Short Staffed: An Epidemic

I have only been a nurse for a couple years and in that time I have found one issue that unites all nurses: a deep loathing for an under-staffed unit. We’ve all experienced it, we all hate it. So how does it keep happening? To understand the how, we must start with the what. Furthermore, to find effective solutions, we must start with the driving causes.

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Short Staffed: An Epidemic

Talk to any nurse and they will have something to say about the staffing at their hospital or facility. More often than not, that something will be an unflattering depiction best summed up with three words: stretched too thin. Additionally, the COVID 19 pandemic, like a flare up of a chronic disease, has only exacerbated the issue. While the problems addressed here can be frustrating, the goal is to rationally examine the causes of under-staffed hospital units in order to then identify potential solutions.

The Problem: Defining Short Staffing

What is short staffing? That depends primarily on the defined nurse-to-patient ratios in each hospital and on each unit. Ask any hospital administrator and any nurse at the same hospital to describe the safe, ideal nurse-to-patient ratio on a given unit and they will be give completely different answers. Why is this? One likely reason is the perspective and roles of each side varies greatly. An administrator considers a completely different set of criteria than a nurse would for the same problem.

The Fix

If nurse-to-patient ratios are the foundation for safe, effective patient care then coming to an agreement on what those ratios should be is paramount. This requires open, honest communication between clinicians and administrators alike. Clearly defined and agreed upon criteria for what adequate staffing on each unit looks like gives everyone a solid foundation with which to start. Nurses are critical to helping define these standards in order to ensure that expectations are realistic.

The Problem: Accounting for Census Changes

There is no question that patient censuses can fluctuate dramatically in short periods of time. We've all left a shift with adequate staffing only to come back 12 hours later to twice the patients and half the staff. These variabilities are difficult to predict, although not impossible to prepare for.

While floating nurses to other units is a commonly used solution, it is a temporary fix and not always seen favorably with floor nurses. Why is floating such a dreaded event? There are many perspectives and reasons although most of these boil down to one common element- the unknown.

On any given shift, there is a lot a nurse can know ahead of time and a lot they cannot. We can know our units- where the supply room or code cart is or the policy for various unit specific procedures and processes, on the other hand we can't know our patients, their conditions, or what may happen over the course of a shift until we are there. Floating to new units takes away the piece of the shift we can know.

The Fix

One option is to give nurses to chance to choose two separate units to work on and then provide full orientations to both units. Allowing nurses the choice of an extra unit gives them some element of control, additionally the orientation gives them the chance to be more comfortable and therefore safe on the unit. Furthermore, this would have the added benefit of reducing potential burn out from being in are place too long.

Another option is to hire nurses specifically as float/pool nurses. Setting the expectation at the time of hire for their role and work expectations will allow the hospital and nurse alike to find and fill roles that fit both parties.

The Problem: Nursing Burn Out and Turn Over

It's a true "chicken or the egg" type question: does short staffing cause nurse burn out or does nurse burn out cause short staffing? There are good arguments for either side, however ultimately addressing both issues is crucial.

The Fix

Hospital administrators have many parameters they use to measure their hospital's success. There are internal considerations such as patient satisfaction surveys and even employee surveys as well as external influences such as various accreditations that can elevate a hospital's standing. Including safe nurse-to-patient staffing ratios as a unit of measurement for success and then getting "dinged" every time a unit operates without appropriate staffing aligns nursing priorities with administration priorities.

This alignment of goals puts everyone on the same page. Which, in turn, helps nurses feel protected by their hospitals leading to a reduction in nurse turn over. All in all, it is mutually beneficial to ensure safe nurse-to-patient ratios.

The Best Chance for Change?

While short nurse staffing can be difficult problem to address, it is not impossible manage. Ultimately, the best chance for change has everyone working towards the same goals: safe, effective, compassionate care for our patients.

What are some of the issues you've found that contribute to under-staffing at your hospital?

What are some possible solutions?

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KellyM RN

About KellyM RN, BSN, RN

KellyM RN has 2 years experience as a BSN, RN and specializes in Pediatrics and Healthcare Content Marketing.

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Specializes in Med-Surg.

My unit is in a crisis.  Many nurses have moved on to other positions in the ER, ICUs and OR.  This is natural as I work in med-surg.   They haven't replaced them and covid took all the travelers elsewhere.  In response administration has made ratios 6:1 and have had to deliberately keep the census low in our unit.  We immediate get a new admission when we discharge someone.  

Three people, two new grads and an experienced nurse quit in the middle of their orientation because they see how hard it is.  So there is no help on the horizon.

I worked at least 16 weeks of overtime and stopped a couple of months ago because I was seriously burning out.  I've lost my filter and instead of being the compliant boomer worker I'm speaking out and writing letters.  In no uncertain terms am I going to put up with 6:1 ratios for much longer.  They've promised it will get better and I've noticed they try hard to hold patients in ER holding so as to keep us to 5:1 sometimes but usually not.

It's not always been this way and I'm being understanding and waiting but my patience is running out.

I don't know what the answer is but sadly for some of us the answer is simply to quit and move on because actually in this town the grass is greener elsewhere.

My unit has 36 beds and I'm the only nurse on the schedule for tomorrow so the census is going to be capped out to give me and another nurse willing to work overtime at 12 patients, 6:1 apiece.  This is their solution.  Not acceptable in the long run.

Thanks for listening.

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Specializes in Psyche Nursing, Med/Surg, LTAC.

