

Other actions that stakeholders can consider include establishing and enforcing policies that create space for nurses to feel safe at work. Among early-tenure and midtenure nurses, 12 percent reported that a top priority was formal policies and enforcement against bullying (Exhibit 6). Bullying, incivility, and verbal abuse can lead to a degradation of safe, quality care and affect an individual’s sense of well-being, creating an unhealthy work environment. 13 “Incivility, bullying, and workplace violence,” ANA, July 22, 2015.

Supporting nurses across their career continuum

Addressing the complexity of this multitenure, multigenerational workforce is critical to supporting the healthcare workforce and ensuring an adequate pipeline of nurses eager and engaged in the profession. Many surveyed nurses expressed positive sentiments toward their peers and colleagues but also shared structural challenges that may be preventing them from fully appreciating the potential benefits of a multitenure workforce.

Bolstering cross-tenure relationships would increase trust and collaboration among nurses, not only increasing the likelihood that they stay in the profession but also improving productivity and engagement in real time. How to address these challenges will depend on the makeup of each specific workforce, but stakeholders can start by evolving their workforce strategies to ensure that tenure-specific needs and preferences are considered.

Gretchen Berlin, RN , is a senior partner in McKinsey’s Washington, DC, office, where Faith Burns is an associate partner; Stephanie Hammer, RN , is a consultant in the Denver office; and Mhoire Murphy is a partner in the Boston office. Adriane Griffen is a vice president at the American Nurses Foundation; Amy Hanley is a program manager at the Foundation; and Kate Judge is the executive director of the Foundation.

The authors wish to thank the nurses, physicians, and staff on the front lines who are caring for patients and communities. They also wish to thank Beth Bravo, Brad Herbig, and Deirdre Keane for their contributions to this article.

This article was edited by Querida Anderson, a senior editor in the New York office.

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• Precepting at YSN
• Event Calendar

Uzoji Nwanaji-Enwerem,

Family Nurse Practitioner

email:  uzoji.nwanaji-enwerem@yale.edu

Dr. Uzoji Nwanaji-Enwerem, a family nurse practitioner and Yale School of Nursing lecturer, focuses on researching psychosocial stressors’ effects on sleep health among individuals from marginalized backgrounds. She’s presently engaged in an NIH/NCATS-funded project, investigating intersectional stigma against Black individuals with co-occurring HIV, post-traumatic stress symptoms, and sleep disturbance. The project also assesses the feasibility, acceptability, and appropriateness of utilizing accelerated resolution therapy (ART) to address these health challenges in efforts to improve trauma informed care.

Concord, NC

Undergraduate Education 

BSN, Winston Salem State University

Graduate Education 

MSN, Family Nurse Practitioner Program, Winston Salem State University -Duke Nursing Bridge to the Doctorate Program

PhD – Yale University School of Nursing

Research Interests

Psychosocial Stress, Stigmatization, Discrimination, Sleep Health

Publications and Presentations: 

Publications:.

Nwanaji-Enwerem, U ., Onsomu, O., Roberts, D., Singh, A., Brummett, B., Williams, R.,  Dungan, J., (2022). Relationship between psychosocial stress and blood pressure: The National Heart, Lung, and Blood Institute Family Heart Study.  Sage Open Nursing, 8 , 23779608221107589.

Nwanaji-Enwerem ,  U . Condon, E., Conley, Wang, K., Iheanacho, T., S., Redeker, N. (2022). Adapting the health stigma & discrimination framework to understand the association between stigma and sleep deficiency: A systematic review.  SleepHealth.

Breazeale, S., Jeon, S., Hwang, Y., O’Connell, M.,  Nwanaji-Enwerem, U ., Linsky, S., … & Redeker, N. S. (2022). Sleep Characteristics, Mood, Somatic Symptoms, and Self-Care Among People With Heart Failure and Insomnia.  Nursing Research.

Redeker, N. S., Yaggi, H. K.,  Jacoby, D., Hollenbeak, C., Breazeale, S., Conley, S., Hwang, Y., Iennacco, J., Linsky, S., Moemeka, L.,  Nwanaji-Enwerem, U ., O’Connell, M., Jeon, S. (2021).  Cognitive Behavioral Therapy for Insomnia has sustained effects on insomnia, fatigue, and function among people with chronic heart failure and insomnia: The HeartSleep Study.  Sleep . 

Redeker, N. S., Rawl, S. M., &  Nwanaji-Enwerem, U . (2021). Expanding the Pipeline of Nurse Scientists to Address the Health Care Needs of a Diverse Society. Nursing outlook, 69(4), 704-706.

Nwanaji-Enwerem, J. C.,  Nwanaji-Enwerem, U ., Van Der Laan, L., Galazka, J. M., Redeker, N. S., & Cardenas, A. (2020). A longitudinal epigenetic aging and leukocyte analysis of simulated space travel: The Mars-500 Mission.  Cell Reports ,  33 (10), 108406.

Moore, D., Onsomu, E. O., Brown, T. L.,  Nwanaji-Enwerem, U ., Esquivel, M., Bush, D., & Richardson, S. (2019). African American nursing students understanding of media images and their role in intercultural exchanges, communication, and the nursing profession.  Journal of Best Practices in Health Professions Diversity: Research, Education and Policy, 12 (2), 154-164.

Redeker, N.S., Rawl, S.,  Nwanaji-Enwerem, U.  (2021). Expanding the pipeline of nurse scientists to address the health care needs of a diverse society [Editorial]. Nursing Outlook, 69(4), 704-706. doi.org/10.1016/j.outlook.2021.06.010

Redeker, N. S., Bessette, A., Breazeale, S., Conley, S., Hollenbeak, C., Hwang, Y., Iennacco, J., Jacoby, D., Kelly-Hauser, J., Linsky, S., Moemeka, L.,  Nwanaji-Enwerem, U. , O’Connell, M., Yaggi, H. K.,  & Jeon, S. (2021).  Cognitive behavioral therapy for insomnia compared with heart-failure self-management education has sustained effects on insomnia among adults with chronic heart failure, Sleep, 44, A136

Nwanaji-Enwerem, J.,  Nwanaji-Enwerem, U. , Laan L., Galazka, J., Redeker, N., Cardenas, A. (2020). A longitudinal epigenetic aging and leukocyte analysis of simulated space travel: The Mars-500 mission. Cell Reports, 33(10), 108406.

