Wide nurse staffing variation across hospitals poses a threat to the public’s health

By Jeff Lagasse for Healthcare Finance

Many hospitals in New York and Illinois were understaffed right before the first surge of critically ill COVID-19 patients, while New York City — an international gateway to the U.S. with three major international airports, and the early epicenter of the coronavirus surge in the U.S. — had the poorest average hospital nurse staffing on the eve of the COVID-19 medical emergency.

That’s according to a BMJ Journal study, “Chronic Hospital Nurse Understaffing Meets COVID-19,” which found that the workload had adverse consequences on nurses and on patient care. One third of patients in New York state and Illinois hospitals did not give their hospitals excellent ratings and would not definitely recommend their hospital to family and friends needing care.

The report documented staffing ratios that varied from three to 10 patients for each nurse on general adult medical and surgical units. ICU nurse staffing was better but also varied significantly across hospitals.

WHAT’S THE IMPACT

In addition to the implications for public health, the findings suggest an increase in overwork and burnout among staff. Even before the COVID-19 pandemic, half of nurses scored high in burnout due to high workloads, while one in five nurses said they planned to leave their jobs within a year. Nurses have largely stayed at hospital bedsides for long hours during the public health crisis — evidence of determination and professionalism even in the face of these staffing challenges.

Half of all nurses gave their hospitals unfavorable rades on patient safety, and two-thirds would not recommend their hospital to family and friends. In Gallup polls, nurses have been ranked as the profession most trusted by the American public for 18 years and running.

The researchers surveyed all registered nurses holding active licenses to practice in New York State and Illinois during the period from December 16, 2019 to February 24, 2020, just before the COVID-19 emergency. Hospital nurses reported on the number of patients assigned to them to care for at one time. These nurse reports were linked to Medicare patient-reported outcomes for the same hospitals. They studied 254 hospitals throughout New York state and Illinois, including 47 hospitals in the metropolitan New York area (the five boroughs plus Nassau and Westchester counties).

Mean staffing in adult medical and surgical units in New York and Illinois hospitals varied from 3.36 patients per nurse to 9.7 patients per nurse, and in ICUs from 1.5 to 4 patients per nurse. Each additional patient per nurse significantly increased the proportion of both patients and nurses giving unfavorable hospital quality and safety ratings, after differences in hospital characteristics such as teaching status, size, and technology availability were taken into account.

About 65% of nurses reported delays in care were common because of insufficient staff, and 40% reported frequent delays in care due to missing supplies, including medications and missing or broken equipment.

NURSE STAFFING STANDARDS

Both New York State and Illinois have pending legislation requiring hospitals to meet minimum safe nurse staffing standards: no more than four patients per nurse on adult general medical and surgical units. The study found that most hospitals in both states currently do not meet these proposed standards, nor do they meet the safe nurse staffing standard of five patients per nurse set by legislation in California 20 years ago.

Among the conclusions drawn from the data are that the majority of hospital nurses in these states were burned out and working in understaffed conditions immediately prior to the surge in critically ill coronavirus patients, while understaffed hospitals pose a public health risk. The Nurse Licensure Compact may offer one solution and ease the strain on hospitals.

THE LARGER TREND

In a paper published in March, Dr. James Adams of Northwestern University’s Feinberg School of Medicine and Dr. Ron Walls of Harvard Medical School wrote that a combination of stress and possible exposure puts healthcare professionals at greater risk of contracting COVID-19 and potentially spreading it to others.

Meanwhile, data published last autumn found clinician burnout is affecting between one-third and one half of all U.S. nurses and physicians, and 45 to 60% of medical school students and residents. It also found a direct connection between clinician burnout and quality and safety in healthcare.