Aims:To explore factors associated with nurses' moral distress during the first COVID-19 surge and their longer-term mental health.

Background Nurse engagement is a modifiable element of the work environment and has shown promise as a potential safety intervention. Purpose Our study examined the relationship between the level of engagement, staffing, and assessments of patient safety among nurses working in hospital settings. Methods A secondary analysis of linked cross-sectional data was conducted using survey data of 26,960 nurses across 599 hospitals in 4 states. Logistic regression models were used to examine the association between nurse engagement, staffing, and nurse assessments of patient safety. Results Thirty-two percent of nurses gave their hospital a poor or failing patient safety grade. In 25% of hospitals, nurses fell in the “least” or only “somewhat” engaged categories. A 1-unit increase in engagement lowered the odds of an unfavorable safety grade by 29% (p <.001). Hospitals where nurses reported higher levels of engagement were 19% (p<.001) less likely to report that mistakes were held against them. Nurses in poorly staffed hospitals were 6% more likely to report that important information about patients “fell through the cracks” when transferring patients across units (p<.001). Conclusions Interventions to improve nurse engagement and adequate staffing serve as strategies to improve patient safety.