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.
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?
We must accept that you can’t be exploited unless you allow yourself to be . Although there are a lot of steaks involved when deciding what is worth fighting for
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
1 hour ago, PMFB-RN said:
I'm well aware that not all hospitals are unionized. But Ill never work in another non union hospital and nobody else should either.
I think that's great. But entire states block unions. The only choice for a nurse then is to move out of state; tough pill to swallow for so many. Striking in a non-union environment is very intimidating as you know.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
22 hours ago, SmilingBluEyes said:
I think that's great. But entire states block unions. The only choice for a nurse then is to move out of state; tough pill to swallow for so many. Striking in a non-union environment is very intimidating as you know.
I spent 3+ years researching where the best place to work as an RN would be for ME. I worked in four states & two countries as a staff RN, and another four states as a traveler. I have a huge network of ICU & ER RN friends around the country.
I discovered that the Twin Cities area of Minnesota has the highest RN pay in the country, relative to cost of living, and that if I drove across the river into Wisconsin to live my COL would be much lower. So I moved my family across the country from California to Wisconsin (to live) and Minnesota (to work).
Now I make well into six figures as a staff RN ($137K in 2020) and live is a fantastic small town in a beautiful home we paid $120K for in 2019.
I know that's not an option for everyone. But I also don't think many nurses ever realize just how much greener the grass can be.
Things I have found indicate a hospital is likely to be a good place to work:
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
14 hours ago, PMFB-RN said:
I spent 3+ years researching where the best place to work as an RN would be for ME. I worked in four states & two countries as a staff RN, and another four states as a traveler. I have a huge network of ICU & ER RN friends around the country.
I discovered that the Twin Cities area of Minnesota has the highest RN pay in the country, relative to cost of living, and that if I drove across the river into Wisconsin to live my COL would be much lower. So I moved my family across the country from California to Wisconsin (to live) and Minnesota (to work).
Now I make well into six figures as a staff RN ($137K in 2020) and live is a fantastic small town in a beautiful home we paid $120K for in 2019.
I know that's not an option for everyone. But I also don't think many nurses ever realize just how much greener the grass can be.
Things I have found indicate a hospital is likely to be a good place to work:
1) Union
2) Publicly owned
3) No religious affiliation
4) NOT Magnet
5) Located in an area that gets a lot of snow
I am tempted all the time to move back to the Minn/Wisconsin area. One of my kids lives there and I would love to be near his family. But right now, real estate is RIDICULOUS (even in smaller towns in the area). I would like to get ahead since I have a lot of equity in the home I own now----not barely break even or do worse. Any such move will have to wait. But I agree MSP is a great area to be a nurse. I would like to do so, if I don't end up retiring first. I am getting closer every day. And I can't wait.
1.Another factor is that nursing is female dominated. I can't tell you how many times we have had new nurses come in and work 2-3 years, start to have kids then go per diem. Per diem nurses are essentially useless as many work the bare minimum which varies by hospital.
I am just stating my observation but this does play some sort of a role, not saying its good or bad.
2. The other factor is work force drain 2/2 higher education. I am an acute care NP and have had dozens and dozens of nurse techs, barely 21, ask me questions and tell me that as soon as they finish RN school they are headed for their NP. Terrible idea.
I am retired, but used to work per diem. You should be grateful that there are per diem nurses who can work a shift or two per month. It is better than nothing. Per diem does not get any benefits or guarantee of work, so the cost is nothing to a hospital.I also suspect some jealousy towards per diem because financially they do not need to work full time.
I am retired, but used to work per diem. You should be grateful that there are per diem nurses who can work a shift or two per month. It is better than nothing. Per diem does not get any benefits or guarantee of work, so the cost is nothing to a hospital.I also suspect some jealousy towards per diem because financially they do not need to work full time.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
1 hour ago, LokelaniRN said:
I am retired, but used to work per diem. You should be grateful that there are per diem nurses who can work a shift or two per month. It is better than nothing. Per diem does not get any benefits or guarantee of work, so the cost is nothing to a hospital.I also suspect some jealousy towards per diem because financially they do not need to work full time.
I felt it keenly when I was per diem in the hospital back when I had young children. A lot of people gave me the crappiest assignments and were very brusque with me. I chalked it up to burnout and frustration. And yes, jealousy.
I am retired, but used to work per diem. You should be grateful that there are per diem nurses who can work a shift or two per month. It is better than nothing. Per diem does not get any benefits or guarantee of work, so the cost is nothing to a hospital.I also suspect some jealousy towards per diem because financially they do not need to work full time.
No I am not grateful. I was an ICU charge who would have to deal with per diem nurses coming in on their mandatory 3 shifts or whatever a month. They were woefully rusty in every sense of the word and in general did not add value to the team. Just hire a competent traveler and eat the cost.
Yup total jealously now that I make 90k more than my RN pay....
They were woefully rusty in every sense of the word and in general did not add value to the team. Just hire a competent traveler and eat the cost.
Heh heh.
Just chuckling here at woefully rusty. I picked up even more PRN work when hospital would start begging about..."yes there are technically enough nurses but we need an ED nurse..." or "we need another person who can take care of sick patients..." < actual statements; not infrequent. It also wasn't rare to find myself de facto CN because a lot of hairy situations arise in the ED and a decent number of these people are deficient in even the basics, like applicable laws. For some, their idea of what's correct is whatever came out of administration's mouth most recently. Scary. Where I have worked per diems are the least of the problems and are often the ones who do have experience.
Either way you should amend your statement to say that you worked at a place that didn't make good choices about per diems, if they were actually woefully rusty.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I was not "woefully rusty" working my mandatory 4 shifts a month. I had to keep up my education and certifications like anyone else. And versus travelers, the nurses at least knew me.
Wow the attitudes about per diem nurses sucks here. No gratitude.
glasgow3
196 Posts
A lot of steaks involved? emmmmmmmm sounds yummy