Moore, D., Onsomu, E. O., Brown, T. L.,  Nwanaji-Enwerem, U. , Esquivel, M., Bush, D., & Richardson, S. (2020). African American nursing students understanding of media images and their role in intercultural exchanges, communication, and the nursing profession. Journal of Best Practices in Health Professions Diversity: Research, Education and Policy

Presentations:

Nwanaji-Enwerem, U.,  Beitel, M., Eggert, K., Zheng, X., Gaeta, M., Redeker, N., Madden, M., Oberleitner, L., Oberleitner, D., Barry, D. (2021, Submitted-Abstract). Correlates of perceived discrimination among patients in methadone maintenance treatment. The College on Problems of Drug Dependence (CPDD). March 25 th -March 26 th , 2021-Annual Conference (abstract)

Nwanaji-Enwerem, U.,  Sadler, S., Sangchoon. J., Barry, D., Yaggi, K., & Redeker, N. (2021, Submitted-Abstract). An explanatory sequential mixed methods study of stigma, sleep and treatment outcomes among individuals on medication for opioid use disorder. Eastern Nursing Research Society (ENRS). March 25 th -March 26 th , 2021-Annual Conference (abstract)

Ruth L. Kirschstein National Research Service Award (F31). Recipient.

National Institute of Health (NIH) Diversity Supplement. Recipient.

Yale Graduate School of Arts and Sciences Dean’s Emerging Scholars Fellowship. Recipient. 

Afro-American Cultural Center at Yale ORD Funding. Recipient.

JI Girls x Brown University Afro Health Campaign Project Funding. Recipient.

Extracurricular Activities

JI Organization- media blogging and entertainment (Website:  https://www.jigirls.org ) 

Afrocultural work

New Director of the Florence S. Downs PhD Program in Nursing Research & Theory Development

April 11, 2024.

Duke School of Nursing MSN Ranking Rises in 2024 U.S. News & World Report Rankings

In the 2024 U.S. News & World Report Best Schools Rankings, the Duke University School of Nursing achieved remarkable accolades including: #3 Best Nursing Schools, Master’s and #3 Best Nursing Schools, Doctor of Nursing Practice.

Duke University School of Nursing once again ranks among the top nursing graduate-level programs in the nation. The Master of Science in Nursing (MSN) program at the Duke University School of Nursing is ranked #3 in the country, according to the 2024 U.S. News & World Report graduate school rankings   released Tuesday, April 9. The Doctor of Nursing Practice (DNP) program ranked #3 (tie) , while all participating specialty programs continued the trend of leading the country among graduate nursing program rankings at #1.

“Our School continues to reimagine the nursing profession and the limitless possibilities for nurses through the ongoing development of innovative offerings that set our MSN and DNP programs apart nationally and globally.”

Interim Dean Michael Relf

PhD, RN, ANEF, FAAN

“These rankings reflect the extraordinary depth of nursing expertise and educational opportunities our programs offer,” said Interim Dean Michael Relf, PhD, RN, ANEF, FAAN. “Our School continues to reimagine the nursing profession and the limitless possibilities for nurses through the ongoing development of innovative offerings that set our MSN and DNP programs apart nationally and globally. I extend my heartfelt gratitude to all faculty, staff, students, and alumni who contribute to making Duke University School of Nursing a premiere destination for excellence in nursing.”

As a result of the School’s dedicated mission to advance health equity and social justice through a commitment to innovation and excellence in nurse-led models of care, these rankings reaffirm the School's position as a visionary leader in nursing education, research, and clinical practice.

U.S. News & World Report Rankings

In the 2024 U.S. News & World Report Best Schools Rankings , the Duke University School of Nursing achieved remarkable accolades:

• Best Nursing Schools, Master’s: the School is ranked #3 in this category, recognizing its outstanding master’s programs. Whether students aspire to become nurse practitioners, nurse educators, or nurse administrators, the School of Nursing provides rigorous training and mentorship.
• Best Nursing Schools, Doctor of Nursing Practice (DNP):  the School claimed the #3 position (tie)  for its DNP programs. These doctoral programs empower nurses to lead in clinical practice, healthcare administration, and policy. The School of Nursing’s commitment to evidence-based practice and leadership shines through its DNP offerings.
• Best Nursing Schools, Doctor of Nursing Practice (DNP) Leadership: Duke University School of Nursing was ranked #1 in the nation for its DNP Leadership programs, a recognition of the School’s commitment to training world-class nurses who will go on to become leaders in the healthcare industry.

Master’s Specialties

The Duke University School of Nursing offers a variety of master’s programs that excel across various specialties. Once again, several of the School’s concentrations and certificate programs received top rankings, including:

• #1 in Master's Nurse Practitioner: Adult / Gerontology, Acute Care
• #1 in Master's Nurse Practitioner: Adult / Gerontology, Primary Care
• #1 in Master's Nurse Practitioner: Family
• #1 in  Master's Nurse Practitioner: Psychiatric / Mental Health, Across the Lifespan
• #1 in  Master's Nursing Administration

For more information, visit the Duke University School of Nursing’s Rankings and Accolades page .

• Research article
• Open access
• Published: 09 November 2005

A qualitative study of nursing student experiences of clinical practice

• Farkhondeh Sharif 1 &
• Sara Masoumi 2  

BMC Nursing volume  4 , Article number:  6 ( 2005 ) Cite this article

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Nursing student's experiences of their clinical practice provide greater insight to develop an effective clinical teaching strategy in nursing education. The main objective of this study was to investigate student nurses' experience about their clinical practice.

Focus groups were used to obtain students' opinion and experiences about their clinical practice. 90 baccalaureate nursing students at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery) were selected randomly from two hundred students and were arranged in 9 groups of ten students. To analyze the data the method used to code and categories focus group data were adapted from approaches to qualitative data analysis.

Four themes emerged from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap"," clinical supervision", professional role", were considered as important factors in clinical experience.

The result of this study showed that nursing students were not satisfied with the clinical component of their education. They experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting.

