The American Nurses Association (ANA) recently sent a letter to the Department of Health and Human Services (HHS) calling for the Biden administration “to declare a national nurse staffing crisis and take immediate steps to develop and implement both short- and long-term solutions.”1

“Nurses have remained steadfast on the front lines since the beginning of the pandemic, [but] the Delta variant is causing cases to soar, overrunning hospital and staff capacity,” said the letter from ANA President Ernest Grant, PhD, RN, FAAN. “These current circumstances have only exacerbated underlying, chronic nursing workforce challenges that have persisted for years.”

It is imperative that the administration take steps to address “a crisis-level human resource shortage of nurses that puts our ability to care for patients in jeopardy,” Grant said. “ANA is deeply concerned that this severe shortage of nurses, especially in areas experiencing high numbers of COVID-19 cases, will have long-term repercussions for the profession, the entire healthcare delivery system, and ultimately, on the health of the nation.”

The ANA cites several national examples of the crisis, with many hospitals losing nurses and demand exceeding staffing needs. There are thousands of unfilled nursing positions, and some hospitals have had to request support from the National Guard, the ANA emphasized. In addition to more staff, Grant urged in the letter that the HHS remove barriers to practice for nurses and increase the annual number of qualified students educated in the field. Moreover, nurses need help and strategies to address fatigue and mental well-being to maintain a resilient workforce, the ANA letter stated.

Again, nurses already were at high levels of burnout before the pandemic, primarily because they are chronically understaffed, says 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. “Burnout has been higher for nurses than in any other occupation for a long time,” she says. “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.”

One of Aiken’s research studies 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

That paper was presented into legislative arguments on a nurse staffing bill the state was considering, but what ultimately was adopted fell short of requiring a specific nurse-to-patient ratio.

“It shows how strong the interests are that are against doing these things, because they presume it would cost so much more money,” she says. “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. It could really produce revenues for hospitals and save them a lot of money, which would offset the costs of employing more nurses.”

California remains the only state that has passed a nurse-patient ratio staffing law, with their model legislation requiring a minimum of one nurse per five medical surgical patients and one nurse per every two intensive care unit beds.

“That was 20 years ago,” Aiken says. “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. The public is 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.”

In that regard, Aiken recently wrote an opinion piece in The New York Times calling for more transparency on hospital nurse-patient ratios, which are not often reported in public-facing data.3

“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,” she says. “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]. So, 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.”

In terms of patient safety and preventing infections, Aiken thinks addressing nurse staffing before the pandemic hit could have made a profound difference. Of course, that must remain speculative, but recently she coauthored a study on sepsis protocols that shows nurse staffing is directly related to patient outcomes.4

“Sepsis is an infection that sometimes starts out innocently, but that can escalate very rapidly and kill people that are normally in good health,” she says. “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.”

New York State passed legislation requiring hospitals to adhere to this protocol, but Aiken’s study showed the hospitals had insufficient nursing staff to implement it.

“They didn’t have enough nurses,” she says. “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. 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. American Nurses Association. ANA urges US Department of Health and Human Services to declare nurse staffing shortage a national crisis. Published Sept. 1, 2021.
  2. Lasater KB, Aiken LH, 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. Aiken, LH. Nurses deserve better. So do their patients. The New York Times. Published Aug. 12, 2021.
  4. 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.