AONL COVID-19 Longitudinal Study Finds Top Challenges for Nurse Leaders

Increasing intensive care unit (ICU) beds is a direct indicator of surge. Similar to the percentage of nurses needed to treat COVID-19 patients, the percentage of ICU beds needed to expand capacity to treat patients increased by 12%, with a total of 66% of leaders reporting an increase in ICU beds. A variance emerged between CNOs and managers’ responses. Fifty-seven percent of CNOs reported an increase in ICU beds to accommodate patients, compared to 70% of managers. Of all respondents who reported having to increase ICU beds to expand capacity, 44% said they increased beds cumulatively over 6 months since the start of the pandemic.  

Professional development

Respondents indicated the percentage of nurses that received professional development to perform additional or new competencies to expand capacity to treat COVID-19 patients. Half of all respondents said 81-100% of their nurses were trained, a 2% increase from July 2020.

In addition to how many nurses received professional training, nurse leaders were asked to identify the percentage of nurses actually utilized to treat COVID-19 patients. One third indicated 81-100% were needed, which was a significant 10% increase from the results in July 2020.

After respondents indicated their top three challenges, they were asked to rate how effectively they have been able to address those specific challenges. They were asked to rate on a 1-5 scale, with 5 being very well. The mean score for all challenges was 3.51, or between neutral and well. The lowest overall mean scores were 1) financial resource availability (2.84); 2) staff retention, furloughs and layoffs (2.92) and 3) health inequity and the impact of social determinants of health (2.97). For CNOs, the lowest score was staff retention, furloughs and layoffs. For directors and managers, the lowest score was indicated for financial resource availability.

For the February 2021 survey, respondents were asked to identify the biggest challenge they face today that they did not face six months ago. For this question, respondents selected only one challenge, opposed to the previous question where they selected the top three overall challenges. In the recent survey 35% of respondents named low morale and burnout as their number one challenge. This is followed by staffing shortages and vaccine administration at 16% and 10%, respectively. A gap between CNOs and managers is evident. Only 28% of CNOs selected low morale and burnout as a new challenge, compared to 43% of managers, for a 15% gap between the roles. This statistic is linked directly to managers’ overall emotional health and well-being. Similar to other questions, directors were in the middle at 34%.

Staffing shortages Staffing shortages were one of the top challenges faced by nurse leaders at the time of the February survey. Staffing shortages, travel nurses and temporary staffing were mentioned in interviews with CNOs, directors, and managers as a constant concern. To provide quantitative data on an ongoing debate, nurse leaders were asked to indicate how likely their organization is to experience a shortage following the pandemic, rating between not at all likely and very likely. The mean score was 3.52, between neutral and likely. More than half of respondents selected likely or very likely, with 23% of all leaders selecting very likely. Notably, directors were most likely to expect a shortage; 25% selected very likely and 37% selected likely. Overall, only 4% said they are not at all likely to experience a staffing shortage.

Respondents were asked to provide an open-ended response to the primary cause of their staffing shortage. Nearly one-quarter of respondents named burnout and fatigue as being the primary cause. Others said early retirements, travel nursing and nurses leaving the profession. In some cases, poor leadership was said to be the primary cause. One nurse leader noted, “Staffing was an issue prior to the pandemic. The pandemic has exacerbated the issue.”

Policy concerns

Another addition to the February 2021 survey was an advocacy question to determine the key areas for desired policy change. Validating the top challenge, burnout and behavioral health received 45% of the response. Following was grants and loan repayments for nurses and faculty, tailed by cost of travel and temporary nurses. These received 18% and 16%, respectively. Clinician childcare, transportation and housing support cumulatively received 9% of selections. Visa recapture was selected by less than 1% of nurse leaders.

Looking ahead

At the end of the first longitudinal survey in July 2020, the total death count in the U.S. was under 130,000 and new cases were declining in the Tri-state region (New York, New Jersey and Connecticut), with the first wave just reaching Florida, Arizona and California. At that time, communicating and implementing changing policies and surge staffing, training and reallocation of staff were the top challenges nurse leaders faced, as well as access to PPE and other equipment. Fast forward six months and the story changed dramatically.

At the end of the second survey in February 2021, the death count in the U.S. exceeded 500,000. Access to PPE was far less of a concern, and emotional health and well-being skyrocketed as a problem, with over 67% of nurse leaders identifying it as a top challenge. As of February 2021, one-fourth of managers reported they were not or not at all emotionally healthy. Surge staffing, training and reallocation remained a challenge, having increased since July 2020.

Going forward, the acute problem facing health care is the emotional health and well-being of nurses. It is clear from this study that nurse managers are exposed to higher levels of stress and that the closer they are to the point of care, the greater the effect the crisis has on emotional health. Staffing shortages, as well as travel and temporary nursing models, must also be considered from an operations perspective and for future policy initiatives.