Peer Review reports

Clinical experience has been always an integral part of nursing education. It prepares student nurses to be able of "doing" as well as "knowing" the clinical principles in practice. The clinical practice stimulates students to use their critical thinking skills for problem solving [ 1 ]

Awareness of the existence of stress in nursing students by nurse educators and responding to it will help to diminish student nurses experience of stress. [ 2 ]

Clinical experience is one of the most anxiety producing components of the nursing program which has been identified by nursing students. In a descriptive correlational study by Beck and Srivastava 94 second, third and fourth year nursing students reported that clinical experience was the most stressful part of the nursing program[ 3 ]. Lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. In study done by Hart and Rotem stressful events for nursing students during clinical practice have been studied. They found that the initial clinical experience was the most anxiety producing part of their clinical experience [ 4 ]. The sources of stress during clinical practice have been studied by many researchers [ 5 – 10 ] and [ 11 ].

The researcher came to realize that nursing students have a great deal of anxiety when they begin their clinical practice in the second year. It is hoped that an investigation of the student's view on their clinical experience can help to develop an effective clinical teaching strategy in nursing education.

A focus group design was used to investigate the nursing student's view about the clinical practice. Focus group involves organized discussion with a selected group of individuals to gain information about their views and experiences of a topic and is particularly suited for obtaining several perspectives about the same topic. Focus groups are widely used as a data collection technique. The purpose of using focus group is to obtain information of a qualitative nature from a predetermined and limited number of people [ 12 , 13 ].

Using focus group in qualitative research concentrates on words and observations to express reality and attempts to describe people in natural situations [ 14 ].

The group interview is essentially a qualitative data gathering technique [ 13 ]. It can be used at any point in a research program and one of the common uses of it is to obtain general background information about a topic of interest [ 14 ].

Focus groups interviews are essential in the evaluation process as part of a need assessment, during a program, at the end of the program or months after the completion of a program to gather perceptions on the outcome of that program [ 15 , 16 ]. Kruegger (1988) stated focus group data can be used before, during and after programs in order to provide valuable data for decision making [ 12 ].

The participants from which the sample was drawn consisted of 90 baccalaureate nursing students from two hundred nursing students (30 students from the second year and 30 from the third and 30 from the fourth year) at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery). The second year nursing students already started their clinical experience. They were arranged in nine groups of ten students. Initially, the topics developed included 9 open-ended questions that were related to their nursing clinical experience. The topics were used to stimulate discussion.

The following topics were used to stimulate discussion regarding clinical experience in the focus groups.

How do you feel about being a student in nursing education?

How do you feel about nursing in general?

Is there any thing about the clinical field that might cause you to feel anxious about it?

Would you like to talk about those clinical experiences which you found most anxiety producing?

Which clinical experiences did you find enjoyable?

What are the best and worst things do you think can happen during the clinical experience?

What do nursing students worry about regarding clinical experiences?

How do you think clinical experiences can be improved?

What is your expectation of clinical experiences?

The first two questions were general questions which were used as ice breakers to stimulate discussion and put participants at ease encouraging them to interact in a normal manner with the facilitator.

Data analysis

The following steps were undertaken in the focus group data analysis.

Immediate debriefing after each focus group with the observer and debriefing notes were made. Debriefing notes included comments about the focus group process and the significance of data

Listening to the tape and transcribing the content of the tape

Checking the content of the tape with the observer noting and considering any non-verbal behavior. The benefit of transcription and checking the contents with the observer was in picking up the following:

Parts of words

Non-verbal communication, gestures and behavior...

The researcher facilitated the groups. The observer was a public health graduate who attended all focus groups and helped the researcher by taking notes and observing students' on non-verbal behavior during the focus group sessions. Observer was not known to students and researcher

The methods used to code and categorise focus group data were adapted from approaches to qualitative content analysis discussed by Graneheim and Lundman [ 17 ] and focus group data analysis by Stewart and Shamdasani [ 14 ] For coding the transcript it was necessary to go through the transcripts line by line and paragraph by paragraph, looking for significant statements and codes according to the topics addressed. The researcher compared the various codes based on differences and similarities and sorted into categories and finally the categories was formulated into a 4 themes.

The researcher was guided to use and three levels of coding [ 17 , 18 ]. Three levels of coding selected as appropriate for coding the data.

Level 1 coding examined the data line by line and making codes which were taken from the language of the subjects who attended the focus groups.

Level 2 coding which is a comparing of coded data with other data and the creation of categories. Categories are simply coded data that seem to cluster together and may result from condensing of level 1 code [ 17 , 19 ].

Level 3 coding which describes the Basic Social Psychological Process which is the title given to the central themes that emerge from the categories.

Table 1 shows the three level codes for one of the theme

The documents were submitted to two assessors for validation. This action provides an opportunity to determine the reliability of the coding [ 14 , 15 ]. Following a review of the codes and categories there was agreement on the classification.

Ethical considerations

The study was conducted after approval has been obtained from Shiraz university vice-chancellor for research and in addition permission to conduct the study was obtained from Dean of the Faculty of Nursing and Midwifery. All participants were informed of the objective and design of the study and a written consent received from the participants for interviews and they were free to leave focus group if they wish.

Most of the students were females (%94) and single (% 86) with age between 18–25.

The qualitative analysis led to the emergence of the four themes from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap", clinical supervision"," professional role", was considered as important factors in clinical experience.

Initial clinical anxiety

This theme emerged from all focus group discussion where students described the difficulties experienced at the beginning of placement. Almost all of the students had identified feeling anxious in their initial clinical placement. Worrying about giving the wrong information to the patient was one of the issues brought up by students.

One of the students said:

On the first day I was so anxious about giving the wrong information to the patient. I remember one of the patients asked me what my diagnosis is. ' I said 'I do not know', she said 'you do not know? How can you look after me if you do not know what my diagnosis is?'

From all the focus group sessions, the students stated that the first month of their training in clinical placement was anxiety producing for them.

One of the students expressed:

The most stressful situation is when we make the next step. I mean ... clinical placement and we don't have enough clinical experience to accomplish the task, and do our nursing duties .

Almost all of the fourth year students in the focus group sessions felt that their stress reduced as their training and experience progressed.

Another cause of student's anxiety in initial clinical experience was the students' concern about the possibility of harming a patient through their lack of knowledge in the second year.