Tweety I'm impressed that your hospital is actually working with you a little bit! Don't stop what you're doing. Keep writing letters and stressing how unsafe it is for patients when the nurses are stretched too thin. We all have to keep working for change. 

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Specializes in Med/Tely Coordinator.

Tweety I understand, we have the same situation at my hospital but they have been forced to accept 8:1 ratio. I feel like there is no one listening to nurses, we are all over worked, and stressed, new nurses are nervous just seeing us running around, 2 new RN didn’t complete their preceptorship. It is sad because we work hard regardless, we do it for the patients, but it’s not safe. 

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Specializes in BSN, RN, CVRN-BC.

It is a cycle.  Nurses leave for one reason or another and if administration can't replace them in a timely manner pretty soon another goes and as the staffing ratios get worse and the remain staff get burned out and leave.  Hospitals ought to have targets for the number of positions filled on each unit and when a unit drops below these numbers it should automatically alert them to use agency and perhaps get a contract nurse in to keep staffing from reaching a crisis point.  By the time the nursing ratio has gotten to 1:12 it is too late and it is going to take a lot of time and money to rebuild the staff on that unit.  New grads burning out before they can even complete orientations?  Agency and contract nurse might be expensive, but so is putting time and money into your new grads only to have them quit.

It is so sad that in many situations the only power that nurses have is to vote with their feet.

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Specializes in Cardiology.

I really like the idea of working 2 units. The mandatory ratio would be nice but for whatever reason nurses who get into upper management seem to forget where they came from and are more focused on making themselves look better so they can climb that next rung instead of making sure their colleagues have a safe working environment. 

I also think if hospitals paid nurses well for what they deal with on a daily basis you might see some drop in turnover. This past year we have seen hospitals pay for agency nurses. The whole "we don't have money" goes right out the window. 

Honestly nothing will change unless the culture changes. Right now nurses are being told to be more focused on customer service instead of taking care of the patient. You come to the hospital because you are sick. It is our job to be the advocate and to educate, not to get you food and be your personal servant. 

My last job was at a very well known hospital. For them it was cheaper in the long run to keep hiring new nurses so they didn't have to pay their senior nurses more. It's sad but true. 

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Mandatory minimum staffing ratios with significant financial penalties for failing to adhere to those ratios at all times.....this is the ONLY answer. Anything short of that is a waste of everyone's time.

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Specializes in Private Duty Pediatrics.
1 hour ago, OUxPhys said:

Honestly nothing will change unless the culture changes. Right now nurses are being told to be more focused on customer service instead of taking care of the patient. You come to the hospital because you are sick. It is our job to be the advocate and to educate, not to get you food and be your personal servant. 

You hit the nail on the head!

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Specializes in Community health.

I work outpatient and this is still a problem. We do not have “nurse to patient ratios” because the structure of working outpatient is completely different. But what is the same is being given an un-doable amount of work, and told that every item is supposed to be your top priority. Administrators will come and say “Why aren’t you (for example) screening every patient for depression, tobacco use, diabetic symptoms, street drug use, alcohol abuse, asthma control, up-to-date colonoscopy and mammography, and anxiety? You should be filling out all of these forms on every patient who walks in the door.”  They do not want to hear that tobacco screening is less important than depression screening, so the list of items to complete just grows and grows. 
 

When a nurse quits, she often isn’t replaced, leaving everyone else to desperately try to handle her workload. And, as mentioned in the article, Covid has done a number on us. Because all the nurses used to work “On the floor” (ie, taking care of patients who come to the clinic, answering phones for triage, taking pharmacy calls, etc), but now they pull half the staff to vaccinate or swab noses. It is overwhelming. 

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
1 hour ago, CommunityRNBSN said:

I work outpatient and this is still a problem. We do not have “nurse to patient ratios” because the structure of working outpatient is completely different. But what is the same is being given an un-doable amount of work, and told that every item is supposed to be your top priority. Administrators will come and say “Why aren’t you (for example) screening every patient for depression, tobacco use, diabetic symptoms, street drug use, alcohol abuse, asthma control, up-to-date colonoscopy and mammography, and anxiety? You should be filling out all of these forms on every patient who walks in the door.”  They do not want to hear that tobacco screening is less important than depression screening, so the list of items to complete just grows and grows. 
 

When a nurse quits, she often isn’t replaced, leaving everyone else to desperately try to handle her workload. And, as mentioned in the article, Covid has done a number on us. Because all the nurses used to work “On the floor” (ie, taking care of patients who come to the clinic, answering phones for triage, taking pharmacy calls, etc), but now they pull half the staff to vaccinate or swab noses. It is overwhelming. 

Yes yes yes. Outpatient is no safe haven!  It's epidemic and everywhere (short staffing).

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Specializes in CMA, CNA.

I work in LTC and the song remains the same. We were so short staffed yesterday that they were offering $400 bonuses for Nurses AND MAs to just come in and pick up an afternoon shift. It's dangerous to both residents and staff, but I fear it's here to stay. God help us once we open up to the public-- Mom hasn't showered in a week? Hello state ?

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Specializes in Psychiatric Nurse.
8 hours ago, SmilingBluEyes said:

Yes yes yes. Outpatient is no safe haven!  It's epidemic and everywhere (short staffing).

This sounds just like inpatient... this form... that form. Everything to CYA of management in case the state shows up and 3 million times less of actual patient care... you know, that far away thing that made us all want to be nurses in the first place.  It's a business, sad but true.  A business before its about patient safety and care. 

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