The Nursing Shortage and Work Expectations Are in Critical Condition: Is Anyone Listening?

Nurses and other health care workers have been saddled with the burden of the pandemic by first being asked to work in unsafe conditions without proper protective personal equipment and then asked to work in crisis mode after crisis mode, as the various waves of the pandemic hit.⁶  And the pandemic is not over. How much more can nurses and other health care professionals be asked to take on? I speak mostly about nurses because this journal is Critical Care Nurse, yet I recognize that nurse leaders, physicians, and other allied health providers are also exhausted and working in crisis mode.

In late January 2022, the incidence of Omicron in US communities is beginning to fall, yet many hospital systems remain burdened by unprecedented high patient volumes and COVID-19–related deaths. Hospital-acquired infections, pressure injuries, and patient falls have increased since the pandemic began.⁷  These adverse outcomes are a consequence of the current work environment—a health system issue. Some nurses who may have cared for 2 critically ill patients in the past are now being asked to care for 3 or 4 critically ill patients. Anyone who has worked at the bedside in critical care knows these high staffing ratios are a recipe for failure.^8,9  Nurses cannot provide optimal care if they are assigned to too many patients. Some patients may not receive all of the necessary elements of evidence-based care, and some patient needs will not be attended to. This situation is not the fault of the nurse—it is a system failure.

The ideal nurse-to-patient ratio can change instantly, especially in critical care. Patients in the intensive care unit (ICU) have fluctuating requirements; they need a nurse who has flexibility in their assignment and is available to run to their room when they have a critical need. The American Association of Critical-Care Nurses (AACN) developed the Synergy Model to illustrate the importance for patient needs to drive nurse competencies.¹⁰  Appropriate staffing is much more than just a number.

Consider a nurse who may have 3 critically ill patients. This situation can be difficult to manage even if all 3 patients remain stable. What happens if one patient’s blood pressure becomes unstable? This scenario is common in critical care and can involve a large amount of nursing time to assess the cause, alert other health care providers, determine the appropriate interventions, and perform or assist with diagnostic testing and/or interventions to monitor and stabilize the patient. This sudden change in workload takes a lot of time and energy. While the nurse is busy stabilizing this patient, who is looking after the other 2 patients? If every nurse has a high patient load, who has flexibility to assist other patients or other nurses during times of critical need? In health care, we may have little or no control over the timing of critical needs or adverse patient events.

Not all patient needs are critical, but they are all important. For example, a patient who is intubated and ventilated may be scared and anxious. Leaving this patient in a room by themselves for extended periods of time without someone there to reassure them that everything will be OK—is that the kind of health care environment we want? There is little flexibility in the system when nurses are overassigned. This situation can be incredibly stressful for the nurses and extremely unsafe for the patients. Natasha Williams, an emergency department nurse in New York City, said she felt like she was “being pulled in too many directions at once.” These constant interruptions may also lead to unsafe work environments.¹¹ 

Insufficient staffing levels were associated with poor outcomes before the pandemic.^8,9  A study of 422 730 surgical patients in 9 European countries showed that patients were more likely to die within 30 days of admission when the nurses’ workload was increased by 1 patient.¹²  This study included hospitalized patients with common surgical diagnoses and did not appear to include ICU staffing. If 1 extra patient per nurse on a medical/surgical unit can affect mortality, imagine the implications of adding 1 or 2 patients to the assignment of an ICU nurse.

Global health care staffing costs are projected to reach $47.8 billion by 2026.¹³  Some hospitals have started cutting nursing hours to save money, but excellent health care costs money. I am not just referring to the cost of nurses’ salaries, but the cost of adequate and safe staffing levels. We should not allow our institutions to use terminology such as nonproductive time to refer to the valuable time spent by nurses obtaining professional development such as learning how to use a new medical device or working on collaborative evidence-based practices.¹⁴  Just because the nurse is not physically touching a patient, it does not mean that their work is not important. Thinking and educational time is valuable. Nurses need to make critical lifesaving decisions. The public and our health care institutions must be prepared to spend the money necessary to obtain the kind of health care that is expected and desired. No one wants to be on a discount budget plan when they are a patient in the ICU. An inadequate staffing budget can lead only to poor outcomes.