One of the students reported:

In the first day of clinical placement two patients were assigned to me. One of them had IV fluid. When I introduced myself to her, I noticed her IV was running out. I was really scared and I did not know what to do and I called my instructor .

Fear of failure and making mistakes concerning nursing procedures was expressed by another student. She said:

I was so anxious when I had to change the colostomy dressing of my 24 years old patient. It took me 45 minutes to change the dressing. I went ten times to the clinic to bring the stuff. My heart rate was increasing and my hand was shaking. I was very embarrassed in front of my patient and instructor. I will never forget that day .

Sellek researched anxiety-creating incidents for nursing students. He suggested that the ward is the best place to learn but very few of the learner's needs are met in this setting. Incidents such as evaluation by others on initial clinical experience and total patient care, as well as interpersonal relations with staff, quality of care and procedures are anxiety producing [ 11 ].

Theory-practice gap

The category theory-practice gap emerged from all focus discussion where almost every student in the focus group sessions described in some way the lack of integration of theory into clinical practice.

I have learnt so many things in the class, but there is not much more chance to do them in actual settings .

Another student mentioned:

When I just learned theory for example about a disease such as diabetic mellitus and then I go on the ward and see the real patient with diabetic mellitus, I relate it back to what I learned in class and that way it will remain in my mind. It is not happen sometimes .

The literature suggests that there is a gap between theory and practice. It has been identified by Allmark and Tolly [ 20 , 21 ]. The development of practice theory, theory which is developed from practice, for practice, is one way of reducing the theory-practice gap [ 21 ]. Rolfe suggests that by reconsidering the relationship between theory and practise the gap can be closed. He suggests facilitating reflection on the realities of clinical life by nursing theorists will reduce the theory-practice gap. The theory- practice gap is felt most acutely by student nurses. They find themselves torn between the demands of their tutor and practising nurses in real clinical situations. They were faced with different real clinical situations and are unable to generalise from what they learnt in theory [ 22 ].

Clinical supervision

Clinical supervision is recognised as a developmental opportunity to develop clinical leadership. Working with the practitioners through the milieu of clinical supervision is a powerful way of enabling them to realize desirable practice [ 23 ]. Clinical nursing supervision is an ongoing systematic process that encourages and supports improved professional practice. According to Berggren and Severinsson the clinical nurse supervisors' ethical value system is involved in her/his process of decision making. [ 24 , 25 ]

Clinical Supervision by Head Nurse (Nursing Unit Manager) and Staff Nurses was another issue discussed by the students in the focus group sessions. One of the students said:

Sometimes we are taught mostly by the Head Nurse or other Nursing staff. The ward staff are not concerned about what students learn, they are busy with their duties and they are unable to have both an educational and a service role

Another student added:

Some of the nursing staff have good interaction with nursing students and they are interested in helping students in the clinical placement but they are not aware of the skills and strategies which are necessary in clinical education and are not prepared for their role to act as an instructor in the clinical placement

The students mostly mentioned their instructor's role as an evaluative person. The majority of students had the perception that their instructors have a more evaluative role than a teaching role.

The literature suggests that the clinical nurse supervisors should expressed their existence as a role model for the supervisees [ 24 ]

Professional role

One view that was frequently expressed by student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

We just do basic nursing care, very basic . ... You know ... giving bed baths, keeping patients clean and making their beds. Anyone can do it. We spend four years studying nursing but we do not feel we are doing a professional job .

The role of the professional nurse and nursing auxiliaries was another issue discussed by one of the students:

The role of auxiliaries such as registered practical nurse and Nurses Aids are the same as the role of the professional nurse. We spend four years and we have learned that nursing is a professional job and it requires training and skills and knowledge, but when we see that Nurses Aids are doing the same things, it can not be considered a professional job .

The result of student's views toward clinical experience showed that they were not satisfied with the clinical component of their education. Four themes of concern for students were 'initial clinical anxiety', 'theory-practice gap', 'clinical supervision', and 'professional role'.

The nursing students clearly identified that the initial clinical experience is very stressful for them. Students in the second year experienced more anxiety compared with third and fourth year students. This was similar to the finding of Bell and Ruth who found that nursing students have a higher level of anxiety in second year [ 26 , 27 ]. Neary identified three main categories of concern for students which are the fear of doing harm to patients, the sense of not belonging to the nursing team and of not being fully competent on registration [ 28 ] which are similar to what our students mentioned in the focus group discussions. Jinks and Patmon also found that students felt they had an insufficiency in clinical skills upon completion of pre-registration program [ 29 ].

Initial clinical experience was the most anxiety producing part of student clinical experience. In this study fear of making mistake (fear of failure) and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. This finding is supported by Hart and Rotem [ 4 ] and Stephens [ 30 ]. Developing confidence is an important component of clinical nursing practice [ 31 ]. Development of confidence should be facilitated by the process of nursing education; as a result students become competent and confident. Differences between actual and expected behaviour in the clinical placement creates conflicts in nursing students. Nursing students receive instructions which are different to what they have been taught in the classroom. Students feel anxious and this anxiety has effect on their performance [ 32 ]. The existence of theory-practice gap in nursing has been an issue of concern for many years as it has been shown to delay student learning. All the students in this study clearly demonstrated that there is a gap between theory and practice. This finding is supported by other studies such as Ferguson and Jinks [ 33 ] and Hewison and Wildman [ 34 ] and Bjork [ 35 ]. Discrepancy between theory and practice has long been a source of concern to teachers, practitioners and learners. It deeply rooted in the history of nurse education. Theory-practice gap has been recognised for over 50 years in nursing. This issue is said to have caused the movement of nurse education into higher education sector [ 34 ].

Clinical supervision was one of the main themes in this study. According to participant, instructor role in assisting student nurses to reach professional excellence is very important. In this study, the majority of students had the perception that their instructors have a more evaluative role than a teaching role. About half of the students mentioned that some of the head Nurse (Nursing Unit Manager) and Staff Nurses are very good in supervising us in the clinical area. The clinical instructor or mentors can play an important role in student nurses' self-confidence, promote role socialization, and encourage independence which leads to clinical competency [ 36 ]. A supportive and socialising role was identified by the students as the mentor's function. This finding is similar to the finding of Earnshaw [ 37 ]. According to Begat and Severinsson supporting nurses by clinical nurse specialist reported that they may have a positive effect on their perceptions of well-being and less anxiety and physical symptoms [ 25 ].

