Evidence-Based Approach to Appropriate Staffing

Q What is an evidence-based approach to appropriate staffing?A Sarah A. Delgado, DNP, RN, ACNP, replies:Nurse staffing shortages are a profound issue in acute and critical care. Randomized controlled trials of nurse staffing levels are ethically and feasibly impossible. Therefore, most research on the impact of staffing comes from cross-sectional or longitudinal observational studies. A consistent finding in large cross-sectional examinations is that a higher number of patients per nurse in acute care hospitals is associated with adverse patient outcomes.1,2 Individual studies demonstrate a correlation between nurse-to-patient ratios and a higher risk of patient mortality from sepsis and after surgery.3,4 The association between nurse staffing and patient outcomes is not isolated to the United States, as similar cross-sectional studies conducted in health systems in other countries have had the same results.5,6 A systematic review of longitudinal studies further confirms these findings, demonstrating that patients exposed to shifts with staffing shortages have an increased risk of mortality and other adverse outcomes.7 The experience of working as a direct care nurse aligns with these observational study results. Having more nurses means more skill, knowledge, hands, eyes, and ears available to provide the needed care. Better staffing translates to earlier recognition of a change in patient status, faster implementation of the plan of care, and a reduced risk of care left undone.8Nurse surveys also demonstrate an association between staffing shortages and patient care. For example, in the American Association of Critical-Care Nurses (AACN) national 2021 survey, nurses who indicated more shifts with appropriate staffing were more likely to give higher ratings to the quality of care in their units.9 Survey data also connect staffing levels to nurses’ well-being and their intent to leave their current positions.10 Nurses are educated professionals and know what must be done to ensure optimal patient outcomes. If placed in a position in which the needed care cannot be provided, nurses may experience moral distress and consider taking their talents elsewhere. A recent survey further confirmed that both nurses and physicians prioritize appropriate nurse staffing as a strategy to address their burnout.11 Although the existing evidence on staffing levels validates nurses’ perspectives, it does not answer practical questions, such as “What do we do about the hole in the schedule next Thursday?” or “How can I advocate effectively for better staffing?”The AACN’s national surveys show that appropriate staffing is the lowest rated of the 6 Healthy Work Environment Standards.9 Because AACN is committed to advocating for healthy work environments, we collaborated to lead 2 national projects to identify strategies for improving staffing: the Partners for Nurse Staffing Think Tank and the Nurse Staffing Task Force. Both groups included a review of evidence on staffing shortages and related issues, and their resulting publications represent evidence at the level of expert opinion.The Partners for Nurse Staffing Think Tank launched in January 2022 during the COVID-19 pandemic and created priorities, recommendations, and actions to address the staffing crisis in the short term, over 12 to 18 months. One of our partners, the American Nurses Association, created a gap analysis tool to facilitate implementation of the think tank’s strategies.12 The Nurse Staffing Task Force was composed of 38 members from diverse professional roles and different practice settings who were asked to consider solutions to the long-standing barriers to appropriate staffing. Similar to the think tank, the task force included imperatives to address the health of the work environment and innovate care delivery; however, task force recommendations also address regulatory, policy, and payment structure interventions.13 Both the think tank and the task force recommended that specialty nursing organizations explore the creation of staffing standards for the populations they serve. In alignment with this recommendation, AACN published the AACN Standards for Appropriate Staffing in Adult Critical Care, described in Table 1.14Appropriate staffing is defined in AACN’s Healthy Work Environment Standards as the match between nurse competencies and patient needs.19 To achieve that match, standard 1 prioritizes the role of direct care nurses in all aspects of staffing. Although retrospective research studies substantiate the connection between nurse staffing levels and patient outcomes, the match between nurse competency and patient needs occurs at the unit level. All stages of staffing, from planning to implementation to evaluation, must include the expertise of direct care nurses who know the resources available to provide care and understand the demand for that care. Every unit is unique, and patient needs are dynamic; therefore, direct care nurses’ expert opinion is the essential evidence in the pursuit of appropriate staffing. Table 2 provides a list of actions direct care nurses can take to leverage their expertise in alignment with standard 1.Standards 2 and 3 address the processes for patient assignment decisions. Standard 2 states that direct care nurses and leaders collaborate to establish unit-specific staffing guidelines, and standard 3 describes developing, testing, and refining tools for measuring nursing workload.14 Because clinical environments are fast paced, and any patient’s status can suddenly change, standard 4 describes the role of a nurse with knowledge and expertise related to the care that the unit provides while serving in a clinical leader role, such as the charge nurse.14 That clinical leader does not take a patient assessment to maintain a holistic view of the unit’s patients and the nurses’ ability to meet their needs.Standard 5 addresses the unique needs of nurses new to the unit, and standards 6 and 7 describe the organization’s role in implementing appropriate staffing. Specifically, standard 6 states that organizational staffing plans prioritize the health of the work environment, which includes planning staffing so that breaks from patient care are routine and assessing staffing levels in root cause analysis of adverse events. Standard 7 addresses the organization’s role in anticipating that critically ill or injured patients generally require a ratio of 1 nurse to 2 patients.14For nurses who provide direct care to patients in acute and critical care units, the evidence reflects what is already known: the number of nurses matters. National work to improve nurse staffing offers specific recommendations and actions for short-term and long-term change, including recommendations to build healthy work environments and test new approaches to care delivery. The AACN’s recent publication offers standards, actions, and resources to implement appropriate staffing. The essential element in achieving appropriate staffing is the engagement, commitment, and expertise of direct care nurses.