Just imagine you or a loved one were admitted to the hospital and had to wait an extended period to receive the care desperately needed. Would that sit right with you?
It has been stated time and time again that there is a nationwide shortage of nurses, but is that the problem?
Nursing, the largest healthcare profession within the U.S. with over 5 million active registered nurses, still needs to improve to maintain safe staffing ratios to improve patient care. There is not a shortage of nurses, but a shortage of nurses willing to work in stressful and unsafe conditions.
The daunting physical, mental, and emotional stress experienced by those in the nursing profession leads to decreased work satisfaction and extreme burnout. This is a primary driving force for those quitting their jobs or leaving the profession.
Safe staffing is essential to reported nurse satisfaction and contributes significantly to improving patient outcomes, minimizing on-the-job injuries, and decreasing medication errors. All of these factors can cost patients their lives!
As an Intensive Care Unit nurse, I love what I do. Nursing can be a gratifying career, but success depends on the support and resources available. Working during COVID-19, I saw firsthand how patient conditions can suffer when staffing is inadequate.
Currently, 16 states have addressed nurse staffing through regulations and laws, but only two have addressed and mandated nurse-to-patient ratios. In May of 2021, a bill was introduced to the Senate and House of Representatives regarding federally mandated safe nursing standards, which dictate hospitals’ responsibilities and expectations, nurse-to-patient ratios, and unsafe working conditions to which nurses may object. Unfortunately, that seems to be where it ended – an introduction. There has been no movement on this bill since May 13, 2021. In April of 2023, this bill was reintroduced to the House of Representatives and the Senate. However, as of March 2023, it remains an introduction, and no further action has been taken.
We MUST do more! Given this “post-COVID Surge Era,” in which many nurses have either left the bedside or retired early due to working conditions, we must put increased pressure on our state and federal legislators to create more ironclad state regulations and ultimately “end all, be all” federal laws.
This can be done by writing to state representatives and urging them to vote in favor of bills H.R. 2530 and S.1113, currently active in Congress. These bills, which outline clear and safe nurse staffing ratios, were introduced to the House of Representatives and the Senate.
Remember, these individuals are not nurses and may not understand how significant these bills are to improving patient outcomes. It is up to us to continue bringing this concern to the forefront. Increasing awareness will bring change, and this change will lead to a safer and happier healthcare system.
The American Nurses Association (ANA) underscores the urgency for Congressional leaders, the Centers for Medicare & Medicaid Services (CMS), and other key stakeholders to advance efforts in implementing safe staffing standards, including minimum nurse-to-patient ratios.
The nurse staffing crisis demands a national dialogue with nurse-led approaches to help ease longstanding work environment challenges that nurses face across numerous specialties and healthcare settings. ANA supports minimum nurse-to-patient ratios enacted by nurse-centered committees dependent upon key factors such as patient acuity, intensity of the unit practice setting, and nurses’ competency, among other variables.
“ANA’s goal is to empower nurses and position them for success. Embracing setting specific ratios for nurses should be viewed as only one piece of a much larger solution. We’re still working to address other longstanding workforce challenges that have dramatically worsened the nurse’s staffing crisis, such as burnout, workplace violence, mandatory overtime, and barriers to full practice authority, says ANA President Jennifer Mensik Kennedy, PhD, MBA, RN, NEA-BC, FAAN.
“Studies have shown unsafe staffing negatively affects patient care outcomes and the well-being of nurses. According to the American Nurses Foundation’s national workplace survey of nurses, 31% of nurses are required on a weekly basis to work beyond their scheduled shifts to provide adequate care to patients. And the National Council of State Boards of Nursing says a quarter to half of the nurses reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out (45.1%), or at the end of the rope (29.4%) “a few times a week” or “every day.”
“We urge health care leaders and policymakers at all levels to effect the necessary change, but we must not underestimate the power of nurse advocacy. Direct care nurses have special relationships with their patients, imparting unique insights into patient care and the dynamics of the practice setting. That is knowledge that can’t be matched. Nurses are the most trusted professionals in the U.S., especially among healthcare consumers, so we should both trust and empower them to be the decision-makers on how to improve their work environment and deliver the best patient care,” says ANA Enterprise CEO Loressa Cole, DNP, MBA, RN, NEA-BC, FAAN.
