There have been many reports about health care workers, especially nurses, leaving the profession because of emotional and even physical abuse wrought by pandemic-fueled overwork, lack of resources and combative COVID patients in hospitals.

But University of Michigan School of Nursing faculty Deena Kelly Costa and Christopher Friese argue in a New England Journal of Medicine Perspective piece that the problem isn’t necessarily a nursing shortage caused by the pandemic: It’s a shortage of safe hospital working environments–a problem that predates the pandemic.

You argue there’s not a nursing shortage but a shortage of hospitals that provide safe working conditions. What would you like patients to understand about working conditions that they don’t currently know?

Deena Costa

Deena Kelly Costa, Ph.D., RN, FAAN

Since March 2020, the public has been inundated with images of nurses working in unsafe conditions during the pandemic—garbage bags as PPE, reusing masks, reports of wildly unsafe workloads. But unsafe staffing and work conditions predate the pandemic.

Better nurse staffing saves lives and ensures hospitals can function; investing in safe working conditions for nurses is a public health priority. Seminal work in the early 2000s demonstrated that every one patient added to a nurse’s workload in acute care settings was associated with a 7% increase in risk of death for patients. Yet, since then, California is the only state to enact legislation to mandate patient-to-nurse ratios. Massachusetts has ICU nurse staffing regulations but a similar bill mandating specific ratios in other care settings did not pass about five years ago for various reasons.

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You’ve listed several measures that could help attract and retain nurses on the state and federal levels. Which of these measures is most attainable in the short term and could make the biggest impact?

Reducing regulatory and documentation burden is likely the quickest short-term approach that would have the greatest impact in retaining nurses. The COVID-19 pandemic has doubled or even tripled acute care nursing workloads.

Chris Friese

Christopher R. Friese, Ph.D., RN, AOCN®, FAAN.

There is considerable evidence supporting limits to the number of patients a nurse can care for in the hospital setting. Legislation can take time, but in the short term, the Centers for Medicare and Medicaid Services could penalize hospitals that do not meet established patient-to-nurse ratios or exceed maximum amounts of mandatory overtime. This has been done in nursing homes, so there is precedent.

“Seminal work in the early 2000s demonstrated that every one patient added to a nurse’s workload in acute care settings was associated with a 7% increase in risk of death for patients. Yet, since then, California is the only state to enact legislation to mandate patient-to-nurse ratios.”

States may have more flexibility for nimble policy implementation. For example, there is considerable data demonstrating the negative impact COVID has had on women’s careers, and more than 90% of U.S. nurses are women. To encourage nurses to remain in the profession and not quit due to family care pressures, states could incentivize hospitals to offer on-site child care, dependent care programs, or other grants to encourage safer workplaces. This approach is similar to how employer-sponsored insurance emerged as an employee retention tool in the mid-1950s.

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Every year, tens of thousands of students are turned away from nursing schools. How big a problem is this, and what’s the solution?

Structural barriers in the education system create a bottleneck. Many nursing schools must cap enrollment due to shortages of qualified faculty to teach in undergraduate and graduate programs. And more than a third of current nursing faculty plan to retire in the next few years, which will worsen the bottleneck. It can be challenging to attract experienced nurses to teach in associate or bachelor degree programs since often the schedule and pay aren’t as competitive as full-time clinical positions. This hurts our ability to grow the supply of high-quality registered nurses.

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States could help with state tuition forgiveness programs for nurses and nurse educators, low-interest rate loans for state nursing school students, or expansion of the graduate nurse education demonstration project, which funds nurse practitioner education, to increase the number of qualified nurse practitioners who could in turn become educators.

In Michigan, nurse industry groups argue that enacting the bipartisan Safe Patient Care Act and easing the scope of practice restrictions on Advanced Practice Registered Nurses would accomplish these safety goals. These measures are opposed by some hospital and physician groups. Where do these stand?

Michigan has one of the strictest scope of practice regulations in the country, meaning that APRNs must be overseen by physicians to a greater extent than in most other states, and can’t function independently to the full extent of their education and training. Thus, some nurses leave Michigan to practice in other states with friendlier scope of practice regulations. If Michigan were to implement full practice authority to APRNs, as was temporarily done during the pandemic by Gov. Whitmer’s office and as is currently proposed in Senate Bill 680, this could attract APRNs to Michigan, which would boost the supply of nurses in the state and possibly assist with other staffing shortages that have recently been documented.

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The bipartisan Safe Patient Care Act would require hospitals to disclose staffing ratios and adhere to specific patient-to-nurse ratios as well as eliminate mandatory overtime and enact restrictions on overtime. In many other labor environments, such as the airline industry or police and fire departments, there are regulations around hours worked, overtime, etc. They currently do not exist in nursing, and are needed to protect patients and retain and recruit nurses. This bill hasn’t yet passed.


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