Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace- A Four Part Series

In part one of this four part patient safety series, we will discuss the major patient safety concern of inadequate staffing ratios and offer nursing lead initiatives that will help to bring patient safety back to the forefront of our healthcare system. Nurses General Nursing Knowledge

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Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace- A Four Part Series

"We are short again today" - A daily phrase used by nursing staff that summarizes the consistent inadequate nursing staff ratios that healthcare facilities seem to continue to support. Inadequate nursing staffing ratios greatly diminish the likelihood of achieving positive patient health outcomes, as well as significantly decreases nursing staff job satisfaction and retention across our nation. Having an upwards of eight or more patients per Registered Nurse, and 15 or more patients per Nursing Assistant in an acute healthcare setting, such as a hospital, has been the norm for far too long now. As our healthcare marketplace expands and becomes more demanding of nursing staff by offering more treatment options, more medications, more technology, longer working hours, more complex patient illnesses, more computerized documentation, etc., healthcare facility staffing procedures should be reconfigured to include more nursing staff resources, rather than remaining unsafe.

According to an article posted in The American Nurse - an official publication of the American Nurses Association, when it comes to achieving high standards of care, optimal patient outcomes and institutional financial growth, adequate nursing staffing ratios should be considered as a necessity. Unfortunately, many healthcare facilities have not set standards for adequate nursing staff ratios. Instead, they continue to base their nursing staff to patient ratios off of a grid that only reflects patient body count - not taking into consideration RN experience levels, patient acuity, or available resources.

In a nursing led effort to provide adequate nursing staff ratios across our country, the American Nurses Association, each individual State's Nursing Association, and Nurses Take DC, have introduced Bills to improve staffing in a variety of care settings. The ANA proposed The Safe Staffing for Nurse and Patient Safety Act (S. 2446, H.R. 5052) to the House and Senate for consideration. According to the American Nurses Association (2018), this proposed legislation would require Medicare-participating hospitals to create a committee, composed of at least 55% direct care nurses, to develop nurse staffing plans that are specific to each patient care unit. The idea of having these committees is to utilize the expertise of the direct care nurses, who are best equipped to determine the adequate staffing levels to safely meet the needs of their patients.

For example, many charge nurses get report from the bedside nurses regarding how much care their patients need. Someone who is completely bed bound, incontinent, has multiple wounds, IV lines, oxygen, and may be confused, would require the assistance of three nursing staff members. This could be a combination of nurses and nursing assistants. The unfortunate reality is that the charge nurse currently collects this information so that they do not assign five of these high acuity patients to the same nurse. Instead of getting additional nursing staff to help with the increased acuity, they try their best to split up the acuity among the nurses and nursing assistants - which rarely works in regards to maintaining adequate and safe nursing staff ratios. However, if the charge nurse were able to bring on an additional nurse, or nursing assistant to help manage the increased acuity, then patient safety and nursing staff job satisfaction would improve significantly.

The ANA states that to date, seven states have enacted nursing staff ratios legislation that closely resembles the American Nurses Association's recommended approach to ensure safe staffing, by utilizing hospital-wide staffing committees, where direct care nurses have a voice in creating appropriate staffing levels. A total of 14 states have implemented laws that address nursing staffing ratios. These states include: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT and WA. For more information on these efforts, you can visit the Nurse Staffing page on the American Nurses Association website.

Nurses Take DC have proposed the RN Ratio Bill S. 1063/HR 2392, which goes further by mandating that each nursing speciality has their own mandated patient to nurse ratio, and places great consideration on other staffing issues such as mandatory overtime, averaging, video monitoring, and keeping nursing administration, such as charge nurses, out of the direct patient care staffing numbers. To see a side by side comparison of the differences among the ANA's Bill and the Nurses Take DC Bill, you can click here.

As of this very moment the fight for adequate nursing staff ratios continues. With all of our continued dedication and service to improving nursing care and standards of practice, I am certain that we will prevail in obtaining legislation for adequate nursing staff ratios.

For articles in this series, go to:

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Damion Jenkins

About Damion Jenkins, MSN, RN

NCLEX Columnist

Damion is the founder and CEO of The Nurse Speak, LLC. - a nurse education and consultation services company and blog.

