Nurses represent the single largest group of healthcare professionals in hospitals, and nursing care consumes a substantial proportion of hospital costs (van Oostveen et al., 2015). Currently, there are approximately 29 million nurses globally, with 3.9 million of those individuals in the United States (Haddad et al., 2023). Nurses are quintessential to any healthcare organization and make up the largest section of the healthcare system, yet the US Bureau of Labor Statistics projects that more than 275,000 additional nurses are needed from 2020 to 2030, and employment opportunities for nurses are projected to grow at a faster rate (9%) than all other occupations from 2016 through 2026 (Haddad et al., 2023). In contrast, there is a crisis facing healthcare workers, especially nurses, in the form of shortages due to a lack of potential educators, high turnover, and inequitable workforce distribution (Haddad et al., 2023).
Dangers of Unregulated Staffing
Medical errors have been identified as a leading cause of death and injury, and an estimated 50% of adverse medical events are preventable (Andel et al., 2022). As more nurses are tasked with the burden of taking on more job requirements, some nurses have adapted the coping mechanism of taking safety related shortcuts to bypass obstacles and be more time efficient (Halbesleben & Rathert, 2008). This can be attributed to chronic understaffing, which Andel et al., believes to be positively related to safety workarounds which have been found to be positively related to near misses. Safety workarounds mediate the relationship between personnel understaffing and near misses (Andel et al., 2022). Instead of addressing these issues head-on, nurses are grossly celebrated and hailed as the masters of workarounds (Andel et al., 2022). The importance of having adequate staffing ratios for patients to nurses in the hospital is often neglected by the capitalist mindset permeating the healthcare system. They stifle the compassion from nurses, steal the lives of their patients, and shield themselves from accountability behind the cost-saving money they desperately cling to. Conversely, as nurse-to-patient ratios increase, so do patients' risks for poor outcomes (Bartmess et al., 2021). For example, it was found that there was a 3% increased risk of incomplete nursing care with each additional patient a nurse had in acute hospital settings (Bartmess et al., 2021). Furthermore, as nurse-to-patient ratios continue to increase, the value of care opportunities diminishes ranging from: nursing documentation, care planning, psychological support, emotional support, patient communication, and patient education (Bartmess et al., 2021). The diminished value of these important aspects of nursing care contributes to the likelihood of higher failure-to-rescue rates among patients, and an increase in patient mortality (Bartmess et al., 2021).
Nurses aren’t monolithic in the staffing shortages and the impact it has. Like nurses and other healthcare professionals, physicians also are facing a staffing shortage as the Association of American Medical Colleges (AAMC) projects a shortfall of 139,000 physicians by 2033, with the largest shortfall being in primary care (Basu et al., 2021). Physician shortages are most severe in rural and impoverished urban areas, resulting in a reduction in life expectancy being 310.9 days shorter in countries with less than 1 physician per 3500 persons (Basu et al., 2021). Consequently, just by increasing physicians staffing to 1 per 1500 residents would increase life expectancy in that country by an additional 56.3 days (Basu et al., 2021). The physician shortage has been maintained by failing to expand physician education opportunities. Furthermore, low compensation for primary care physicians has created a disproportionate shortfall that most affects already underserved communities. The healthcare system of physician labor, particularly hospital-based specialty, is maintained by the under-paid labor of residents. Ultimately, these systems result in poor outcomes for patients and physicians. As a result, it is imperative that healthcare organizations, leaders and policymakers consider the safety implications of nurse staffing shortages and physician shortages as they reach beyond outcomes commonly associated with understaffing (Andel et al., 2022).
