Nurses are the primary patient-facing members of most health care organizations and often the first point of contact for many people seeking medical care. They initiate screening exams, draw blood, administer medications, provide education and counseling, and are often the customer service side of any facility. My hospital once ran a campaign called “Nurses are the one you remember,” but now it unfortunately seems that hospitals are not remembering the nurses.
This country currently faces a massive nursing shortage that began long before the pandemic. Hospitals have tried everything to compensate, from adding additional shifts to a nurse's already full-time schedule to increasing patient loads and bringing in expensive travel nurses. (Modern Healthcare. Sept. 16, 2021; https://bit.ly/3dwnlp8.) These solutions create their own problems.
The first is that higher patient loads can lead to delays in evaluation and treatment. Data from the Emergency Department Benchmarking Alliance demonstrated that the percentage of patients who leave a hospital's emergency department before treatment is completed is more strongly correlated with nurse staffing than the total number of patients being seen. (Am J Emerg Med. 2016;34:155.) Hospitals in Massachusetts, Illinois, and Delaware also reported that higher nurse-to-patient ratios led to longer wait times and subsequent higher numbers of patients who leave without being seen. (J Emerg Nurs. 2017;43:138; West J Emerg Med. 2018;19:496; Acad Emerg Med. 2004;11:459; https://bit.ly/32WJtHd.) Problems with poor staffing ratios is not a uniquely American phenomenon. Administrative data from public hospitals in Victoria, Australia, found that overall ED lengths of stay are directly correlated with the number of nurses on duty. (Emerg Med J. 2010;27:508; https://bit.ly/3rHXq6n.)
Waiting room times can be a source of bragging rights for many hospitals, but real harm results when busy nurses cannot see a patient right away. An investigation of inpatient safety funded by the Agency for Healthcare Research and Quality found that a decrease in a hospital unit's total nurse staffing times by just eight hours resulted in a two percent higher rate of death. (N Engl J Med. 2011;364:1037; https://bit.ly/3rIBqrW.)
The numbers are even bleaker among surgical patients. Data from postoperative cases at hospitals in Pennsylvania, Florida, New Jersey, and California demonstrated that adding one additional patient per nurse is associated with an eight percent increased chance of readmission (Int J Qual Health Care. 2016;28:253) and a seven percent increased chance of dying within 30 days. (JAMA. 2002;288:1987; https://bit.ly/3rGnCON.) Again, the United States is not the only place where poor nurse-to-patient ratios are associated with bad outcomes. Each additional patient in South Korean hospitals is associated with a five percent increase in patient death within 30 days of admission. (Int J Nurs Stud. 2015;52: 535.)
The Pennsylvania JAMA study above also found that adding one more patient was associated with a 23 percent increase in the odds of burnout, which will inevitably lead to job turnover. Inadequate staffing in surveys of nurses from Arizona to Oman continues to be a key predictor of career dissatisfaction. (Am J Crit Care. 2021;302]:113; J Nurs Scholarsh. 2020;52:95.)
Other elements of a poor work environment include loss of decision-making autonomy, lack of participation in hospital affairs, and a lack of recognition. American hospitals currently use many layers of hierarchy between frontline nursing staff and administrators that can lead nurses to feel as if their concerns cannot be addressed by their immediate supervisors. Problems brought up at the local clinical level are often met with unsatisfactory answers that seem to serve the interests of the company over the interests of the patient.
Patient satisfaction scores also decrease. (J Nurs Care Qual. 2021;36:7; https://bit.ly/3lLd3Gq.) Staff cannot address customer service requests such as warm blankets, pillows, on-time medication administration, or other reasonable and expected amenities with so many patients assigned per nurse. Unhappy nurses make for unhappy patients.
The nursing profession can be dangerous. The majority of American nurses reported over the past year that they had been verbally abused by patients and family members. (Workplace Health Saf. 2021 Aug 3;21650799211031233; https://bit.ly/3rJFisT.) Many had also experienced physical violence. Curiously, patients with COVID-19 are more than twice as likely to be perpetrators of abuse compared with all other patients. I graduated medical school more than a decade ago, and have witnessed firsthand an increase in bad behavior among our patients who come to the ED. Clearly, some remedies are needed.
The first real solution involves decreasing the number of patients per nurse. The American Academy of Emergency Medicine issued a position statement on staffing ratios 21 years ago calling for a nurse-to-patient ratio of 1:3 in addition to having dedicated triage and charge nurses. (AAEM. Feb. 22, 2001; https://bit.ly/339a7wN.) Yet many hospitals still assign four or even five patients per nurse.
California was the first state to mandate minimum nurse staffing based on patients' illness severity. These rules took effect in 2001 and led to an expected outcome of decreased waiting room times and decreased overall length of stay times in emergency departments. (Acad Emerg Med. 2010;17:545; https://bit.ly/31F199C.) Adding extra staff paradoxically need not be expensive. Queensland, Australia, introduced mandatory ratios in 2016 that decreased deaths and readmissions while saving the medical system millions of dollars. (Lancet. 2021;397:1905.)
Hospitals also need to grow their nurses by providing in-house continuing education. They should also be willing to pay for university courses. Doing so shows a commitment to their employees. My facility has historically offered training in using ultrasound to place intravenous lines and sexual assault nurse examiner certification. We also offer tuition assistance to registered nurses so they can work on getting a bachelor's degree. Having a more educated workforce pays dividends. Research from the United States and Europe has demonstrated that having more nurses with bachelor's degrees is correlated with lower rates of patient death. (Med Care. 2011; 49:1047; Lancet. 2014;383:1824.)
Finally, hospitals need to work on their culture and improve the work environment. Places where doctors and nurses have good working relationships, nurses are involved in hospital affairs, and management responds to safety concerns are linked to lower patient mortality. (J Nurs Adm. 2008;38:223; Health Serv Res. 2008;43:1145; Med Care. 2011;49:1047.)
Hospitals can fight the continued nursing shortage by decreasing nurse-to-patient ratios, investing in employee education, and improving the work environment. These steps result in measurable benefits by decreasing death rates and burnout and potentially saving money in the long run.
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Dr. Aycockis an emergency physician at West Florida Hospital in Pensacola, FL, and is a clinical assistant professor at Florida State University College of Medicine.