Nurse Burnout and Stress

4 Journal of Nursing Regulation

Examining the Impact of the COVID‑19
Pandemic on Burnout and Stress Among
U.S. Nurses
Brendan Martin, PhD; Nicole Kaminski-Ozturk, PhD; Charlie O’Hara, PhD; and Richard Smiley, MS

Background: The COVID‑19 pandemic has amplified long‑standing issues of burnout and stress among the U.S. nursing

workforce, renewing concerns of projected staffing shortages. Understanding how these issues affect nurses’ intent to leave

the profession is critical to accurate workforce modeling. Purpose: To identify the personal and professional characteristics

of nurses experiencing heightened workplace burnout and stress. Methods: We used a subset of data from the 2022 National

Nursing Workforce Survey for analysis. Binary logistic regression models and natural language processing were used to

determine the significance of observed trends. Results: Data from a total of 29,472 registered nurses (including advanced

practice registered nurses) and 24,061 licensed practical nurses/licensed vocational nurses across 45 states were included

in this analysis. More than half of the sample (62%) reported an increase in their workload during the COVID‑19 pandemic.

Similarly high proportions reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out

(45.1%), or at the end of their rope (29.4%) “a few times a week” or “every day.” These issues were most pronounced among

nurses with 10 or fewer years of experience, driving an overall 3.3% decline in the U.S. nursing workforce during the past 2

years. Conclusion: High workloads and unprecedented levels of burnout during the COVID‑19 pandemic have stressed the

U.S. nursing workforce, particularly younger, less experienced RNs. These factors have already resulted in high levels of

turnover with the potential for further declines. Coupled with disruptions to prelicensure nursing education and comparable

declines among nursing support staff, this report calls for significant policy interventions to foster a more resilient and safe

U.S. nursing workforce moving forward.

Keywords: Workforce, burnout, stress, pandemic, COVID‑19, nursing shortage

For decades, scholars have warned of looming nursing short-
ages across the United States, citing an aging workforce and
long-standing issues of burnout and stress stemming from

high patient-to-nurse ratios, low pay, and concerns regarding work-
place safety. The surge in patient volume and acuity driven by the
COVID-19 pandemic compounded many of these pre-existing
issues. Simultaneously, prelicensure nursing education programs
were forced to rapidly re-invent themselves in response to clini-
cal site disruptions, potentially affecting the supply and clinical
preparedness of new nurse graduates. This combination of factors
has led to unprecedented levels of burnout among newly licensed
and tenured nurses alike. We used a subset of data from the 2022
National Nursing Workforce Survey to identify potential indi-
cators of stress and burnout among the current nursing work-
force to better target resources, tailor solutions, and inform policy
decision-making.

Background
The overall number of registered nurses (RNs) in the United
States has steadily risen over the past decade (NCSBN, 2023; U.S.
Bureau of Labor Statistics, 2022), but the number of employed
RNs per capita in each state varies widely (U.S. Bureau of Labor
Statistics, 2022; United States Census Bureau, 2022). Even within
single jurisdictions, regional differences exist (Scheidt et al., 2021;
NCSBN Environmental Scan, 2023). Long-standing concerns over
nursing shortages existed prior to the pandemic (Buerhaus et al.,
2007; Snavely, 2016; Marć et al., 2019), but COVID-19 appears
to have accelerated this trend and exacerbated many pre-existing
workforce issues (Haas et al., 2020), such as nurses’ experiences of
burnout and stress (Aiken et al., 2002; McHugh et al., 2011; Aiken
et al., 2018). Emerging evidence suggests that between 22%–32%
of the nursing workforce is actively considering retiring, leaving
the profession, or leaving their current position in the near future
(Smiley et al., 2021; Berlin, Lapointe, Murphy, & Wexler, 2022;
Nurse.com, 2022; Smiley et al., 2023). Within specific subsets of
the profession, such as critical care, the picture is even bleaker, with

www.journalofnursingregulation.com 5Volume 14/Issue 1 April 2023

an estimated 67% of nurses indicating that they plan to leave their
current position in the next 3 years (Ulrich et al., 2022).