The students identified factors that influence their professional socialisation. Professional role and hierarchy of occupation were factors which were frequently expressed by the students. Self-evaluation of professional knowledge, values and skills contribute to the professional's self-concept [ 38 ]. The professional role encompasses skills, knowledge and behaviour learned through professional socialisation [ 39 ]. The acquisition of career attitudes, values and motives which are held by society are important stages in the socialisation process [ 40 ]. According to Corwin autonomy, independence, decision-making and innovation are achieved through professional self-concept 41 . Lengacher (1994) discussed the importance of faculty staff in the socialisation process of students and in preparing them for reality in practice. Maintenance and/or nurturance of the student's self-esteem play an important role for facilitation of socialisation process 42 .

One view that was expressed by second and third year student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

The finding of this study and the literature support the need to rethink about the clinical skills training in nursing education. It is clear that all themes mentioned by the students play an important role in student learning and nursing education in general. There were some similarities between the results of this study with other reported studies and confirmed that some of the factors are universal in nursing education. Nursing students expressed their views and mentioned their worry about the initial clinical anxiety, theory-practice gap, professional role and clinical supervision. They mentioned that integration of both theory and practice with good clinical supervision enabling them to feel that they are enough competent to take care of the patients. The result of this study would help us as educators to design strategies for more effective clinical teaching. The results of this study should be considered by nursing education and nursing practice professionals. Faculties of nursing need to be concerned about solving student problems in education and clinical practice. The findings support the need for Faculty of Nursing to plan nursing curriculum in a way that nursing students be involved actively in their education.

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Sharif, F., Masoumi, S. A qualitative study of nursing student experiences of clinical practice. BMC Nurs 4 , 6 (2005). https://doi.org/10.1186/1472-6955-4-6

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2 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Linda H Aiken

Douglas sloane, rachel french, brendan martin.

3 National Council of State Boards of Nursing, Chicago, Illinois, USA

Maryann Alexander

Matthew d mchugh, associated data.

bmjopen-2021-052899supp001.pdf

No data are available.

To evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.

Cross-sectional analysis of multiple data sources including a 2020 survey of nurses linked to patient outcomes data.

Setting : 87 acute care hospitals in Illinois.

Participants

210 493 Medicare patients, 65 years and older, who were hospitalised in a study hospital. 1391 registered nurses employed in direct patient care on a medical–surgical unit in a study hospital.

Main outcome measures

Primary outcomes were 30-day mortality and length of stay. Deaths avoided and cost savings to hospitals were predicted based on results from regression estimates if hospitals were to have staffed at a 4:1 ratio during the study period. Cost savings were computed from reductions in lengths of stay using cost-to-charge ratios.

Patient-to-nurse staffing ratios on medical-surgical units ranged from 4.2 to 7.6 (mean=5.4; SD=0.7). After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by 16% for each additional patient in the average nurse’s workload (95% CI 1.04 to 1.28; p=0.006). The odds of staying in the hospital a day longer at all intervals increased by 5% for each additional patient in the nurse’s workload (95% CI 1.00 to 1.09, p=0.041). If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.

Conclusions

Patient-to-nurse staffing ratios vary considerably across Illinois hospitals. If nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.

Strengths and limitations of this study

• Study design, staffing and outcome measures are similar to previously published studies evaluating the link between nurse staffing and patient outcomes.
• Staffing measures collected as prepolicy implementation baseline data to quantify the scope of the variation in staffing within Illinois state, and the impact of staffing variation on the public’s health.
• Patient-to-nurse staffing measures are derived directly from staff nurses on medical and surgical units.
• Patient outcomes are risk-adjusted 30-day mortality and hospital length of stay.
• The cross-sectional study design precludes causal statements about the relationship of nurse staffing and patient outcomes.

Introduction

Despite substantial evidence that high registered nurse (RN) workloads are related to patient mortality—among other adverse patient outcomes 1–4 —no US states, except for California, 5 have implemented minimum hospital nurse staffing requirements. While many US states have pursued legislation to regulate hospital nurse staffing levels, support for such regulation is dampened for three primary reasons: (1) lack of prepolicy data documenting significant variation of hospital nurse staffing ratios across the state debating staffing regulation, (2) lack of local, timely evidence demonstrating variation in nurse staffing adversely affects patient outcomes and (3) an underdeveloped business case to justify the fiscal investments required to staff greater numbers of nurses at the bedside.

In this study, we address each of these three concerns using 2020 data from a large sample of 87 hospitals in Illinois where legislation to mandate patient-to-nurse staffing ratios is actively being debated (HB 2604 Safe Patient Limits Act ). 6 We project the number of deaths and hospital days that could be avoided, if Illinois hospitals staffed medical–surgical nurses at the 4:1 patient per nurse ratio proposed in the legislation. Because reductions in patient length of stays have economic implications for hospitals, we estimate the potential cost savings to hospitals through reduced lengths of stay if hospitals moved to the 4:1 staffing ratio.

This is the first study to report local and timely evidence about staffing variation in a large sample of hospitals across Illinois, and the consequences of staffing variation for patient outcomes and costs of care to directly inform public policy efforts actively under consideration. The main objectives of this study are to evaluate variation in Illinois hospital nurse staffing ratios and to determine whether higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals.

