Changes in Registered Nurse Employment Plans and Workplace Assessments

This survey study compares career plans as well as associated workplace and personal factors as self-reported by practicing registered nurses in the 2022 and 2023 Michigan Nurses’ Study.


Introduction
Registered nurse (RN) workforce challenges predate the COVID-19 pandemic. 1Multiple studies have identified high levels of burnout and intention to leave their positions among nurses. 2Reports vary on future nursing workforce adequacy.A 2017 report estimated a shortage of 510 000 nurses by 2030. 3 A 2024 analysis projected that by 2035, nurse employment would rebound close to prepandemic estimates. 4 the early phases of the COVID-19 pandemic, high proportions of health care workers reported their intention to leave their positions, especially female workers and nurses. 5News reports suggested that nurses were leaving their positions, citing unsafe conditions. 6Hospital leaders reported acute vacancies and demand for expensive temporary personnel, triggering congressional inquiries. 7Nurses reported increased vacancies, citing the workload as a primary reason. 1 Yet the size and trajectory of the problem are unclear, which has hindered policy implementation.
To narrow knowledge gaps, a team at the University of Michigan launched the Michigan Nurses' Study in 2022. 8Using a statewide mailing list, the team queried RNs on their employment plans and workplace assessments.The survey found that 39% of respondents in active practice planned to leave their employer within the year.Factors associated with departures included younger age, abusive events, emotional exhaustion, unfavorable workplaces, and staffing and resource inadequacy. 8The 2022 cohort was not queried on their future plans or the reason for their planned departure.It is important to discern whether nurses are leaving their employers (a retention issue) or the nursing profession (an overall supply issue).
We repeated this survey in 2023 to identify changes in practicing RNs' employment plans and workplace assessments from the 2022 survey.We added questions to the 2023 survey to explore reasons for departures and factors associated with the departure plans.The data generated can inform recruitment and retention strategies locally as well as workforce policy proposals nationally.

Survey Procedures
Survey methods have been previously reported and were identical in both survey years. 8The State of Michigan's publicly available database of RNs was used to identify potential participants; 99% of all nurses in Michigan provide an email address during licensure renewal.Up to 3 email invitations with a survey link were sent 8 days apart via Qualtrics (Silver Lake).No incentives were offered, but Survey eligibility included an active, unrestricted license in Michigan and a valid individual email address.Individuals were excluded if the Michigan database indicated a disciplinary process or license suspension and if their email address was not formatted correctly or the email could not be delivered.We restricted the present analysis to those who stated on the survey they were in active clinical practice.

Measures
Variable selection was informed by the National Academy of Medicine framework 10 and prior work. 8l data were obtained from survey respondents.Outcomes were nurses' intention to leave their current position, planned reduction in clinical hours, and pursuit of travel nursing, all within the year.
The 2023 respondents who reported plans to leave were asked to indicate their next career step (eg, leave current employer but remain in nursing, retire or stop working, remain with current employer but change nursing position, leave nursing profession for another career, or pursue additional education) and the primary reason for their planned departure (eg, workloads, management and leadership concerns, pay and benefits, family and/or caregiving responsibilities, workplace abuse or violence, or employer's approach to the COVID-19 pandemic).
Identical workplace assessment questions were asked in the 2022 and 2023 surveys, except the neutral rating was omitted from the 2023 survey.Emotional exhaustion was measured using the Oldenburg Burnout Inventory (score range: 1-5, with higher scores indicating more emotional exhaustion). 11Participants rated their agreement with 8 items using a 4-point Likert scale, ranging from strongly agree to strongly disagree.Participants with mean values across all items that exceed 2.25 have a clinically notable degree of burnout. 12In the 2022 survey, participants rated their job satisfaction using an established 5-point scale, ranging from extremely satisfied to extremely dissatisfied. 13In the 2023 survey, a 4-point scale was used to harmonize participants' answers with those in a simultaneous physician survey (which will be reported separately).Nurses rated their practice environment's delivery of high-quality care as favorable, mixed, or unfavorable. 14Nurses reported workplace abuse or violence in the past year (physical, verbal, sexual, or bullying, collapsed into 1 category). 15Additionally, nurses reported their staffing levels in the past week worked (overstaffed, staffed appropriately, or understaffed) and use of mandatory overtime (not used, used rarely, or used frequently). 8rticipant characteristics were obtained similarly in the 2022 and 2023 surveys.Factors included age (categorical), advanced practice RN (APRN) role (yes or no), primary practice setting (as categorized by the annual Survey of Michigan Nurses 16 ), gender identity, and race and ethnicity.
Given that the US nursing population is composed of predominantly White and female individuals, exploring the differences across these factors could inform workforce diversity considerations.