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Thank you for your informative article about Safe Staffing. I attended the NursesTakeDC rally a few weeks ago and was fortunate enough to talk to senators about the bills supported by NursesTakeDC, Show Me Your Stethoscope and allnurses.com - S. 1063 / HR 2392 - Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2017. Now is the time for nurses to let their voices be heard.

Like this post if you agree!!

1 Votes

Just a warning about ratios: hospitals are using bogus acuity tools to undermine the ratio laws. So, since your patient doesn't have certain qualifiers, they aren't that sick or shouldn't take up that much time, so they only count as 0.3 of a patient, etc... It sucks and it is terribly disappointing I can tell you that. Just a warning, I guess, for nursing doing the victory dance about ratio laws. In MA they have been made essentially meaningless. The law needs to be written in a way that forces real numbers; 1 equals 1!

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Specializes in Safe Staffing Advocate/Group.
BedsideNurse said:
Just a warning about ratios: hospitals are using bogus acuity tools to undermine the ratio laws. So, since your patient doesn't have certain qualifiers, they aren't that sick or shouldn't take up that much time, so they only count as 0.3 of a patient, etc... It sucks and it is terribly disappointing I can tell you that. Just a warning, I guess, for nursing doing the victory dance about ratio laws. In MA they have been made essentially meaningless. The law needs to be written in a way that forces real numbers; 1 equals 1!

I work in MA and that is why we do need ratios and not just "acuity based staffing". Acuity based staffing is what allows hospitals to manipulate acuity tools. Mandated ratios does not. As of now in MA the only specialty that has mandated ratios is the ICU. And from the hospitals I have worked in... it works.

1 Votes
Specializes in Nephrology, Cardiology, ER, ICU.

Excellent topic. Hope that ratios soon exist in all states for both nurses and patients' sakes

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

We staff pretty religiously per our professional organization's staffing guidelines. I even go a bit further by adding acuity "points" for discharges, people with complicated psych/social issues, etc. Yes, we staff based on acuity, but that also means that there is a maximum nurse:patient ratio that we must uphold, or be in violation of or staffing plan, which makes us in violation of state law.

I know I keep beating this drum, but not all situations where units are short-staffed are because leadership is making the unit work short-staffed. Sometimes a unit is short staffed because they don't have enough nurses, period.

1 Votes
Specializes in NCLEX Prep Expert - 100% Pass Rate!.

Thank you @BedsideNurse for pointing out that some facilities utilize acuity tools to undermine ratio laws. If you look into the description of the RN Ratio Bills as compared to the ANA ratios proposal -

https://allnurses.com/federal-nurse-staffing-bill-comparison-t677496/

You will see that there are protections against this kind of manipulation. By demanding additional ancillary staff beyond RNs for increased patient acuity, and prohibiting averaging, these bills definitely cover what you are describing.

Thank you for adding to this discussion!

1 Votes
Specializes in NCLEX Prep Expert - 100% Pass Rate!.

Thank you @klone, MSN, RN for adding to this discussion! Many of us do understand that it's not always leadership's fault when the nursing units are understaffed. Emergencies, illness, and injuries definitely add to reduced numbers on any given day. Other than those reasons, why do you think that facilities have problems getting enough nurses?

From my personal experience, there are several reasons why many of my nursing colleagues no longer work at particular facilities, and they include: low pay, decreased benefits, increased workloads, workplace bullying, under-representation, unsafe staffing ratios, broken or missing patient care equipment, and workplace violence (mostly from patients and visitors). I understand for some rural areas, the amount of nursing graduates may have a direct impact on nurses that are available to work, but here in Baltimore, there are a lot more nursing graduates than there are positions available, and yet we find ourselves working short staffed.

We'd love to hear what you think are some of the major contributing factors on why facilities are having a hard time staffing nurses.

1 Votes
Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Instead of rehashing all the reasons why a facility would have difficulty finding nurses, I will just link you to this very involved discussion we recently had on the topic:

https://allnurses.com/nursing-shortage-its-real-bites-t670992/

1 Votes
Specializes in NCLEX Prep Expert - 100% Pass Rate!.

Thank you very much for sharing! This is a valuable addition to this discussion!

Best,

Damion

1 Votes
Damion Jenkins said:
Many of us do understand that it's not always leadership's fault when the nursing units are understaffed. Emergencies, illness, and injuries definitely add to reduced numbers on any given day. Other than those reasons, why do you think that facilities have problems getting enough nurses?

