National Nurses United’s (NNU) new nationwide survey of more than 2,500 registered nurses reveals significant increases in staffing issues, workplace violence, and moral distress compared to NNU’s previous survey results released on Sept. 27, 2021. Hospital RNs also reported that their hospitals are still not adequately prepared for a Covid-19 surge.
This survey is the seventh national survey of nurses during the pandemic by NNU, the nation’s largest and fastest-growing union of registered nurses.
Zenei Cortez, RN, President of National Nurses United.
“We are now more than three years into the pandemic and not only is staffing worse, but workplace violence is increasing,” said Zenei Triunfo-Cortez, RN and a president of National Nurses United. “Nurses are experiencing alarming levels of moral distress and moral injury due to the unsafe working conditions. Since our last survey in September 2021, even more nurses have reported feeling more stress and anxiety as well as feeling traumatized by their experiences caring for patients.
“In addition, many nurses reported that their hospitals do not have surge plans or enough personal protective equipment in stock to protect staff during a surge,” said Triunfo-Cortez.
“It is unconscionable that some RNs are still reusing single-use PPE and putting their health and well-being at risk.
“Despite these challenges, nurses have continued to fight for safe working conditions and patient safety and they are organizing,” said Triunfo-Cortez. “During the pandemic, nurses at Mission Hospital in Asheville, North Carolina, Maine Medical Center in Portland, Maine, and Longmont United Hospital in Longmont, Colorado, organized and voted to join affiliates of National Nurses United. We have also been strongly advocating for federal RN-to-patient ratios legislation and for the Occupational Safety and Health Administration to issue a permanent standard to protect nurses and other health care workers from Covid-19 in the workplace.”
Here are the responses from 2,575 nurses, gathered from both NNU union nurses and nonunion nurses in all 50 states plus Washington, D.C. The results cover the period Feb. 2, 2022 to March 20, 2022.
Staffing Issues
Hospital RNs reported that staffing is worse: 69 percent reported that staffing has gotten slightly or much worse recently, a 20.2 percent increase from NNU’s September 2021 survey and a 47.8 percent increase from our March 2021 survey.
More than a quarter of nurses (26.5 percent) reported being “floated” or reassigned to care for patients in a clinical care area that required new skills or was outside of their competency, up from 17.8 percent reported in September 2021. Meanwhile, 46 percent of hospital RNs reported that they did not receive any education or preparation before being floated to units outside of their expertise, up from 44.3 percent reported in Sept. 2021.
Excessive overtime and use of travel nurses:
64.5 percent of hospital nurses reported that their facilities are using excessive overtime to staff units, up from 49.3 percent, a significant increase from our September survey.
72.3 percent hospital RNs reported an increase in the use of travel nurses in the prior month.
Workplace violence on the rise
Nearly half of hospital nurses (48 percent) reported a small or significant increase in workplace violence, up from 30.6 percent in September 2021 and 21.9 percent in our March 2021 survey. This is a nearly 57 percent increase from September 2021 and a 119 percent increase from March 2021.
Alarming evidence of moral distress and mental health
Covid-19 is still having a deep impact on the mental health of hospital nurses, who continue to face moral distress and moral injury at work. There are significant increases in all of the mental health impacts reported in our September 2021 survey.
66.8 percent of hospital RNs fear they will contract Covid, a 59.4 percent increase from September.
Nearly three-quarters (74.6 percent) are afraid they will infect a family member, a 47.4 percent increase from September.
Nearly 60 percent (58.4 percent) are having more difficulty sleeping, a 66.4 percent increase from September.
83.5 percent feel stressed more often than before the pandemic, a 56.1 percent increase.
77.2 percent feel anxious more often than they did before the pandemic, a 53.2 percent increase from September.
68.7 percent feel sad or depressed more often than they did before the pandemic, a 64.6 percent increase from September.
More than half (56 percent) feel traumatized by their experiences caring for patients, a 65.7 percent increase from September.
23 percent sought treatment for a mental health condition related to caring for patients during the pandemic, a whopping 87 percent increase from September.
Personal protective equipment
Only 71.8 percent of hospital RNs reported wearing a respirator for every Covid-positive patient encounter, up from 60.8 percent in our September 2021 survey. Meanwhile, 62 percent of hospital RNs reported having to reuse single-use PPE, an unsafe practice.
