State-level RN density and age-adjusted covid-19 mortality: Contribution of the nursing workforce to pandemic response

Nurses represent the largest segment of the United States healthcare workforce and played an instrumental role in the countrys response to the COVID-19 pandemic. Yet, little attention has been given to the contribution of this component of the U.S. medical personnel in the nations ability to face public health crisis. We present a cross-sectional, ecological analysis using cumulative annual reports from different national databases to assess the relationship between registered nurse (RN) density at a state level and age-adjusted COVID-19 mortality within the state, using data from 2021 when mortality rates were peaking in the U.S. At the state level, an increase of 1,000 RNs per 100,000 people, was associated with an estimated 24 to 44 fewer COVID-19 deaths per 100,000 residents (B= -0.024, {beta}= -0.146, 95% CI: -0.044 to -0.003, p = .024). In this multivariate analysis including medical co-morbidities, vaccination, health insurance, and poverty level, RN density explained nearly 11% of the variability in COVID-19 mortality among states. Our findings underscore the critical role played by nurses in responding to the COVID-19 pandemic, and the importance of incorporating nursing workforce data into planning for future public health emergencies.