Medical team walking down hallway away from camera
HealthSeptember 18, 2020

The importance of safe patient staffing for nurses and the benefit for grads

By: Dr. Daniel Eaton
The Covid-19 crisis that we are all living in has taught us a lot. We have learned that many things that we once took for granted could be in short supply at any given moment. We have found a shortage of things from toilet paper, meats, bicycles, and healthcare professionals like nurses.

The recent pandemic has highlighted the importance of safe staffing for nurses. We have all known for quite some time that there is a shortage of bedside nurses, and there are many reasons for this. Anyone who works in healthcare knows that our healthcare delivery system isn’t really that healthy. The looming question is what are we doing about this problem?

Safe staffing

Many nurses believe that nurse staffing is a major issue. Many hospitals and administrators believe this as well. As of now, only one state (California) has laws that set forth a mandatory minimum staffing level. A handful of other states have passed some sort of legislation related to nurse staffing. Mostly just stating that healthcare facilities must have a staffing plan or staffing committee. Many facilities have staffing committees and other guidelines that suggest what the staffing levels should be. The problem that many have encountered with these guidelines is that they can easily be broken and have no ability to actually force minimum staffing. Plus, the majority of states have no legislation related to nurse staffing.

It seems that in today’s society we have legislation and an attempt to enact so many mandates related to healthcare. Those of us who have worked in long term care can especially attest to the high amount of regulation. Isn’t it a bit odd that the majority of states have not addressed the issue of safe patient staffing? We all know that we are caring for sicker and sicker patients in just about every setting, but staffing plans remain out of date and, oftentimes, have not kept pace with the changing landscape in healthcare. There is a large body of evidence that supports the benefits of safe staffing. There are benefits to safe staffing that range from better patient care and outcomes, higher nurse satisfaction, and decreased costs of care.

Key findings from recent research related to patient care include:

  • Lower patient-to-nurse staffing ratios have been significantly associated with lower rates of hospital mortality, failure to rescue, cardiac arrest; hospital-acquired pneumonia, respiratory failure; patient falls (with and without injury); and pressure ulcers.
  • Higher numbers of patients per nurse was strongly associated with the administration of the wrong medication or dose, pressure ulcers, and patient falls with injury.
  • Short-staffing increases patients’ risk of death by between 4% and 6%. This risk is higher within the first five days of admission

Many nurses leave their jobs at the bedside due to chronic low staffing and being asked to do too much with too little. Burnout and nurse turnover are major issues for many hospitals and other healthcare facilities. Burnout and turnover can lead to many problems from a straight-up cost perspective but also the toll this could potentially take on a human life, which is more difficult to measure. I was recently talking with one of my students who was a very bright student. She works in a busy medical-surgical unit. One recent shift she was the most senior nurse on her unit and the most experienced. She graduated with her BNS just over two years ago. Now, I have the benefit of knowing this student and would feel comfortable with her taking care of myself or a loved one, but generally speaking, who do you want taking care of you or your family? A nurse with two years of experience who has worked on the unit for a short period of time or a nurse who has 15 years of experience and has worked on the unit for 10 years? We all know that burnout and nurse turnover are complex issues that have been studied numerous times. However, maybe there is a simple and obvious solution that may help the problem? From a patient perspective, we can easily see the benefits of safe staffing. I mean, who wouldn’t’ want a nurse caring for them that has fewer patients to care for? There are also benefits of safe staffing to view from a hospital or administrative perspective. Safe staffing has proven to be financially beneficial as well.

Key findings related to the financial benefit of safe staffing include:

  • Safe staffing can lead to a decrease in hospital-acquired infections, decreased, decreased risk of readmission, shorter hospital stays, decrease falls and patient injuries
  • It has been found that short-staffing increases the nurse’s risk of experiencing burnout which can lead to an increased turnover in employment. We all know this is costly, in 2012 the cost to replace one nurse was found to be $82,000
  • High levels of nurse burnout and turnover lead to lower quality of care

Now, I bet I know what many of you are thinking, especially those of you who have worked in management like myself. Nurses are expensive and if I hire another nurse it will kill my budget! This is where we need to start to see things from the bigger picture. A recent national study found the financial costs and benefits of increasing nurse staffing for hospitals more or less evened out. The cost of increasing nurse staffing to safe levels had a less than 1.5% increase. The decision to increase or reduce staffing is largely based upon the value placed on human life. Sure, it will cost more to hire more nurses, but also remember the cost savings and benefits related to improved outcomes in care.

Reasons why we have less than safe staffing

Badge that says safe staffing saves livesWe have just scratched the surface of the benefits of safe staffing so let’s discuss some potential reasons why we have less than safe staffing. First off, the term itself, “safe staffing” is subjective. What is the number of staff that would provide both safe and efficient care? I believe the answer to this question is in the research which has guided much of the proposed legislation and suggestions for mandatory minimum staffing, yet this question remains up for debate. Above I mentioned some of the financial implications for staffing and I often hear of the expense of nurses and organizations are reluctant to hire additional staff. However, most often I hear that organizations have trouble finding the staff they need to fill positions. Again, there are reasons for this. Sure pay, benefits, etc. all play a role, but there are other reasons as well. One question that was recently posed to me was, “Do we have a shortage of nurses or a shortage of nurses willing to work in areas where we see the shortage?” Hospitals and nurses are under enormous amounts of pressure as we see continue to deal with the rapid turnover of patients and staff. We are seeing sicker and sicker patients in every unit and in every setting.