ANA’s call for staffing solutions that include ratios was voted on and approved at its 2022 Membership Assembly, the official voting and governing body of the association, which led to nearly 400 members of ANA convening on the U.S. Capitol to petition Congress to address the national nurse staffing crisis last month. ANA is not only advocating but seeking solutions, launching the Nurse Staffing Think Tank in 2022 in partnership with other leading organizations, which produced a series of actionable strategies that healthcare organizations could implement within 12 – 18 months. In May 2023, the Nurse Staffing Task Force identified another 65 proposed long-term recommendations to spur innovation, policy, and regulatory action, encourage new care models, and effectively support direct care nurses and nurse leaders.
ANA continues to advocate for nurses, remain a collaborative partner, and call on Congress to enact meaningful legislation and policies that improve nurse staffing and work environments. ANA provides nurses at all levels key resources to help inform advocacy and approaches to address the nurse staffing crisis.
New York nurses are going to play a key role in forming and implementing safe hospital staffing policies. On June 18, Governor Andrew Cuomo signed a law that will require all general hospitals in the state to establish clinical staffing committees that will set guidelines for nurse-patient ratios and ancillary staff. The committees will be jointly composed of RNs, LPNs, administrators, and other staff members providing direct patient care. The legislation also creates an advisory commission to evaluate the effectiveness of the staffing committees.
As the governor describes it, “This legislation requires hospitals to create committees that include the very same staff who treat patients on the ground every single day and come up with plans that take their concerns into consideration when allocating staff. We need to make sure nurses and ancillary staff have a voice in their hospitals, and these new requirements will make sure they collaboratively plan for the future.”
According to the new law, nurses and administrators on the committees will be responsible for collaboratively developing clinical staffing plans that specify how many patients are assigned to each nurse and how many ancillary staff are assigned to each unit. The New York State Nurses Association is fully behind the legislation, with NYSNA Executive Director Pat Kane remarking, “COVID-19 devastated hospitals throughout New York State that weren’t adequately prepared to handle a pandemic, and this critical legislation will require them to have plans for the future. We need to protect the vital nurses and doctors who do the important work to keep New Yorkers safe and healthy, and these new committees will include the frontline workers who gave so much to all of us during the pandemic. I thank Governor Cuomo… and look forward to more accountable and prepared hospitals throughout the state.”
The law gives individual facilities more latitude than California’s set nurse-patient ratio law, but the intent is the same: “This law doesn’t state that ratios must be stipulated, but inevitably that’s what it means,” Judy Sheridan-Gonzales, NYSNA president, told Healthcare Dive. NYSNA describes the key points of the law as follows:
For New York hospitals, the hospital staffing committees bill (A108B/S1168A) will:
Establish clinical staffing committees including 50% frontline nurses and direct care staff that will set annual staffing standards for each unit of a facility. Standards must be expressed in ratios or grids that meet or exceed those set in existing union contracts.
Make the yearly staffing plans enforceable by the Department of Health, with civil penalties against hospitals that fail to create staffing standards and abide by them, effectively making NYSNA-negotiated staffing ratios state law.
Require the DOH to establish new minimum staffing standards for ICUs and critical care units that must be incorporated in each hospital’s annual staffing plan.
Make the staffing data publicly available to staff and patients.
Create an independent commission to study the effectiveness of the new law in improving patient care and nurse staffing levels and make recommendations for further action to the legislature.
Details on the new law and the NY Governor’s announcement can be found here.
On February 15, 2018, the newest safe nurse staffing bill was introduced to the U.S. Congress. The bill (H.R.5052 and S.2446) has bipartisan support, and is championed by Reps. David Joyce (R-OH), Suzan DelBene (D-WA), Suzanne Bonamici (D-OR), and Tulsi Gabbard (D-HI), as well as Sen. Jeff Merkley (D-OR).
In the past, several safe staffing bills have been presented in previous Congresses but have failed to pass committee. This bill, the Safe Staffing for Nurse and Patient Safety Act of 2018, is slightly different than previous iterations. Under this staffing legislation, Medicare-participating hospitals would be required to form committees that would create and implement unit specific, nurse-to-patient ratio staffing plans. At least half of each committee must comprise direct care nurses.
“It is so important for nurses on the front lines to be able to have a say in what they believe is safe staffing,” says Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, the president of the American Nurses Association (ANA). “This bill benefits bedside nurses by giving them decision-making power, control, and the ability to influence the delivery of safe care,” Cipriano continues.
A committee made of staff nurses—who would make staffing decisions that directly affect their own units—is so important because it is nurses who can best assess patient needs and the resources required to provide safe patient care. Staffing committees would be able to address the unique needs of specific units and patient populations by involving specialty nurses in the decisions, and would have the ability to modify the hospital safety plans as needed.