Although the COVID-19 pandemic has exacerbated many
of these trends, it is often not the root cause of the problem, nor are
the issues isolated to the United States. The main drivers of nurses’
intent to leave are frequently identified as more durable issues or
problems, such as insufficient staffing levels, desire for higher pay,
not feeling listened to or supported at work, and the emotional toll
of the job (Lasater et al., 2021; Galanis et al., 2021; Murat et al.,
2021; Berlin, Lapointe, & Murphy, 2022). In fact, when ranked,
McKinsey research found that financial considerations and plans
to retire or return to school often played bigger roles in nurses’
decision-making than the pandemic (Berlin, Essick, et al., 2022).
Furthermore, scholars have found that intent to leave is typically
influenced by a multitude of factors, including individual char-
acteristics such as job satisfaction and frequency of experienc-
ing “moral distress,” and work environment characteristics, such
as appropriate staffing, quality of care, safety, etc. (Aiken et al.,
2022; Ulrich et al., 2022). Surveys have found that these experi-
ences translate internationally as well, with substantial proportions
of nurses in France, Singapore, Japan, and the United Kingdom
indicating they also plan to leave direct care for many of the same
reasons (Berlin, Essick, et al., 2022).

Fissures in the U.S. healthcare system were apparent from
the start of the pandemic, with multiple reports identifying criti-
cal staffing shortages from the onset of COVID-19 (Spetz, 2020)
and throughout surge events driven by variant strains of the virus
(Office of the Assistant Secretary for Planning and Evaluation,
2022). Distressingly, emerging evidence suggests the pandemic has
even stalled the decades-long workforce growth trend, with data
now showing that a decline in the RN population by approximately
100,000 may be primarily due to a 4% dropoff in the number of
RNs younger than 35 years (Auerbach et al., 2022). While it is not
yet clear whether the trend of younger nurses pausing or leaving
nursing “is a temporary or more permanent phenomenon” (Firth,
2022), there is reason for concern. Some researchers now project a
gap of 200,000 to 450,000 nurses by 2025—a gap partly driven by
a decreased supply of the absolute RN workforce but also amplified
by increased in-patient demand from or related to COVID-19 and
an aging population (Berlin, Essick, et al., 2022).

In addition, many healthcare facilities closed their doors to
clinical experiences to reduce the spread of COVID-19 and pre-
serve their limited supplies of personal protective equipment early
in the pandemic (Dewart et al., 2020). As a result, many preli-
censure nursing programs faced enormous difficulty in securing
traditional in-person clinical placements, directly affecting the sup-
ply and preparedness of new nurse graduates (Emory et al., 2021;
Lanahan et al., 2022). In response, most nursing programs shifted
their face-to-face lectures to online platforms and their traditional
clinical placements to simulation-based and virtual simulation-
based experiences (Benner, 2020; Innovations in Nursing Education,
2020; Kaminski-Ozturk & Martin, 2023; Martin et al., 2023). The

scope and speed of this pivot presented particular challenges for
faculty and administrators in the health professions, as the rapid
development and implementation of online and simulated curri-
cula often ran counter to their own academic training (Booth et
al., 2016; Seymour-Walsh et al., 2020). Despite many challenges
(Michel et al., 2021; Smith et al., 2021), some evidence suggests pre-
licensure nursing students maintained learning outcomes (Konrad
et al., 2021). However, others have documented the need for more
hands-on training and the frustration of new nurse graduates over
the apparent mismatch between their clinical experiences and
their role entering the clinical setting during a global health crisis
(Crismon et al., 2021; Emory et al., 2021; Bultas & L’Ecuyer, 2022;
Lanahan et al., 2022).

Taken together, the U.S. nursing workforce is at a critical
crossroads (NCSBN, 2023). To better inform and target policy
solutions with the goal of fostering a more sustainable workforce,
we analyzed a subset of data from the 2022 National Nursing
Workforce Survey to address two primary research questions:
1. What are the personal and professional characteristics of nurses

experiencing heightened workplace burnout and stress?
2. How do nurses’ experiences of burnout and stress inform their

intent to leave the profession?

Methods
Survey Sample

All RNs, advanced practice registered nurses (APRNs), and licensed
practical nurses/licensed vocational nurses (LPNs/LVNs) with an
active license in the United States and its territories were eligi-
ble to be survey participants. The bulk of the sample was drawn
from Nursys, NCSBN’s licensure database. This database contains
basic demographic and licensure information for RN and LPN/
LVN licensees. For Georgia, the licensee list and addresses were
purchased directly from Medical Marketing Service, Inc. Separate
RN and LPN/LVN samples were drawn at random and stratified
by state. As nurses can hold multiple single-state licenses, an initial
review of all data was undertaken to de-duplicate license counts for
individual practitioners by assigning licensees a single home state
based on primary address.