Only 32 percent of hospital nurses report that their employer has sufficient PPE stock to protect staff from a rapid Covid surge. (For more on surge plans, see “Surge preparedness” section below.)
Exposure, testing, and screening
Nearly a quarter (24 percent) of hospital RNs reported that their employer notifies them of Covid exposures in a timely manner. Meanwhile, 29 percent of hospital RNs reported that nurses are informed of exposures but not in a timely fashion. Prompt notification is essential for infection control.
Access to testing is still an issue at some hospitals: 17.8 percent of RNs report that access to testing has declined since the beginning of the pandemic.
Only 56.8 percent of hospital RNs report that every patient is screened for recent exposure history to covid, down from 61.7 percent in our September survey. Screening of visitors has also gone down since our last survey: 48.6 percent of hospital nurses reported that all visitors are screened for Covid signs and symptoms at their facility, down from 52.7 percent in our September survey.
Only 23.8 percent of hospital RNs report that every visitor is screened for recent Covid exposure history at their facility, down from 38.5 percent in our September survey.
Woefully inadequate surge preparedness
Only 24 percent of hospital RNs reported that their employer has an overflow plan to place additional, trained staff to safely care for Covid patients on isolation. This is a decrease from our first Covid survey in March 2020 when 29 percent reported that there was a plan in place to isolate patients with possible novel coronavirus infection.
Previous surveys
In 2020, NNU’s four surveys covered hospitals’ lack of preparedness for Covid-19 (March); government and employers’ disregard for nurse and patient safety (May); the devastating impact of reopening too soon (July); and hospitals’ and health care employers’ lack of preparation for the fall/winter surge, despite more knowledge about the dangers of the virus and effective measures to prevent spread (November). In 2021, NNU’s March 2021 survey highlighted the continuing disregard of hospitals and health care employers for the safety of nurses and health care workers. The September 2021 survey revealed that employers must do more to be fully compliant with the Occupational Safety and Health Administration emergency temporary standard to protect nurses and other health care workers.
National Nurses United (NNU), the largest union of registered nurses in the United States, today applauded the Occupational Safety and Health Administration (OSHA) for taking a critical step in protecting health care workers in Arizona, South Carolina, and Utah who had been left behind when their states failed to adopt the OSHA Emergency Temporary Standard (ETS) on Covid-19 in Health Care issued in June. The OSHA ETS on Covid-19 mandates optimal PPE and other critical protections for health care workers.
Twenty-two states across the country that have state-based OSHA programs are legally required to have those state plans be at least as effective as federal OSHA. When Arizona, South Carolina, and Utah failed to implement the Covid-19 ETS in their state plans, however, they abrogated their legal requirements. Federal OSHA announced today that it is reconsidering and potentially revoking the final approval for these three noncompliant states.
“It’s unconscionable that some states think they can just ignore their responsibility to protect health care workers. Registered nurses had been demanding the OSHA ETS since day one of this pandemic, and we finally won our fight in June of 2021. At that point, Arizona, South Carolina, and Utah had the duty—legally and morally—to come into compliance and protect workers. They did not, and we could not be more proud that OSHA is standing up to hold them accountable today,” said NNU President Deborah Burger, RN. “We are beyond grateful to OSHA for the work they are already doing to enforce this standard, and to the Biden administration for standing up for nurses on the front lines of this pandemic.”
After leading the campaign to win the OSHA ETS, NNU has been campaigning to ensure health care employers across the country comply. When NNU nurses in Arizona filed complaints about their hospitals’ non-compliance, Arizona’s state OSHA plan stated they will not enforce the requirements of the federal OSHA ETS. So NNU nurses testified at the most recent meeting of the Industrial Commission of Arizona (ICA). The ICA voted against emergency rulemaking needed to protect nurses and other health care workers, and NNU filed a Complaint About State Plan Administration (CAPSA) with federal OSHA.
“Nurses and other health care workers in Arizona, Utah, and South Carolina must be assured the same protections as they would receive in other states that have already adopted and begun enforcing the ETS,” said Burger. “We urge federal OSHA to act expeditiously to put in place the necessary elements for federal OSHA to resume enforcement in Arizona, Utah, South Carolina, and any other states which fail to enforce the ETS to ensure protections for health care workers. We will never emerge from this pandemic if we don’t make sure nurses and health care workers are safe at work.”
National Nurses United is the largest and fastest-growing union of registered nurses in the United States with more than 175,000 members nationwide.
