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POV: Overworked nurses need relief : Emergency Medicine News

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nursing, EM workforce, nurse-patient ratio

Nurses are the primary patient-facing members of most healthcare organizations and often the first point of contact for many people seeking medical care. They initiate screening exams, draw blood, administer medications, provide education and counseling, and are often the customer service side of any facility. My hospital once ran a campaign called “Nurses are the ones you remember”, but now, unfortunately, it seems that hospitals don’t remember nurses.

This country is currently facing a massive shortage of nurses that began long before the pandemic. Hospitals have tried everything to compensate, from adding extra shifts to a nurse’s already full-time schedule to increasing patient numbers and hiring expensive traveling nurses. (Modern healthcare. September 16, 2021; https://bit.ly/3dwnlp8.) These solutions create their own problems.

The first is that higher patient loads can lead to delays in assessment and treatment. Data from the Emergency Department Benchmarking Alliance demonstrated that the percentage of patients who leave a hospital emergency department before treatment is completed correlates more strongly with nursing staffing than the total number of patients seen. (Am J Urgent Med. 2016;34[2]:155.) Hospitals in Massachusetts, Illinois, and Delaware also reported that higher nurse-to-patient ratios resulted in longer wait times and more patients leaving without being seen. (J Emergency Nurses. 2017;43[2]:138; West J Emergency Med. 2018;19[3]:496; Acad Emergency Med. 2004;11[5]:459; https://bit.ly/32WJtHd.) The problems of low staffing ratios are not just an American phenomenon. Administrative data from public hospitals in Victoria, Australia, revealed that the overall length of stay in the emergency department is directly correlated with the number of nurses on duty. (Medical emergency J. 2010;27[7]:508; https://bit.ly/3rHXq6n.)

Waiting room wait times can be a source of bragging rights for many hospitals, but real harm happens when busy nurses can’t see a patient right away. A hospital patient safety survey funded by the Agency for Healthcare Research and Quality found that a decrease of just eight hours in total nursing staffing time on a hospital unit led to an increase in 2% death rate. (N English J med. 2011;364[11]:1037; https://bit.ly/3rIBqrW.)

The numbers are even bleaker among surgical patients. Data from postoperative cases in hospitals in Pennsylvania, Florida, New Jersey and California have shown that adding one additional patient per nurse is associated with an eight percent increase in the risk of readmission (Int J Qual Health Care. 2016;28[2]:253) and a seven percent increased risk of dying within 30 days. (JAMA. 2002;288[16]:1987; https://bit.ly/3rGnCON.) Again, the United States is not the only place where poor nurse-to-patient ratios are associated with poor outcomes. Each additional patient in South Korean hospitals is associated with a 5% increase in the number of patient deaths within 30 days of admission. (Int J Nurs Stud. 2015;52[2]: 535.)

Pennsylvania JAMA The study above also found that adding an extra patient was associated with a 23% increased risk of burnout, which will inevitably lead to staff turnover. Inadequate staffing in surveys of nurses from Arizona to Oman continues to be a key predictor of job dissatisfaction. (Am J Crit Care. 2021;302]:113; J Nurs Scholarsh. 2020;52[1]:95.)

Other elements of a poor work environment include loss of decision-making autonomy, lack of involvement in hospital affairs, and lack of recognition. American hospitals currently use many levels of hierarchy between frontline nursing staff and administrators, which can lead nurses to feel that their concerns cannot be addressed by their immediate supervisors. Issues raised at the local clinical level are often met with unsatisfactory responses that appear to serve the interests of the company at the expense of the interests of the patient.

Patient satisfaction scores also decline. (J Nurs Care Qual. 2021;36[1]:seven; https://bit.ly/3lLd3Gq.) Staff cannot respond to customer service requests such as warm blankets, pillows, on-time medication administration, or other reasonable and expected amenities with so many nurse assigned patients. Disgruntled nurses make disgruntled patients.

Nursing can be dangerous. The majority of American nurses said in the past year they had been verbally abused by patients and family members. (Safe occupational health. 3 Aug 2021;21650799211031233; https://bit.ly/3rJFisT.) Many had also experienced physical abuse. Curiously, patients with COVID-19 are more than twice as likely to be abusers compared to all other patients. I graduated from medical school over ten years ago and have witnessed firsthand an increase in bad behavior among our patients who come to the emergency room. Obviously, some remedies are needed.

The first real solution is to reduce the number of patients per nurse. The American Academy of Emergency Medicine released a position statement on staffing ratios 21 years ago calling for a 1:3 nurse-to-patient ratio in addition to having nurses dedicated to triage and load . (AAEM. February 22, 2001; https://bit.ly/339a7wN.) Yet many hospitals still assign four or even five patients per nurse.

California was the first state to mandate minimum nurse staffing based on the severity of a patient’s illness. These rules came into effect in 2001 and have had an expected result of reduced wait times in waiting rooms and overall length of stay in emergency departments. (Acad Emergency Med. 2010;17[5]:545; https://bit.ly/31F199C.) Ironically, adding extra staff doesn’t have to be expensive. Queensland, Australia introduced mandatory ratios in 2016 that reduced deaths and readmissions while saving the medical system millions of dollars. (Lancet. 2021;397[10288]:1905.)

Hospitals also need to develop their nurses by providing in-house continuing education. They must also be willing to pay for college courses. This shows a commitment to their employees. My facility has always offered training in the use of ultrasound to place IV lines and a sexual assault nurse examiner certification. We also offer tuition assistance to registered nurses so they can work toward a bachelor’s degree. Having a more educated workforce pays dividends. Research from the United States and Europe has shown that having more nurses with bachelor’s degrees correlates with lower patient death rates. (Medical care. 2011; 49[12]:1047; Lancet. 2014;383[9931]:1824.)

Finally, hospitals must work on their culture and improve the working environment. Places where doctors and nurses have good working relationships, where nurses are involved in hospital affairs, and where management responds to safety issues are linked to lower patient mortality. (J Adm Nurses. 2008;38[5]:223; Health services. 2008;43[4]:1145; Medical care. 2011;49[12]:1047.)

Hospitals can combat the continuing shortage of nurses by lowering nurse-to-patient ratios, investing in employee training and improving the work environment. These steps translate into measurable benefits by reducing mortality and burnout rates and potentially saving money in the long run.

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Dr Aycockis an emergency physician at West Florida Hospital in Pensacola, Florida, and an assistant clinical professor at Florida State University College of Medicine.