Nurses are the around-the-clock surveillance system of hospitals; closely monitoring changes in patients’ clinical condition and administering treatments and care as appropriate. When nurses care for fewer patients at time, they are able to spend more time at each patient’s bedside, and as a result, patients are less likely to experience an adverse outcome such as a hospital-acquired infection, 7 poor glycaemic control, 8 readmission 9 and even death. 10–14 The clinical benefits of nurse staffing have primarily been studied in adult medical and surgical populations, but have also been observed in special populations including babies in neonatal intensive care units 15 and children; 16 and may also be key to reducing racial disparities in outcomes. 9 17–19 The benefits of better nurse staff extend to nurses as well; with nurses in better-staffed hospitals reporting less burnout, less job dissatisfaction and being less likely to intend to leave their employer. 10 20

An emerging body of research evidence articulates the human and economic consequences of adverse patient outcomes that result from hospital nurse understaffing. For example, an analysis of hospital nurse staffing among New York hospitals found that if hospitals staffed medical–surgical units with four patients per nurse, as opposed to the average hospital ratio of 6.3 patients per nurse, then thousands of deaths could have been avoided and many hundreds of millions of dollars saved through shorter lengths of stay and avoided readmissions. 21 The same study 22 showed that improving nurse staffing in New York hospitals would have reduced deaths among sepsis patients more than a policy passed earlier that mandated adherence to a standardised set of services for sepsis patients. A study of adult medical patients showed that patients in hospitals with better nurse resources had better outcomes including less mortality, fewer readmissions and shorter lengths of stay—at no difference in cost, when compared with similar patients in hospitals with poorer resources. 23 These study findings have been corroborated in surgical patients; 24 25 and find that improving nurse staffing would avoid adverse outcomes with sizeable cost savings to hospitals. 26

Despite the social and economic case for improving hospital nurse staffing, California remains the only US state to have implemented required staffing standards. Passed in 1999 and implemented in 2004, the California legislation resulted in improved staffing, with the greatest improvements observed among safety-net hospitals. 27 Compared with other states which did not implement safe staffing requirements, patients in California hospitals experienced lower mortality and failure-to-rescue rates. 5 28 The California experience serves as an example of a successfully implemented and sustained state-wide policy mandate for safe hospital staffing and patient care.

Data and methods

This observational study of hospitals and patients uses multiple linked data sources including Medicare patient claims data, American Hospital Association (AHA) data of hospital characteristics and a survey of RNs to provide data on hospital nurse staffing ratios on medical and surgical units.

Patient sample

The patient sample includes persons insured by Medicare who were 65 years and older (the qualifying age for Medicare—the US federal government health insurance programme) and who were admitted to an acute care hospital in Illinois in 2018. Data on Medicare patients were obtained from the Centers for Medicare and Medicaid Services (CMS) MEDPAR files. Patients admitted for psychiatric reasons and drug/alcohol use were excluded, as were patients with lengths of stay greater than 60 days. Each unique patient was assigned an index hospitalisation, created by selecting the first admission during the study period. The analytic sample included only these index hospitalisations, which accounted for roughly half of all the Medicare hospitalisations in Illinois during the study period.

Hospital sample

Short-term acute care and critical access hospitals that had medical and surgical direct care nurses who responded to the survey of nurses were included. The survey of nurses was sent via email to all actively licensed RNs in the state of Illinois (n=168 001). Data collection ran from 16 December 2019 to 24 February 2020. Nurse responses were anonymous, but nurses were asked to report the name of their employer, thus allowing responses from nurses working in the same hospitals to be aggregated together to create hospital-level measures of patient-to-nurse staffing ratios. Our data collection method relies on nurses as key informants of their hospital. 29 Thus, while we directly survey nurses, our interest is in hospital-level organisational measures, in this case, patient-to-nurse staffing ratios.

The nurse response rate was 18% of the 168 001 RNs surveyed, which is anticipated considering endemic difficulties with survey response rates 30 and the fact that our sampling frame consisted of 100% of licensed nurses in the state, only a fraction of whom are employed in hospitals, which was the focus of our study. A similar survey conducted in other states yielded comparable response rates. In the broader multistate study, the survey implemented a double-sampling approach to evaluate for potential non-response bias. The results demonstrated that nurse reports of patient-to-nurse staffing ratios were no different among nurses who responded to the main survey and those that responded to the non-respondent survey. 29 Thus despite an 18% response rate, evidence suggests that even if non-response bias were present, it likely does not affect the validity of the resultant staffing estimates.

Because this is a study of hospitals and the patients in them, the nurse survey response rate is of somewhat lesser importance than the degree to which the survey achieved adequate representation of hospitals (via a high hospital response rate) and the patients in them. We excluded hospitals that were long-term rehabilitation hospitals, psychiatric facilities or free-standing children’s hospitals. Based on the remaining acute care hospitals, our analytic sample of 87 hospitals represented 86.5% of Medicare index admissions in the state and roughly two-third of the short-term acute care hospitals in Illinois. We have less representation of critical access hospitals since we were not able to obtain data from enough nurses in those small facilities to reliably estimate staffing ratios.

Patient-to-nurse staffing

Surveyed nurses were asked to report whether they were working in direct patient care or indirect care positions (eg, management); which type of unit they worked on and how many patients they were assigned to care for on their most recent shift. Only data from direct care RNs who reported working their most recent shift on a medical or surgical unit were used to create our measure of staffing. Responses were then aggregated to create a hospital-level measure of medical–surgical patient-to-nurse staffing. The survey also asked nurses to report how many patients they could safely care for in their job setting.

Patient outcomes

Patient outcome measures included 30-day mortality and hospital length of stay. 30-day mortality was defined as a death occurring 30-days from date of admission and included deaths that occurred outside of the hospital. Hospital length of stay was defined as total number of days in the hospital during the index admission.

Cost outcomes

Cost savings were estimated using Medicare-specific cost-to-charge ratios using patient-level charge data from the MEDPAR files. Cost savings from reductions in length of stay were computed by first estimating the predicted reduction in patient days if hospitals staffed at the 4:1 ratio, then applying the reduction to total charges and then converting to costs using the hospital-level Medicare-specific cost-to-charge ratios from CMS Impact Files.

Risk-adjustment

Hospital risk-adjustment variables included hospital size, defined by number of beds, from the AHA Annual Survey. Patient covariates included patient age, sex, Elixhauser comorbidities, 31 dummy variables for diagnostic-related groups—and in models estimating effects of staffing on length of stay, patient discharge disposition status.

Statistical analysis

Descriptive statistics were used to show medical–surgical nurse staffing ratios, and the numbers of patients and nurse survey respondents in the 87 study hospitals. Patient characteristics (eg, age, sex, transfer status, comorbidities) as well as percentage of patients who died within 30-days of admission and average (and SD) length of stay are reported. We also show percentages of nurses who reported that the number of patients they cared for during their last shift exceeded the number of patients they felt they could safely care for. Prior to accounting for confounding factors, we show variation in patient mortality rates and lengths of stay among hospitals with different staffing levels (ie,<5, 5≤6, ≥6 patients per nurse).

