Expert Opinion

Is It Time to Call ‘Code Blue’ on Nursing Infrastructure? A Nurse’s Perspective from the COVID-19 Front-line

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The COVID-19 pandemic has highlighted the significance of every role within the interdisciplinary team and has exacerbated the challenges posed to every member. From the nursing perspective, many of these challenges were present before the pandemic but have become significantly larger problems that continue to demand global attention. This has provided an opportunity to critically evaluate and learn from the challenges the pandemic has both highlighted and created. We conclude that the nursing infrastructure requires a revolution in order to support, grow and retain nurses, who are vital to the delivery of high-quality healthcare.

Disclosure:The authors have no conflicts of interest to declare.



Published online:

Correspondence Details:Taylor Rali, 1211 Medical Center Drive, Nashville, TN 37232, US. E:

Open Access:

This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

‘Why did you become a nurse?’ This is a question nearly every one of us in the profession hears, from when we first started nursing school to when we are decades into our careers. It can be a deeply personal and loaded question; it also becomes a question we ask ourselves when faced with adversity on the job. Nurses work through a unique set of challenges that have led many to leave the profession entirely from on-the-job training; limited or unavailable supplies; social stigma and negative media perception of nursing; increased personal risk of physical, mental and emotional harm; staffing shortages; higher patient acuity; increased patient-to-nurse ratios; compassion fatigue; mandatory overtime; workplace violence and the inability to take time off.

To lose a nurse is to lose a vital component of the healthcare team. Nurses are responsible for front-line care, working together with the interdisciplinary team to accomplish a common goal: safe patient care. Nurses are trained to implement a countless variety of tasks – including those that are immeasurable, such as translating medical jargon and explaining treatment plans to patients. Continuing to carry out these tasks safely and effectively has been one of the many challenges the pandemic has posed to nursing, in addition to maintaining the safety and mental well-being of ourselves and our families. COVID-19 highlighted many problems that already existed in the nursing profession and created its own set of unique challenges, but in doing so, the pandemic also provided us with the opportunity to identify what we can do better. Without reformation and organisational attention to these issues and the well-being of nurses, every field of healthcare in which nurses serve a role remains vulnerable.

COVID-19 and the Nursing Crisis

‘The Great Resignation’ is the term given to the tremendous loss of nursing professionals throughout the pandemic.1 Many of the cited reasons for leaving included issues that predated COVID-19 but were made significantly worse during the pandemic. Since 2020, approximately 30% of the US nursing workforce has resigned or left the profession entirely, equating to about 900,000 nurses.1 With hundreds of thousands of nurses gone, an already understaffed profession became even more strained. Fewer nurses stayed to pick up the rising workload that amassed during the pandemic, while also combating a worsening shortage of supplies that occurred due to supply chain issues. These supplies included both equipment and medications considered to be a standard component of many treatment plans, from something as simple as 0.9% saline to heparin.2

The Food and Drug Administration (FDA) attempted to combat medical shortages by granting emergency use authorisations, providing permission to use alternatives when the primary option was not available. However, this meant nurses had to quickly learn how to administer alternative medications and use new patient equipment in an already fast-paced environment.3 Insufficient staffing and a lack of available supplies led to increasing stress levels and burnout. These were not the only factors that nurses cited when asked why they left their jobs or the profession – a lack of emotional support and appreciation for nursing care were also frequently cited as reasons for leaving.1 As a nurse providing direct patient care, relationships formed with patients and families are inevitable. Given the nature of our work, especially those in critical care settings, occasional patient losses are also inevitable. With the increased mortality rate of COVID-19, nurses were frequently in rooms with patients as they gasped for their final breaths, holding their hands and an iPad screen so their families could say their last goodbye. With rising emotional stress and worsening workplace conditions, many nurses decided to leave and many more will follow them unless there are some serious reforms.4

While many long-standing nursing issues were made more apparent during the pandemic, problems unique to COVID-19 also became prevalent. With rising patient admissions, available beds ran short in areas that were already full, creating a need for overflow units and more physical space within hospitals. This led to the need for hospitals to be restructured to accommodate the influx of patients. In several locations, parking garages were converted to emergency rooms designed specifically for patients with COVID-19 symptoms.5 Other hospitals built large tents in their car parks dedicated to COVID-19 emergency rooms and/or COVID-designated units.6 Nurses were pulled from teams already battling poor staffing to accommodate these new ‘pop-up’ spaces, leading to additional staffing crises across the hospital. Team nursing, a model in which two or more nurses are assigned to care for a large group of patients together instead of a set patient-to-nurse ratio, became necessary to manage the increase in patient numbers and acuity.7 Quarantining patients with COVID-19 within specific units also became a necessity. The need for non-COVID-related procedures, such as heart transplants, did not stop during the pandemic, but such immunocompromised patients could not be placed in a room near a COVID-19 patient for fear of increased morbidity. This ultimately led to the development of COVID intensive care units (COVID-ICUs), in which nurses were tasked with caring exclusively for COVID patients every day, placing them at further risk of burnout.8 The remaining ICUs accepted the overflow of patients from numerous specialties, so cardiac ICU nurses would care for patients with burns. This posed an additional risk to patient safety, as nurses were not able to work in their specialties.

