David Keepnews, PhD, JD, RN, FAAN, WSNA Executive Director
The public is becoming increasingly aware of a problem nurses have known about for a long time: the nurse staffing crisis that is dangerously depleting our hospitals. The COVID-19 pandemic has both highlighted and accentuated this crisis. Certainly, close to two years of caring for acutely and critically ill patients who can’t have family or other loved ones at their side and repeatedly facing death has made a stressful job that much more difficult. It has also led to increased burnout, driving many nurses and other health care workers from their jobs. This, in turn, has added even more to the stress of those who remain and who often find themselves working even longer hours under more difficult conditions, caring for even more patients.
How many nurses, faced with an unsafe assignment, have been told, “Just do the best you can?” In those circumstances, “do the best you can” translates to “leave some things undone.” But nursing doesn’t work that way, and nurses can’t work that way. Being unable to do what patients need — to provide good, safe care — only adds to nurses’ stress (and distress) and drives more nurses from the bedside.
But the pandemic doesn’t tell the whole story of the nurse staffing crisis. It is a crisis that has been mounting for years — even decades. Chronic understaffing in hospitals is not a new problem. Nurses and other health care workers have long been experiencing it and trying to do something about it.
I have been in nursing long enough to remember when staffing issues would bubble up occasionally on a shift-by-shift, unit-by-unit basis and could usually be worked out without any real problems. But that was a very long time ago. For as long as most of our members can remember, the issue has been an ongoing, consistent one — driven by a larger picture that sees nurses primarily as cost-drivers and obstacles to maximizing profits (or “margins.”)
I also remember a time during widespread hospital restructuring in the 1990s when WSNA, the American Nurses Association (ANA) and others sounded the alarm about how decreasing the use of RNs threatened patient care quality and safety, — but the response we received from many hospitals and policymakers at that time was that there was no research to show how staffing and quality were linked. This lack of “hard” data didn’t mean there weren’t real problems — as attested to through widespread reports of patient care incidents, deaths and countless near-misses.
But since that time, a mounting body of research has consistently demonstrated the connection between nurse staffing and patient outcomes. These have included early studies associating nurse staffing levels with lower post-surgical mortality (Kovner and Gergen, 1998), 30-day patient mortality and failure to rescue (Aiken, et al., 2002), and lower rates of failure to rescue, urinary tract infection, upper gastrointestinal bleeding, pneumonia, and shock or cardiac arrest (Needleman, et al., 2002). “The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis” provided a systematic review and meta-analysis of studies associating nurse staffing levels and lower hospital-related mortality in intensive care units, in surgical and medical patients, and in length of stay (Kane, et al., 2007). Subsequent research has only added to the evidence that nurse staffing is associated with better patient outcomes, including lower incidence of sepsis (Lasater, et al., 2021), while understaffing was associated with increased health care-associated infections (Shang, et al., 2019).
The above is just a small sample of the numerous studies on staffing and outcomes. Today, no one can seriously dispute the fact that nurse staffing is closely linked to patient care quality and patient safety — that better staffing is associated with positive outcomes and, conversely, lower staffing is linked to poorer outcomes.
To drive this reality into policy, nurses and other health care workers have pushed for legislative solutions. In Washington state, WSNA, in partnership with SEIU Healthcare 1199NW and UFCW 21, won legislation in 2008 that requires each hospital to establish a staffing committee composed 50% of staff nurses to determine staffing plans that include staffing levels for each unit on each shift. The law was strengthened in 2017 to increase hospital accountability for staffing according to the committee-developed staffing plans.
The idea behind this legislation was to create a collaborative process that could take into account the range of factors (including type of unit, numbers of nurses and other staff, experience levels, patient condition and others) that help account for safe staffing.
The results, while inconsistent, have by and large been unsuccessful in achieving safe staffing. Collaboration between staff nurses and hospital administration can only work if both parties are committed to it. Some hospitals have yet to even adopt charters for their staffing committees, despite having had more than three years to do so. Hospital CEOs have the power to reject staffing plans — and some have.
Some compromise provisions in the staffing law, agreed to in good faith, have been stretched into big loopholes. For example, the Department of Health, charged with enforcing the staffing law, may not investigate a complaint “in the event of unforeseeable emergency circumstances.” On the face of it, that may seem reasonable: An unanticipated disaster or a sudden and unexpected surge may leave a hospital briefly unable to meet the standards set by its staffing committees. However, the entire COVID-19 pandemic has served as “unforeseeable emergency circumstances,” effectively exempting hospitals from enforcement of the staffing law. The timing and severity of the pandemic could have been considered “unforeseeable” in its early weeks or even the first few months. But, by now, we’ve seen almost two years of the pandemic; it is hardly “unforeseeable” today.
Many hospitals have instituted expensive, short-term fixes to the current staffing crisis, such as offering significant sign-on bonuses and increasing their use of travel nurses at top rates. All this accomplishes is to create a bidding war, encouraging many nurses to leave one job for another, temporarily filling gaps in some hospitals by worsening them in others — and thus driving away even more nurses. These practices are unsustainable and offer no long-term solution.
Of course, we need to increase the pipeline into nursing, which requires better funding for nursing schools; more scholarships and loan forgiveness programs for nursing students; and increased use of resources such as clinical simulation. But we can’t simply educate new generations of nurses to face the same conditions that are already driving too many seasoned nurses out of patient care. We need to provide practice conditions that will sustain a career-long commitment to nursing. Better staffing means better patient care. It will build practice environments that will retain nurses and even attract many who have left.
Too many hospitals have demonstrated that they cannot be relied upon to provide safe staffing levels. Washington’s current framework, using staffing committees to develop unit- and shift-specific staffing plans, provides nurses with a voice in working with hospital administrations to ensure safe staffing — but it can’t work if those voices aren’t listened to. Simply put, the law needs more muscle behind it.
WSNA has been working in coalition with SEIU Healthcare 1199NW and UFCW 21. Together, representing more than 71,000 nurses and health care workers, we are campaigning throughout the state for safe staffing. This is our top priority: to speak up with one voice to advocate for our members, for all nurses and all health care workers. Safe staffing is an investment in patient care and a commitment to safety and quality.
We are taking this message to the public — to our co-workers, our neighbors, our patients and our communities. We also are taking this message to Olympia to press for stronger staffing laws with stronger standards and enforcement. You, our members, will have a critical role to play in making sure policymakers hear from you and understand the critical need to ensure safe staffing in Washington state.
I know that our members will stand up, as you always have, to advocate for yourselves and your patients. As WSNA’s new executive director, I am excited to work with you as we ramp up our efforts to win safe staffing in Washington!
Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288:1987–1993.
Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., & Wilt, T.J. (2007). The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Medical Care, 45(12):1195-204.
Kovner, C., & Gergen, P. J. (1998). Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image: Journal of Nursing Scholarship, 30(4), 315-321.
Lasater, K. B., Sloane, D. M., McHugh, M. D., Cimiotti, J. P., Riman, K. A., Martin, B., Alexander, M., & Aiken, L. H. (2021). Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes. American Journal of Infection Control, 49(7), 868-873.
Needleman J, Buerhaus P, Mattke S, Stewart, M., & Zelevinsky, M. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346:1715–1722.
Shang, J., Needleman, J., Liu, J., Larson, E., & Stone, P. W. (2019). Nurse Staffing and Healthcare-Associated Infection, Unit-Level Analysis. Journal of Nursing Administration, 49(5), 260-265.