. . . here in Baltimore, there are a lot more nursing graduates than there are positions available, and yet we find ourselves working short staffed.

We'd love to hear what you think are some of the major contributing factors on why facilities are having a hard time staffing nurses.

With all due respect, if your facility is chronically short staffed because of emergencies, illness and injuries, leadership most certainly is at fault. If X = the number of hours budgeted in a year to provide adequate staffing and Y = the number of hours your facility actually ran short because of absences, then your plan for staffing next year should be at least X + Y. If it doesn't, your leadership is prioritizing something else, most often profits, over excellence in care, which includes safety.

Comedienne Brett Butler says of her devotion to her second husband, "You let one dog get away, you're gonna build a taller fence and put better food out." Translated to nursing, that means employers need to provide attractive opportunities, including some combination of compensation, benefits, scheduling, training, and workplace environment and culture. Then, equally importantly they need to prioritize retaining the staff they hire by actively showing they respect and value the commitment, knowledge, caring and experience of their staff, both seasoned and newer.

It's kind of that simple.

You mention several reasons for your colleagues leaving certain facilities: low pay, decreased benefits, increased workloads, workplace bullying, under-representation, unsafe staffing ratios, broken or missing patient care equipment, and workplace violence. With the exception of bullying and violence which are only partly leadership's to address, those issues are leadership's to resolve.

When my daughter was born, I took my maternity leave and then tried to go back to the small company I worked for. I couldn't make myself get out of the car at the sitter's house. I tearfully called my boss, told him what was going on, and attempted to resign. He asked me how long I thought I needed. I said six weeks. He said, "Take it, we'll see you when you're ready." Six weeks later, back at work, I was the most loyal employee you could have imagined. I would have walked through fire to do what needed to be done for them. They showed me what meant everything to me was important to them. I felt VALUED.

When I talk with nursing colleagues, NOT feeling valued is what will break the camel's back, so to speak. And $5 Starbucks cards don't do it. A rote closing at the bottom of every poorly written memo, "And thank you for all you do every day," doesn't do it. For me, having the time, support, policies and equipment to do what I need to do every day would do it. But it doesn't happen because it isn't a leadership priority.

As far as an area like yours that's rich with new grads but facilities are somehow short staffed, well, Brett's got a solution.

2 Votes
Specializes in ED, ICU, Prehospital.
On 5/17/2018 at 3:35 PM, BedsideNurse said:

Just a warning about ratios: hospitals are using bogus acuity tools to undermine the ratio laws. So, since your patient doesn't have certain qualifiers, they aren't that sick or shouldn't take up that much time, so they only count as 0.3 of a patient, etc... It sucks and it is terribly disappointing I can tell you that. Just a warning, I guess, for nursing doing the victory dance about ratio laws. In MA they have been made essentially meaningless. The law needs to be written in a way that forces real numbers; 1 equals 1!

This. Exactly.

There is no other excuse, and they all do it in California---Kaiser Permanente is the worst offender, with UC system close behind. Some smaller hospitals simply dare you to report them, because they know...you want to work in CA? A notoriously difficult and saturated market? You keep your yap shut and do the work. Acuity is routinely used in KPH emergency depts to lower ESI so that any given RN gets their 4. That means dying peritonitis, active GI bleed barfing up 2 L, septic found down after 3 days and altered, and malaria 5 year old goes to ONE RN, NO CNA, NO TECH, and spread out all over the entire unit with eyeballs on only one at a time, because tele is not tethered nor is it available in any but a few beds.

Yep. THIS is the result of a lax "ratio law". As long as acuity levels are up to the most "pliable and compliant" RN who is willing to sell their fellow nurses down the river for a cushy place at the desk.....the floor RNs are royally s****d.

UNIONIZE, first of all. Second---get out of nursing. Period. I am leaving and not looking back. When I explain what is happening to friends and family---they offer things like a free place to stay if I need it in order to retrain, or go back to my former profession (which I am doing right as we speak. )

If I had any advice from students considering nursing? DO NOT DO IT. You can make just as much or more being an Xray or CT or MRI or Nuc Med Technologist, and you can SIT DOWN and take bathroom breaks. 8 or 10 hour shifts. None of this "rotating shift" malarkey and 12 hours without a pee break, with threats coming hard and fast from management about you not taking a temp q4hr on the damn dot.

ALL DONE WITH NURSING. If anybody can do it....quit now.

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