Safe Staffing Saves Lives: A Call to Action

As nurses, we know the “real” crisis in hospitals: safe nurse staffing ratios. Our healthcare system faces many challenges. Nursing staff shortages were increased amid cost-cutting decisions, an aging population, and increased patient complexity/needs, which stressed working conditions for nurses and ultimately affected patient care and overall outcomes (1). In 2014, Massachusetts was the second state where lawmakers passed a law requiring a 1:1 or 1:2 nurse-patient staffing ratio in the intensive care unit, depending on the patient’s condition and the assigned nurse’s discretion (1); however, there are no laws regarding the nurse-to-patient staffing ratios outside of this setting. This article will discuss the challenges nurses face with unsafe staffing ratios, the implications those have on patient care, and finally, a call to action for healthcare administration to create environments wherein safe staffing is not only an expectation but a reality.

On March 1, 2022, the American Hospital Association wrote a letter to Congress demanding immediate attention to the workforce challenges, calling them a national emergency (2). Similarly, the Surgeon General issued a public advisory declaring healthcare clinician burnout an urgent public health issue (3). This notable workforce shortage is likely related to the unprecedented number of nurses who left the workforce during the COVID-19 pandemic, which amplified long-standing issues of burnout, stress, and staffing shortages (4). Berlin and colleagues are projecting a 250,000 to 450,000 shortage in the registered nursing workforce in the US by 2025 (5).

Nurses are integral to the healthcare system, making up roughly 30% of total hospital employment (6). Often, leadership attempts to reduce costs by reducing the nursing workforce. However, low nurseto-patient ratios are associated with increased medical errors, infection control, and accidental deaths (7). Each additional patient over four per nurse is associated with a 7% increase in the likelihood of dying within 30 days of admission (8). Similarly, there was a 16% increase in 30-day patient mortality, with each patient above nurses’ average workload (9). Lower nurse-to-patient ratios are also strongly associated with emotional exhaustion, job dissatisfaction, and fatigue/burnout [10]. Each additional patient over four per nurse carries a 23% risk of increased burnout and a 15% decrease in job satisfaction (8).

A 2002 landmark cross-sectional study by Aikens et al. with data collected from 10,184 staff nurses, 232,342 surgical patients, and administrative data from 167 nonfederal adult general hospitals in Pennsylvania, highlighted that among hospitals with low nurse-to-patient ratios, surgical patients had higher 30-day mortality and higher failure-torescue rates with burnout and job dissatisfaction reported more frequently by nurses (8). Hospitals that staff 1:8 nurse-to-patient ratios experience five additional deaths per 1,000 patients compared to hospitals that staff a 1:4 nurse-to-patient ratio and a 7% increase in the likelihood of dying within 30 days of admission was noted for each additional patient beyond four that the nurse assumed care of (8). The most important comprehensive study by Aitkens et al. compared hospitals in California with a required staff ratio to hospitals in New Jersey and Pennsylvania without one (7). The study concluded that with laws legally setting nurse-to-patient staffing ratios, patient outcomes were better in lowering surgical mortality rates, reducing inpatient deaths within 30 days of admission, and a lower likelihood of death from failing to respond to systems appropriately (7).

While increasing nursing staff significantly improves hospital patient outcomes, safe nurse staffing improves favorable nurse working conditions and reduces turnover. The American Association of Colleges of Nursing (AACN) characterizes the hallmarks of suitable nursing work environments as those exhibiting a philosophy for clinical care that emphasizes quality and safety, professional collaboration, and accountability, recognizes nurses’ knowledge and expertise in clinical care quality and patient outcomes, and facilitates collaborative interdisciplinary relationships (11). Schlak et al. suggest that improving nursing work environments alleviates burnout and reduces turnover (12). The cost of rehiring nurses is high, and hospitals estimate huge revenue losses related to nursing turnover. AACN reports the average cost to hire an RN is approximately $2,820 and the average price of turnover for a staff RN is $52,350, with the range averaging $40,200 to $64,500, which resulted in the average hospital losing $8.55 million in 2022, ranging from $6.57 million to $10.53 million.

Prominent healthcare figures and associations declared short-staffing a national emergency and an urgent public health issue in 2022. However, here we are—over two years later—in the same, if not worsened, position. While policy reform is needed, nurses and patients nationwide cannot wait for legislation. We call on all healthcare workers, providers, and, most importantly, leadership to act. We must put aside our differences, remove barriers, and seek a viable solution for the safety of our nursing staff and better outcomes for patients.

William Mar, RN, PhD Student, Tan Chingfen Graduate School of Nursing, UMass Chan Medical SchoolEmail: william.mar@umassmed.edu

Ellen Burgess, RN, DNP Student, Tan Chingfen Graduate School of Nursing, UMass Chan Medical SchoolEmail: Ellen.Burgess@umassmed.edu