Hospital Workforce Staffing and Work-Pace Safety Perceptions During the COVID-19 Pandemic: A Cross-Sectional Analysis.

Abstract

Background and objectives: The COVID-19 pandemic placed unprecedented strain on US hospitals, creating conditions of high patient acuity, elevated mortality, and staffing shortages. These pressures threatened care quality and shaped how workers perceived their ability to provide safe care. This study examined national trends in hospital workers' staffing and work-pace safety perceptions (SWSP) during the pandemic and evaluated whether changes in hospital mortality rates were associated with worsening perceptions. We further assessed whether intensive care unit (ICU) staff experienced sharper declines in SWSP compared with non-ICU counterparts.

Methods: We conducted a quantitative analysis using de-identified responses from the Hospital Survey on Patient Safety Culture, linked with mortality data from the Healthcare Cost and Utilization Project State Inpatient Databases. A total of 258 987 responses from more than 400 hospitals were included from the pandemic period (April 2020-July 2022). Staffing and work-pace safety perception was measured using a composite of 2 Hospital Survey on Patient Safety Culture items on staffing adequacy and work pace, dichotomized into negative/neutral versus positive perceptions. Logistic regression models assessed associations between monthly mortality rates and SWSP, adjusting for individual- and hospital-level covariates. Stratified analyses compared ICU and non-ICU settings.

Results: Nationwide, SWSP declined steadily, decreasing by an average of 3.5 percentage points per year. Periods of heightened mortality, including the Delta and Omicron waves, coincided with sharper deterioration. A doubling of overall mortality was associated with a 38% increase in odds of negative/neutral SWSP (odds ratio [OR] = 1.38, standard error [SE] = 0.02, P < .01). Stratified analyses showed differences by setting: for non-ICU patients, a mortality doubling was linked to a 14% increase (OR = 1.14, SE = 0.02, P < .01), while for ICU patients, odds rose by 40% (OR = 1.40, SE = 0.12, P < .01).

Conclusions: During the pandemic, healthcare workers' perceptions of staffing adequacy and work pace deteriorated, varying by position group and showing greater sensitivity to mortality surges among ICU staff than non-ICU peers. These findings indicate that SWSP represents an important dimension of safety culture that responds dynamically to systemic strain. For health system leaders, this underscores the value of complementing external performance measures with proactive monitoring of workforce perceptions. Attention to SWSP may provide early warning of stress, inform resource allocation, and support interventions to mitigate burnout, improve retention, and strengthen resilience in times of crisis.