What nurses really want: sufficient staffing for patient care

Pizza. Coloring books. Goody bags. They could be activities at a 5-year-old’s birthday party. But they’re not: These are many employers’ attempts to lift the morale of nurses on the frontlines of chronically understaffed organizations. What nurses really want are better working conditions so they can deliver the best care possible to their patients.

As researchers at the University of Pennsylvania School of Nursing, we asked thousands of nurses why they are leaving their profession. Their answers are straightforward — short staffing is so rampant that the public’s health care is at risk.

The playbook of corporate health care asks nurses to do much with little, but nurses aren’t willing to skimp on quality and safety. There isn’t a nursing shortage — it’s nurses’ refusal to be part of a system that puts profits before safety.

In our study, which was published in JAMA Network Open, nurses from hospitals, primary care, nursing homes, and hospice told us they left their jobs because of burnout, insufficient staffing, and poor work-life balance. Close to half of all retired nurses had an unplanned retirement, suggesting many were leaving their careers early.

Insufficient nurse staffing has contributed to a persistent cycle of burnout driving turnover and vacancies. In the average U.S. hospital, 47% of nurses have high burnout, and some hospitals have rates as high as 66%.

Health care executives admit these issues keep them up at night. They should, given evidence linking insufficient nursing care to preventable deaths, longer hospital stays and avoidable readmissions.

Evidence shows that nurse burnout can be eased by better working conditions. Stress balls and Nurses’ Week parties aren’t going to change that. Nurses want serious solutions.

Nurses beget nurses

Here’s one intervention that nurses say would reduce burnout and stem their exodus: make sure that enough registered nurses are at the bedside around the clock to care for patients safely. As one nurse in the study stated, “I would have worked another year or two if we had safe staffing ratios.”

It’s surprising that executives in the nation’s most nursing-intensive setting — hospitals — are not championing the leading evidence-based solution. With rare exceptions, hospital executives and industry groups have not only failed to promote safe staffing practices but, in Massachusetts for example, have spent as much as $25 million opposing bills to set minimum staffing standards for patient safety.

It’s true that nursing services comprise a large portion of employers’ budgets: about 30% to 40%. But having too few nurses on duty is costly to the bottom line, insurance payers, and patients.

Opponents to safe staffing practices use fear tactics like the possibility of closing hospital units or turning away patients if hospitals have to follow strict staffing standards. But there is no evidence of compromised health care access in California, the only state with hospital-wide staffing standards. In fact, in states without staffing standards, hospitals are already closing down essential services like birthing care at unprecedented rates, in part because of challenges retaining health care workers.

Employer accountability to workforce sustainability

The public consistently ranks nurses as the most trusted profession and admires them as frontline heroes of health care. So it’s remarkable that employers are able to exploit such valuable human capital with virtually no accountability to ensure that nurses are OK.

As the largest payer of health care, the Centers for Medicare & Medicaid Services could incentivize employers to protect their workers. Most U.S. systems receive payments from CMS and are required to meet certain standards known as conditions of participation. These include reporting hospital performance on patient satisfaction and avoidable readmissions. By existing means, CMS could leverage its payer power and penalize systems with excessively high rates of nurse burnout. Patients would benefit from this transparency to make well-informed decisions about where they choose to receive their care.

Patients’ voices are powerful, especially since health care finances are affected by where consumers choose to get care. The public can demand hospital transparency in how much nursing care health care facilities have on their staffs: after all, nursing care is one of the most important factors in whether patients get to go home alive.

Nursing authority in the C-suite

In systems where business executives dominate the highest levels and where health professionals are in the minority, strategies to increase profits too often supersede a patient-first mission of delivering safe care.

To be sure, there is a delicate tension that must be negotiated between sensible business strategy and health care ethics. But the current climate, which suffers from an overdominance of the former, needs to be righted with stronger clinician authority. Fewer than 1% of hospital trustee boards include a registered nurse. Given their expertise in patient-centered care, the C-suites of hospitals and health care systems need to include more nurses.

Nurses often can’t attend the pizza parties hosted by their employers in break rooms because they are too busy caring for their patients. It’s time to keep them — and their patients — safe by making sure that hospitals have the nursing staffs they need.

Karen B. Lasater and K. Jane Muir are both registered nurses and senior fellows at the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Lasater is an associate professor and Muir is a postdoctoral fellow at the University of Pennsylvania School of Nursing in the Center for Health Outcomes and Policy Research. Funding for research cited in this essay was awarded to the Center for Health Outcomes and Policy Research at Penn Nursing by the National Institute of Nursing Research (R01NR014855 and T32NR007104), the Agency for Health care Research and Quality (R01HS028978), and the National Council of State Boards of Nursing.

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