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Staffing and Scheduling Education
Managed care and capitation-based insurance have led hospitals to reduce nursing staffs across the country. By 1996 the U.S. Department of Labor warned that the restructuring of hospital work had led to the hiring of lesser-skilled hospital staff, resulting in a 20 to 50 percent reduction in the number of RNs offset by increasing numbers of less-skilled staff.110 Asked to name the organizational changes implemented in their workplaces over the previous two years, nurses most commonly cite an increased patient care load. Among the other commonly cited staffing changes are administrative and non-patient-care activities assigned to RNs, increased use of "floating" between departments, cuts in needed support services, and the use of mandatory overtime to cover staffing needs. Fully 64 percent of nurses report that they have less time available for direct patient care than they did two years ago.111 While hospitals were cutting nursing staffs, however, they were directing the remaining staff to serve a growing population of patients. Indeed, the median number of inpatient admissions increased by 17.5 percent from 1994 to 1999.
Not only were hospital admissions rising during the 1990s, but the concerted effort to cut patients' length of stay meant that the average patient was sicker than in the past, thus increasing the nursing demand for any given patient.112 The U.S. General Accounting Office reports, "When adjusted to reflect the rise in acuity levels, the number of hospital employees on staff for each patient discharged, including nurses, declined by more than 13 percent between 1990 and 1999."113
The combination of nursing staff cuts, rising patient loads, and increased acuity has been disastrous. When nurses rate the seriousness of selected problems, staffing levels are at the top of the charts. Two-thirds of nurses report that inadequate staffing for the number of patients they serve is a serious problem at their workplace.114 Similarly, a 2002 survey by the AONE found that 68 percent of nurses have experienced an increase in the number of patients they were responsible for and 66 percent experienced increases in the use of overtime and double shifts. As a result, six of 10 RNs working in hospitals witnessed a negative impact on the quality of patient care. Fully 59 percent stated that the "job is so stressful that I feel burned out."115 It is not surprising then that 72 percent of working RNs have also observed an increase in the turnover of experienced nurses.
A 2001 survey conducted by the American Federation of State, County and Municipal Employees (AFSCME) indicated staff shortages as the top concern of the union's nurses. Inadequate staffing — including high caseloads, mandatory overtime, turnover and lack of time for patient care — was cited as the number one problem impacting work conditions. Moreover, increased patient loads was reported as the single most common change in work conditions over the previous two years. Less common but still prevalent were increases in administrative and non-patient-care responsibilities assigned to RNs, cuts in support service, and increased "floating" of nurses between departments. Apart from the impact of these practices on work conditions, AFSCME nurses reported increasing worry that short-staffing was resulting in substandard patient care.116
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Median Number of Inpatient Admissions
For Moody’s-Rated Hospitals* |
| 1995 |
11,879 |
| 1996 |
12,285 |
| 1997 |
12,987 |
| 1998 |
13,261 |
| 1999 |
13,960 |
Source: Nursing Executive Center, Becoming a Chief Retention Officer, The Advisory Board
Company, Washington, D.C., 2001, p. 9. |
*Moody’s Investors Service, a credit rating, research and risk analysis firm, publishes
research on securities and credit obligations. |
Linda Aiken's massive survey of working conditions in Pennsylvania hospitals paints a picture in which staffing shortages affect virtually every aspect of nursing work:
- 65.6 percent of RNs reported that there are not enough staff to get the work done.117
- Only 56.9 percent believed there were adequate support services.118
- 83.2 percent reported an increase in the number of patients assigned to them in 1998–99.
- Inadequate support staff forced RNs to spend valuable time on non-nursing tasks. More than 42.5 percent of nurses reported delivering and retrieving food trays in the year 1998–99, 34.3 percent reported doing housekeeping duties, 45.7 percent reported transporting patients, and 68.6 percent reported ordering, coordinating or performing ancillary services.119
- At the same time, time available to perform nursing tasks was reduced. One in five nurses reported that necessary oral hygiene was left undone, 31 percent reported that skin care was left undone, 27.9 percent reported that teaching patients or family was left undone, 39.5 percent reported that comforting or talking to patients was necessary but left undone, 40.9 percent said developing or updating care plans was left undone, and 12.7 percent said that preparing patients and families for discharge was left undone.120
Often, it is nurses' own commitment to patient care that contributes to unbearably stressful conditions — many nurses report going out of their way (skipping lunch, skipping breaks, working late) to assure quality of care when staff on the job are unable to tend to patient needs.121 The 7,000 RNs who responded to the ANA online survey tell a story of nurses making huge personal sacrifices in an effort to provide decent care to their patients.122 According to that survey, during the past two years:
- 78 percent of nurses skipped meals and breaks to care for patients.
- 58 percent worked voluntary overtime.
