By Sarah Delgado, MSN, RN, ACNP
The phenomenon of inappropriate nurse staffing as a reason for nurses to leave their jobs is an epic catch-22: Poor staffing causes nurse attrition, and nurse attrition sustains poor staffing. The COVID-19 pandemic raised awareness about inappropriate nurse staffing and may accelerate this dangerous cycle.
What is the solution to poor nurse staffing and high turnover in acute and critical care nursing? There is no simple answer, so we must seek solutions through multiple approaches. Let’s take a closer look at some of the issues that contribute to nurse staffing challenges, as well as six strategies that can make a difference.
Nurse Staffing Issues
Nurse turnover: Patient care is not what drives nursing turnover. Nurses leave their jobs based on factors such as a lack of administrative support, unhealthy work environments and inappropriate staffing, all of which can be frustrating barriers to effective care delivery. Hospitals compete to hire nurses but sometimes neglect incentives that can contribute to nurse retention, such as opportunities for professional development and a voice in the decisions that affect their work.
Nurse well-being: Burnout, moral distress, compassion fatigue, anxiety, depression and post-traumatic stress disorder (PTSD) threatened nurse well-being before the pandemic. Early studies (and common sense) indicate that COVID-19 has magnified these issues. Nurse well-being partly depends on developing resilience, the ability to adapt to stressful situations and experience growth. For some nurses who encounter insurmountable threats to their well-being, resilience means finding a different job. In the absence of interventions to comprehensively address nurse well-being, nurse turnover is likely to increase.
Patient safety: Staffing doesn’t only affect nurses. A growing body of research links nurse staffing to patient outcomes in the United States and other countries. For example, a large, prospective, quasi-experimental study published in May 2021 showed that better nurse staffing in medical-surgical units in Queensland, Australia reduced patient mortality, lowered readmissions and shortened hospital length-of-stay.
Another study conducted in Finland prior to the COVID-19 pandemic noted a correlation between nurse staffing in intensive care units (ICUs) and multi-organ failure in patients. The study evaluated staffing based on nurse-to-patient ratios and also measured nursing workload based on patient acuity. The researchers found that their measure of understaffing based on patient acuity occurred more often than understaffing defined by a simple ratio. In other words, even when the expected nurse-to-patient ratio was met, patient acuity indicated a need for more nurses.
The experience-complexity gap: As described in an AACN blog, the experience-complexity gap is a key issue in nurse staffing. Patient care is increasingly complex, and high turnover may prevent nurses from developing a full range of experience to meet patients’ needs. Considering only the number of nurses – and not their level of experience – offers a shortsighted view of patient care resources.
Outdated Hospital Payment Models: Most hospitals pay direct care nurses by the hour and view nurses as an operating cost. This view is similar to the industrial model used in factories. However, when the product is patient care, the industrial model is a dangerous paradigm. Nursing care is not a single step in an assembly line of patient hospitalizations. Nurses ensure patients are safe, help prevent complications, monitor changes in their status, ease symptoms and provide treatment and emotional support. As noted in “AACN Guiding Principles for Appropriate Staffing,” an industrial model fails to capture the essential value of nursing.
Six Strategies To Advance Nurse Staffing
The issues related to nurse staffing are complex. Following are a few ideas for moving forward.
- Include direct care nurses in staffing decisions While leaders and administrators have expertise regarding staffing, input from direct care nurses who understand the work is crucial. Direct care nurses must be represented in all staffing decisions. Within an organization, nurses can be represented through shared governance structures or given paid time to attend hospital-based staffing committees. Another strategy is to start a new committee, such as the unit-based staffing committee created by an AACN member and her colleagues to ensure they had a voice at their organization.
- Examine the nursing workload Implementation of appropriate staffing also involves examining how nurses spend their time. For example, members from one innovative unit shared their efforts to decrease patient falls. In examining care delivery, they realized that nurses spent a lot of time moving back and forth across the unit. As a result, the team changed their staffing model to incorporate unit geography and saw a decrease in patient falls. Similarly, the editor of Critical Care Nurse recalls being a new nurse and questioning a long-standing practice in her unit. Her simple inquiry about the evidence for routine baths every 12 hours led to a practice change that reduced nursing workload. It’s always worth asking a question if a process or task seems unnecessarily cumbersome.