Many nurses are angry and leaving the profession early. Jessica Fink left ICU nursing to focus more on preventative, primary care.¹⁵  She said, “I worry for America’s nurses, and I am angry. The problems they face are inflicting a deep and lasting wound.”¹⁵  As the public gets angry about pandemic issues such as delayed elective surgeries, they need to realize that these delays are caused by systems in crisis. Hospitals in almost half of the US states postponed surgeries during the Omicron wave.¹⁶  If customers are angry about long waiting times for hospital admission or delayed and canceled surgeries, they should also be upset and angry about the type of work environments that nurses are currently working in. If our customers want to receive excellent health care for themselves and their loved ones, they need to support changes to the nursing work environment, such as safe and flexible nurse-to-patient ratios and healthy work environments. I think customers expect safe and appropriate staffing in health care.

Prepandemic research identified 2 major reasons for understaffing of nursing care: (1) poor workplace conditions and (2) inadequate staffing models and flexibility.¹⁷  Dr Linda Aiken, a top researcher on nursing workforce issues, blames inadequate staffing on lack of government legislation, especially at the state level¹⁷ ; she believes that states can assist by mandating staffing ratios. Dr Mary Ann Fuchs, president of the American Organization for Nursing Leadership, says that decisions around flexible staffing should be driven by professional nursing judgment.¹⁸  According to Dr Fuchs,¹⁸  “To truly commit to patient safety—always the number one priority— nurses[,] not legislators[,] need to be empowered with flexibility to determine appropriate staffing for the needs of their patients.” Dr Aiken also highlights the importance of nurses and says that “health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.”¹⁷ 

Policies must be in place to help safely manage nurse-to-patient ratios. It is one thing to say that health care systems can adjust staffing as needed during times of crisis, but when the crisis continues 2 years after the start of the COVID-19 pandemic, enough is enough. Nurses and other health care professionals are human. As they have cared for all of us, many nurses have fallen ill with COVID-19 and too many nurses have died. Some of the nurses are still recovering. We tell nurses to look after themselves to maintain health and resiliency, but how can they do that when their scheduled days off are canceled due to mandatory overtime or they are begged to come into work on their days off? Nurses cannot authentically engage in self-care if they feel guilty about saying no to working when their colleagues are short staffed and overworked. Many nurses are exhausted and our system is failing them. We cannot afford to lose or harm more nurses. Action needs to happen and it needs to happen soon because our health care system is in crisis.

The answer is Yes! Although I have written about some of the deplorable realities of the current work conditions for many nurses around the globe, I feel hopeful that meaningful and substantive changes will be made to nurse staffing and healthy work environments. We have seen positive changes during the pandemic such as enhanced, interdisciplinary teamwork and expansion of the scope of practice for advanced practice nurses.¹  AACN and other organizations such as the American Nurses Association (ANA), American Organization for Nursing Leadership, Healthcare Financial Management Association, and the Institute for Healthcare Improvement are collaborating to develop strategies for positive change in the health care environment.¹⁹  These organizations will work hard to push for action in a timely manner.

Hopefully, by the time you read this editorial, many nurses will have joined ANA’s initiative to send a strong message to state representatives in Congress.²⁰  The ANA letter states that “… it’s time for Congress and the Administration to take concrete steps towards finally addressing the nursing shortage to ensure that we have a robust workforce now and in the future.”²⁰  Nurses can personalize their message to describe the difficult work situations they have been enduring.

We need to create an environment in which nurses can autonomously use their nursing skills at the highest level. We need to create a system where nurses want to work and feel proud about the excellent care that they can deliver. Great health care costs money, and that money should be spent where it is most needed, at the bedside.

Nurses, if you are asked what you would like for Nurses Week in May, I suggest asking one of your hospital administrators to shadow a critical care nurse for a day. This exercise may lead to administrators gaining a greater understanding of the nursing role and the extraordinary demands being placed on nurses.

We have an opportunity to create change, so let us make it happen and soon—before we lose or harm more nurses and other health care professionals. As AACN president Beth Wathen²¹  says, “The future of nursing starts now.”