It is critical that leaders address the problem of worldwide registered nurse shortages in the healthcare workplace, which were exacerbated by the global COVID-19 pandemic. Nursing education serves as a resource and pipeline to address these shortages. To increase the number of nurse educators, more advanced training for nurses is essential. The pandemic has created workforce challenges in health care, additional stress and an increased shortage of nurses. Less is known about the impact of COVID-19 in the context of healthcare on nurses' intent to pursue additional education. Specifically, the authors aimed to describe and interpret this impact.
Nursing shortages in clinical and academic settings are not new and it is generally accepted that the pandemic has exacerbated this. In the USA, Auerbach et al (2022) reported a 1-year (2020-2021) loss of 100 000 nurses from the workforce, the largest exit in any year over the past 40 years. In addition, many of these nurses who left the workforce were aged under 35 years and employed in hospitals. Before the COVID-19 pandemic, analysts had already projected major nursing shortages across the USA (Juraschek et al, 2019). Much of the projected nurse shortage nationally at that time was attributed to a significant portion of the nursing workforce reaching retirement age (American Association of Colleges of Nursing (AACN), 2020).
According to US national projections, one-third of the nursing faculty in baccalaureate and graduate programmes are expected to retire by 2025, compounding the workforce shortages (AACN, 2020).
Fraher and the Sheps Health Workforce Team (2024) forecast that nurses' experiences and stress during the pandemic will lead to a much larger projected shortage of nurses because they will depart from clinical nursing early and/or leave the profession altogether. These clinical and academic shortages will exacerbate the existing and new COVID-19 pressures on the healthcare workforce.
Background
During staffing shortages, nurses experienced stress when hospitals employed travel nurses (temporary or contract nurses hired through a staffing agency), and often moved experienced nurses from their area of expertise to areas with urgent staffing needs to fill clinical vacancies (DeForest, 2022).
In some cases, nurse pay increased for those able to adapt to the workplace demands; however, remuneration alone cannot compensate or account for the stress experienced in a shifting workforce and its overall impact on the profession (DeForest, 2022). McHugh and Ma (2014) identified that low pay was associated with job dissatisfaction and intent to leave the nursing profession but had little influence on burnout/stress.
Surveyed US healthcare practitioners reported significantly more COVID-19 related stress than non-healthcare workers (Pearman et al, 2020). Associated with the COVID-19 related stress were higher anxiety, depression, fatigue and health concerns (Pearman et al, 2020). In addition, Pearman et al (2020) identified that clinical staff providers were at risk of poor mental health and expressed less perceived control and coping than an age-matched control group. Before the pandemic, application of the Job-Demands Resources Framework identified burnout and, in particular, a lack of engagement as being predictive of decisions to leave the nursing profession (Moloney et al, 2018).
The clear demarcation between life before the pandemic and the present provides a unique opportunity for researchers to examine the impact of pandemic stress. Stress related to COVID-19 has been reported as a response to loss of life, increased generalised anxiety, fears of dying, increased parental responsibility for children's education, decreased availability of resources, social isolation and much more (Usher et al, 2020; Adams and Grupac, 2021; Cowden et al, 2022; Rourke et al, 2024). It follows that the additional strain of increased workloads and disrupted work–life balance during the COVID-19 pandemic has impacted intention to stay in nursing practice and/or pursue additional education.
Historically, nursing education programmes developed graduates who became the solution for workforce demands by filling vacancies and addressing nursing shortages. However, the pandemic has altered the delivery of nursing education as well as students' nursing education experiences. During COVID-19, pedagogical changes in course delivery were experienced by all students and faculty across academic disciplines. These educational changes have demonstrated both benefits and drawbacks that have yet to be fully explored. For example, the pandemic exposed and exacerbated existing weaknesses in the supervision of practice hours needed for advanced nursing practice (Gaffney et al, 2021).
Access to clinical sites was lost in some settings and schools relied on simulation to achieve clinical hours. Despite the loss of clinical training sites, enrolment in US preregistration degrees increased by 3.3% between 2019 and 2022 (AACN, 2022); in the USA, a graduate of a 2-year associate degree in nursing (ADN) or diploma programme can become a registered nurse. However, postregistration degree programmes saw enrolment decline during the same 3-year period: the nurse to bachelor of science in nursing, a bridge programme popular with ADN graduates, saw a 9.6% reduction; the master of science in nursing saw a fall in 3.8%; and the doctor of philosophy in nursing saw a 0.7% reduction (AACN, 2022). All three of these programmes with declining enrolment contribute to the nurse educator pipeline.