Study Design

The core of the National Nursing Workforce Survey is comprised
of the National Forum of State Nursing Workforce Centers’ Nurse
Supply Minimum Data Set, which was approved in 2009 and
updated in 2016 (The National Forum of State Nursing Workforce
Centers, 2016). However, the survey instrument also includes sev-
eral custom items for a total of 39 questions across the following
six domains: (1) COVID-19 Pandemic; (2) License Information; (3)
Work Environment; (4) Telehealth; (5) Nurse Licensure Compact;
and (6) Demographics. Items specific to respondents’ experiences
during the COVID-19 pandemic and work as travel nurses dur-
ing the past 2 years were added for the 2022 cycle. The survey

6 Journal of Nursing Regulation

was initially fielded on April 11, 2022, via direct mail outreach in
partnership with Scantron, a leader in assessment and technology
solutions, and hosted online via Qualtrics (Provo, UT). The sur-
vey remained open for approximately 6 months, with two sched-
uled mail reminders at weeks 10 and 20 and regular weekly email
reminders for online surveys. A comprehensive overview of the
survey methods, including the sampling strategy, and detailed
national results will be available in a forthcoming publication of
the 2022 National Nursing Workforce Survey as a supplement to
the Journal of Nursing Regulation. Prior to commencing any outreach,
the study was approved by the Western Institutional Review Board.

Dependent and Independent Variable Coding

The Maslach Burnout Inventory-Human Services Survey (MBI-
HSS) is a reliable, and valid survey instrument comprising three
domains: Emotional Exhaustion, Depersonalization, and Personal
Accomplishment (Maslach et al., 1997). Nurses completing the
2022 National Nursing Workforce Survey were asked to complete
5 Likert-scale items originating from the Emotional Exhaustion
domain, which has a Cronbach’s alpha of .90 (Iwanicki & Schwab,
1981; Gold, 1984). Respondents were asked to indicate how fre-
quently they feel emotionally drained, used up, fatigued, burned
out, or at the end of their rope using a seven-point scale, where
1 meant “never” and 7 meant “every day.” After a review of the
distribution of raw responses and to simplify interpretation, each
dependent variable was collapsed to identify and isolate respon-
dent characteristics that aligned with a reported frequency of “a few
times a week” (6) or “every day” (7). In addition, for the primary
independent variable (years’ experience), receiver operator charac-
teristic (ROC) curves were generated for each of the five included
outcomes to identify, as possible, a general inflection point at which
respondents’ sentiments appeared to consistently shift regarding
experiences or drivers of burnout and stress. In aggregate, this cut
point emerged at approximately 9 to 10 years of experience, so 10
years was selected to simplify the analysis and readers’ interpreta-
tion of the results.

Data Analysis

A descriptive summary of the sample includes counts and pro-
portions for categorical variables, while continuous variables are
expressed as means and standard deviations or medians and inter-
quartile ranges (IQR), as appropriate. For most descriptive mea-
sures, there was minimal variation by license type, so sample-based
estimates are reported. Where notable differences emerged, they are
presented. Univariable and multivariable binary logistic regression
models were used to compare respondents’ experiences of stress or
burnout. An alpha error rate of p ≤ .05 was considered statistically
significant and all analyses of structured survey items (e.g., fixed-
item, check all that apply, etc.) were conducted using SAS version
9.4 (Cary, NC).

Analysis of unstructured data was performed using the
Natural Language Toolkit (Bird et al., 2009) and gensim (Řehůřek

& Sojka, 2010) packages in Python 3.10. Data were first pre-pro-
cessed, removing punctuation, numbers, and stop words (domain
general and domain specific). Common bigrams, trigrams, and
quadgrams were identified. Frequently used abbreviations and their
fully spelled-out forms were also collapsed, and word tokens were
lemmatized using the WordNet Lemmatizer. To extract recurrent
themes identified in the responses, a Latent Dirichlet Allocation
(LDA) probabilistic model (Blei et al., 2003) was employed.

The LDA model assumes there are a set number of latent
topics—where a topic is a probability distribution across words
found in the dataset—and each individual response has its own
probability distribution across these latent topics. The LDA model
can generate a response by sampling a topic based on the response’s
probability distribution and then sampling a word based on the
probability distribution of that topic. The model searches across
possible topics to maximize the likelihood of generating the
observed dataset. These topics group words that are commonly
used together. LDA models were run using gensim for a range
of topics; in the present article, we chose to use five-topic mod-
els because they performed better on the U Mass Coherence met-
ric than models with other topic thresholds (Mimno et al., 2011).
Because coherence metrics do not necessarily align with coherence
as observed by humans, several five-topic models were evaluated
and compared for final inclusion. An alpha error rate of p ≤ .05 was
considered statistically significant, and all analyses were conducted
using the scipy.stats package (Virtanen et al., 2020) in Python.