National Nurses United asserts that the United States is not experiencing a nursing shortage, only a shortage of nurses willing to risk their licenses or the safety of their patients by working under the unsafe conditions the hospital industry has created. By deliberately refusing to staff our nation’s hospital units with enough nurses to safely and optimally care for patients, the hospital industry has driven nurses away from direct patient care. When we add the complete failure by the hospital industry to protect the health and safety of nurses and patients during the Covid pandemic, many nurses have made the difficult decision to stop providing hands-on nursing care in order to protect themselves, their nursing licenses, their families, and their patients.
The hospital industry is crying false tears over the lack of nurses willing to stay in direct care when these untenable working conditions are entirely of their own making.
To ensure a strong pipeline of new nurses for the sustainability of the profession, NNU has long advocated for more funding for public nursing schools and better pay for nursing faculty; one of the main barriers to becoming a nurse is the exorbitant expense and lack of admission slots in nursing education programs.
Hospitals are Understaffing
The hospital industry is crying false tears over the lack of nurses willing to stay in direct care when these untenable working conditions are entirely of their own making. For decades and even before Covid, the hospital industry has driven nurses away from direct nursing care in multiple ways.
Hospitals intentionally understaff every unit, every shift with fewer numbers of nurses than is actually required to safely and optimally care for the numbers of admitted patients and their severity of illness. Hospitals do this to maximize profits and excess revenue. Hospital administrators prefer to staff shifts with a bare-bones number of nurses, which often fails to account for deterioration in patient conditions; new admissions, transfers, and discharges; coordination of care with other departments; the need for nurses to safely take meal and rest breaks; and other complicating factors. Instead of scheduling greater numbers of nurses to ensure that each RN has a manageable workload and patients are safely and properly cared for, hospitals have historically routinely forced the nurses on duty to sacrifice their own health and safety and make morally distressing choices about how to allocate their available time for nursing care.
In addition to deliberately failing to provide safe RN staffing on each shift, hospitals are not maintaining a robust pool of nurses from which to draw when scheduling shifts. From our experience, hospitals often cancel or “call off” nurses who are scheduled to work on a daily contract basis, will send nurses home who have reported for their scheduled shifts, are not hiring or are extremely slow to hire for open positions, and will cancel contracts with travel or agency nurses.
Listen to Nurses
During Covid, hospitals rejected nurses’ advice from the beginning of the pandemic to prepare and plan for predictable staffing needs, including hiring and training more nurses, and cross-training current staff nurses to work in critical care departments. Instead, hospitals cut and laid off staff from units that had temporarily low patient census, and canceled RN traveler contracts. Again, the industry was shortsightedly looking for immediate ways to cut costs and boost profits instead of planning for patient and public health needs. Hospitals’ actions, and inaction, have resulted in a lack of critical care staff during Covid.
National Nurses United has a simple and effective solution for encouraging the nation’s nurses to return to providing the direct patient care that we desperately need during this pandemic: ensure safe and optimal working conditions for nurses, including scheduling sufficient numbers of nursing staff on every shift, and implementing all the multiple measures of infection control that nurses need to protect themselves and their patients.
The hospital industry’s response to nurses unwilling to work under unsafe conditions is to overload the remaining nurses with more patients and, in states where it is not prohibited, try to force them to work mandatory overtime. This is dangerous for both nurses and patients and will only exacerbate the problem. And during Covid, working under unsafe conditions is even more likely to expose and infect nurses, further sidelining them from caring for patients.
It’s clear that hospitals have no excuse for a staffing crisis they have created. The solution we can start implementing today is for hospitals to immediately staff up every unit, every shift, and create a safe, sustainable work environment where nurses can feel confident about their ability to provide the best nursing care possible for their patients.
Karen Jo Young wrote a letter to her local newspaper criticizing executives at the hospital where she worked as an activities coordinator, arguing that their actions led to staffing shortages and other patient safety problems.
Karen Jo Young, former activities coordinator at Maine Coast Memorial Hospital.
Hours after her letter was published in September 2017, officials at Maine Coast Memorial Hospital in Ellsworth, Maine, fired her, citing a policy that no employee may give information to the news media without the direct involvement of the media office.
But a federal appellate court recently said Young’s firing violated the law and ordered that she be reinstated. The court’s decision could mean that hospitals and other employers will need to revise their policies barring workers from talking to the news media and posting on social media.