Fraher and the Sheps Health Workforce Team (2024) concluded that, if the trend of nurses choosing to exit their roles or leave the profession holds true for nurse educators as well as bedside nurses, the shortage of nurse educators will more than double and further limit workforce capacity to meet nurse demand. Therefore, it is imperative to understand nurses' intent regarding further education today.
Methods
The authors aimed to describe and interpret nurse intent for future education with content analysis. Content analysis enables flexible coding and interpretation of data (Morgan, 1993). They purposely chose to study responses to a single, open-ended online survey question selected from a larger, state-wide nurse workforce quantitative survey conducted in April 2022 in North Carolina in the USA. The larger survey included 64 questions using Richardson's (2011) adaptation of Vallerand and Associates Academic Motivation Scale (Vallerand et al, 1992).
The single open-ended survey question, ‘How has COVID-19 impacted your plans for future education?’, informs the understanding about nurse educational intent. This open-ended question was added to the quantitative study to more fully explore nurses' intent through their own voices and the researchers were open to other findings as the data analysis unfolded. The authors, who have a combined 30 years of research experience, used an analytical framework (Terry and Hayfield, 2021), with an inductive approach for analysis. They acknowledged their biases as practising nurses and nurse educators and sought to genuinely follow and represent the responses of the nurses who participated.
Setting and sampling
The authors obtained participants purposely with a survey that provided equal opportunity for participation in the study across all registered nurses licensed in North Carolina during the COVID-19 pandemic. North Carolina is a geographically diverse state with varying population density and both rural and metropolitan areas. Of the 108 384 nurses in the North Carolina Board of Nursing database in 2021, 47 132 reported having a bachelor of science in nursing (BSN) as their highest degree. Juraschek et al (2019) forecast a 2030 North Carolina nurse shortage with a report card grade of a D, the median forecast across the USA. A grade of D indicates a less than satisfactory performance level. Grades are ‘assigned based on the difference between the national mean and each state's ratio, using the [standard deviation] (SD) as the framework of the grading rubric. A and F grades were ±2 SD, B and D grades were ±1 SD, and C+ and C− grades were ±0.5 SD’ (Juraschek, 2019: 475).
For the larger, quantitative study, the authors recruited North Carolina nurses via email in batches of 1910 randomly selected nurse names/emails per day every 3 days until a sample size of 382 respondents was achieved.
The online survey could be completed with a mobile device or computer. Participants who completed the survey and passed an attention check to confirm thoughtful participation and quality response received a $12 Starbucks e-card. Of the 382 online survey respondents, 370 (96.9%) answered the open-ended question that is the focus of this report. All 370 responses to this specific question were included in this analysis.
Data analysis
Content analysis with counts was used to expand and contract codes, themes and relationships as the authors interpreted the data during analysis. In addition, they interacted with the data using the following analytical framework: familiarisation, coding, thematic extraction, thematic contraction and theoretical application (Terry and Hayfield, 2021).
Familiarisation/coding
All participant responses to a single open-ended survey question using the online QualtricsXM platform were transferred to an Excel spreadsheet to facilitate the analysis.
The first stage of the analytical process was to read the data through repeatedly to become familiar with the survey responses to the question of interest. Next, the authors made a coding decision to independently classify data related to each response as ‘No impact’ or ‘Impact’.
The researchers independently categorised each ‘Impact’ respondent short answer as impacts that are: favourable towards pursuit of advanced education (positive); resistant to furthering education (negative); and neither favourable nor resistant to or unrelated to education (ambiguous).
The authors met and discussed until they reached agreement on the determination of each response using this coding across the data set.
Thematic extraction
Following coding, the authors again independently examined each of the responses for themes and later met and discussed them until they reached agreement on the combined 18 subthemes, which were later contracted into 10 subthemes.