Results
Sample Summary

A total of 54,025 respondents across 45 states were included in
the sample. The sample was roughly evenly divided between
RNs (50.0%, n = 26,749) and LPNs/LVNs (45.0%, n = 24,061),
with APRNs (5.0%, n = 2,723) constituting a smaller subset.
Respondents were on average 51 years old (M: 51.4, SD: 14.4) and
reported a median of 19 years of experience (IQR: 9–34), with
minimal variation by license type. A majority of respondents self-
identified as female (92.5%, n = 48,546), non-Hispanic (95.%,
n = 49,465), and White (79.9%, n = 41,728). In general, LPNs/
LVNs tended to be more racially diverse (75.2% White) compared
to RNs (82.5%) and APRNs (85.8%). While most respondents
reported full-time employment in nursing (66.3%, n = 35,382),
only 4.6% (n = 2,006) indicated they engaged in travel nursing.
APRNs reported the highest rate of full-time employment (75.7%),
while the full-time employment rates among LPNs/LVNs (66.3%)
and RNs (65.7%) were more comparable. The median reported sal-
ary for LPNs/LVNs was $50,000 (IQR: $38,000–$60,000) com-
pared to $75,000 (IQR: $58,000–$95,000) for RNs and $110,000
(IQR: $87,500–$140,000) for APRNs.

More than half of the sample (62.0%, weighted
n = 3,002,301) reported an increase in their workload during the
COVID-19 pandemic. Similarly, high proportions reported feel-

www.journalofnursingregulation.com 7Volume 14/Issue 1 April 2023

ing emotionally drained (50.8%, weighted n = 2,352,775), used
up (56.4%, weighted n = 2,601,572), fatigued (49.7%, weighted
n = 2,296,545), burned out (45.1%, weighted n = 2,080,380), or at
the end of their rope (29.4%, weighted n = 1,353,809) “a few times
a week” or “every day.” Nurses with 10 or fewer years of experience
consistently reported a 28% to 56% increase in their frequency of
feeling emotionally drained (OR: 1.41, 95% CI: 1.36–1.47), used

up (OR: 1.50, 95% CI: 1.44–1.56), fatigued (OR: 1.56, 95% CI:
1.50–1.63), burned out (OR: 1.43, 95% CI: 1.38–1.49), or at the
end of their rope (OR: 1.28, 95% CI: 1.23–1.34) compared to their
more experienced counterparts (all p < .001, Table 1). Nurses who
reported an increased workload during the pandemic displayed a
similar pattern: emotionally drained (OR: 3.31, 95% CI: 3.19–3.44),
used up (OR: 3.32, 95% CI: 3.19–3.45), fatigued (OR: 2.99, 95%

TABLE 2

Multivariable Results for Respondents Who Reported a Frequency of “A Few Times a Week”
or “Every Day” Across all Outcomes

Years’ Experience |
Increased Workload
Interactiona

Emotionally
Drained

Used Up Fatigued Burned Out End of Rope

≤10 y | Yes All p < .001 All p < .001 All p < .001 All p < .001 All p < .001

≤10 y | No (Ref) 3.13 (2.85, 3.43) 2.93 (2.68, 3.21) 2.67 (2.44, 2.93) 2.77 (2.52, 3.04) 2.47 (2.21, 2.76)

11+ y | Yes (Ref) 1.13 (1.07, 1.20) 1.18 (1.11, 1.25) 1.23 (1.16, 1.31) 1.18 (1.11, 1.25) 1.10 (1.03, 1.17)

11+ y | No (Ref) 4.14 (3.85, 4.45) 4.23 (3.93, 4.54) 3.86 (3.59, 4.15) 3.66 (3.40, 3.94) 3.10 (2.84, 3.38)

Note. Ref = reference. Multivariable model n ranges from 29,941 to 30,060 observations across all five dependent variables. Dependent variables were collapsed

to identify and isolate respondent characteristics that align with a reported frequency of “a few times a week” or “every day” across each of the five outcomes.

Results presented as odds ratios and 95% confidence intervals.
a In addition to years’ experience and increased workload, each model further adjusted for respondents’ self‑reported sex, ethnicity, race, salary, and license

type, as well as indicators for full‑time nurse employment, direct patient care, and travel nurse designation.

