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A U-M study by Nursing associate professor Deena Kelly Costa and Nursing professor Christopher R. Friese identified state and federal policy implementations that would positively affect the declining number of nurses in the workforce. The study, published in The New England Journal of Medicine, found that the COVID-19 pandemic has caused nurses to leave their job. 

Nurses, physicians and other healthcare professionals were essential for the functioning of the U.S. healthcare system during the COVID-19 pandemic. A 2021 national survey by the American Association of Critical-Care Nurses found that 66% of respondents reported having thought about leaving the profession, with the pandemic listed as a key contributor to their decision. Many hospitals have turned to hiring traveling and foreign nurses to fill the shortage caused by the pandemic. 

The U-M study focused on state and federal policy solutions that could be implemented to address workforce losses and to increase the supply of nurses. One suggestion was to implement federal regulations that specify maximum patient-to-nurse ratios, with penalties for hospitals that violate such regulations.

Nursing senior Lauren Hokanson started working as a nurse technician at Michigan Medicine in May 2022. She said that methods for treating patients safely had to evolve because of the pandemic.

“I think the public was frustrated with policies changing every day, and the same thing went for hospitals (with regard to) our visiting policies and how we treated patients safely,” Hokanson said. “I know from a (nurse) tech standpoint, we were very understaffed. Most of the time, a safe patient load (for nurse techs) is eight patients, and I worked September through probably January with the whole floor, so a 16-patient load.”

Hokanson said her unit generally implements a safe patient load of three patients per nurse. Safe patient load limits ensure patients receive high-quality care and do not suffer complications from missed care. She said nurses were given more high acuity patients, or those who required increased attention, during the pandemic than would have typically been the case. 

“For nurses on my unit, a safe load would probably be three,” Hokanson said. “And they kept about that (number), but they gave some higher acuity patients where a nurse should have probably only had just that one patient, or maybe two patients, and they were still having three of higher acuity.”

Costa said the requirement that nurses produce clinical documentation of all provided care often leads to job dissatisfaction and could also benefit from updated policy.

“It’s kind of like the lowest hanging fruit that hospitals try to implement now,” Costa said. “There’s lots of data that suggests that documentation is a burden and can be contributing to burnout on healthcare clinicians.”

Costa said double documentation may be a negative consequence of current documentation practices that could be eliminated.

“There’s also a considerable amount of evidence suggesting that nurses conduct what’s called double documentation,” Costa said. “You want the electronic health record and nurse’s chart in a variety of spots, often the same information, which is called double documentation. That’s done partially for regulatory purposes, as well as quality assurance purposes. So we argue that reducing documentation efforts might be helpful in reducing clinician burnout, potentially retaining nurses at the bedside.”

In an email to The Michigan Daily, Friese wrote that the emphasis on documentation processes in health care may be misplaced.

“There is ample evidence that much of what hospital systems require clinicians to document doesn’t help patients and detracts from clinical care,” Friese wrote. “One of our studies has shown that safety and communication scores are lower in (healthcare) systems that had 100% documentation in electronic systems. The work ahead is making sure the key elements are included to make sure we deliver care safely and communicate well across all the settings where patients get care.”

The study also discusses the importance of retaining and increasing the supply of nurses. It states that faculty positions for nursing instructors are not highly desirable since salaries for practicing nurses are typically higher. The subsequent shortage of nursing instructors can lead to fewer nursing school enrollments, even though there are an abundance of qualified candidates.

“Some (members) of the profession (have) taken some approaches to address some of these threats,” Costa said. “We’ve introduced Bachelor of Science in Nursing (BSN) to Ph.D. programs as a way to increase the number of doctorally prepared nurses. While I think those approaches have helped, COVID-19 has really demonstrated that we have a lot more work to do.” 

Costa said she received positive feedback from readers of the study.

“We’ve actually had really overwhelming support for the work … Health care professionals have been really thrilled that it was published in The New England Journal of Medicine, partly because I think it helped elevate and introduce it as part of the national health care policy discussion, which is really where it needs to be.”

Daily Contributor Maanasa Bommineni can be reached at