Those media policies have been a bitter source of conflict at hospitals over the past year, as physicians, nurses and other health care workers around the country have been fired or disciplined for publicly speaking or posting about what they saw as dangerously inadequate covid-19 safety precautions. These fights also reflect growing tension between health care workers, including physicians, and the increasingly large, profit-oriented companies that employ them.
On May 26, the 1st U.S. Circuit Court of Appeals unanimously upheld a National Labor Relations Board decision issued last year that the hospital, now known as Northern Light Maine Coast Hospital, violated federal labor law by firing Young for engaging in protected “concerted activity.” The NLRB defines it as guaranteeing the right to act with co-workers to address work-related issues, such as circulating petitions for better hours or speaking up about safety issues. It also affirmed the board’s finding that the hospital’s media policy barring contact between employees and the media was illegal.
“It’s great news because I know all hospitals prefer we don’t speak with the media. We are careful about what we say and how we say it because we don’t want to bring the hammer down on us.”
—Cokie Giles, president of the Maine State Nurses Associationnurses union
The 1st Circuit opinion is noteworthy because it’s one of only a few such employee speech rulings under the National Labor Relations Act ever issued by a federal appellate court, and the first in nearly 20 years, said Frank LoMonte, a University of Florida law professor who heads the Brechner Center for Freedom of Information.
Cokie Giles, president of the Maine State Nurses Association. (National Nurses United)
The 1st Circuit and NLRB rulings should force hospitals to “pull out their handbook and make sure it doesn’t gag employees from speaking,” he said. “If you are fired for violating a ‘don’t talk to the media’ policy, you should be able to get your job back.”
The American Hospital Association and the Federation of American Hospitals declined to comment for this article.
While the 1st Circuit’s opinion is binding only in four Northeastern states plus Puerto Rico, the NLRB decision carries the force of law nationwide. The case applies to both unionized and non-unionized employees, legal experts say.
Hospitals and health care organizations often have policies requiring employees to clear any public comments about the workplace with the organization’s media office. Many also have policies restricting what employees can say on Facebook and other social media.
Hospitals say requiring employees to go through their media office prevents the spread of inaccurate information that could damage the public’s confidence. In Young’s case, the hospital argued that her letter contained false and disparaging statements. But the 1st Circuit panel agreed with the NLRB that her letter was “not abusive” and that its only false statement was not her fault.
Health care organizations have undisputed legal authority to prohibit employees from disclosing confidential patient information or proprietary business information, legal experts say.
“If you go to the media and say, ‘There are unsafe working conditions impacting me and my colleagues,’ that’s protected concerted activity.”
—Eric Meyer, FisherBroyles
But the 1st Circuit panel made clear that an employer cannot bar an employee from engaging in “concerted actions” — such as outreach to the news media — “in furtherance of a group concern.” That’s true even if the employee acted on her own, as Young did in writing her letter. The key in her case was that she “acted in support of what had already been established as a group concern,” the court said.
“I think employers with a blanket ban on talking to the media need to relook at their policies,” said Eric Meyer, a partner at FisherBroyles in Philadelphia who often represents companies on employment law matters. “If you go to the media and say, ‘There are unsafe working conditions impacting me and my colleagues,’ that’s protected concerted activity.”
Chad Hansen, Young’s attorney in a separate federal lawsuit alleging discrimination based on a disability against the hospital, said she has not yet been reinstated to her job. Young would not comment.
The hospital’s parent company, Northern Light Health, said only that its news media policy — which was amended after Young’s firing — meets the NLRB and 1st Circuit requirements and will not be further changed. The new policy created an exception allowing employees to speak to the news media related to concerted activities protected by federal law.
Speech rights under the National Labor Relations Act are particularly important for employees of private companies. Although the Constitution protects people who work for public hospitals and other government employers with its guarantee of unrestricted speech, employees at private companies do not have a First Amendment right to speak publicly about workplace issues.
Dr. Ming Lin was fired from his position as an emergency room physician after publicly criticizing his hospital’s COVID-19 preparations.
“I hope this case keeps alive the right of health care workers to speak out about something that’s dangerous,” said Dr. Ming Lin, an emergency physician who lost his job last year at PeaceHealth St. Joseph Medical Center in Bellingham, Washington, after publicly criticizing the hospital’s pandemic preparedness.