TABLE 1

Descriptive Summary for Respondents Who Reported a Frequency of “A Few Times a Week”
or “Every Day” Across Each Emotional Exhaustion Outcome

Emotionally
Drained

Used Up Fatigued Burned Out End of Rope

License Type

LPN/LVN 48.1% (10,774) 52.9% (11,770) 47.3% (10,532) 41.9% (9,328) 27.7% (6,154)

RN 48.6% (12,169) 54.5% (13,584) 47.5% (11,845) 42.6% (10,613) 27.8% (6,922)

APRN 45.3% (1,196) 50.3% (1,328) 40.5% (1,070) 36.5% (962) 20.9% (550)

Years’ Experience

≤10 y 53.4% (7,400) 59.8% (8,258) 53.8% (7,444) 47.3% (6,552) 30.3% (4,182)

11+ y 44.7% (13,568) 49.7% (15,024) 42.7% (12,903) 38.5% (11,640) 25.3% (7,628)

Travel Nurse

No 47.8% (19,537) 53.3% (21,711) 46.6% (19,026) 41.0% (16,710) 26.2% (10,649)

Yes 59.8% (1,192) 65.1% (1,290) 60.1% (1,195) 54.4% (1,079) 37.2% (739)

Increased Workload

No 30.4% (5,663) 35.5% (6,572) 30.7% (5,697) 27.1% (5,021) 17.6% (3,255)

Yes 59.1% (18,238) 64.6% (19,836) 57.0% (17,519) 51.0% (15,681) 33.4% (10,247)

Direct Patient Care

No 44.0% (5,200) 48.3% (5,682) 41.7% (4,910) 36.9% (4,345) 23.4% (2,758)

Yes 50.0% (15,578) 56.0% (17,380) 49.4% (15,354) 43.4% (13,487) 27.9% (8,646)

Notes. APRN = advanced practice registered nurse; LPN/LVN = licensed practical nurse/licensed vocational nurse; RN = registered nurse. Data presented as

unweighted % (n). Dependent variables were collapsed to identify and isolate respondent characteristics that align with a reported frequency of “a few times a

week” or “every day” across each of the five outcomes.

8 Journal of Nursing Regulation

CI: 2.88–3.11), burned out (OR: 2.80, 95% CI: 2.70 – 2.92), or at
the end of their rope (OR: 2.35, 95% CI: 2.25–2.46) (all p <.001).
Consistent univariable patterns also emerged by license type (RN,
LPN/LVN vs. APRN), for those providing direct patient care, and
for those who reported engaging in travel nursing (all p < .001).
Trends related to years’ experience and increased workload held
on multivariable analysis after further adjustments for respondents’
self-reported sex, ethnicity, race, salary, and license type, as well as
indicators for full-time nursing employment, direct patient care,
and travel nurse designation. Furthermore, a meaningful interac-
tion between years of experience and increased workload emerged.
Nurses with 10 or fewer years of experience who also reported an
increased workload during the pandemic were between two and
a half to more than three times more likely to report higher fre-

quencies of feeling emotionally drained, used up, fatigued, burned
out, or at the end of their rope compared to similarly inexperi-
enced nurses with normal workloads (all p < .001, Table 2). Even
compared to more experienced nurses with comparable workloads,
early career respondents with high workloads still reported a 10%
to 23% increase in feeling emotionally drained, used up, fatigued,
burned out, or at the end of their rope (all p < .001). The most pro-
nounced differences emerged when comparing early career nurses
with higher workloads to their more experienced peers with nor-
mal workloads. In this comparison, early career respondents with
high workloads were more than three to four times more likely to
report higher frequencies of feeling emotionally drained, used up,
fatigued, burned out, or at the end of their rope (all p < .001).

TABLE 3

Free Response Topics and Keywords

Subjective Topic % (n) of
Responses

Keywords Representative Responsea

COVID‑19 Stress 20.2%
(3,783)

home, covid, working, worked,
resident, people, clinic, job, vac‑
cine, agency, stressful, forced,
family, mask, hospital,
vaccination

During COVID‑19, homecare nursing was never addressed as a
high risk job. Paramedics, hospital staff, and other essential work‑
ers seem to get addressed and considered for vaccines but I was
told by my physician that I was not eligible for the vaccine when it
came out. It was and still is like playing Russian roulette going
into patients’ homes, not knowing if they have been exposed or
not. PPE equipment was not always available, and every assisted
living facility had different rules for homecare to follow.