When nurse organizations' recommendations for safe staffing measures are disregarded by hospital administrations, nurse lobbyists and interest groups often pursue legislative action to protect patients and nurses from unsafe staffing conditions (Bartmess et al., 2021). As a result of the collaborative legislative efforts federal regulation have been indoctrinated in the form of bill 42 CFR 482.23 (b) that requires Medicare-certified hospitals to “have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed (Centers of Medicare & Medicaid, 2010). Furthermore, more than 15 states have created laws regulating nurse staffing utilizing a variety of three approaches: mandated ratios, acuity-based nurse staffing plans, or public disclosure of staffing (ANA, 2019). Staffing levels should be flexible to account for unexpected changes, including the intensity of patient acuity, the admissions to the hospital, discharges and patient transfers, the experience of the nursing staff, and the availability of resources (Wolterskluwer, 2018). Utilization of staffing models is beneficial as they account for the number of nurses, the nurse to patient ratio, and can be amended to account for unprecedented staffing factors (Wolterskluwer, 2018). Despite the legislative efforts, progress on a universal staffing bill has been staggered. For example, bill S.1567, has been in the Senate Committee for Health, Education, Labor, and Pensions since May 11, 2021. This bill, modeled after the California ratios law, would require hospitals nation-wide to meet minimum safe-staffing ratios for RNs and LPN/LVNs. Currently, since 2004 California is the only state to have a law regulating minimum nurse to patient ratios demonstrating its success by improving patient outcomes and system-wide cost savings (Pittman et al., 2021). Furthermore, the bill also includes a safe harbor statute, preventing retaliation against nurses who refuse an assignment in good faith, and would increase Medicare payments to hospitals (117th, 2021-2022). Healthcare organizations and policymakers are challenged and encouraged to take steps to address understaffing issues through proper staffing or training initiatives, especially during periods in which the healthcare system is overburdened and/or facing a public health crisis, such as the COVID-19 pandemic, or when new knowledge and skill demands may emerge (Andel et al., 2022).
Understaffing is a perennial and chronic stressor and issue in the nursing profession, and the challenges it presents have been amplified and worsened by the recent COVID-19 pandemic in 2020 (Andel et al., 2022). Healthcare systems that implement appropriate safe nurse staffing can produce clinical and economic improvements in patient care and patient and staff quality of life (Wolterskluwer, 2018). By increasing the focus on value-based care, optimal nurse staffing delivers high-quality, cost-effective care to patients. How well we treat the members of our society who rely upon others for care is a measure of our greatness and empathy. Nursing home residents and workers deserve safe, adequate working and living conditions. They deserve to live in a society that values their lives and contributions. The literature is conclusive: safe staffing saves lives. Staffing is a matter of justice and survival for our patients. Physicians, Nurse Practitioners, Nurses, Physical therapists, Occupational therapists, Speech Therapists, Case managers, social workers, phlebotomists, environment services providers, and most importantly the patients they serve all deserve safe and equitable staffing.
- American Nurses Association (2019). Nurse staffing advocacy.
- Andel, S. A., Tedone, A. M., Shen, W., & Arvan, M. L. (2022). Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic. Journal of advanced nursing, 78(1), 121–130.
- Bartmess, M., Myers, C. R., & Thomas, S. P. (2021). Nurse staffing legislation: Empirical evidence and policy analysis. Nursing forum, 56(3), 660–675.
- Basu, S., Phillips, R.S., Berkowitz, S.A. et al. (2021). Estimated effect on life expectancy of alleviating primary care shortages in the United States. Annals of Internal Medicine, 174(7), 920-926.
- Centers of Medicare & Medicaid Services (2010). 42 CFR S 482.57 - Condition of participation: Respiratory care services. Department of Health and Human Services.
- Halbesleben, J. R., & Rathert, C. (2008). The role of continuous quality improvement and psychological safety in predicting work-arounds. Health care management review, 33(2), 134–144.
- Kluwer, W. (2018, March 8). Update on nursing staff ratios. Back to top. https://www.wolterskluwer.com/en/expert-insights/update-on-nursing-staff-ratios
- Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing Shortage. [Updated 2023 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
- National Council of State Boards of Nursing (2020). NCBSN’s environmental scan a portrait of nursing and healthcare in 2020 and beyond. Journal of Nursing Regulation, 10(4), S1-S35.
- Pittman, P., Chen, C., Erikson, C. et al. (2021). Health workforce for health equity. Medical Care, 59(10), 5.
- 117th Congress (2021-2022). S.1567 - Nurse staffing standards for hospital patient safety and quality care act of 2021. United States Congress.
- van Oostveen, C. J., Mathijssen, E., & Vermeulen, H. (2015). Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses' perceptions of nurse staffing. International journal of nursing studies, 52(8), 1300–1309.