- 58 percent were unable to attend in-service continuing education programs due to increased work.
- 51 percent experienced stress-related illness.
- 42 percent stayed late (off the clock) to finish charting and patient care.
- 34 percent experienced an increased use of sick time.
- 33 percent worked involuntary overtime.
Despite these heroic efforts, nurses are simply unable to scramble fast enough to make up for the cuts in hospital staffing. Three-quarters of nurses believe the quality of care provided in their hospital has declined in the past two years, citing a troubling array of problems caused by short-staffing:123
- 69 percent of nurses report that their unit suffers from inadequate staffing.
- 61 percent report decreased job satisfaction for nurses.
- 58 percent cite delays in providing basic patient care, such as feeding and bathing.
- 50 percent believe patients have been discharged without adequate preparation.
- 50 percent believe overall patient satisfaction is worse.
- 38 percent cite treatment errors, such as putting patients on the wrong diet or delays in laboratory testing.
- 37 percent cite failures of staff to recognize significant patient symptoms.
- 36 percent cite increased medication errors.
The worst staffing shortages occur among specialty nurses. A recent survey of oncology nurses and physicians found that between 59 and 65 percent of both RNs and MDs believed staffing was inadequate in their units and nearly 80 percent of RNs reported their units had difficulty retaining experienced staff. Among those surveyed, fully 80 percent of RNs had experienced an increase in double shifts or overtime during the past year, and more than half reported working overtime at least once per week. Both nurses and doctors stated their conviction that the combination of understaffing and, partly as a result, the difficulty of retaining experienced staff, was harmful to cancer patients.124 The authors of this study concluded,
The emotional and mental stress associated with the problems of inadequate staffing can only add to the physical stress and exhaustion caused by short staffing and taking care of too many increasingly sick patients in ever-compressed time periods. ... It is imperative that policy-makers develop strategies aimed at helping health care organizations increase staffing.125
Similarly, RNs who work in the ICU cope with levels of stress so extreme as to lead to clinical levels of Post-Traumatic Stress Disorder (PTSD).126 One survey found that more than half of ICU nurses suffered from "high-moderate to severe" PTSD symptoms.127 Indeed, when compared with other professions, nurses suffer a higher degree of PTSD-like symptoms than almost any other occupation, including several traditionally considered much more taxing.
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Stressful Occupations, Ranked by Degree of
Post-Traumatic Stress Disorder |
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1. ICU nurses |
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2. Israeli soldiers |
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3. U.S. Vietnam vets |
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4. Rescue workers |
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5. Medical students |
Source: J. J. Allen. Intensive Care Nurses: Post-traumatic Stress Disorder-like
Symptomatology. 1999. |
The "top stressors" leading to PTSD symptoms include patient families, patient load, patient deaths, patient acuity levels, scheduling problems, fear of patient's death, co-workers, auxiliary departments, treatment by physicians, and lack of management support.128 It is noteworthy that three of these top stressors — patient load, acuity levels and scheduling — are in turn related to staffing levels.
Understaffing not only leads to nurse burnout and poorer patient care but also makes hospitals more dangerous places to work. In one recent study, 40 percent of RNs reported that they had been injured on the job. Three-quarters said unsafe working conditions interfered with their ability to provide quality care. Almost one in five nurses report that their hospitals do not have safe needle devices, and patient lifting devices are often not available. With an aging RN workforce, such ergonomic issues are becoming more important than ever.129
The stress, danger, exhaustion and frustration that are now part of the daily routine of hospital nurses constitute one of the key dynamics driving nurses out of the industry. An American Federation of Teachers' Federation of Nurses and Health Care Professionals survey found that among the 50 percent of current nurses who have considered leaving for non-retirement reasons, 56 percent wanted a less stressful or physically demanding job.130 Unfortunately, hospital managers have often made a stressful and dangerous job even worse by imposing increasing demands for overtime, often against nurses' will. One recent national survey found that 61 percent of working nurses had observed increases in overtime or double shifts during the past year. Almost half reported that the "amount of overtime required" had increased, and 32 percent stated that overtime was technically voluntary but felt like it was required.131 The institution of mandatory overtime is one of the most commonly cited factors leading nurses to quit the profession; 22 percent of nurses who leave direct care work report that they are leaving in search of "more regular hours."132
The increased patient load and concomitant stress levels affect not only current nurses, but also those who are considering going into the field. One study reports that potential nursing students are deterred by the long hours of work, highly stressful environments and concern over the quality of care nurses are able to provide.133
By contrast, clear evidence suggests that reducing nurse-to-patient ratios leads to safer workplaces, less stress and higher job satisfaction for hospital nurses. Studies of the magnet hospitals show what any working RN knows firsthand: The ratio of RNs to patients has a direct impact on nurse burnout, job satisfaction and quality of patient care.134
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