Nurses leaving the bedside

One problem that we continue to see is nurses running from the bedside. As the demographics of our country continue to shift, we have seen older experienced nurses retiring from the bedside. We also see many younger or newer graduate nurses getting just enough experience at the bedside then applying to graduate school looking to obtain a career as an advanced practice nurse. Many institutes of higher education also encourage this. We often attempt to recruit our best and brightest students to graduate programs while students are still in undergraduate programs. This is all well and good, but it doesn’t negate the need for highly skilled bedside nurses. We also see new graduates who leave the bedside because they may have not known just what they were in for. Nursing school programs oftentimes don’t have clinical experiences that prepare them for the realities they will face. Many clinical rotations never go beyond caring for one assigned patient and rarely go beyond caring for two to three patients. Maybe this is done on purpose because we don’t want to scare students off of nursing before they even become licensed, but probably not. We need enhanced partnerships between schools of nursing and hospitals where clinical rotations are being offered. We are also seeing a paradigm shift in nursing education and examining ways we prepare students for practice. This is evidenced by the looming next-generation NCLEX. This is being done because the reality is that many students are not prepared for practice regardless of the program they graduate from. Safe staffing will help adjust novice nurses to their new role and help keep new graduates in the profession and at the bedside.

Keeping nurses at the bedside

If we are seeing a problem with nurses leaving the bedside in our area what can we do? We can increase the enrollment at schools of nursing, which isn’t a bad idea. This will help keep the pipeline full. However, it doesn’t fully solve the problem of nurses fleeing the bedside.

We also have to look at things like job satisfaction. We need to examine the ideas of what makes a nurse “satisfied” at their job? Again, in a recent report conducted of over 1,000 nurses it was found that:

  • 51% of nurses report that their input on how things are done has decreased in the last five years
  • 69% of nurses report that their time spent at the bedside has decreased over the past five years
  • 94% of nurses reported that they felt that their facility did not have enough nursing staff and 87% of nurses reported that staffing levels affecting patient care are getting worse

It is time that we begin to listen to bedside nurses and what they are telling us. Sure, we can look at things like wages, our investment in support staff and our access to technology. We can look at training and support to use available technologies and examine things that allow nurses to do their jobs more efficiently, thus (hopefully) allowing them to spend more time with their patients. We need to continue to improve training and mentorship opportunities for all nurses. We also need to look at how we can implement processes that give nurses more input on care delivery systems. I also think we should examine more out of the box solutions like how we can support nurses at home with flexible or creative scheduling options, support for childcare or other family care needs, and retirement planning. Examining all these things will likely help improve staffing and staff retention.

Time for action

As mentioned above, there are many strategies that we can look at to help improve staff retention, but then we must examine safe patient staffing and think about mandatory patient limits for nurses. We must listen to what bedside nurses are telling us. If they are telling us they feel short-staffed, canned responses like needing to learn better time management and prioritization only go so far. Nursing has forever changed form a vocation where nurses provided a support role and comforted sick patients. Nursing is now a career where highly trained and skilled experts hold a degree, have licenses, and must keep up with continuing education and the advances in their specific field. Nurses are on the frontline of care delivery in a variety of settings and we all play a central role in the care of the patients we serve. Just as nursing has changed over the years, so has the healthcare delivery system. As the healthcare system has shifted it hasn’t always done so in a way that supports nurses. Many staffing guidelines and recommendations have not been updated in years. This is if facilities even have them, let alone follow them. Hospital systems and other care delivery networks seem to be in a never-ending quest to cut costs. Much of these costs have impacted what nurses need to provide the best care, even while many facilities seem to have increased profit margins. In many cases, the time nurses are able to spend with their patients has not kept pace with best practices and recommendations. The time for action is now. Nurses must advocate for transparency in staffing levels for patients and healthcare professionals alike. Bedside nurses must have a greater say in what safe staffing looks like and what their needs are. In Pennsylvania, many nurses are becoming involved and advocating for legislation, similar to that enacted in California, which would set mandatory nurse to patient ratios. Currently, house bill 867 and senate bill 450 set ratios for patients to nurses in acute care hospitals. Nurses are beginning to come together and advocate for their patients, advocate for their profession and work towards progress on issues they support.

As was discussed in this blog there are many things to think about when we are discussing safe staffing and nurse to patient ratios. However, one thing is clear. We must act to encourage more qualified nurses to stay at the bedside and improve our staffing levels in many areas of nursing. It is also clear that nurses must have their voices heard and have a bigger seat at the table when discussing staffing and issues that impact it. Nurses are the ideal advocates for our patients by the nature of our training. We must continue this advocacy when we examine important issues like staffing. Our advocacy can and does make a difference!

Dr. Daniel Eaton
Nursing Education Author, Wolters Kluwer Health
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