Not only was patient care at risk, but so was the physical safety and mental well-being of nurses. Many feared exposure to the virus, as personal protective equipment (PPE) guidelines changed frequently early in the pandemic and mortality rates from the virus rose. Some hospitals provided hotel rooms for healthcare workers who did not wish to risk exposing family members after caring for patients with COVID-19, while other nurses slept in their vehicles and did not see their families for extended periods of time. These factors all contributed to the ‘Great Resignation’ which ultimately created a dependence on contract workers known as travel nurses (or agency staff in the UK), or those who are hired at higher income rates to cover temporary staffing shortages. While this helped cover initial staffing shortages, it also exposed large numbers of exhausted staff nurses to the opportunities that travel nursing offers.9 Considering the transition to contract work as some form of relief from the pandemic and/or a method of career advancement, many nurses left staff positions to become travel nurses, leading to hospitals having nurses with fluctuating skill sets, varying years of experience, and frequent staff turnover. In 2020, the number of travel nurses listed with nationwide agencies grew by 35% and is continuing to grow despite a reduction in hospital admissions for COVID-19.10 The COVID-19 pandemic presented unique challenges to the nursing profession, and the consequences are leading to issues with staffing models nationwide in the US and internationally.

Potential Solutions

The COVID-19 pandemic has taught us that there is a need for change within our healthcare system. Many of the issues in need of change existed before the pandemic, but have become severely exacerbated, while others became prevalent because of the pandemic. As a nation in the US and globally, we were not prepared to handle such a tremendous influx of critically ill patients in an already strained healthcare system. We were not prepared to protect our own healthcare workers. Should another COVID wave hit, or a new pandemic hit, the healthcare system we currently have established could very well collapse. Nurses have long been undervalued, underpaid and under-protected, the COVID-19 pandemic highlighted this fact. More nurses are bound to leave if this situation repeats itself. If there is anything positive to come out of this global disaster, it is the opportunity to implement changes to prepare and protect the healthcare of people around the world.

Nursing retention severely declined during the pandemic. Pre-pandemic turnover rates were around 20% and in 2021 around 30–36% of nurses reported that they intended to leave the profession.11 A focus on nurse retention is crucial as a strong and consistent workforce greatly improves patient care and outcomes. Satisfied employees are more likely to stay in their jobs, so how can we help improve nurses’ satisfaction? Adjusting nursing pay to match their market value or offering hazard pay could be one very valuable institutional strategy. The culture of an organisation also greatly affects nurse satisfaction. Fostering a culture of inclusion and recognition for nurses can help improve job satisfaction, reduce burnout and improve their confidence. Building up nurses to become confident, competent and empowered is crucial, as hospitals with a positive practice environment can have lower burnout levels and better quality nursing care.12 Finding creative strategies to help nurses advance in their careers, such as a career pathway that identifies nurses that would like to go to graduate school and helping them do this could lead to nurse retention by helping nurses achieve their goals. The psychological impact of the pandemic on nurses cannot go unrecognised. Developing systems to support nurses through therapy, debriefing and allowing paid time off can reduce the psychological toll that plagues the nursing profession. The pandemic posed personal risks to nurses and their families and many felt unsafe returning to their own homes after caring for patients with COVID-19 due to the risk of transmission. Emergency housing plans, laundry services and hazard pay can help reduce the toll that a pandemic plays on nurses’ families.

Supply issues are a major source of dissatisfaction and can create a time-consuming process when nurses need to search for items or their substitutes. Developing strategies to reduce supply shortages, creating back-up plans and crisis allocation of resources would make an impact. Finally, creating a strategy and plan if or when another pandemic occurs is crucial. We need to develop a system to reduce supply and medication shortages, which allows for the emergency allocation of ventilators and has nurses and healthcare professionals on reserve to cover severe staff shortages as well as systems in place to support healthcare workers psychologically and physically in the event of another pandemic. Nurses are critical members of the healthcare team and there needs to be change within the healthcare field to support, grow and retain them. COVID-19 affected numerous aspects of nursing care and exposed a critical need to revolutionise healthcare. Albert Einstein once said that ‘insanity is doing the same thing over and over again and expecting a different result’.13 The current pandemic has exposed and exacerbated several challenges front-line nurses have faced for far too long. The time for change is now; it is time to call a ‘code blue’ on our nursing infrastructure.


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