Inappropriate staffing – either in terms of numbers or a mismatch between the level of caregiver and the acuity of patients — is a chronic issue in healthcare that puts both patients and staff at higher risk.

To address the issue, the American Association of Critical-Care Nurses (AACN) held a summit meeting May 18 in New Orleans. They discussed variables that create staffing mismatches, identified barriers to solving the problem, and explored potential solutions. Though staffing influences patient and worker safety, fiscal pressure on healthcare facilities means doing more with less in many areas.

Of some 400 nurses at the summit, 64% responded that staffing in their unit was appropriate less than half the time during the past month. Among the solutions discussed was establishment of a formal process to evaluate staffing needs. So-called “acuity-based” staffing systems allocate the number and skill level of nurses on a shift according to patient needs — not solely according to number of patients. Another strategy to consider is the establishment of nurse-driven staffing committees that focus on collaborative scheduling, nursing teams working together, and staff-developed incentive programs, the AACN reports. Other possible solutions discussed include using off-site expertise via telehealth in some cases as well as of having an in-house pool of experienced nurses to draw from. Hospital Employee Health asked Connie Barden, RN, MSN, CCRN-K, CCNS, chief clinical officer at AACN, a few questions on this important issue.

HEH: What effect does inadequate staffing — either in sheer numbers or a mismatch between staff level and patient acuity — have on critical care nurses and other healthcare workers? One would intuitively think they are more vulnerable to fatigue and burnout, and could be more likely to incur patient lifting and sharps injuries and exposures. Can you please comment on this concern?

Barden: Chronically inappropriate staffing has been shown to contribute to nurse fatigue, decreased job satisfaction, and ultimately high turnover rates in some organizations. Fatigued and chronically overworked staff have a higher likelihood of committing errors, which threatens patient safety. Ultimately, these factors can even contribute to burnout, which has been shown to have a high prevalence among healthcare teams in critical care.

The AACN is collaborating with our colleagues at CHEST, Society of Critical Care Medicine, and the American Thoracic Society to publish a call to action, citing the rate of burnout syndrome in critical care teams as high as 50%. The high-stress environment of critical care combined with chronic understaffing and other factors may contribute to this syndrome, symptoms of which can include exhaustion, insomnia, gastrointestinal problems, anxiety, and hopelessness.

HEH: Do you think the staffing problems in critical care nurses are similar to what other nurses are facing, or is there something (i.e. high acuity?) particularly challenging about staffing in critical care?

Barden: The literature reflects concerns about staffing from nurses fairly consistently regardless of patient location. Critical care units can be particularly challenging since those are the areas where the sickest, most unstable and vulnerable patients receive care. Many types of patients require specific, unique, and specialized knowledge and skills in order for appropriate care to be delivered. Appropriate staffing requires a careful match of the knowledge, skills, and abilities of the nurse with the needs of the patient and their family.

HEH: Of the some 400 nurses at the summit, 64% responded that staffing in their unit was appropriate less than half the time during the past month. In addition, only 8% thought their unit had appropriate staffing at least three-quarters of the time. What are some of the major factors that are driving this trend?

Barden: AACN has studied the reality of nurses’ work environments over the past decade using multiple National Critical Care Nurses’ Work Environment studies, as well as an extensive assessment of the barriers that are getting in the way of optimal patient and nurse outcomes. Those studies, which date back to 2006, show that inappropriate staffing is a major barrier to optimal nursing practice and one of the most dangerous threats to patient safety and to the well-being of nurses. The trend seems to have intensified more recently with budgetary constraints and reimbursement cutbacks that are impacting the financial bottom line of hospitals.

HEH: From the patient safety side, do suboptimal staffing levels contribute to healthcare-associated infections and other adverse outcomes?

Barden: Yes. Numerous studies document that poor nurse staffing contributes to suboptimal patient outcomes, including hospital-acquired infections, falls, and complications after surgery, for example. In addition, injuries to nursing staff may increase as well as frustration, moral distress, missed nursing care, and ultimately burnout.

HEH: Can you explain some of the variables that create staffing mismatches?

Barden: Staffing mismatches are sometimes simply about inadequate numbers of staff being present, but not always. For example, if a unit is staffed with a seemingly appropriate number of nurses, but the knowledge and skills of those nurses don’t match the needs of the patient and family, then a mismatch continues to exist. A unit with 75% inexperienced nurses may be sufficient on one day — depending on patient/family needs — and totally unacceptable on another. The high-acuity and high-stakes environment of critical care — that is, life and death — often hangs in the balance. The solution, therefore, must include the effective match between the needs of the patient and family and the knowledge, skills, and abilities of the nurse. This requires nurses to be involved in all aspects of staffing from planning to evaluation. It includes the provision of strong support resources so that nurses’ time is spent on activities that only nurses can provide. And it must entail the use of technology that assists and augments the contribution of nurses.

HEH: What are some of the commonly identified barriers to solving staffing problems?

Barden: Poor or ineffective communication about staffing challenges can hinder progress. Communications must include data and impact — on both patients and nurses — to be effective. Skilled communication and collaboration between staff caring for patients and unit/division/organizational leaders is key. Some units or organizations don’t have a well-defined staffing plan. Such a plan must include a defined evaluation process that considers feedback from those delivering care to patients, unit leaders, and ideally, patients and/or families themselves. A staffing plan that includes goals and metrics by which the appropriateness of staffing will be measured is key.

Another barrier may be insufficient support services. Without strong support resources, nurses’ time is spent on activities that take them away from the real work that only skilled, knowledgeable nurses can provide. Finally, technology must be selected in collaboration with frontline nursing staff so that it supports nursing work (and therefore care delivery) rather than hinders or complicates it.

HEH: Can you cite an example or two of how these barriers can be overcome?

Barden: Many units are using innovative approaches to addressing staffing challenges. At our recent National Teaching Institute and Critical Care Exposition held in New Orleans in May, several speakers highlighted novel approaches to addressing staffing challenges. Julie Reisetter, chief nursing officer at Banner Telehealth Services, discussed the use of the tele-ICU in supporting staff in the care of critically ill patients at Banner Health in Phoenix. Diane Buntyn, CNO at Southwest Alabama Medical Center, told participants about the acuity-based staffing system implemented at her organization. Staff nurses Oletha Riley and Margaret Sumovich talked about a new and creative nurse-driven scheduling program in place at Children’s Mercy Hospital in Kansas City, MO, that has improved morale and decision-making around difficult staffing issues.

Sharing these and many other stories about successes creative nurses and their leaders are finding to address this important challenge is critical not only to patients’ well-being, but for nurses’ as well.

AACN’s work on creating healthy work environments through publication of the AACN Standards for Establishing & Sustaining Healthy Work Environments (2005) provides the blueprint for how healthy environments can be created and implemented, including a standard specific to Appropriate Staffing. In March 2016, AACN published a 2nd edition of the standards, which are now supported by additional research and new evidence confirming the link between healthy work environments and optimal outcomes for patients, healthcare professionals, and organizations.

In addition, the AACN Synergy Model of Patient Care discusses the alignment of nurse competencies with patient needs.