Multilevel random-effects logistic regression models and zero-truncated negative binomial regression models were used to estimate the association between nurse staffing with 30-day mortality and length of stay, respectively. These associations were estimated before and after accounting for potentially confounding hospital and patient characteristics. Using adjusted estimates from our regression models, we estimated how many deaths could have been avoided and how much money could have been saved (from shorter lengths of stay) were hospitals to staff medical–surgical nurses at the levels proposed in the legislation (4:1 patients per nurse). STATA was used to perform the analyses. This study received IRB approval from the University of Pennsylvania (Protocol #834307).

Patient and public involvement

No patient involved.

Our analytic sample included 210 493 Medicare beneficiaries in 87 Illinois hospitals ( table 1 ). Staffing estimates were derived from an average of 16 direct care medical–surgical nurse respondents per hospital, with as many as 68 nurse respondents in larger hospitals. Medical–surgical staffing ratios ranged from 4.2 to 7.6 patients per nurse, with the lower bound just above the four patients per nurse proposed in the legislation. The average staffing ratio in Illinois hospitals was 5.4 and somewhat higher (5.6) among smaller hospitals than larger hospitals (5.3).

Hospital size, numbers of patients and nurse respondents and patient-to-nurse staffing ratios among 87 Illinois study hospitals

Among the study patients, 5.8% died within 30-days of admission and the average length of stay was 4.1 days, with a SD of 3.7 days ( online supplemental table 1 ). Forty percent of the patients were 80 years of age or older, and 56% were female. The most common comorbidities included hypertension, fluid and electrolyte disorders, chronic pulmonary disease and renal failure. Nurses reported safety concerns related to the number of patients they cared for during their last shift ( table 2 ). Half of nurses (51.2%) reported that their patient assignment during their last shift exceeded the number they assessed they could safely care for. Two-thirds of nurses (67.0%) who were assigned 6 or more patients assessed that workload was unsafe. Most nurses (82.7%) who were assigned four or fewer patients assessed that patient assignment constituted a safe workload.

Percent of nurses reporting that the number of patients assigned to them during the last shift exceeded the number they could safely care for

Note. 148 of the 1391 nurses did not provide a response about how many nurses they could safely care for. Thus, the analytic sample in table 2 is 1243 nurses for whom the relevant data were available.

RN, registered nurse.

Supplementary data

Prior to adjusting for confounding variables of the hospitals and patients, we found that patient mortality and lengths of stay in hospitals varied with different nurse staffing ratios ( table 3 ). The average 30-day mortality rate among hospitals with an average staffing ratio of <5 patients per nurse was lower (5.6%) compared with mortality among hospitals where nurses cared for between 5≤6 patients (6.1%) and ≥6 patients (6.1%). Lengths of stay were shorter in hospitals where nurses cared for fewer patients at a time (4.0 days in hospitals with <5 patients per nurse, vs 4.1 days in hospitals with 5≤6 patients per nurse, vs 4.5 days in hospitals with ≥6 patients per nurse).

Average mortality and lengths of stay for patients in hospitals with different patient-to-nurse staffing ratios

Table 4 presents the effect of nurse staffing on mortality and length of stay. After adjusting for hospital and patient characteristics, the odds of 30-day mortality for each patient increased by a factor of 1.16 (or 16%) for each additional patient added to the average nurse’s workload (OR 1.16, 95% CI 1.04 to 1.28; p 0.006). The odds of staying in the hospital a day longer at all intervals increased by a factor of 1.05 (or 5%) for each additional patient in the nurse’s workload (IRR 1.05, 95% CI 1.00 to 1.09, p 0.041).

Effect of medical–surgical patient-to-nurse staffing on patient outcomes

Note. 30-day mortality outcomes are estimated from 196 270 patients and excludes DRGs with <5 cases and admissions by transfer. Hospital controls included number of beds. Patient controls included age, sex, comorbidities and dummy variables for DRG. Length of stay outcomes are estimated from 210 493 and excludes DRGs with zero deaths and patients transferring in or out. Hospital controls included number of beds. Patient controls included age, sex, comorbidities, dummy variables for DRG and discharge disposition of death or transfer.

DRG, diagnostic-related groups.

Using these results from the adjusted regression models, we estimated the number of deaths that would have been avoided if hospitals staffed at the four patients per nurse recommendation in the proposed policy (as opposed to the observed ratio which was greater than four patients per nurse in all hospitals and nearly eight patients per nurse in some of them). Roughly 1595 deaths could have been avoided among Medicare beneficiaries in the study hospitals during the 1-year study period. Improving staffing ratios to the 4:1 ratio was projected to reduce patient lengths of stay by over 40 000 days. These reductions in lengths of stay would collectively save Illinois hospitals over $117 million per year ( table 5 ).

Deaths avoided and cost savings from shorter lengths of stay with 4:1 staffing ratios

Note. Data from 84 short-term acute care hospitals were used in the projection of cost savings from reduced lengths of stay. Three critical access hospitals were excluded from the cost-saving analyses reported in table 5 because critical access hospitals do not report cost-to-charge ratios needed to compute cost savings.

Studying a large sample of 87 acute care hospitals in Illinois, we found considerable variation in medical–surgical nurse staffing ratios, ranging from 4.2 to 7.6 patients per nurse. The average hospital staffing across the state (outside intensive care settings) was 5.4 patients per nurse, which is nearly 1.5 patients above the recommended staffing levels proposed in the HB 2604 Safe Patient Limits Act . 6 Half (51.2%) of nurses reported their patient assignment during their last shift was unsafe; and among nurses assigned four of fewer patients, only 17.3% found that staffing ratio to be unsafe.

Staffing conditions were associated with adverse health outcomes for Medicare patients, including mortality and longer lengths of stay. Each additional patient in a nurse’s workload increased the odds of patient death by 16%. If the study hospitals had been staffing medical–surgical nurses at the proposed ratio during the 1-year study period, we projected that 1595 deaths would have been avoided just among Medicare patients. Had our study considered patients of all ages who would benefit from improved nurse staffing, we anticipate considerably more deaths would have been avoided.