Overwhelmingly, research supports adequate nurse staffing. Over the last several decades, literature has demonstrated a decrease in patient morbidity and mortality and an increase in patient safety when units are well staffed. “With adequate amounts of staffing we see mortality go down and patient complications can be prevented or diminished,” Cipriano says. “It is important for nurses to have sufficient resources to care for patients, because nurses experience moral distress when they cannot provide the care they know a patient needs.”
Short-changing patients also contributes to nurse burnout, and low nursing retention is expensive. Additionally, adequate nurse staffing leads to reduced health care costs, as a result of fewer hospital readmissions, hospital-acquired infections, medical errors, and other significant measurable patient outcomes. “Patients deserve to have the right care,” Cipriano says. “They need to be kept safe, and the best way to prevent problems and complications is to have the right nurse staffing.”
Is there hope that this bill will pass, when so many previous iterations have not? “It may be difficult to pass the legislation, even this time around,” Cipriano admits. “But the most important impact is that every time we have an opportunity to have this legislation discussed, it’s another opportunity to educate another decision maker. Whether it is congresspeople, their staff, or other leaders in their communities, it gives us the opportunity to continue to reinforce why it is so important to have the right nursing care.”
It is ethically challenging when a nurse is asked to take staffing assignments that do not feel safe. On many units, nurses are expected to care for several acute and critically ill patients at a time, and are given patient loads that stretch them far beyond their reasonable care delivery capabilities. What should a nurse do when faced with an unsafe assignment? Nurses should raise immediate concerns by following the chain of command, and talking with immediate supervisors to express that they believe the situation is unsafe. “The first obligation is to make sure that no patient is left uncared for,” Cipriano says. “Short term, use the chain of command and do everything you can within in your power to make sure that you’re providing at least the minimum care the patient needs.” Longer-term, if nurses truly believe that their organization is not supporting the right staffing ratios, the ANA encourages an active dialogue with leadership, such as a conversation with responsible nursing leaders, quality directors, or patient care committees or councils to focus attention to the issue.
“Nursing care is like a medication,” Cipriano says. “You wouldn’t withhold a life-saving medication, so why would you withhold the right amount or right dose of nursing care?”
If you are passionate about safe staffing laws, consider calling or writing your congressperson and encourage them to support the Safe Staffing for Nurse and Patient Safety Act of 2018.
Stethoscopes dangled around the necks of nurses wearing navy NursesTakeDC t-shirts and big smiles. “Where are y’all from? We’re from Arizona!” More than 800 nurses from 40 U.S. states congregated at the NursesTakeDC Rally on May 5th in Washington, DC. The rally was to support legislation establishing federally mandated requirements for safe nurse-to-patient staffing ratios, while drawing public attention to the staffing crisis in many U.S. hospitals. This was the second such rally; last May, the inaugural event drew about 250 participants to the steps of the U.S. Capitol.
The rally was cosponsored by the grassroots nursing movement Show Me Your Stethoscope, a group that formed spontaneously on Facebook after nurse Janie Harvey Garner watched The View host Joy Behar ask why a nurse in the Miss America pageant was wearing “a doctor’s stethoscope” around her neck. That group now has more than 650,000 members. Other rally sponsors and supporters included the Illinois Nurses Association, Hirenurses.com, Nursebuzz, The Gypsy Nurse, Century Health Services, and UAW Local 2213 Professional Registered Nurses.
The NursesTakeDC rally was originally scheduled to take place on the steps of the Capitol, but thunderstorms and downpours forced the meeting indoors at a hotel in nearby Alexandria, Virginia. Although the setting lacked symbolism, participants still raised handmade posters and shouted rally cries. Rally organizers estimated the weather had an impact on overall attendance, but they were still encouraged by the turnout. After the speakers wrapped up, a group of about 150 nurses headed to the U.S. Capitol steps for photographs and final thoughts.
“We aren’t laughing, we want staffing!” Cheers and whistles erupted out of the crowd. After 10 minutes of rally cheers and chants, the gathering turned its attention to the first of many speakers who would highlight issues faced by nurses in every specialty and across the profession. Actress Brooke Anne Smith began by reciting a moving poem about nurse warriors on the front lines.
Event organizer Jalil Johnson then took the stage, giving a keynote speech that addressed the challenges bedside nurses face every day. He spoke about nurses as the foundation of health care, and the unrelenting pressure to perform in deteriorating conditions. While discussing dire staffing situations, Johnson said that he fought every day, “making sure I didn’t give anyone a reason to come after the license I had worked so hard for.”
