The Impact of Short-Staffed Shifts (From a Nurse's POV)

It began as just a normal shift and then the “bus unloaded”, as we nurses say. The House Supervisor contacted my department to let us know we were going to be getting three patients in the next few hours. Unfortunately, each of the nurses on the unit were at their max patient load of four, so we’d have to call in extra resources. In the meantime, the Charge Nurse would help admit the first patient on their way up from the ED until the Staffing Department could reach some nurses at home and have them come in to help with the surge.

Reinforcements never came-- but the patients did. 

This is not uncommon. It happens on virtually every department at virtually every hospital. Long term care facilities, clinics, and stand alone facilities all experience spikes in census (the number of patients at a given time) without enough staff to care for them, too. The burden then falls on the nurse to pick up the slack, but the repercussions are much deeper.

First, a background on staffing ratios and matrixes. Nurses often have a maximum number of patients they can care for at a time. Depending on the unit acuity, facility type, or sometimes state laws, these numbers differ. In the ICU, nurses often take care of one patient at a time for a 1:1 ratio. On a standard medical floor it is usually four patients at a time (4:1). In long term care settings, it can be a whopping 24 patients at a time! And while the acuity (or level of care required) differs dramatically, there are ceilings on these numbers for a reason. When every nurse working on a hospital department has their max 4 patients and 3 extra patients arrive, additional staff resources are required to meet the demands of those patients. From a nurse’s perspective, taking care of additional patients is unacceptable but it happens time and again.

For a nurse, their day is already 100% full. There is no such thing as 120%, so when thrown another patient, something has to give. It’s usually our breaks and our backs. 

Imagine this from the nurse’s perspective: you have 4 patients, each with meds due at 0800 and some at 0900. The IV bag you hung in room 304 will be done at 1000 (don’t worry, it’ll beep to tell you it’s done). Your patient in 307 has to get down to therapy at 0830. The family member in room 306 has concerns about their husband’s health trajectory, requiring some education and conversation, lest she begin to panic. The Doctor for room 305 has new orders for the patient that you have to process. Don’t forget rounds with the doctor. Answer those call lights. Grab those pain meds now. Chart. Turn that patient to their other side. Chart. Draw those labs. Chart. Fix the label printer because it broke again. Pee… well, pee later. Get your 15 minute breaks (or act like you did because the paperwork to say why you didn’t is more annoying than missing the break).

For a nurse, their day is already 100% full. There is no such thing as 120%, so when thrown another patient, something has to give. It’s usually our breaks and our backs. From the patient’s perspective, when their nurse has 20% more work to do that means their call light takes longer to get answered, their pain meds are late, their questions go unanswered, they’re late to therapy, or their IV Pump goes beeping for too long (patients learn where the silence button is, and even though they shouldn’t touch the equipment nurses often turn a blind eye). 

The repercussions of short staffing are destructive and costly. To name a few:

• Falls: With less nurses and more patients, patients try to do more themselves when their call lights are not answered. Or, when a bed alarm goes off alerting staff that someone who is a ‘fall risk’ is getting out of bed, all staff are stuck in other patient rooms. A single inpatient fall with an injury costs on average $14,000 and can often lead to further health risks for elderly patients.
• Med Errors: When nurses are rushed, they are more likely to miss things they otherwise would’ve caught. Despite a number of fail safes in hospitals, the last one is the nurse, and when they are exhausted from yet another short-staffed shift, that fail safe can fail. Each year there are 100,000 deaths related to med errors with an estimated increase of $136 billion in healthcare costs.
• Bed Sores: Patients who are immobile require being turned at specific times throughout the day so that they do not develop bed sores. Turning patients usually requires 2 staff at a minimum, but every nurse has turned patients themselves way too often because other staff are busy. This is when backs go out. Unfortunately for the ever-empathetic nurse, they sacrifice their back to prevent the sore. Bed sores costs show are range of $20,000 - $150,000 per case.
• Burnout: Nursing is emotionally and physically exhausting with proper patient ratios, so the more short-staffed shifts they have to endure the faster they’ll burnout. This shouldn’t need much explaining, but each nurse that a hospital loses can cost around $60,000 to find a new one.
• Patient (Dis)satisfaction: The longer patients have to wait for their pain meds or assessments the more likely they are to rate their hospital experience poorly. And HCAHPS scores are tied to billions in reimbursements. 

While states like California have enacted strict safe staffing levels and unions try to regulate those ratios as well, nearly every nurse has been shouldered the burden of short-staffed shifts. It’s not fair, but it is reality. And to be honest, nurses are fed up with it, but hospitals don’t know how to solve the issue. There just aren’t enough nurses to care for our aging population, and current contingent labor models just aren’t quick enough to adjust staffing levels when the “bus unloads.” Something needs to change, because as nurses burnout at a faster rate than ever before, the problem is only going to get worse.

<A version of this blog originally appeared on NurseGrid>

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Zach Smith is a BSN-RN, founding member and current VP of Nursing for NurseGrid. Zach helped create NurseGrid's mobile app-- the #1 nurse app in the nation-- and is currently helping NurseGrid build technology solutions to solve the short-staffing crisis.