The odds of Medicare patients staying in the hospital a day longer increased by 5% for each additional patient in the nurse’s workload. Hospitals would have collectively saved over $117 million annually from length of stay reductions just among Medicare patients—cost savings which could be reinvested into financing safer nurse staffing ratios. These findings are consistent with other research conducted in New York hospitals 32 and internationally 33 34 which show that patients in hospitals with better nurse staffing have shorter lengths of stay as well as fewer readmissions, both of which translate to avoided costs. Studies conducted in Queensland Australia and Chile demonstrate that the magnitude of the cost savings associated with better nurse staffing were in excess of the costs of hiring more nurses; 33 34 a illustration of the value proposition for increasing nurse staffing.

In the current study, estimates of avoidable deaths and cost savings are conservative. Our analysis used roughly half of the annual Medicare hospitalisations in Illinois state since we restricted the sample to index hospitalisations. Other studies show that patients of all ages benefit from improved hospital nurse staffing. 16 35 Thus, if the staffing policy were to be enacted, the human and economic benefits would likely be much greater. Additionally, our cost savings analysis is conservative because it does not account for the savings that may be realised from reductions in nurse burnout and turnover that result from chronic understaffing. In a previously published paper on nurse staffing in Illinois hospitals, we showed that hospital understaffing is associated with poor nurse outcomes including burnout, job dissatisfaction and intent to leave. 20 36 Nurse burnout has been linked with worse patient outcomes including mortality and longer lengths of stay 37 and intent to leave is associated with turnover. 38–40 Turnover of nurses is cost consequential for hospitals, with estimates of replacing a single bedside nurse ranging from $20 561 41 to $88 000. 42 Although evidence demonstrates that cost savings can be achieved—via shorter lengths of stay and reduced readmissions—from staffing more nurses at the bedside, future research could expand the scope of the economic consequences of improving nurse staffing in terms of other patient and nurse outcomes with their associated cost savings.

Strengths and limitations

This study uses hospital medical–surgical nurse staffing data collected in 2020 to inform current staffing policy debates in Illinois. Rarely is timely, rigorous and objective evidence, analysed by an independent team of researchers, available to inform policy in this way. Reporting lags in claims data meant that the most recent available data on patients were from 2018. Although the hospital staffing and patient data do not coincide, hospital nurse staffing has changed little in the last decade. 43 Thus, the staffing estimates obtained in 2020 likely resemble those in 2018. While our study included most large and medium size hospitals in Illinois, which account for most hospitalised patients in the state, smaller hospitals including critical access hospitals are underrepresented in the study. The cross-sectional study design precludes causal statements about the relationship between nursing staffing and patient outcomes.

Implications for policy decision-making

A recent US Harris Poll 44 suggests that 90% of the US public favour requiring hospitals to meet minimum safe nurse staffing standards. Our study finds uneven nurse staffing among Illinois hospitals which poses unfavourable consequences for patients and hospitals. If Illinois enacted the Safe Patient Limits Act , our analysis suggests thousands of deaths per year could be avoided. Additionally, hospitals could save substantially through reductions in patients’ lengths of stay associated with improving nurse staffing. These savings could be reinvested into the costs of employing additional nurses.

Enacting the Safe Patient Limits Act would likely create opportunities for more nurses to enter the workforce, raising questions about where these nurses would be drawn from. There is currently no widespread shortage of actively licensed RNs. Nurse graduations are at an all-time high, with enough nurses entering the workforce annually to more than replace retirements. 45 California, the only state to enact nurse staffing ratio mandates similar to what is being proposed in Illinois, has successfully implemented the ratios despite have a lower nurse-to-population ratio compared with Illinois (11.3 RNs per 1000 population in California; 16.7 RNs per 1000 population in Illinois). 46 Finally, the Nurse Licensure Compact, which is state legislation to permit nurses to hold a multistate US license is currently under consideration in Illinois. 47 Passing such legislation would enable nurses licensed in any of the 34 states currently in the Compact to practice in any other Compact state, without the burden of having to obtain an additional license. Such legislation permits greater mobility of nurses to practice across state lines. Thus, trends in the nursing workforce and the opportunity for Illinois to join the Nurse Licensure Compact suggest it is unlikely that passing mandated safe nurse staffing legislation would result in nursing shortages that would negatively affect access to care or care quality.

Nurse staffing on medical and surgical units in Illinois hospitals averaged 5.4 patients per nurse and ranged from as few as 4.2 patients per nurse to as many as to 7.6. These estimates suggest that few Illinois hospitals are currently meeting the minimum staffing levels which would be required by the Safe Patient Limits Act currently under consideration. We found that each additional patient in a nurses’ workload was associated with 16% higher odds of death and longer lengths of stay. If Illinois hospitals staffed medical and surgical units at the ratio proposed in the legislation, we project thousands of deaths could be avoided each year and patients would experience shorter lengths of stay resulting in hundreds of millions of dollars in cost-savings for hospitals.

Supplementary Material

Acknowledgments.

The authors wish to acknowledge Tim Cheney for his contributions to data management and analysis.

Twitter: @LindaAiken_Penn, @rachel_e_french, @matthewdmchugh

Contributors: All authors meet the criteria recommended by the International Committee of Medical Journal Editors (ICMJE). KBL, LHA, BM, MA and MDM contributed to the original idea and design of the study. KBL, LHA, RF, BM, MA and MDM contributed to the collection of data. KBL and DS conducted the data analysis. All authors contributed to the interpretation of the data and preparation of the submitted manuscript. All authors approved the submitted manuscript. KBL is responsible for the full overall content as the guaranator and accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

Funding: This study was supported by funding from the National Council of State Boards of Nursing (Lasater, PI), and National Institute of Nursing Research, National Institutes of Health (R01NR014855, Aiken, PI; T32NR007104, Aiken, Lake, McHugh, MPIs).

Disclaimer: The researchers are solely responsible for the findings and their interpretation and do not necessarily represent the views or conclusions of NCSBN or NINR.

Competing interests: None declared.

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

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not required.

Ethics approval

The study was approved by the University of Pennsylvania Institutional Review Board(IRB) (PROTOCOL #834307).