He discussed the paradox that year after year, nurses are rated the most trusted profession, yet no one trusts nurses when they say they are overworked, overburdened, and practicing in unsafe conditions. Nurses alone are not enough to fight this battle, he said. “To the public, we say: Trust us when we say the industry makes it nearly impossible to deliver the care you need. Trust us when we say we need your support.”
Other NursesTakeDC rally speakers included Katie Duke, Terry Foster, Deena McCollum, Linda Boly, Julie Murray, Catherine Costello, Kelsey Rowell, Leslie Silket, Dan Walter, Nicole Reina, Monique Doughty, Doris Carroll, Charlene Harrod-Owuamana, Debbie Hickman, and Janie Harvey Garner.
The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act
On May 4th, the day before the rally, Representative Jan Schakowsky (D-IL) and Senator Sherrod Brown (D-OH) reintroduced the latest iterations of the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (H.R. 2392 and S. 1063). The bills seek to amend the Public Health Service Act to establish registered nurse-to-patient staffing ratio requirements in hospitals.
In a press release, Rep. Schakowsky’s office writes: “This bill is about saving lives and improving the health of patients by improving nursing care—ensuring that there are adequate numbers of qualified nurses available to provide the highest possible care.” The press release acknowledges that study after study has shown that safe nurse-to-patient staffing ratios result in better care for patients. “It’s time we act on the evidence and the demands of nurses who have been fighting to end to dangerous staffing,” the release continues. “I’m proud to be a partner with nurses across the country in promoting this bill and working to ensure quality care and patient safety.” Rep. Schakowksy attended last year’s event, but was unable to attend this year. The Nurse Staffing Standards Act is the latest in a string of bills that have been introduced to Congress every session. Previous bills S. 864 and H.R.1602 died in committee last session. S. 864 was first introduced in May of 2009; H.R. 1602 was first introduced in 2004 and has been sponsored seven times so far. Rally co-chair Doris Carroll explained why: “The legislation is reintroduced session after session, and it continues to die in committee because there is no bipartisan support.”
In today’s environment, politics can be touchy. The day before the rally, the House of Representatives passed the American Health Care Act of 2017. Among nurses there are very polarized viewpoints on health care, abortion, assisted suicide, and other controversial topics. In his speech, Johnson acknowledged that not all nurses think alike. “We are a profession divided,” he admitted. “But when it comes to safe staffing, we all agree. This is a movement devoid of partisanship. Staffing is not a partisan issue.”
The proposed text and ratios for the Nurse Staffing Standards Act are below:
A hospital would be required during each shift, except during a declared emergency, to assign a direct care registered nurse to no more than the following number of patients in designated units: 1 patient in an operating room and trauma emergency unit 2 patients in all critical care units, intensive care, labor and delivery, and post anesthesia units 3 patients in antepartum, emergency, pediatrics, step-down, and telemetry units 4 patients in intermediate care nursery, medical/surgical, and acute care psychiatric care units 5 patients in rehabilitation units 6 patients in postpartum (3 couplets) and well-baby nursery units
Rally speakers encouraged nurses to reach out to their representatives in Congress to show support for safe staffing legislation, and handouts for participants detailed how to find representative names and numbers for letter writing campaigns and phone calls.
Where Is Everybody?
When one of the speakers asked why there wasn’t more involvement in the grassroots movement, and why there weren’t more nurses present, several voices called back from the crowd. “Everyone’s working!” one shouted. Another called out, “They don’t have the money!”
“Really, where the heck is everybody else?” one rally participant said. She gestured to the conference room, which at the time held about 100 nurses. This nurse was part of a group attending from New Jersey, including Kate McLaughlin, a registered nurse and founder of NJ Safe Patient Ratios, a group dedicated to the support of safe staffing in New Jersey and promotion of ratio law S. 1280 in New Jersey’s Senate.
“In New Jersey, multiple bills have been introduced, every single session, and nothing ever passes,” McLaughlin said. “In California it was the same thing, and then the tenth year, they involved unions and patients and it finally worked.” She said she started to pay attention to safe staffing laws in her state, and launched a petition on change.org. “I stalked nurses on Facebook and found people that way,” she continued. “Each week, we organize and post the contact information for two state senators.” She is starting a movement in New Jersey, hoping to motivate others to show support for these bills. “It’s an election year,” she said. “Now is the time.”
McLaughlin said her state’s ratio law was first introduced in February 2016, but there has been no vote and no hearings, “which just feels disrespectful.” She was told the governor didn’t support the bill, and “that we might need to wait until there’s a new governor.”