- Look at time spent documenting in the electronic health record (EHR) Recent research demonstrates that the usability of the EHR directly impacts nurse job satisfaction and patient outcomes. This relationship can be addressed by including direct care nurses when evaluating EHR systems and seeking strategies that improve usability and streamline documentation.
- Delegate to ensure team member contributions Delegating tasks and leveraging the contributions of other team members can help nurses focus on the care they uniquely provide. Just like any other clinical skill, delegation gets better with practice. Watch AACN’s webinar about delegation, which describes this skill and its impact on implementing new staffing models during COVID-19 surges. In your next shift, identify one task you can let go of and another team member who could pick it up.
- Use a different skill mix to meet patient care needs After examining workload and considering tasks to delegate, it may be time to question long-standing approaches to nurse staffing. The needs of patients on any given unit are likely not the same as they were five years ago. It may be worthwhile to examine team composition and seek new approaches to safe nurse staffing. AACN’s Clinical Scene Investigator (CSI) project “Teamwork Leads to Dreamwork” features one example of finding a new approach. The CSI team analyzed the care their unit provided and found they could shift the skills mix to include more certified nursing assistants (CNAs). This cost-effective approach improved collaboration between CNAs and registered nurses (RNs) and the efficiency of care delivery.In another example, a hospital faced an increased demand for trauma care. They formed a trauma team that included both ICU and emergency department (ED) staff. Their unique skills combined to create greater efficiency in specialized care delivery for their higher volume of patients. Both of these examples reflect a deliberate effort to move away from “We’ve always done it this way” and toward “Let’s try something new.”
- Advocate for appropriate staffing Nurses and nurse leaders need a comprehensive approach when advocating for appropriate staffing. A few specific suggestions include:
- Leverage cost data: In a session at AACN’s National Teaching Institute & Critical Care Exposition (NTI), nurse leader Nancy Blake urged her fellow nurse leaders to use data when advocating for appropriate staffing. She cited a report from NSI Nursing Solutions that estimates nurse turnover costs an average hospital $3.6 million to $6.5 million per year. The same report notes that each percent change in nurse turnover will cost or save an additional $270,800 per year. Gathering unit-specific data regarding the cost of recruiting and orienting new nurses and the cost of supplemental staff, such as travel nurses, helps build the case for investing in appropriate staffing and nurse retention.
- Look at acuity, not just numbers: Data that accurately captures patient acuity can also inform safe nurse staffing decisions. In an AACN interview, Therese Fitzpatrick notes that looking at patient census at a single point in time, such as midnight each day, fails to accurately capture nursing workload, which is driven by patient complexity, not just the number of patients. Analysis of EHR data can create a more comprehensive understanding of patient care needs and the skill mix required to meet them.
- Partner with information technology experts: An AACN nurse story involving Children’s Hospital Los Angeles describes the implementation of Clairvia, a workforce management technology tool that uses clinical documentation data to calculate patient acuity in real time. Charge nurses use the system to adjust assignments, and the hospital’s finance department reviews the data to understand staffing needs. Implementation of this system required nurse leaders to partner with technology experts and finance leaders.
Staffing and The Acute and Critical Care Work Environment
Appropriate staffing is one of six AACN Healthy Work Environment (HWE) Standards. The others are:
- Skilled communication
- True collaboration
- Effective decision making
- Meaningful recognition
- Authentic leadership
Each of these standards requires deliberate attention to achieve effective implementation, and all are interrelated. Consider how the strategies described above to promote appropriate staffing can influence implementation of the other five HWE standards:
- Including direct care nurses in staffing decisions is a form of effective decision making
- Identifying an appropriate nursing workload requires meaningful recognition of nurses’ unique contributions
- Delegating is a specific type of skilled communication
- Implementing new approaches in the skill mix requires true collaboration
- Advocating for appropriate staffing is an act of authentic leadership
In units that implement AACN’s six standards, fewer nurses report an intent to leave. To build a case for implementing the HWE standards, consider this review of the evidence that shows the relationships between the health of the work environment, staffing and patient outcomes. AACN also offers a free work environment assessment tool to help units start implementing the standards. Just as poor staffing is sometimes a reason to leave a nursing position, a healthy work environment is a reason to stay.