Leadership for Public Education

Nursing staffing: Issues and solutions


As the national health care debate continues, many unresolved issues exist at the patient’s bedside that staff nurses encounter on a daily basis. Staffing shortages in hospitals in particular have a tremendous impact on the quality of care nurses struggle to provide. 

A 2006 report released by the prestigious Agency for Healthcare Research and Quality (AHRQ), “Nurse Staffing and Quality of Patient Care,” described what nurses already know: inadequate nurse staffing and heavy workloads threaten care quality and patient safety, and can lead to nosocomial infections, shock, and failure to rescue. An earlier report by the Institute of Medicine (IOM), “Keeping Patients Safe: Transforming the Work Environment of Nurses,” also reached similar conclusions. Adverse effects noted in other research studies include a higher incidence of patient falls, pneumonia, postoperative infections, pressure ulcers, and urinary tract infections. Better staffing was linked to lower death rates and shorter hospitalizations as well as a significant decrease in the cost of care.

Several researchers have analyzed the relationship between nurse staffing and length of stay (LOS). By increasing the number of registered nurses and providing more nurse hours per patient day, patient LOS decreases. Adequate staffing and balanced workloads have also been linked to improvements in nurses’ health and job satisfaction as well as a decrease in turnover and burnout. Inadequate staffing and excessive workload contribute to a difficult work environment.

Additional costs occur with decreased retention and the use of overtime or agency nurses. The use of unlicensed staff results in an increased cost of supervision, which is often not measured when cost is considered. Higher nurse-to-patient ratios provide better patient monitoring and surveillance as nurses detect and treat complications. The principles and techniques utilized for the prevention of adverse events as well as the degree of skill and knowledge necessary for the continuing development of policies and procedures are inherent to the nursing profession. As the experience of nursing staff increases, more efficient and effective health services are delivered.

 A 2008 study, “Overcrowding and Understaffing in Modern Health-Care Systems: key determinants in MRSA transmission,” directly connects these issues. The epidemic of MRSA, which causes substantial health and economic burdens on patients and health-care systems, has occurred simultaneously with higher patient throughput in hospitals, forcing them to operate at, or near, full capacity. This results in hospital overcrowding and understaffing, with services spread thin. Overcrowding and understaffing has led to decreased hand-hygiene compliance, increased movement of patients and staff between various hospital units, and the overburdening of screening and isolation procedures. In turn, a higher MRSA incidence leads to increased inpatient LOS and bed blocking, which exacerbates overcrowding and makes it difficult to control further infection. Both system failure and human failure are at fault.

The Journal of the American Medical Association in 2008 addressed the issue of survival rates for hospital cardiac arrests being substantially lower during nights and weekends, even when the rates were adjusted for significant characteristics. Noting that the mechanisms are multifactorial, hospital staffing and operational issues are an important variable to be addressed. Landmark studies by Dr. Linda Aiken with the University of Pennsylvania Nursing Department indicate that for each additional patient over four assigned to a registered nurse, the risk of death increased by 7 percent for all patients—patients in hospitals with a 1 to 8 nurse-to-patient ratio have a 31 percent greater risk of dying than patients in hospitals with a 1 to 4 nurse-to-patient ratio. 
Factors such as time constraints, inadequate supervision of support staff and communication, and a generally chaotic or stressful work environment may add to errors in patient care. Nurses do not report to work with the intent of harming patients, yet errors continue to occur. The Journal of Health Services Research recently published a study calculating that the cost of preventable error and complications may contribute as much as 30 percent to the cost of health care. 

As hospitals seek to increase and measure patient satisfaction, it should be noted that studies also support improvement in patient satisfaction when a richer mix of nurses are employed for care. In addition to the professional expertise of nurses, patients and families appreciate the compassion, communication, and emotional support provided by the bedside nurse.

In 1999, California enacted the first law in the U.S. to establish minimum staffing levels for registered nurses working in hospitals. Research supporting the law pointed to the changing health-care environment, where the decentralization of ancillary services and the redesign of the acute care delivery system beginning in the late 80s occurred in conjunction with increased patient acuity and rapidly developing technology and pharmacopeia. This resulted in a markedly more complex, severely ill hospitalized patient population. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), has since developed staffing effectiveness standards for hospitals. Although these standards do not specify patient-to-nurse ratios, the standards require hospitals to analyze indicators, which correlate with staffing effectiveness, including staffing ratios. In 2002, JCAHO found that low staffing levels were a contributing factor in 24 percent of patient safety errors resulting in injuries or death. The California regulations, requiring California hospitals to assign no more than six patients per nurse in general medical-surgical units and labor units were implemented two years later. A survey of nurses in California found that nurses perceived a significant improvement in their working conditions and were more satisfied with their jobs following this implementation.

Some states, such as Delaware, have enacted legislation that requires health-care facilities to develop nurse-staffing plans. Connecticut enacted a prototypical regulatory law designed to analyze nurse staffing levels and patient outcomes, and a mandatory limit on nurse overtime.

Although federal bills have been introduced in Congress to address these issues, no bill has been passed. But that doesn’t mean lawmakers aren’t working to address staffing issues. Earlier this year, U.S. Rep. Jan Schakowsky (D-IL) introduced the Safe Nursing Staffing for Patient Safety and Quality of Care Act, which would hold hospitals accountable for the development of unit-by-unit staffing plans with the input of direct care nurses. Under the bill, the plans would be based on patient numbers and acuity, the level of education, training, and experience of registered nurses, the availability of support staff, and the physical layout and technology available in the unit. The bill would also preclude nurses from working in units where they are not trained or experienced. A number of compliance provisions also are included such as whistle blower protection for nurses who file a complaint. Similar legislation has been introduced in the U.S. Senate.

The introduction of this legislation along with the release of, “The Future of Nursing: Leading Change, Advancing Health,” has already garnered national attention—the report clearly articulates the agenda for change within the nursing profession necessary to meet these challenges. The fight for adequate and appropriate staffing is a cornerstone of this effort.

References provided upon request. Contact JFiesta@PSEA.org