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Analysis: US nurse shortages and the fight for better staffing ratios

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The US is in the midst of a major nursing shortage that has brought nurses into dispute with hospitals over safe staffing levels. Nicole Friedberg analyses the causes and latest developments.

In the United States, low nurse-to-patient ratios are running rampant and have been for a long time.

“What is unusual about this particular shortage is that it’s quite variable across regions of the United States”

Jacqueline Dunbar-Jacob

At present, there is only one state – California – that has a law which dictates how many patients one nurse should care for at a given time depending upon which care unit a patient is in (i.e. intensive care, operating room, paediatrics, etc).

There are currently two pieces of legislation in congress – one in the House of Representatives and one in the Senate – that are aimed at replicating the California law on a federal level.

The difficulty with this situation is that there are multiple reasons why US hospitals are without enough nurses. One big issue is the high burnout rate of nursing staff.

Since nurses must regularly care for more patients than what has been deemed safe, they carry a burden too great to bear and become physically, mentally and emotionally exhausted, causing them to leave their positions.

Based on the Maslach Burnout Inventory (MBI), burnout syndrome is a “syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity”.

There is even a version of the MBI that is tailored specifically to clinical personnel. In a video on the National Nurses United website explaining why having a greater nurse-to-patient ratio is so important, one nurse said that she covered 12-24 patients at once on a regular basis in the past.

“The opportunities for nurses have expanded exponentially… people see opportunities for good careers”

Jacqueline Dunbar-Jacob

In addition, many of the nurses who are part of the so-called baby boomer generation of 1946 to the 1960s continue to retire, which is inevitably leading to a rising need for more incoming new nurses.

Increasing the number of nurses in a hospital, which effectively lowers the nurse-to-patient ratios, was so successful in California that hospital income in the state rose from $12.5bn to greater than $20.6bn.

In fact, by hiring more nurses and making the workload for each individual nurse more manageable, there was less turnover and fewer complications in patients, which saved the hospitals money rather than increasing costs.

The pressures that nurses face in the US due to inadequate staffing affect more than just them and their patients – it affects their medical colleagues’ abilities to properly care for patients as well.

As one doctor from Emory Johns Creek Hospital noted, nurses are key to patients getting the best possible care. Because of the inherent role of a nurse, he or she is with a given patient more than the patient’s doctor is.

When a nurse can give a patient the amount of time and attention they deserve and that is actually safe, they can catch things like poor nutrition or prescribing errors – such as a doctor giving a drug that a patient is allergic to.

Likewise, when a nurse notices a situation where a patient is finding it difficult to eat solid foods, he or she can make a call to the kitchen and ensure they receive more protein shakes so the patient can be more comfortable and receive the necessary nutrients to get better. If a nurse is spread too thinly, these sorts of issues can go unnoticed, causing unnecessary complications.

Dr Jacqueline Dunbar-Jacob, dean of the University of Pittsburgh’s School of Nursing – one of the top nursing schools in the US – was part of the team that put together a study published in 2017 entitled A national study links nurses’ physical and mental health to medical errors and perceived worksite wellness.

The study, which covered 1,790 nurses throughout the US, was aimed, among other things, at learning more about the link between nurses’ mental and physical health and medical errors made.

University of Pittsburgh

Dr Jacqueline Dunbar-Jacob

Jacqueline Dunbar-Jacob

Not only did more than half of the nurses in the study report making medical errors in the past five years, but researchers also found that “compared with nurses with better health, those with worse health were associated with 26% to 71% higher likelihood of having medical errors”.

Even after years of studies like the one Professor Dunbar-Jacob worked on, nurses are still holding strikes to demand safer nurse-to-patient ratios.

Last month, the New York State Nurses Association notified the city of New York that if its demands were not met by 2 April, 10,000 nurses from three of the city’s largest hospitals – Mount Sinai, Montefiore, and New York-Presbyterian – would walk out of work and go on strike.

The threat was enough to extract promises from the hospitals on Tuesday 9 April. The association said it had struck a ground-breaking agreement with the hospitals that would lead to the hiring of 1,450 additional nurses and for the first time establish minimum ratios of nurses to patients.

According to Professor Dunbar-Jacob, the fact that the US has a nursing shortage is “historically not an unusual thing,” but “what is unusual about this particular shortage is that it’s quite variable across regions of the United States”.

She highlighted that within the same state, there were sometimes opposite conditions in different areas. “Western Pennsylvania is reporting a shortage”, while Eastern Pennsylvania is in the position of having to turn applicants away, she noted.

She suggested there was currently a lack of evidence to identify why certain areas were affected by nurse shortages more than others. For example, she noted there might not be data showing “areas that have a shortage have a particular characteristic”.

“One can generate hypotheses, but we just don’t have the data to say why that is,” she told Nursing Times.

In the past few years, Professor Dunbar-Jacob said the University of Pittsburgh had seen “a substantial increase in the numbers of students who are interested in nursing careers”.

Professor Dunbar-Jacob said she believed that, among the various reasons for the increase, it was possible that since “the opportunities for nurses have expanded exponentially… people see opportunities for good careers”.

As to whether or not the current US shortage may improve in the next decade or so, Professor Dunbar-Jacob said it was only possible to speculate at the moment but she highlighted that changes in setting were underway.

“More and more of what is traditionally hospital care is being moved out into the community – same-day care, home care – and as we see more and more of that happening we’re very likely to see less demand within the hospitals themselves for nurses,” she said.

“It is easy to miss something when you have an abundance of patients”

Caroline Powers

Caroline Powers, a nursing student in the Second Degree Accelerated BSN program at Duquesne University, has already been made aware of the nursing shortage and its consequences.

Regarding her own course, Ms Powers said that the shortage was a “big reason why programmes like [hers] exist and are becoming much more popular”.

What makes the programme that Ms Powers is on so special is that it takes only 12 months for her to become a nurse, whereas nursing school typically takes two years to complete in the US.

In just her first two semesters, Ms Powers has already been warned about burn out and that “it is easy to miss something when you have an abundance of patients”.

Fast-track course like Duquesne’s are very important for the US because they allow a faster influx of nurses into the field. However, despite their brevity, are also viewed as providing a thorough education for the next generation of nurses.

Students like Ms Powers in programmes like that of Duquesne’s and the University of Pittsburgh’s may offer hope for a much needed increase in nurses for the US.

  • Nicole Friedberg, a student at the University of Pittsburgh, is on an internship with Nursing Times.
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