Statistical Analysis
In this study, χ 2 statistics were used to compare differences in employment plans and workplace assessments between the 2022 and 2023 survey cohorts.Multivariable logistic regression was used to evaluate the likelihood of 2023 survey respondents leaving their current employer within 12 months.Given the number of personal and workplace factors identified in prior work 8 and consistent with the holistic conceptual model posited by the National Academy of Medicine Action Collaborative, 10 we used backward selection with a threshold of α = .05to identify a parsimonious set of variables for inclusion in the reported logistic regression model.Statistical significance for all analyses was preestablished at 2-sided P = .05.Data analysis was performed with SAS 9.4 (SAS Institute Inc).
The study protocol allowed participants to skip any survey questions they wished.Therefore, a small amount of missing data was present across all variables and outcomes.For descriptive analyses, missing values were treated as a distinct category.For regression analyses, complete case analysis was used.
Three sensitivity analyses were performed, and all were directed toward the multivariable analysis.First, to address the potential implications of missing data, we estimated a logistic regression model with multiple imputation as opposed to the complete case analysis.Second, in addition to backward selection, we performed forward and best set analysis, which generated similar results.Third, we estimated a regression model on the subset of respondents who were APRNs.
Advanced practice nurses have unique practice patterns and employment relationships; hence, it was important to examine them separately for potential differences.The results with the imputation model and a model restricted solely to APRNs are summarized in eTables 1 and 2 in Supplement 1.

Results
In 2022, 13 687 eligible nurses responded to the survey for an overall response rate of 8.3%. 17 Employment Plans Among Surveyed Nurses outcomes were less frequently reported, with 2259 nurses (32.0%) planning to leave their position, 1270 (18.0%) planning to reduce clinical hours, and 494 (7.0%) planning to pursue travel nursing (P < .05).
Among 2287 respondents to the 2023 survey who planned on leaving within the year, 957 (41.8%) planned to leave their current employer but remain in nursing, 514 (22.5%) planned to retire or stop working, 307 (13.4%) planned to remain with current employer but change nursing position, 299 (13.1%) planned to leave the nursing profession for another career, and 139 (6.1%) planned to pursue additional education (Figure 2A).When combining those planning to seek a non-nursing position and those planning to retire, we found a total of 813 RNs (35.5%) with plans to exit the field of nursing.Among these respondents, the primary reasons for departure were workloads (672 [29.4%]), management and leadership concerns (585 [25.6%]), and pay and benefits (476 [20.8%]) (Figure 2B).

Differences in Working Conditions Between 2022 and 2023 Cohorts
Notable differences in workplace assessments were reported between the 2022 and 2023 surveys (

Factors Associated With Plans to Leave the Nursing Profession
The sample size for this analysis was restricted to 5445 participants who were practicing as an RN in 2023 and had requisite data for analysis (Table 3).Among the 2023 survey respondents, factors associated with an increased likelihood of planning to leave the nursing profession were an abusive or violent workplace event in the past 12 months (odds ratio [OR], 1.39; 95% CI, 1.05-1.82)and higher emotional exhaustion scores (OR, 3.05; 95% CI, 2.38-3.91).Compared with those who reported unfavorable work environments, nurses who rated their environment as favorable (OR, 0.37; 95% CI, 0.22-0.62)or mixed (OR, 0.67; 95% CI, 0.49-0.90)were significantly less likely to plan to leave nursing.Nurses who reported excellent (OR, 0.28; 95% CI, 0.14-0.56),good (OR, 0.34; 95% CI, 0.20-0.59),or acceptable (OR, 0.48; 95% CI, 0.29-0.80)clinical setting safety were also significantly less likely to have such plans.While younger vs older nurses were more likely to plan to leave their current position, these differences were not significant in the complete case analysis.
In a sensitivity analysis in which a multiple imputation model was used to account for missing data, nurses between 35 and 44 years of age were significantly more likely to report plans to leave than nurses between 45 and 55 years of age (OR, 1.41; 95% CI, 1.04-1.90)(eTable 1 in Supplement 1).
Otherwise, these findings were consistent with primary results.
In another sensitivity analysis restricted to nurses who reported being APRNs, similar to our model with all nurses, APRNs were significantly more likely to plan to leave nursing as a profession if they reported higher emotional exhaustion scores (OR, 2.21; 95% CI, 1.16-4.20)(eTable 2 in Supplement 1).These APRNs were also significantly less likely to have such plans if they deemed their work environment as favorable (OR, 0.15; 95% CI, 0.04-0.55)and the quality of care provided in their primary work setting as excellent (OR, 0.17; 95% CI, 0.04-0.80).