Unsafe Staffing/
Work Environment

23.2%
(4,338)

staff, covid, stress, pandemic,
short, staffing, anxiety, med, load,
covid‑19, always, leaving, regula‑
tion, increased, short staffed, ra‑
tio, facility, heavy, mandated,
supply, burnout, job

The amount of extra work I have been required to perform at
work without financial compensation is outstanding. My working
environment is unsafe for both staffing and lack of security. There
have been many times I thought I was in danger or a patient was
in danger. These situations have led to me having anxiety and
even full‑blown panic attacks every morning when I clock in. I am
terrified for my own safety, as well as for the patients I see every
day.

Underappreciated 22.6%
(4,219)

feel, management, underpaid,
overworked, administration, em‑
ployer, shortage, underappreciat‑
ed, support, under appreciated,
burned out, burnout, lack, re‑
spect, feeling,

It isn’t the job, it is the lack of respect from everyone, especially
when it comes from patients/clients and/or their support groups. I
believe that there are fewer and fewer people wanting to be in
healthcare due to the demands of what it takes to care for others.
So when there are less people taking care of others as a health‑
care professional, it puts more pressure and demands on a limit‑
ed workforce.

Retirement/Career
Change

16.5%
(3,086)

retired, license, burnout, 2020,
busy, part time, back, stress, tired,
shift, job, years ago, pandemic,
illness, breathing, covid, exercise

I am retired and a widow. I’m active in church and help with my
grandkids. I keep my LPN license because who knows. It would
have to be light and low stress to return.

Compensation 17.5%
(3,275)

pay, increased, increase, load,
paid, enough, workload, short_
staffing, wage, staff, raise, staff‑
ing, poor, short_staffed, job, trav‑
el, incentive, too much, salary,
ethic, stress, burnout, decreased,
rate, money, need, ratio

Burn out, short staffed, not enough pay, and yet they want to cap
nurses on wages, but you don’t see them capping physician pay
or lawyer pay.

a Responses were lightly edited for punctuation and journal style.

www.journalofnursingregulation.com 9Volume 14/Issue 1 April 2023

Free-Response Analysis

Subjective characterizations were developed for each of the five
topics included in the results (Table 3). This was achieved in two
ways: first, by analyzing the set of words that were most frequent
and salient for each topic, and, second, by identifying the 15 most
representative survey responses. Topic 1, labeled COVID-19 stress,
typically involved acute stressors relevant to the pandemic, rang-
ing from both anti-vaccination and anti-public health intervention
sentiments to more commonplace concerns about PPE shortages,
vulnerability to COVID-19 infection, and long-haul infections.
Topic 2 was characterized by stressors that may have predated
but ultimately were exacerbated by the pandemic, such as staff-
ing shortages, unsafe work environments, and workplace violence.
Topic 3 was represented by more emotional responses, including
respondents’ sense of feeling underappreciated and disrespected by
patients and superiors. Responses that scored high for Topic 4 were
focused on retirement and other types of career change, usually
with the sentiment that stress and burnout were bad, but now that
the respondent was no longer working in that environment, it was
much better. Finally, Topic 5 was predominantly characterized by
complaints about compensation levels.

There was fair saturation across all five topics based on
respondents’ license types (Figure 1). However, select themes
appeared to resonate more with certain groups. For example, dis-
cussion of compensation was more common among APRNs, while
unsafe staffing and work environments appeared more often in
RNs’ narrative accounts, as did issues related to retirement or
career change. Stress related to COVID-19, including both work-
place and personal concerns, was more concentrated among LPNs/
LVNs. Across all groups, issues related to feeling underappreciated
emerged.

When compared against respondents’ years of work experi-
ence, even clearer patterns emerged, providing valuable interpreta-
tive context (Figure 2). There was a significant and positive linear
relationship between reported years’ experience and topics one and
four. In other words, more experienced nurses were more likely to
self-report higher levels of burnout and stress specifically due to
the pandemic and were more likely to share free-text comments
regarding retirement or career change as a result. By contrast, an
inverse relationship emerged between years of experience and top-
ics two, three, and five. Thus, less experienced nurses, in particular
those with <5 years’ experience, but also 5 to up to 15 years expe-
rience, were most likely to report unsafe staffing or work environ-
ments and feeling underappreciated. This less experienced cohort
was also significantly more likely to raise concerns regarding com-
pensation levels as well. Although these topics also emerged among
more experienced nurses, they were significantly less pronounced.