The counts of the subthemes within the three codes (positive, negative and ambiguous) were recorded to understand the volume of each theme's voice. This provided another lens through which to understand the common and unique responses and not to value one response more or less than the others. Counts were used to describe and interpret patterns of response and not for quasi-statistical use (Sandelowski, 2000). In this way, the authors also considered how the themes in each code were similar or different from each other.
Thematic contraction/application
Next, the authors further contracted these subthemes theoretically based on familiarising themselves with the responses and the question prompt.
The respondents' experiences with COVID-19 aligned with what the researchers recognised as Lazarus and Folkman's (1984) theory of stress, appraisal and coping. Satisfied that the themes fitted well with the data, they returned iteratively to the responses as a whole as, within the data, the participant voices reflected concepts in the self-determination theory (autonomy, competence and relatedness), and they found within this understanding a useful schema with implications for nursing practice and education in the data.
Ethical considerations
The Appalachian State University internal review board determined study #21-0209 to be exempt from further oversight as a category 2 study: survey, interview and public observation.
Participants responded online and having a large number of respondents contributed to anonymity. In addition, privacy was supported with survey data stored electronically in the QualtricsXM platform and accessed only through a password-protected survey on a password-protected computer.
The $12 e-card was certainly an incentive to participate but was not coercive in its amount and the attention check contributed to data quality.
Findings
Familiarisation/coding
Almost half (n=181) of the respondents indicated that COVID-19 had had an impact on their educational plans. The responses of those affected were coded as positive, negative or ambiguous as described in the data analysis (Table 1).
| Themes | Codes | ||||
|---|---|---|---|---|---|
| Primary theme | Subtheme (theory) | Negative counts (n=84) | Positive counts (n=53) | Ambiguous counts (n=44) | Totals |
| Nurse stress | 42 | ||||
| Financial (autonomy) | 13 | 6 | 4 | 23 | |
| Safety (competence) | 6 | 3 | 7 | 16 | |
| Legal (relatedness) | 2 | 1 | 0 | 3 | |
| Nurse appraisal | 83 | ||||
| Burnout/stress (autonomy) | 22 | 9 | 10 | 41 | |
| Changes in education (competence) | 15 | 2 | 2 | 19 | |
| Changes in nursing profession (relatedness) | 7 | 5 | 11 | 23 | |
| Nurse coping | 97 | ||||
| Work–life balance (autonomy) | 16 | 1 | 4 | 21 | |
| Desire to learn (competence) | 0 | 7 | 1 | 8 | |
| Education deferred/accelerated (competence) | 21/0 | 2/3 | 0/0 | 23/3 | |
| Exit bedside/nursing profession (relatedness) | 1/12 | 21/2 | 0/6 | 22/20 | |
Of those who had made a clear statement regarding COVID-19's impact on their education (n=137), 84 reported a negative effect on their educational plans. Fifty-three respondents reported a positive impact on their educational plans. Forty-four respondents were coded as ambiguous as they were less clear about the impact of COVID-19 on their educational plans.
Thematic extraction/contraction
Using content analysis, the authors identified and agreed on 10 subthemes from the responses: financial; safety; legal; burnout/stress; changes in education; changes in the nursing profession; work–life balance; desire to learn; deferred/accelerate education; and exit bedside nursing/nursing profession.
The subthemes that reflected responses were contracted and aligned with the question prompt to inform the three primary themes. The three themes on the impact of COVID-19 were nurse stress; nurse appraisal; and nurse coping.
The data and subthemes were examined then organised around Lazarus and Folkman's (1984) understanding of primary and secondary appraisal with emotional or problem-focused coping for further analysis. In this way, theory guided the understanding of differences and similarities between and within the primary themes (Table 2).
