Hanging on through Omicron, then what? A pre-exit baseline of the U.S. emergency nursing workforce, 2018 to 2022, with implications for the 2026 NSSRN cycle
- 1University of Virginia
Abstract
BackgroundThe emergency department in the United States of America functions as a residual access point for healthcare and social services for populations including rural communities, the uninsured, mental health and addiction patients, and the unhoused. The workforce variable that determines unit function (experience density, the concentration of accumulated clinical judgment within a unit workforce) is not measured in hospital accounting systems.
ObjectiveTo document workforce composition changes in U.S. emergency nursing across the 2018 and 2022 cycles of the National Sample Survey of Registered Nurses (NSSRN), and to specify falsifiable predictions for the 2026 cycle.
MethodsWe analyzed NSSRN public-use files using a current-position ED definition following Castner et al. (2024) and a hospital-bedside-restricted comparator. Variance estimation used jackknife replicate weights for 2018 and Successive Differences Replication for 2022. Burnout was operationalized using the Norful et al. (2023) leaving-reasons proxy across cycles, with sensitivity analysis using the 2022 direct burnout item.
ResultsA 15-year trajectory (2008-2022) documents progressive experience-density compression: the EDs 15+ year veteran cohort fell from 41.9% to 28.0% over the decade preceding the pandemic, a contraction of approximately one-third in the senior share and a 19.6% decline in mean experience density, before recovering modestly to 33.3% as veteran nurses remained through the pandemic acute phase, leaving the ED as the youngest hospital setting throughout. Hospital non-ED bedside nurses lost senior tenure between cycles (mean 15.65[->]14.06 years since first licensure; 15+ year share 43.5%[->]38.7%), while ED nurses retained their senior tail (mean 11.60[->]12.58). Burnout endorsement rose sharply in both populations (non-ED 27.3%[->]46.0%; ED 34.2%[->]61.2%), with the ED-vs-non-ED gap more than doubling. Controlling for tenure, ED status was not independently associated with burnout in 2018 (OR 1.15, 95% CI 0.83-1.59) but was strongly associated in 2022 (OR 1.92, 95% CI 1.44-2.55; p<.001). The direct burnout item showed a parallel pattern (OR 2.92, 95% CI 1.62-5.28).
ConclusionsA pandemic-era setting-specific burnout effect emerged in emergency nursing that workforce-composition controls cannot explain. The 2022 cycle establishes a pre-exit baseline against which the 2026 NSSRN will serve as the falsifiable test of post-Omicron veteran exit. Nursing pipeline replacement lag exceeds the interval before 2026 data arrives; the consequences of inaction fall on populations dependent on ED-based residual access.
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BibTeX
@misc{squire2026hanging,
title = {{Hanging on through Omicron, then what? A pre-exit baseline of the U.S. emergency nursing workforce, 2018 to 2022, with implications for the 2026 NSSRN cycle}},
author = {K. Squire},
howpublished = {medRxiv},
year = {2026},
month = jun,
doi = {10.64898/2026.06.07.26355097},
url = {https://www.medrxiv.org/content/10.64898/2026.06.07.26355097v2},
note = {CC BY},
}
RIS
TY - UNPB
TI - Hanging on through Omicron, then what? A pre-exit baseline of the U.S. emergency nursing workforce, 2018 to 2022, with implications for the 2026 NSSRN cycle
AU - K. Squire
PY - 2026
DA - 2026/06/07
PB - medRxiv
DO - 10.64898/2026.06.07.26355097
UR - https://www.medrxiv.org/content/10.64898/2026.06.07.26355097v2
AB - BackgroundThe emergency department in the United States of America functions as a residual access point for healthcare and social services for populations including rural communities, the uninsured, mental health and addiction patients, and the unhoused. The workforce variable that determines unit function (experience density, the concentration of accumulated clinical judgment within a unit workforce) is not measured in hospital accounting systems. ObjectiveTo document workforce composition changes in U.S. emergency nursing across the 2018 and 2022 cycles of the National Sample Survey of Registered Nurses (NSSRN), and to specify falsifiable predictions for the 2026 cycle. MethodsWe analyzed NSSRN public-use files using a current-position ED definition following Castner et al. (2024) and a hospital-bedside-restricted comparator. Variance estimation used jackknife replicate weights for 2018 and Successive Differences Replication for 2022. Burnout was operationalized using the Norful et al. (2023) leaving-reasons proxy across cycles, with sensitivity analysis using the 2022 direct burnout item. ResultsA 15-year trajectory (2008-2022) documents progressive experience-density compression: the EDs 15+ year veteran cohort fell from 41.9% to 28.0% over the decade preceding the pandemic, a contraction of approximately one-third in the senior share and a 19.6% decline in mean experience density, before recovering modestly to 33.3% as veteran nurses remained through the pandemic acute phase, leaving the ED as the youngest hospital setting throughout. Hospital non-ED bedside nurses lost senior tenure between cycles (mean 15.65[->]14.06 years since first licensure; 15+ year share 43.5%[->]38.7%), while ED nurses retained their senior tail (mean 11.60[->]12.58). Burnout endorsement rose sharply in both populations (non-ED 27.3%[->]46.0%; ED 34.2%[->]61.2%), with the ED-vs-non-ED gap more than doubling. Controlling for tenure, ED status was not independently associated with burnout in 2018 (OR 1.15, 95% CI 0.83-1.59) but was strongly associated in 2022 (OR 1.92, 95% CI 1.44-2.55; p<.001). The direct burnout item showed a parallel pattern (OR 2.92, 95% CI 1.62-5.28). ConclusionsA pandemic-era setting-specific burnout effect emerged in emergency nursing that workforce-composition controls cannot explain. The 2022 cycle establishes a pre-exit baseline against which the 2026 NSSRN will serve as the falsifiable test of post-Omicron veteran exit. Nursing pipeline replacement lag exceeds the interval before 2026 data arrives; the consequences of inaction fall on populations dependent on ED-based residual access.
ER -