Discussion
This survey study showed persistently high planned departures from the RN workforce in Michigan, the tenth most populous US state.Unfavorable workplace assessments decreased in the 2023 cohort compared with the 2022 sample.Specifically, fewer nurses in the 2023 survey reported plans to leave their current position, reduce their clinical hours, or pursue travel nursing.These findings suggest somewhat improved working conditions and possible easing of workforce pressures.Based on these findings, additional work is needed to elucidate why and how conditions are improving.As an example, the reduction in mandatory overtime use over the 2 time points suggests that hospital executives recognized the adverse consequences of this managerial practice and have adjusted related policies.Analyses by specific clinical settings would add granularity to the findings and potentially target intervention strategies more precisely.
While improvements have been noted, lingering concerns persist.Over one-third of practicing nurses surveyed in 2023 indicated a plan to leave their current position, suggesting a higher potential for a destabilized health care workforce.Nurses were more likely to plan to leave their employer if they had experienced an abusive or violent workplace event, reported higher levels of emotional exhaustion, and rated their hospital more poorly on patient safety.Employer's COVID-19 response was not cited frequently as a primary reason for departure.Both the 2022 and 2023 surveys were conducted in early spring into summer, when COVID-19 cases in Michigan were not at peak incidence, further discounting the COVID-19 pandemic approach as a factor in job dissatisfaction. 18aced into context, the findings from these 2 surveys conducted approximately 1 year apart indicate moderately improved but persistently problematic workplace environments for RNs.
Michigan nurses reported high emotional exhaustion or burnout scores, understaffed patient care areas, occurrence of abusive or violent workplace events in the past 12 months, and job dissatisfaction.In a study of nurses from New York and Illinois who left their employers between 2018 and 2021, planned retirement, burnout, and insufficient staffing were the most frequently cited reasons for departure. 19This analysis also identified a worrisome pattern, which was reported in a prior study, 8 of high rates of job dissatisfaction and intention to leave their position among nurses aged 34 years or younger.This finding, now observed in at least 2 large surveys, calls into question whether gains in the RN workforce will be sufficient to offset these planned departures.
There may be larger societal factors associated with the high rate of planned departures observed in the present study, including general economic conditions, family factors, and alternative job opportunities.A 2023 cross-sector survey of job satisfaction revealed that only half of US individuals are satisfied at work, 20 with the lower rates of satisfaction observed among employees younger than 50 years.Yet compared with staff in other employment sectors, health care workers are more difficult to train and orient due to their specialized knowledge and skills.This finding suggests that novel retention strategies are needed for this unique sector of the workforce.
An underappreciated but concerning finding is that between 18.0% (in 2023) and 27.9% (in 2022) of respondents indicated plans to reduce their clinical hours.Health care systems rely on a large part-time nursing workforce to fill acute and persistent staffing gaps.A high proportion of nurses planning to reduce their clinical hours suggests that fewer nurses will be available to serve this vital function, a situation which may be associated with increased demand for potentially expensive temporary personnel.
The study provides insights into the future plans and motivations of dissatisfied nurses, most of whom intend to remain in nursing but wish to leave their current employers, affirming the adage that many nurses love their work but hate their jobs. 21Dissatisfied nurses consistently identified workloads as a primary reason for their dissatisfaction.Strategies should focus on retaining practicing nurses, and the priority tactic recommended by nurses is to increase nurse staffing levels above the individuals could request copies of study findings.The 2022 survey was open from February 22 to March 1, 2022, and the 2023 survey was open from May 17 to June 1, 2023.The University of Michigan Institutional Review Board deemed the study exempt from review.All participants provided online informed consent.This survey study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) 9 and the American Association for Public Opinion Research (AAPOR) reporting guidelines.

Figure 1
Figure 1 compares participants' plans for employment for the 2022 and 2023 samples.In 2022, 3576 nurses (39.1%) surveyed planned to leave their position within the next year, 2549 (27.9%) planned to reduce their clinical hours, and 1652 (18.1%) planned to pursue travel nursing.In 2023, these 3

Figure 1 .
Figure 1.Practicing Nurses' Planned Job Changes in the 2022 and 2023 Surveys 100

Figure 2 .B
Figure 2. Nurse-Reported Career Change Plans and Reasons in the 2023 Survey

Table 2 .
Differences in Workplace Assessments Between 2022 and 2023 Surveys b A neutral option was not offered in the 2023 survey.Given the difference in question options, a χ 2 analysis was not performed to compare 2022 and 2023 responses for this question.

Table 3 .
Estimated Association Between Selected Factors and Plan to Leave the Nursing Profession Within 12 Months in the 2023 Survey a a There were 5445 survey respondents in 2023.bAsmeasured by Oldenburg Burnout Inventory (score range: 1-5, with higher scores indicating more emotional exhaustion).