| Themes | Subtheme (theory) | Nurse response exemplars |
|---|---|---|
| Nurse stress | Financial (autonomy) | ‘Earn this money while I can and postpone any further education’ |
| Safety (competence) | ‘Fear of catching COVID again during clinical rotations’ |
|
| Legal (relatedness) | ‘I will pursue higher education in a different field or none at all. I have zero aspiration to go further in my nursing career. Nurses are overworked and undervalued and now being charged when mistakes are made’ |
|
| Nurse appraisal | Burnout/stress (autonomy) | ‘The healthcare system is much more fragile right now, high burnout and a lot of risks to the nurse’ |
| Changes in education (competence) | ‘Made it [education] easier due to more online programmes’ |
|
| Changes in nursing profession (relatedness) | ‘With the changes to bedside nursing since the pandemic, I have been more motivate[d] to progress to a higher level of practice’ |
|
| Nurse coping | Work–life balance (autonomy) | ‘It did change that I am now an outpatient nurse which is much less stressful and I have more work-life balance’ |
| Desire to learn (competence) | ‘COVID made leaving the bedside all the more appealing, and also sparked an interest for me in research’ |
|
| Education deferred/accelerated (competence) | ‘Desire for education has greatly increased after COVID, want a job that is secure, flexible and safe’ |
|
| Exit bedside/nursing profession (relatedness) | ‘I realised more than ever that bedside nursing feels unsustainable. For my mental health, I needed to step away from COVID ICU and I decided it was time to pursue my MSN [master's of science in nursing]’ |
Stress, appraisal and coping
The participants identified multiple stressors related to their experiences during the COVID-19 pandemic. These stressors included financial strain, health and safety concerns and legal worries.
Across all three codes, the most common nurse appraisal was burnout/stress. These appraisals included a negative perception of how the nursing profession and nursing education had changed. In this way, participants appraised their external environments including both practice and education.
Finally, the respondents identified plans to cope with stressors. Coping strategies included finding a work–life balance, exiting bedside nursing for another nursing role, leaving the profession completely and changing the time frame of their plans for education. Coping with the stress of COVID-19 changed the timing of educational plans in different ways. Those reporting a negative impact on educational plans often mentioned a plan to delay or defer education whereas those reporting COVID having a positive impact on their educational plans often stated that they chose to accelerate them.
Those reporting COVID-19 had a negative impact on educational plans desired a good work–life balance and showed problem-focused coping, with an intent to delay or defer their education, high levels of burnout/stress, and/or they anticipated leaving the profession altogether.
Those who reported the pandemic had a positive impact on their educational plans had a desire to leave bedside nursing, planned to change their professional role and/or reported high levels of burnout/stress.
Those with an ambiguous description of COVID-19's impact on their educational plans discussed their perceptions of the negative changes in the nursing profession, the stress of short staffing, patient and nurse safety as well as their own burnout/stress. Their problem-focused coping focused on leaving the profession or finding a good work–life balance.
Patterns were identified based on the coding of intent to pursue education with different voices around the subthemes. The subthemes patterns differed within the coding of the impact of COVID-19 on educational plans (negative, positive, ambiguous) (Table 1).
Thematic application
Self-determination theory of motivation
In addition to supporting the theory of stress, appraisal and coping, the findings of the analysis indicated that the nurses' responses to educational intent in the COVID-19 context were transferable into the theoretical frame of the self-determination theory of motivation (Deci and Ryan, 2013). The concepts of autonomy, competence and relatedness from the self-determination theory of motivation further guided understanding of the nurse stress appraisals and coping related to educational intent. Specifically, the authors interpreted the nurse descriptions of their appraisal of impact on education (positive, negative or ambiguous) and the variation in prominence of the nurses' expressed need for support with the self-determination theory of motivation.
Through this inductive theoretical lens, the authors concluded that those with positive views of education in response to COVID-19 coped with education to increase competence and to leave bedside nursing. Those with negative views of further education sought autonomy with work–life balance; they did not feel a connection to the nursing profession and would not be pursuing education. Those without a clearly positive or negative report of COVID-19's impact on their educational plans (ambiguous) expressed disruption in their relatedness to the nursing profession and desired autonomy with work–life balance.
Discussion
The self-determination theory of motivation (Deci and Ryan, 2013) differentiates between types of motivation, the conditions that facilitate motivation, the consequences connected to motivation, and the internalisation of processes that shape an individual. This theory suggests that individuals are able to become fully self-determined when they are afforded autonomy, competence and relatedness. All three of these areas of influence on motivation were under pressure during the pandemic and are discussed below in relation to the study findings.
Autonomy
Changes in nurse employment requirements had demonstrable impacts on nurse autonomy which, in the findings of this study, included the subthemes of financial, burnout/stress and work–life balance.