Discussion
The U.S. nursing workforce is at a critical crossroads (NCSBN,
2023). Many of the problems currently confronting the nursing pro-

fession long predated the global health crisis (Aiken et al., 2022).
Nonetheless, the COVID-19 pandemic has amplified these con-
cerns, and current evidence has identified unprecedented levels of
stress and burnout among the key factors driving high rates of pro-

FIGURE 1

Free-Response Topics by License Type

0

5

10

15

20

25

Topic 5: Compensation
Topic 4: Retirement/Career Change
Topic 3: Underappreciated
Topic 2: Unsafe Staf�ng/Work Environment
Topic 1: COVID-19 Stress

LPN/LVNRNAPRN

18
.1

%
23

%
23

.4
%

15
.4

%
20

%

17
.8

%
23

.7
%

21
.8

%
18

.2
%

18
.3

% 21
.1

%
21

.6
%

22
.2

%
16

.9
%

18
.1

%

License Type

M
ea

n
P

ro
p

o
rt

io
n

, %

FIGURE 2

Free-Response Topics by Years’ Experience

0

5

10

15

20

25

Topic 5: Compensation
Topic 4: Retirement/Career Change
Topic 3: Underappreciated
Topic 2: Unsafe Staf�ng/Work Environment
Topic 1: COVID-19 Stress

20–6615–205–150–5

16
.2

%
24

.5
%

23
.9

%
14

.9
%

20
.2

%

17
.9

%
24

.1
%

23
.2

%
14

.4
%

20
.1

%

20
.4

% 22
.8

%
23

%
15

.6
% 18

.1
% 20

.9
%

21
.3

%
20

.5
%

20
.6

%
16

.6
%

Number of Years Licensed

M
ea

n
P

ro
p

o
rt

io
n

, %

10 Journal of Nursing Regulation

jected turnover (Berlin, Lapointe, Murphy, & Wexler, 2022; Nurse.
com, 2022; Smiley et al., 2021; Smiley et al., 2023). In this large,
nationally representative survey of licensed nurses, approximately
50% of respondents reported feeling emotionally drained (50.8%),
used up (56.4%), fatigued (49.7%), or burned out (45.1%) “a few
times a week” or “every day.” More than a quarter of the workforce
also reported feeling at the end of their rope (29.4%) at a similar
frequency. This analysis confirms some of the potential drivers of
these trends, such as significant increases in nurses’ workload dur-
ing the pandemic (62%). However, even more importantly, it pro-
vides critical contextual evidence to better understand implications
for the U.S. nursing workforce moving forward. Specifically, the
findings illustrate a differential but equally meaningful impact of
the COVID-19 pandemic on both ends of the experience spectrum,
particularly among RNs. Furthermore, this report links such devel-
opments to simultaneous disruptions to traditional prelicensure
nursing education models and comparable shortfalls among the
supply of support workers (LPNs/LVNs). In doing so, this report
seeks to inform policy aimed at fostering a more sustainable and
safe U.S. nursing workforce.

In line with emerging evidence (Lasater et al., 2021; Galanis
et al., 2021; Murat et al., 2021; Berlin, Lapointe, & Murphy, 2022),
issues that often predated the pandemic, such as insufficient staff-
ing levels, unsafe work environments, desire for higher pay, and not
feeling appreciated emerged as concrete drivers of stress and burn-
out among respondents to this national survey. The findings of
this study confirm that these concerns have been felt most acutely
by less experienced nurses. RNs (+20%) and LPNs/LVNs (+16%)
with 10 or fewer years of experience were significantly more likely
to report an increased workload during the pandemic compared to
their more experienced peers, leading to higher rates of reported
burnout and stress (p < .001 across all outcomes). In the past 2
years, this has resulted in a net decline of 3.3% of the nursing work-
force across all levels. Although the the RN workforce decline is a
bit lower (2.7%), the absolute decline in frontline RNs is striking.
In 2022, a nationally weighted estimate of 97,312 RNs reported
they left nursing during the COVID-19 pandemic. Alarmingly,
RNs with 10 or fewer years of experience, who were a mean age of
36 (SD: 10.3) years, left at an even faster pace (3%) and accounted
for nearly 41% of the total dropoff in practicing RNs (39,785).
These trends mirror findings from the Current Population Survey,
which was sponsored jointly by the United States Census Bureau
and the U.S. Bureau of Labor Statistics (Auerbach et al., 2022).

