Nurses already experienced high levels of burnout before the pandemic, primarily because of chronic understaffing. A regression to the mean in the coronavirus aftermath would greatly hurt the profession and the patients they protect, emphasizes Linda Aiken, PhD, RN, FAAN, 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.

Recently, Aiken wrote an op-ed in The New York Times, where she described the futile effort to improve patient-nurse staffing ratios, even though it improves patient safety and saves no small amount of money.

“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,” she wrote.1 “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.”

The public strongly agrees in polls that hospitals and nursing homes should be required to meet safe nurse staffing standards, she notes.

“But powerful industry stakeholders — such as hospital and nursing home organizations and, often, medical societies — are strongly opposed and usually defeat legislation,” Aiken wrote. “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.”

Hospital Employee Health spoke to Aiken about this issue in the following interview, which has been lightly edited for length and clarity.

HEH: We know patient safety has been linked to inadequate nurse staffing, but how much do nurses suffer due to poor staffing?

Aiken: Burnout has been higher for nurses than in any other occupation for a long time. We were doing a big study that turned out to be immediately before COVID. We studied all the nurses and all the hospitals in New York and Illinois. We found that before COVID, 46% of all the nurses scored in the high burnout range. We just resurveyed, while COVID is still going on, and the rate has increased to 50%. The point being, nurses are more stressed now than they were, but the problem was there before COVID even started. We know that those high burnout rates are associated with understaffing. That is the biggest reason why nurses are burned out. There are not enough nurses, and they each have too many patients to safely take care of.

HEH: Were you surprised the high burnout rate only went up four percentage points?

Aiken: Yes, but when you look at some of the subgroups, as you might imagine, burnout has increased more among ICU nurses. ICU nurses went from 47% being highly burnt out before COVID, to 62% now. That’s consistent with where all these critically ill patients are. But the point is the same — more than 45% of them were already burnt out before COVID. Yes, we should thank nurses for their sacrifices, but the reason that they’re making so many sacrifices now is that conditions were so bad before COVID. If we go back to those bad conditions before COVID [after the pandemic] we’re not giving any gratitude to nurses whatsoever or helping [patients] because the care is unsafe.

HEH: In another study, you found that with adequate nurse staffing, New York state could prevent 4,370 patient deaths and save $720 million over a two-year period.2

Aiken: Can you believe the legislature didn’t pass the legislation after we showed them that? It shows how strong the interests are that are against doing these things, because they presume it would cost so much more money. But they’re really not open to the idea that science is pointing out that it’s not as expensive as you think it is. In fact, they’re wasting money now by not having enough nurses, because the length of stay is longer than it needs to be, which they’re not being reimbursed for. Their readmission rates are higher than they need to be, for which they’re being penalized financially by Medicare. They’re just not being knowledgeable in how they look at nursing. They look at it as a cost and not as a revenue. I mean, it could really produce revenues for hospitals and save them a lot of money — which would offset the costs of employing more nurses. The stakeholders greatly overestimate what it would cost to improve nurse staffing, and that scares the public and the legislators, so they don’t pass it.

HEH: California remains the one state that passed a nurse staffing law.

Aiken: It’s the only successful one that’s passed — and that was 20 years ago. It’s been very successful, and there are plenty of studies that show it’s been successful. But the special interests mobilize and the public’s not paying attention. I think what’s going to happen with more publications like mine in The New York Times is the public’s going to realize that their own representatives are not acting in their interests by improving nurse staffing. I think this is a matter of educating the public to educate their legislators.

HEH: You call for more transparency on hospital nurse-patient ratios, which are not often reported in public-facing data.

Aiken: Right. There really isn’t any way for the public to figure out what the staffing is in hospitals or nursing homes so they could choose one that has good staffing. I’ve recommended that the federal government add mandated reporting of hospital patient-to-nurse staffing on the existing Hospital Compare website. That website allows any consumer to go in and evaluate any hospital on things like mortality rates, but there’s not a word on there about nursing [levels]. The public just has no idea if nursing is either good or really horrible in their local hospital, where they’re thinking about going to for serious surgery.

HEH: This is a speculative question, but what difference would it have made to have adequately staffed hospitals during the pandemic? From your research, it sounds like the effect could have been profound.

Aiken: I think it would have been. One of the ways we tried to get at that was to look at another mortality problem that is similar in some respects to COVID, which is sepsis. Sepsis is an infection that sometimes starts out innocently, but that can escalate very rapidly and kill people that normally are in good health. We chose that because there’s a great focus on hospitals implementing standardized protocols to save people’s lives who have sepsis, and these have been tested by the National Institutes of Health and shown to be effective.

The New York State Legislature — the same one that turned down nurse staffing [legislation] — passed a requirement that New York hospitals had to adhere to this protocol. We looked at that as an example of what would happen if we tried to improve COVID outcomes without changing nursing staffing. What happened with sepsis — despite [the legislature] mandating that hospitals had to follow the protocols — is they couldn’t. They didn’t have enough nurses. We put all the data together and estimated that they could have saved more lives by requiring an improvement in nurse staffing instead of mandating that protocol.3 All these things are out there in the scientific literature. We informed the state legislature of that. I think it’s a very good example that you can’t save really sick people by mandating a committee or a process if the cause of excess mortality has to do with not enough nurses.


  1. Aiken, LH. Nurses deserve better. So do their patients. The New York Times. Aug. 12, 2021.
  2. Lasater KB, Aiken L, Sloane DM, et al. Is hospital nurse staffing legislation in the public’s interest?: An observational study in New York state. Med Care 2021;59:444-450.
  3. Lasater, KB, Sloane DM, McHugh MD, et al. Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes. Am J Infect Control 2021;49:868-873.