For example, in the USA, before COVID-19, many Magnet hospitals required nurses to obtain a BSN for continued employment. Since then, some of these healthcare organisations have found it difficult to recruit nurses and have removed these requirements to address shortages in critical areas (Winslow et al, 2022).
Other policies that directly govern a nurse's autonomy include mandatory vaccination requirements that, if not met, may limit or terminate an nurse's employment (Peterson et al, 2022; Gooch, 2023).
In addition, working while caring for children or others at home was a pandemic challenge for many, including nurses (Carlson and Petts, 2022).
Supporting autonomy, health systems that successfully addressed nurse shortages identified flexible scheduling as an attractive aspect of travel nursing; large hospitals created their own travel/contract employment approach using their existing staff (Gooch, 2023).
Regarding autonomy, one nurse reported:
‘Work is no longer my priority in life. Personal time with my family and just living life is more important. I'm no longer living to work, I'm working to live!’
Competence
In this study, competence included subthemes of safety, changes in education, desire to learn and education being deferred or accelerated.
Applicable to the concept of competence, the abrupt addition of an unknown disease and unestablished nursing care standards created fear and uncertainty over practitioners' own nursing competence. These areas of uncertainty impacted nursing competence in both the procedural and personal practice knowledge realms (Mantzoukas and Jasper, 2008).
These two forms of knowledge, along with ward (unit) cultural knowledge, contributed more than half of the knowledge types required for effective hospital nursing care (Mantzoukas and Jasper, 2008). Periods of chaotic employment transition disrupted nursing cultural knowledge. During the pandemic, nursing practice evolved rapidly, with an increased need for critical care, which unsettled the more stable pre-pandemic clinical employment settings. The influx of nurses choosing contract employment (travel nursing) disrupted units' cultural knowledge as long-term employees were moved into unfamiliar areas, and more temporary and novice nurses were working on wards.
These changes influenced both nurses' motivation for learning and their ability to do so:
‘COVID has me [on] travel nursing. [It's] harder to do any nursing degrees with [fewer] clinical sites.’
‘I have always planned to further my education/career, and COVID has not affected that negatively. If anything, I am more determined to obtain a graduate degree.’
Enhancing the competence of nurses supports a stressed workplace. One nurse stated:
‘I'm also tired of having to be the experienced nurse, and the demands that come with that for running a healthy unit.’
Relatedness
Relatedness is the third concept that affects self-determination and the subthemes included legal, changes in nursing profession and exit bedside/nursing profession.
Again, many of the social isolation components associated with the pandemic were new to nursing and directly impacted relationships between nurses and others (Rourke et al, 2024). For example, the use of masks decreased nurses' social connectedness between each other, patients and other practitioners. Communication changed dramatically from in-person interactions to technologically driven communication (Rourke et al, 2024).
The elimination of visitors for hospitalised patients changed the relatedness and communication between nurses and patients' families. An increase in social isolation disconnected and disrupted the nurse–patient relationship, which is core to nursing practice. Increased social isolation in addition to patient acuity, mortality rates and nursing responsibilities in an environment of doing more with fewer resources increased feelings of burnout (North Carolina Nurses Association, 2022).
One nurse expressed:
‘Being in leadership during the pandemic and the unrealistic asks we had to deliver did not sit well with me.’
Additionally, nurses voiced a lack of relatedness between employer and employee:
‘Hospitals take really lousy care of their bedside nurses. We're just numbers to them, easily replaceable, apparently.’
‘Healthcare is collapsing and, instead of hospital administrators, big corporations and legislators looking for ways to make the system more sustainable, they're lashing back out at nurses by charging us criminally and civilly when we began to ask to get paid for what we're worth. This is not just culture, there's no way to change it, I'm working on an exit strategy.’
At the time of the survey, RaDonda Vaught, a nurse in Tennessee, an adjacent state to North Carolina, was convicted of two felonies following a fatal medication error (Kelman 2022). This was reflected in respondents' voices:
‘Nurses are overworked and undervalued and now being charged when mistakes are made.’
‘My concern for continuing in the nursing field comes from both COVID and the recent legal precedents that have affected nurses.’
It follows that strengthened relatedness in the workplace could support nurse commitment to the profession.
Practice implications
Leaders in nursing practice need to understand the perspectives of these post-pandemic nurses to maintain their workforce.