Disconcertingly, a high proportion of RNs with 10 or fewer
years’ experience also reported they planned to leave nursing in
the next 5 years (15.2%). If this were to come to pass, it would
result in a net decline of an additional 188,962 RNs (nationally
weighted estimate) currently younger than 40 years. Although it
is not yet clear if the trend will hold (Firth, 2022), these results
align with McKinsey research, which projected a gap of 200,000
to 450,000 nurses in the United States by 2025 (Berlin, Essick, et
al., 2022). Again, increased workload emerged as a potential driver

of this trend in this analysis (OR: 1.35, 95% CI: 1.15–1.58, p < .001).
Furthermore, these results are compounded by the emergence of a
dumbbell distribution in the findings, which suggest that stress
directly linked to the pandemic is simultaneously driving a high
proportion of RNs with more than 10 years of work experience and
a mean age of 57 (SD: 11.7) years to consider leaving their position
or retiring in the next 5 years (44.8%, 610,388). This is on top of
the 50,009 RNs (weighted national estimate) with more than 10
years of experience who reported they already left nursing due to
the pandemic.

Against this backdrop, traditional support and re-supply
apparatuses (e.g., LPN/LVNs and new nurse graduates) appear less
resilient than they once were. On one hand, prelicensure nursing
education programs have faced considerable and somewhat unprec-
edented disruptions (Benner, 2020; Dewart et al., 2020; Innovations
in Nursing Education, 2020; Kaminski-Ozturk & Martin, 2023;
Martin et al., 2023). This has, in turn, spurred concerns regarding
the supply and clinical preparedness of new nurse graduates. On
the other hand, this report confirmed comparable declines (4.2%)
among nursing support staff, which resulted in 33,811 fewer LPNs/
LVNs (weighted national estimate) in the U.S. nursing workforce
compared to the start of the pandemic. Paired with documented
trends among currently licensed RNs, and absent some form of
intervention, these combined results raise considerable concerns
regarding the resilience of the U.S. nursing workforce moving
forward.

Limitations

Despite a large and geographically diverse respondent pool, we
were not able to capture pandemic-related feedback from respon-
dents in five nursing jurisdictions due to our sampling method.
That may somewhat limit our ability to generalize our findings to
nurses in Missouri, Wyoming, New Mexico, North Carolina, and
Washington. Furthermore, nationally weighted estimates associ-
ated with projected intent to leave represent a potential loss in the
number of licensed nurses. As some nurses hold multiple licenses
and indeed practice across state lines, there is a possible multiplica-
tive effect associated with the potential attrition. Combined with
the state sample limitation, it is likely the projections shared in
this report are conservative regarding the scale of any future loss.
In addition, the LDA model defines topics via word co-occurrence
relationships, but it has no direct understanding of semantic or con-
textual information, and it is equally unable to capture semantic
connections as elements of respondent dialect and/or style. Given
that respondent demographics might influence a respondent’s word
choice (e.g., older respondents may choose to use different words
than younger respondents), it is possible that the topics discovered
here may be influenced simply by how different respondent groups
talk about burnout. Finally, the quantitative trends documented
in this study are correlational and do not support causal inference.

www.journalofnursingregulation.com 11Volume 14/Issue 1 April 2023

Conclusion
High workloads and unprecedented levels of stress and burnout
during the COVID-19 pandemic have strained the U.S. nursing
workforce. This has already resulted in high levels of turnover dur-
ing the past 2 years among younger, less experienced nurses. In
parallel, disruptions to prelicensure nursing education coupled
with comparable declines among nursing support staff suggest the
U.S. nursing workforce may be at a critical juncture. This report
serves to confirm and quantify projected trends that have recently
begun to emerge in the literature, but it also provides critical con-
textual evidence to better understand implications for the nursing
workforce moving forward. Should some of the projections derived
from this analysis and mirrored by government data and market
research come to pass, the outlook for the U.S. healthcare system
could be dire. Fortunately, projected intent to leave or retire is not
static but rather a manipulable outcome depending on policymak-
ers’ future decisions. This work seeks to inform debates on future
workforce policy and, in doing so, better target resources and tailor
solutions aimed at fostering a more sustainable and safe U.S. nurs-
ing workforce.

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Brendan Martin, PhD, is Director, Research Department, National
Council of State Boards of Nursing (NCSBN), Chicago, Illinois.
Nicole Kaminski‑Ozturk, PhD, is a Research Scientist, Research
Department, NCSBN. Charlie O’Hara, PhD, is a Data Scientist,
Research Department, NCSBN. Richard Smiley, MS, is a Senior
Statistician, Research Department, NCSBN.
Corresponding Author: Brendan Martin, [email protected]

Conflicts of Interest: None.