Lin, who was employed by TeamHealth, which provides emergency physician services at the hospital, lost his assignment at PeaceHealth in March 2020 soon after saying on social media and in interviews with news reporters that PeaceHealth was not taking urgent enough steps to protect staff members from covid. He had worked at the hospital for 17 years.
In an April 2020 YouTube interview, PeaceHealth’s chief operating officer, Richard DeCarlo, said Lin was removed from the hospital’s ER schedule because he “continued to post misinformation, which was resulting in people being afraid and being scared to come to the hospital.” DeCarlo also alleged that Lin, who was out of town for part of the time he was posting, refused to communicate with his supervisors in Bellingham about the situation. PeaceHealth declined to comment for this article.
PeaceHealth’s social media policy at that time stated that the company does not prohibit employees from engaging in federally protected concerted activity and that they “are free to communicate their opinions.” TeamHealth’s social media policy, dated July 15, 2020, states the company reserves the right to take disciplinary action in response to behavior that adversely affects the company.
Lin, who’s now working for the Indian Health Service in South Dakota, has sued PeaceHealth, TeamHealth and DeCarlo in state court in Washington claiming wrongful termination in violation of public policy, breach of contract and defamation.
Dr. Jennifer Bryan, board chair of the Mississippi State Medical Association, who publicly defended two Mississippi physicians fired for posting about the inadequacy of their hospitals’ covid safety policies, said she faced pressure from her hospital for speaking to the news media without approval.
The medical association pushed its members to talk to the media about the science of covid, while employers insisted doctors’ messages had to be approved by the media office. That reflected a conflict, she said, between medical professionals primarily concerned about public health and executives of for-profit systems who were seeking to shield their corporate image.
Bryan predicted the court ruling and NLRB decision will be helpful. “Physicians have to be able to stand up and speak out for what they believe affects the safety and well-being of patients,” she said. “Otherwise, there are no checks and balances.”
Published courtesy of KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
After 27 years as an emergency RN and over a year as a frontline nurse in the Covid-19 pandemic, Rhode Islander Timothy Aurelio has seen a lot. But, during the height of last year’s surge, the Nurse of the Week was taken aback when the CDC told hospitals that workers should tote their (suddenly-classed-as-reusable) N95 masks in a brown paper bag. One day, as he arrived at the hospital, Aurelio says he saw “This security guard had his N95 in a brown paper bag, and it was completely crushed. His metal nose bridge was completely flat.”
Rhode Island emergency nurse, Timothy Aurelio, RN, BSN-DC.
There was some logic to the instruction, as a brown paper bag permits the free flow of air around the N95 and should help prevent bacteria from growing inside the mask. However, Aurelio quickly discovered the downside: “With a mask in this integrity, it’s not going to protect you… I saw their masks being stored in their duffel bags, and in their pocketbooks, and hanging from the hook next to the printer Anything from the air is dropping down into their mask.” As he told a local reporter, “Last July… we didn’t have a safe place to store our N95 masks and our masks were getting crushed and soiled, people were leaving them on the desk.” In fact, he added, “This is how I first developed the idea: a security guard had his N95 in a brown paper bag and it was intertwined in his belt. And I said, ‘What is that?'”
This could literally be a matter of life or death, so the RN began to think of a way to create PPE for his PPE. Aurelio’s solution? The N95 Mask Preserver. Designed with the aid of engineers at MassChallenge Rhode Island, RIHub, and Michael Katz of the University of Rhode Island, Aurelio’s PPE protector consists of a hinged case made of medical-grade plastic, which he says is “the same material that’s used for our hospital syringes. It also has an additive called WITHSTAND, which is antimicrobial, anti-fungal, anti-mold, and anti-mildew.” The Preserver also includes a 1/4″ hole so healthcare workers can clip the case to their scrubs so they always have their PPE ready to hand.
Aurelio’s N95 preserver has proved so popular that he now has a patent pending. He told ABC in Rhode Island, “The docs at the ER at my place are wearing them, our nurses are wearing them and using them, and they’re seeing such a difference in the integrity of their mask.”
As he sees it, Aurelio was acting as a nurse more than as an entrepreneur: “I saw that my colleagues were getting sick with Covid,” he said. “If I can eliminate one of those risk factors by having a safe N95 mask that’s in good integrity, that’s why I did this.”
For more on Aurelio’s N95 tote, visit his website.
