What’s It Gonna Take to Improve Nurse Staffing?

From otisarchives4, via Flickr

From otisarchives4, via Flickr

It’s easy to forget that nurses are the ones who will continue to provide most of the care in whatever health care system we end up with in the coming years. Unfortunately, two recent announcements about how nurses rated staffing and workloads gave me a nasty sense of déjà vu.

On July 6, the American Nurses Association (ANA) announced the results of an online survey it conducted for several months last year: 70% of the 10,000 plus respondents say staffing is insufficient; 52% said they are considering leaving their job (of these, 42% say it’s because of inadequate staffing). Slightly more than 35% say they “rarely or never” are able to take full meal breaks. Over half say the quality of care has declined and almost half (49.5%) are unsure if they’d want someone they care about treated in the facility in which they work.

And a survey of 2,203 nurses from 11 countries shows that nurses around the world have the same issues. On July 1, at its meeting in Durban, South Africa, the International Council of Nurses (ICN) released the results of a survey it conducted in collaboration with Pfizer. It found that 46% of nurses say that compared to five years ago, the workload today is worse. The conclusion? “’Staffing issues’ appear to be the most important problem facing nurses on a global basis.”

So why the déjà vu? Back in 1996, AJN published the AJN Patient Care Survey. Author Judith Shindul-Rothschild noted, “Nurses across the nation, in every setting and specialty, report that they’re taking care of more patients, have been cross-trained to take on more nursing responsibilities, and have substantially less time to provide all aspects of nursing care.” Of the 7,560 respondents, 40% said they wouldn’t want a family member to be a patient in their facility.

Sound familiar? That was 13 years ago. I remember reading it and thinking, “Now we have data; now hospitals will take note.”

Then in 2001, the Agency for Healthcare Research and Quality (AHRQ) published Making Health Care Safer: A Critical Analysis of Patient Safety Practices. In the chapter on nurse staffing and models of care delivery, it noted that “richer nurse staffing is associated with better patient outcomes.” In 2002, Linda Aiken in JAMA and Jack Needleman in NEJM each published data linking inadequate staffing to complications and poor patient outcomes. In 2003, the Institutes of Medicine (IOM) published Keeping Patients Safe: Transforming the Work Environment of Nurses, which reaffirmed nurses’ pivotal role in safe patient care and put forth several recommendations to change workplace practices.

Well, I thought, now we’re cooking: when the IOM speaks, people listen.

How has it happened that we have made such little progress in seven years that the primary work environment for our profession still doesn’t allow us to do what we should be doing for our patients? How is it that even with hard data, nursing can’t make the case for nurse staffing as the key to not just safe but quality care? Why is it so much easier for hospitals to invest in technology that has not been proven to improve outcomes? While the literature suggests Magnet hospitals offer better staffing and a better work environment, nurses at many still have serious concerns about staffing. (In June, nurses in a Magnet facility in my northern New Jersey neighborhood struck over staffing issues.)

Next week, the IOM is embarking on another nursing initiative: the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, at the Institute of Medicine. I’m optimistic because the RWJF has a stellar track record in creating initiatives that work for nursing—its myriad nursing leadership programs and its Transforming Care at the Bedside initiative (a joint project with the Institute for Healthcare Improvement) are cases in point.

But meanwhile, I’d like to know: is there a hospital out there where the staff nurses wouldn’t echo the results of these recent surveys?

Shawn Kennedy, MA, RN, AJN editorial director
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Editor-in-chief, AJN


  1. sfoleyajn July 13, 2009 at 9:20 am

    Shawn, thanks for this post — I really hope the RWJF’s involvement helps shake things loose a bit, before another 13 years go by. Those so inclined might also check out Lynn Unruh’s article, which appeared in AJN in Jan 2008 (full disclosure: I was the editor). Unruh conducted an extensive literature review covering the impact of nurse staffing levels on nurses, patients, and hospital finances. She also came up with several recommendations, and spoke specifically about the need for “an evidence-based, standardized measure of workload in which the effects of all known contributing factors are assessed.” Here’s the link: http://bit.ly/1aV1c. (Open the PDF for the cleanest read.)

  2. geena July 12, 2009 at 12:17 am

    I myself find that my unit in my hospital is staffed very well. We almost always have the charge nurse free AND a dedicated break nurse to provide breaks and lunches.

    I have complaints about where I work, but staffing is definitely not one of them!

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