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At Your Defense

At Your Defense

Ending the Vicious Nursing Shortage Cycle

Reyes, Carlo MD, JD

doi: 10.1097/01.EEM.0000559982.59726.f0
    nursing shortage
    nursing shortage:
    nursing shortage

    ED nursing burnout is getting worse over time. I fondly reminisce about the feeling I would get when I walked into my ED, saw all the familiar faces, and got ready to see a barrage of patients, knowing the nurses had my back and I had theirs. But seasoned ED nurses have left for greener pastures over the years, and hospitals have experienced ED nursing shortages.

    ED nurses left because of too much work and not enough gratification, an experience EPs share. We toil through each shift, lamenting the lack of experienced nurses. We practice inpatient medicine when we treat ED-boarded patients and hope that a bed (meaning nurse) becomes available to allow us to transport admitted patients out of the ED.

    I don't blame hospitals for striving to achieve efficiencies in care. They must to stay afloat. Trying to reduce overhead for ED nurse staffing and simultaneously improve ED metrics such as length of stay, patient satisfaction scores, and sepsis metrics, however, is like staring at two ends of a teeter-totter at the same time.

    Nursing Ratios

    The move toward nursing ratios started in California when legislation was passed in 1999 mandating a minimum nurse-to-patient ratio for acute care hospitals. (American Nursing Today. 2009;4[3]; Thirteen states soon followed. The intent seemed to make sense: Nurses should be limited to a maximum number of patients at a time to care for them safely.

    One unintended consequence of the California statute was that licensed vocational nurses and licensed practical nurses, accounting for up to 50 percent of licensed nurses on most units, suddenly could not be part of the nursing workforce to assist when satisfying the nursing ratio. (American Nursing Today. 2009;4[3]; This contributed to the nursing shortage in California, and acute care hospitals continue to struggle with nursing shortages because of this law.

    Nurses in California acute care hospitals have to work twice as hard as a result. This created burnout, and nurses had to work part-time, leave their jobs prematurely to work in less demanding environments, or change careers, perpetuating the vicious cycle of a worsening nurse shortage.

    To add insult to injury, new research suggests that staffing ratios, an approach found in some states intended to improve patient safety, don't seem to work. (Crit Care Med. 2018;46[10]:1563.) Physician researchers at Beth Israel Deaconess Medical Center in Boston studied whether the 1:1 or 2:1 nurse-to-patient ratios in ICUs improved patient safety. Compared with 246 medical centers throughout the country, patient outcomes were not improved.

    Unintended Consequences

    The natural response to the nursing shortage is to hire more nurses, but that is easier said than done. Because LPNs and LVNs cannot work in the acute care setting, the eligible nursing pool is smaller, and that forces hospitals to hire less experienced and even newly minted nurses in the hospital's most demanding setting: the emergency department.

    The upshot of this is less experienced ED nursing care and an increased medical-legal risk in the riskiest place in the hospital. Inexperienced ED nurses are thrown into the fire to treat unstable patients, and they are less able to identify and react to clinical changes in conditions. To compound this, inexperienced medical-surgical nurses are asked to come down to the ED to care for boarded patients in an unfamiliar environment, a potential recipe for a medical-legal disaster unless an experienced nurse helps these patients.

    An experienced nurse can rapidly evaluate and stabilize sick patients, initiate complex treatment protocols, stand up to physicians when necessary, and advocate for the best patient care, increasing the likelihood of positive patient outcomes. This is what was unwittingly sacrificed to the nursing shortage and may directly relate to worse patient outcomes. At a minimum, this can explain why the Beth Israel Deaconess Medical Center study on nurse staffing ratio has demonstrated no improvement in patient outcome.

    Addressing the Issue

    Nursing ratios assume an antiquated model for nurse staffing: One nurse is responsible for a number of patients. Acute medical care has evolved to team-based approaches, however. Physicians align their skills to treat a septic patient: the EP responds and stabilizes, the intensivist/pulmonologist continues critical care, the infectious disease specialist ensures optimal antibiotic regimens, the surgeon operates when necessary, and so on.

    Similarly, nursing models that incorporate a team-based approach may align better with shifting staffing demands in the ED and inpatient units. Initial stabilization, including IV access, time-to-treatment protocols, and code responses, can be managed initially by front-end triage nurses. Once stabilized, main ED nurses can continue care, reassess patients, and coordinate the transition to inpatient care. Additional staff should be utilized, including ED scribes, LVNs, and ED technicians, to ensure the completion of protocols and to inform EPs promptly of important results.

    My EP group has used a team-based approach in a California hospital that resulted in a substantial improvement in length-of-stay and sepsis metrics. Addressing the nursing shortage with a team-based approach gets us part of the way. The rest of the way is addressing the unpredictable fluctuations in ED and hospital census. The answer should not be to ask nurses to do more but to get them more support to do their jobs more efficiently. This will reduce the ill effect of the nursing shortage while restoring nursing (and physician) satisfaction and end the vicious nursing shortage cycle.

    Dr. Reyesis the vice chief of staff and the assistant medical director of emergency medicine at Los Robles Hospital in Thousand Oaks, CA. He is also a clinical professor in emergency medicine and pediatrics at Olive View/UCLA Medical Center, a health law attorney with Boyce Schaeffer Mainieri, LLP, in Oxnard, CA, and the founder and CEO of Health-e-MedRecord, a patient-centered and emergency physician-designed EHR solution. ( Follow him on Twitter@carloreyesmdjd, and read his past articles at

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