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?
Specializes in Community Health, Med/Surg, ICU Stepdown.
2 hours ago, JKL33 said:
Where I have worked per diems are the least of the problems and are often the ones who do have experience.
Same. Where I worked per diems were experienced nurses who could fill in and often ended up helping out when emergencies happened.
I enjoy working with a variety of age groups. The older nurses I've worked with have taught me so much, and most keep up with current evidence based practice and can discuss how nursing has changed. Us younger nurses teach them how to use the EHR, let them know what scrubs are trendy (although my 56 year old coworker said she'll never wear $60 Figs skinny leg scrub pants!), and introduce them to nursing memes and TikTok.
I think we need to leave behind the generalizations about different age groups, for example that older nurses are stuck in their ways and their practice is outdated, or millennials are lazy and want constant positive feedback. I'm sure there are some nurses who act like this, but not the majority. We don't need to add interpersonal judgment on top of the toxicity management already generously provides.
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.
No I will not, every RN job I had had rusty entitled per diems who would never come in when needed (literally the whole point of per diems) and complained all night about their assignment.
Also to add insult to injury, they were oddly confident in their skills and knowledge which was poor to fair at best.
The only half decent ones were in school to be an NP or something and at leas they had a decent attitude.
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.
Yup I am sure you don't cherry pick those precious 4 shifts months too. Nope not at all.
Oh noes, the point and click dreaded nursing "education and certifications". How awful. Yes Ctrl-P CNE and ACLS/BLS every 2 years is such a drag.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
7 hours ago, Numenor said:
Yup I am sure you don't cherry pick those precious 4 shifts months too. Nope not at all.
Oh noes, the point and click dreaded nursing "education and certifications". How awful. Yes Ctrl-P CNE and ACLS/BLS every 2 years is such a drag.
and what if I did???? That was my right. I did not get benefits and was guaranteed no shifts. Oh and by "cherry picking" well that would mean, I worked weekends/nights. Not exactly prime shifts.
You refer to us as rusty, but we maintain our skills and continuing education. So no was are not at all "woeful". I maintained certification in my specialty, something that not only requires time but lots of continuing education.
You, my friend, sound woefully bitter and jealous.
Wow the attitudes about per diem nurses sucks here. No gratitude.
It's why I quit working PRN once I had a year in dialysis. I got the crappiest assignments. Most staff, and some management, acted like I was the step cousin that didn't deserve to be there. In subsequent years I've gotten the "why won't you come help us anymore?" calls. I like my sanity and self respect more than I need money
No I will not, every RN job I had had rusty entitled per diems who would never come in when needed (literally the whole point of per diems) and complained all night about their assignment.
Also to add insult to injury, they were oddly confident in their skills and knowledge which was poor to fair at best.
The only half decent ones were in school to be an NP or something and at leas they had a decent attitude.
Lucky You. I encountered about the same with staff at the last facility I worked.. After mgmt made enough of a mess to cause a big turn-over what they were left with was garbage. Made worse by mgmt's acceptance. So perdiem-sneum, it ain't restricted to per diems.?
This staffing thing as some have mentioned is nothing new. It's a cycle of sorts. Though that cycle will increasingly shift faster thru it's phases up/down/up/down due to one big change yet mentioned in the thread and that's the add-on of Admin jobs/time. See chart below for what I mean.
I worked with top notch diploma nurses, great CNA's & good facilities here and there. Decent pay as staff and better pay as travel. I only left due to the ever increasing workload as someone mentioned without their being a balance of what was added by taking something else away. Just add, add, add. It was real obvious that mgmt was in it for itself only. Much like a parasite.
The avg. good nurse who loves nursing is gonna be hard pressed to find that sterling facility to work at. I know they are out there, but I think they're getting harder to find.
Lastly, when I left I went to no job. I just left.
So at a recent “town meeting” a nurse stood up to verbalize to our CNO our desire to provide good patient care which cannot happen with the bare bones staffing we have. His response to her…”Amazon is hiring”.
So at a recent “town meeting” a nurse stood up to verbalize to our CNO our desire to provide good patient care which cannot happen with the bare bones staffing we have. His response to her…”Amazon is hiring”.
I have no words.
If only the public knew.
I think they know but what choice do they have ? Hospitals are your best or only chance
I think they know but what choice do they have ? Hospitals are your best or only chance
I don’t think they really do. We put on a front that convinces them that everything is okay when they are actually at risk because we are stretched too thin. Woe be to the nurse that even hints at our staffing situation.
I don’t think they really do. We put on a front that convinces them that everything is okay when they are actually at risk because we are stretched too thin. Woe be to the nurse that even hints at our staffing situation.
Here in New England they are woefully aware. There has been a pop up of concierge medicine service just due to the fact that hospitals and offices are so backed up. It may be location dependent it is just so painfully aware of the presentation of patient safety and the reality of the opposite in this part of the county
LibraNurse27, BSN, RN
972 Posts
Same. Where I worked per diems were experienced nurses who could fill in and often ended up helping out when emergencies happened.
I enjoy working with a variety of age groups. The older nurses I've worked with have taught me so much, and most keep up with current evidence based practice and can discuss how nursing has changed. Us younger nurses teach them how to use the EHR, let them know what scrubs are trendy (although my 56 year old coworker said she'll never wear $60 Figs skinny leg scrub pants!), and introduce them to nursing memes and TikTok.
I think we need to leave behind the generalizations about different age groups, for example that older nurses are stuck in their ways and their practice is outdated, or millennials are lazy and want constant positive feedback. I'm sure there are some nurses who act like this, but not the majority. We don't need to add interpersonal judgment on top of the toxicity management already generously provides.