Have Nursing Work Conditions Improved?

I wondered if nursing conditions had changed during the past 3 years since my editorial “The Nursing Shortage and Work Expectations Are in Critical Condition: Is Anyone Listening?” was published in April 2022.¹  The online version of that editorial was viewed more than 54 300 times (Altmetric. 2025. Altmetric database in JSON format.) and cited at least 37 times.²  Although the large volume of downloads suggests that the content may have helped to increase awareness, awareness alone seldom translates into action. Some of the major concerns in my 2022 editorial included inappropriate staffing levels, high patient-to-nurse ratios, and inadequate staffing budgets. Many nurses were being forced to work mandatory overtime and were under constant pressure to pick up extra shifts, contributing to increased levels of nursing burnout and decreased quality of care. Due to these and other challenges, many nurses were leaving their roles and the profession or expressing intent to leave nursing.³ 

Despite the challenges experienced in numerous nursing work settings, countless units and nurses continued to excel. Many units celebrated earning American Association of Critical-Care Nurses (AACN) Beacon awards for excellence throughout and following the COVID-19 pandemic.^4,5  Beacon awardees earn the status of excellence by meeting criteria in 3 categories, (1) patient outcomes, (2) work environment, and (3) nursing workforce. While some units celebrated this accomplishment, other acute and critical care nurses persevered in unhealthy work environments. Despite the disparities within our health care systems, nurses remained committed to delivering excellent patient- and family-centered care to limit complications and promote positive outcomes.

Appropriate staffing is known to be associated with better patient outcomes, such as decreased mortality rates and decreased adverse events,⁶  but appropriate staffing is more than just numbers. The American Nurses Association (ANA) nurse staffing task force defined appropriate staffing as “a dynamic process that aligns the number of nurses, their workload, expertise, and resources with patient needs in order to achieve quality patient outcomes within a healthy work environment.”⁷  The ANA definition aligns with the AACN Synergy Model for Patient Care.⁸  The AACN has been at the forefront of appropriate staffing efforts, developing the 2024 AACN Standards for Appropriate Staffing in Adult Critical Care, which are free to AACN members.⁹  This document includes a worksheet to calculate return on investment, which may help to convince administrators about the value of appropriate staffing within their organization. I suggest that Critical Care Nurse readers share the new AACN staffing standards widely with leaders and nurses in their workplaces.

The nursing staffing issue has been identified not only as a crisis¹⁰  but an existential threat.⁹  In some states, mandatory nurse-patient ratios and mandatory overtime regulations have been successfully implemented,¹¹  but in other states, nurses continue to face understaffing and unsafe working conditions.¹²  According to AACN’s Appropriate Staffing Work Group, chronically dysfunctional staffing practices are underpinned by causes such as “inflexible models of care, non-collaborative decision-making, economic pressures, and power dynamics.”⁹ 

Our health care systems should value nursing care, promote appropriate staffing, and create healthy environments where professional nurses can continue to provide excellent patient care. As new stand-alone medical facilities are created,¹³  I am concerned about their impact on local and regional nursing communities. Will stand-alone emergency departments (EDs) dilute the already compromised pool of experienced nurses? How will this affect the health care systems in the area? I am not referring to rural communities where emergency services provide increased access to care; I am speaking of urban settings with many health care facilities in competition with each other to attract new business. I worry that professional nursing expertise will be further diluted by spreading a limited number of nurses over a growing number of clinical sites. In a US study,¹⁴  more than 50 000 nurses reported that the ED had the highest proportion of novice nurse hires and the highest turnover rate in comparison with other nursing specialty areas. Sixteen percent of nurses working in EDs reported having at least 2 employers.¹⁴ 

Although many nursing academic programs in the United States have expanded enrollment in an effort to increase the pipeline of new nurses,¹⁵  we will continue to have a nursing retention problem if we do not make substantive changes that can be sustained over time. Because we have not fixed our underlying, dysfunctional working conditions, an unacceptably high volume of novice nurses from across the United States (>17%) quit their job within their first year in the nursing profession.¹⁶  In 2020, nurses with fewer than 2 years of experience expressed greater intent to leave their position, but not the profession.³ 

An innovative blueprint for changes to nursing practice was recently published by nurse leaders who are also members of the American Academy of Nursing’s expert panel for acute and critical care nursing.¹⁷  Nurses in hospital settings are caring for patients with more complex medical and social issues while locked into outdated and ineffective staffing models. The authors’ call for action focuses on the development of new outcome metrics to recognize excellence in acute and critical care nursing and to demonstrate nursing’s value and return on investment. Curley et al¹⁷  call attention to the current focus on harm metrics such as infections, falls, and pressure injuries as proxy measures for nursing care. They suggest that future measurements of nursing care include what nurses do rather than what nurses do not do. The following examples are from a long list of suggestions for future measurements of nursing care: symptom relief, provision of family-centered care, satisfaction with health education, respect for the dignity of patients and families, and patients rescued.

The article by Curley et al may help nurses and others articulate what makes nursing care unique and important. Although the scope of this work may seem daunting, the authors recommend the creation of a National Nursing Workforce Commission to lead the way. They encourage nurses at the bedside to engage in conversations about nursing practice that is meaningful to patients and their families. They also have suggestions to engage nurse leaders and others.¹⁷  I encourage Critical Care Nurse readers to print a copy of the Curley et al article for your break room, help spread the message, and begin discussions. As mentioned earlier, awareness is a starting point, but without action, any progress made in changing nurse staffing models will continue to stall.

Another champion for nursing, Lynda Benton, shared her thoughts on what is needed for the future of nursing after she announced her retirement from Johnson & Johnson Nursing.¹⁸  Benton’s advice for nurses who are not invited to participate was to “bring your own chair.”¹⁸  This statement is bold. Her suggestions below are not new, but they are direct and actionable.¹⁸ 

• Help change the narrative. Nurses must share their positive stories about the skills, knowledge, and impact they have every day.

• Advocate for the nursing profession. Talk about nursing careers and specialties with students and second-career adults.

• Help be the voices of nursing. Get involved by joining boards, sharing your expertise, and bringing forth ideas to create change and workplaces where nurses thrive.

• Champion nurse-led innovation. These champions will ensure a pathway for innovative nursing ideas to be raised, discussed, and trialed in workplaces.

Many innovative solutions have been identified since my 2022 editorial, but the hard work has just begun. The current AACN presidential theme, “Courage to Soar,” encourages acute and critical care nurses to aspire to boldness and take risks. An RNAction Center is available to help nurses with their advocacy efforts to address issues such as the nursing shortage, nurse staffing, nurse overtime, workplace violence, health care provider protection, and more.^19,20  The AACN staffing standards work group states it best by reminding us that “the timeline is critical, the stakes are high, and patients depend on us.”¹⁰  I applaud the thousands of acute and critical nurses who continue to find their voices and take action to rebuild and create the profession of nursing in their own vision.