Mandated Nurse Staffing Ratios

Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Like many of you, I watch the news about the push for mandated staffing ratios. Nurse advocates confidently tell legislators that with 5.2 licensed nurses (if that number is even accurate), there are more than enough nurses to staff the US health system. The only reason they are not working in acute care is because of poor work environments.

I understand what is leading unions and professional associations to pursue this legislation. We are not seeing the level of change in the work environment that we need to. Nurses don’t feel listened to – this comes up on every survey. But the flip side of this is that I am very concerned about whether the assurances that have been given to legislators are magical thinking that does not reflect the true picture of workforce demographics, the expanded opportunities nurses have for employment, or the career choices that nurses are now making relative to their work. Consider the following information about the 5.2 licensed nurses from recent NCSBN data and other research:

• 89% are actively working in the field.
• 70% are already working full-time in this time of intense shortage.
• 31% of licensed nurses are over 55, with more than half expected to retire in the next three years.
• The Department of Labor predicts a 6% growth in job demand for nurses between now and 2030.
• BSN nursing program enrollments dropped 1.3% in 2022, and this trend is expected to continue as the birthrate declines.

Nurses’ work environments have changed significantly since the decades-old research assessing the impact of mandated staffing ratios was conducted. The population of the United States is rapidly aging, which is reflected in high patient volumes. In this post-COVID environment, nurses have less experience, and patient acuity has dramatically risen. Nurses have increasingly assumed tasks once done by support staff. Nurse leaders now estimate that up to 50% of the work done by nurses does not require a nursing license. California is a poster child for what could happen nationally – their health systems have among the highest utilization of contingent staff to meet their ratios, and yet many are not.

Researchers at Gallup have studied workforce and workplace issues for over 50 years. They are well-positioned to look at data across time and advise leaders on the future of the work. Their researchers report that the data indicates we are amid a massive culture shock in the workplace that will not change. Today’s acute care nursing workforce is primarily Millennials and Generation Z. We are seeing the following trends in how they view their careers:

• Many younger nurses now work part-time to maintain their life-work balance.
• Night shifts, weekends, and on-call shifts have become impossible to staff consistently.
• Younger staff see their careers as “tours of duty,” most will not stay in their roles beyond a couple of years in even the best nursing environments.
• Patients and families have become less appreciative, and micro-aggression and even physical assault are growing concerns among nurses.

My other concern is healthcare costs – no one (not payers, patients, employers, or the government) wants to pay more for healthcare. If we have nurses who are not working at the top of their scope of practice – that is the first issue we should be tackling. If other healthcare team members could do some care delivery less expensively – why would we not start there?

Right now, I am leading an AONL workgroup looking at the impact of high staff turnover on the manager’s role. Some of the unit turnover rates reported from even Magnet Hospitals are jaw-dropping. Nurses don’t want to work Med-Surg, ED, Behavioral Health and now Pediatrics – reasons are far more complex than staffing ratios.

Less can sometimes be more if nurses are fully utilized. We need to have frank discussions now about things nurses should stop doing. There are not enough of us – probably will never be so we need to leverage both technology and other team members so RNs work at the top of their scope of practice. Health systems are not moving quickly enough to redesign their care models and provide more flexible staffing, so it is not surprising that nurses are burned out and exhausted. If we keep doing what we are doing – we will keep getting what we are getting, which is an unhappy and disengaged nursing workforce.

There are significant challenges both now and in the future in nursing and healthcare. The path forward is unclear and deep change can be paralyzing. Many healthcare leaders are somewhat risk-averse because this is part of clinical training, but you need to start somewhere with at least a few initiatives to move the needle —– and probably most important include your frontline staff in the planning so you don’t lose the lens of what is happening from their perspective. Mandating staff ratios that are impossible to achieve will not move us forward in improving our environments of care and could have unintended consequences, such as restricted access to care.

References

Martin B, Kaminski-Ozturk N, O’Hara C, Smiley R. Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses. J Nurs Regul. 2023 Apr;14(1):4-12. doi: 10.1016/S2155-8256(23)00063-7. Epub 2023 Apr 5. PMID: 37035777; PMCID: PMC10074070.

Smiley RA, Allgeyer RL, Yetty Shobo, et al. The 2022 National Nursing Workforce Survey. J Nurs Regul. 2023; 2023;14(1):S1-90.doi:http://doi.org/10.1016/s2155-8256(23)00047-49.

NSI 2023 National Nursing and Healthcare Recruitment and Retention Report. Available at https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf

US Surgeon General Advisory. (2022) Addressing Healthcare Worker Burnout. Available at https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf

Clifton J, Harter J. (2023) Culture Shock: An Unstoppable Force Changing How We Work and Live. Gallup Press.

© emergingrnleader.com 2023

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