Hospital administrators who can take a long-term, strategic view of hiring and retention practices will reap the rewards. Clinical managers who address nurse concerns by supporting nurse autonomy, competence and relatedness will likely improve nurses' motivation to persist in a challenging healthcare context.
Organisations should address nurses' autonomy concerns, including financial strain, burnout/stress and work–life balance. Likewise, employers need to address nurse concerns about competence related to safety with changing skills and protocols which should include consideration of staff education, resources and nurse:patient ratios.
Finally, managers need to recognise and implement problem-focused solutions to address how changes in the nursing profession have impacted and challenged relatedness between clinical personnel and their organisation.
Academic implications
This study is significant because meeting workforce needs requires more nurse educators. Nursing educators need to understand the perspectives of these post-pandemic nurses to support their students.
Many respondents interested in further education indicated a desire to leave the bedside, with themes of burnout/stress being frequently reported. Therefore, the departure from hospital/bedside nursing practice may have a silver lining for nursing education as nurses will have to undertake further learning to gain more skills and knowledge to further their careers.
However, the nurse who chooses additional education is likely to be still employed in a setting of burnout/stress while undertaking an academic pursuit to boost their career. This stressed nurse seeking professional change is likely to have unique academic challenges related to their experiences and the additional stress burden associated with learning. Academic nursing will need to support these students' autonomy, competence and relatedness with strategies such as resilience training, awareness of realistic expectations, time and stress management and building community within the learning environment. Creating curricula that are self-paced and allow for pauses may support autonomy more effectively than the traditional academic semester for these working professionals.
The shortage of clinical training sites for advanced practice nurses will need to be addressed with educational strategies to increase competence. Online educators need to increase relatedness with and between students to support motivation. The need for online and flexible education will require well-compensated nurse educators who have advanced skills to address these workforce and educational needs.
Strengths and limitations
The descriptive method used contributes to further understanding of the phenomenon of interest not previously reported in the literature because of the unique nature of the healthcare context during the pandemic and it does not claim to demonstrate causal relationships.
The nature of data collection methods precluded going back to participants for confirmation or clarification of their responses. The authors do not know if they achieved data saturation although the quality, volume and variety of responses was promising.
The use of surveys for data collection may result in response and social desirability bias; however, respondent anonymity in this online survey may have mitigated this limitation. Researchers used an audit trail and analytical strategies to limit researcher biases including transparency of coding and confirmability to improve the credibility and trustworthiness of findings.
Although the study was limited to nurses licensed in the state of North Carolina, the nurse shortages here are similar to those in other states in the USA and globally (Juraschek et al, 2019).
Recommendations for research
Further study is needed to evaluate the effectiveness of strategies to support nurse needs, conceptualised around the constructs of autonomy, competence and/or relatedness.
Further development of assessment tools aimed at understanding how nurses appraise workplace stress and how their appraisal impacts their professional decision-making is needed.
Conclusion
These descriptive and interpretive findings from nurses in North Carolina inform both clinical and academic nursing with the voice of the nurse and adds to the understanding of responses to the stress of the global pandemic. The study draws on the nurse voice to make recommendations for practice and education to support nurses as they navigate their response to a strained workplace. After the COVID-19 pandemic, the voices of those who experienced this unique workplace stress and its persistent impact must be heard and acknowledged.
Work-related stress has always been present in the nursing profession. However, the global pandemic has impacted nurses in new and unforeseen ways. The researchers identified three primary themes with a combined 10 subthemes (Table 1): nurse stress (financial, safety, legal); nurse appraisal (burnout/stress, changes in education, changes in nursing profession); nurse coping (work–life balance, desire to learn, education deferred/accelerated, exit bedside/nursing profession).
Nurses perceiving that COVID-19 had a positive effect on their educational intent sought education to increase competence;. Those reporting that COVID-19 had a negative impact on their intent for further education sought autonomy with work–life balance. Nurses who did not have a clear statement of COVID-19's impact (ambiguous) expressed a loss of relatedness to the nursing profession.
Understanding the perspectives of nurses as well as their experiences at the height of the global pandemic and its effects on them may help build resilience in nurses and influence planning for both practice and academic settings in efforts to retain and enhance the qualified global nursing workforce.