The problem, according to several nurses at the rally, isn’t a lack of awareness. “I think it’s apathy,” McLaughlin said. “This is a profession of predominantly women, and we are taken advantage of. They know we don’t get breaks, but they’re okay with the labor law violations. We’ve somehow accepted that this is normal—this is not normal.”
Carroll also expressed discontent that no one seems to care about this issue. “Why has this taken so long? Why hasn’t California’s success spread like wildfire?” she asked. “Well, health care changed, and it became a multi-billion dollar business for hospitals and insurance companies.”
Dan Walter, another speaker, acknowledged that sometimes nurses do not report safety issues because they fear retribution. Walter is a former political consultant and publisher of HospitalSafetyReviews.com, a web site that he established for nurses to anonymously post about patient safety issues where they work. In his speech, he explained the inspiration for creating the site: “You are the activists and you know what needs to be done. I want people to be able to go there, post, and we will keep it as anonymous as possible so we can protect you.” He expressed hope that this web site will be a powerful platform to improve patient ratios.
How Bad Is Staffing?
Nurses from a hospital in downtown Washington, DC, expressed frustration with the lack of support and resources from hospital administrators. “The other day, we had so many critical patients in the department we ran out of monitors,” one said. Another said that 80% of the nurses who work in her hospital’s emergency department have less than two years’ experience. “The turnover is so high,” she said. “People get so burned out because of the short staffing.”
Just how short are units staffed? “In our ED [emergency department], someone the other night was taking care of seven patients,” one nurse from this group said. “And these were sick patients, people with LVADs [left ventricular assist devices], and ICU patients.” This is common all over the country. A medical-surgical nurse may be taking care of up to eight or more patients at a time.
Llubia Albrechtsen, a registered nurse and family nurse practitioner at the rally, said there have been times she has refused to take on additional patients in the emergency department where she works. “When I have five patients, I need to take a step back and pay more attention, because their conditions may worsen,” she said. “It’s hard, because we could be providing excellent care to many of our patients, but with limited resources we have to do the best we can and hope nothing bad happens.”
Albrechtsen said that although hospital administration makes an effort to listen to nurse concerns about staffing, through town halls or open meetings, not much has changed. “Many areas still work understaffed,” she said.
Why Does Staffing Matter?
A policy brief disseminated at the rally lists the effects of inadequate nurse staffing, including the overwhelming evidence that safe staffing saves lives. High patient-to-nurse ratios lead to poor outcomes and a demonstrated increase in patient morbidity and mortality. Inadequate staffing has been associated with an increase in hospital readmissions, falls, pressure ulcers, hospital-acquired infections, and medication errors.
Poor staffing is expensive. In addition to causing poor patient outcomes, nurse burnout causes injuries, illness, and contributes to the growing nursing shortage. Replacing nurses due to turnover takes between 28 to 110 days, and costs the average hospital $6.2 million per year.
“The health care industry generates $3 trillion annually,” Johnson said in his address. “We are living in an age of greed, where the health care industry measures patient satisfaction by a customer service model. This is prioritized over quality and safety. Reducing burnout, staff retention, and caring for your staff are at the bottom of the barrel of priorities.”
What’s Next?
The grassroots movement behind safe staffing is fighting for environments that allow nurses to do their work in the way in which they were trained. “[A nurse’s] work has been diminished to defensive practices; it has been reduced to a list of tasks to complete,” Johnson said. “That is not nursing.”
In Johnson’s final remarks, he spoke to empower nurses to return to their states, hospitals, and colleagues with a message to inspire change. “We have to show up in person, put boots on the ground, and be ready to engage and pull more nurses into this movement,” Johnson said. “Most importantly, we have to believe that with over 3 million registered nurses and over 1 million licensed practical nurses, our profession can come together as one. We will take back our profession and regain control of our practice.”
Another rally is already in the works for next year. The organizers of NursesTakeDC will now direct their focus toward supporting any state that has pending policy and legislation aimed at improving nurse-to-patient ratios and safe staffing. Organizer Carroll said that this year is a learning curve for the organizers, and they hope that next year they will have something even better with an even bigger audience.
“We encourage all nurses, practicing at all levels and in all settings, to unify and support beside nurses in the fight for safe staffing,” said Johnson to a room full of applause and cheers. “We fight for recognition—we will not justify our existence! There is no health care industry without us, and we will determine what is best for our practice and for our patients.”
Where Is Everybody?
Why Does Staffing Matter?