An excerpt from Healing Healthcare: Evidence-Based Strategies to Mend Our Broken System.

The greatest challenge facing our professional workforce today is creating a healthy work environment in which nurses care for patients. A significant characteristic of a healthy work environment is appropriate staffing. Nurse staffing is a multifaceted issue, and it is extremely difficult to objectively advocate for change. Different members of the health care team have different concepts of nurse staffing. To some, proper staffing means staying within a budgeted, fixed nurse-to-patient ratio, or accurately scoring a patient’s acuity, or maximizing an employee’s responsibilities to their full potential within their scope of practice. Each factor influences staffing decisions.

Nurses enter the health care profession because they want to help someone in need and make a positive impact on patients’ lives, but it is incredibly challenging to consistently capture accurate data that allows for nursing representatives to objectively advocate for additional help. As a unit manager, trying to keep talent and decreasing the unit’s turnover rate is one of the many challenges I’ve faced. When the unit’s staff is consistent and professionals stay, continuity of care can be established. Once this baseline is set up, we must ask these questions: 1) Do we have the right number of nurses to care for our patients? 2) How do we know? 3) How do we find out?

The pandemic effect

In 2017, I was fortunate to manage a neuroscience intensive care unit (NSICU) that changed its nurse-to-patient (RN) ratio from 1 registered nurse (RN) for every 1.75 patients (1:1.75) to 1 RN for every 1.5 (1:1.5) patients. This change in ratio allowed the department to add 4.3 full-time equivalents (FTEs) to the unit’s workforce. This was an amazing win for the patients, the unit, and the hospital, but we still needed to fill the FTEs, keep the staff, and then measure the outcome. We creatively used added staff, recovering patients directly from the operating room in a 1:1 fashion for the first hour post-op based on the guidelines of the American Society of PeriAnesthesia Nurses (ASPAN). With this change, we saw a decrease in falls and an increase in staff retention. Our turnover rate dropped from 19.8 percent in 2017 to 16.7 percent in 2018 and 5.7 percent in 2019. As we entered the pandemic, our staff retention set us up to positively affect our continuity of care and allowed time for leadership to devote to coaching and developing the bedside staff.

During the pandemic, our hospital experienced an increase in staff attrition, and our five adult intensive care units became more reliant on partnerships than we ever had before, as we had to use a central staffing office. RNs were scheduled in their home units, but our central staffing office would consider all ICUs’ patient acuity levels and deploy RNs to units most in need. Increasing COVID-19 patient acuity due to multiple complications, plus hospital attrition, began to have a bigger impact on staffing ratios. Average RN ratios in the NSICU are shown in Table 1.

One can see that there is more to it than ratios—retention must be considered for achieving and maintaining appropriate staffing.

Overcoming potential barriers

In March of 2020, when the pandemic was declared, my unit’s leadership team discussed what we knew about the pandemic, what the staff wanted to know, and how our leadership team could communicate essential information to staff. Since we float nursing staff to our medical intensive care unit (MICU), our leadership team took the initiative and partnered with our MICU. We learned about our infection prevention processes, and then trained our staff on caring for the COVID-19 patient population.

During this time, I also attended an advisory board lecture titled “Leading Through Crisis,” presented by Carol Boston-Fleischhauer. In her lecture, Boston-Fleischhauer covered topics such as nursing shortages, increasing burnout, and early COVID-19 pandemic data. But one of the most beneficial takeaways for me as a leader was her slide titled “Psychological and Logistical Barriers That Promote Fear.” This slide addressed what staff need to feel safe at work—staffing, equipment, and training—plus what staff need to feel safe going into work, like childcare, transportation, and the ability to protect their families.

We then listened to multiple weekly updates offered by our president, chief executive officer, and chief nurse executive. Their input supplied context for our biweekly staff presentation. Virtual presentations added value; we could record these updates and send them to staff who were unable to attend the live meeting. Communicating with transparency allowed us to connect with staff twice a week, encouraging open questions and dialogue. This process helped us lead our staff into the unknown with as much knowledge as possible. Change was constant, and it was challenging to keep up with it all. Our open forum allowed our staff to share their experiences when floated to various intensive care units (ICUs). Open lines of communication and preventing as many surprises as possible helped us to create and maintain a healthy work environment and to keep staff.

Engagement and advocacy

Everyone is busy. For us to advocate for the nursing workforce, we need to continue to explore how nursing units can objectively capture and report being overstaffed, appropriately staffed, or understaffed. Variables such as number of staff, number of patients, patients’ acuity, patient outcomes, patient satisfaction, staff satisfaction, and fiscal impact should be measured and evaluated. We then need to be transparent about our findings and publish the outcomes to keep the conversation ongoing. Thinking outside the box to advocate for added help will be necessary to make sure nurses are getting the help they need.

Reflection

You have the power to contribute to a sound, healthy work environment, one that attracts and retains staff and delivers good outcomes, but your role is to first take care of yourself, at work and at home. Ensure that you take your lunch and biological breaks. Identify a hobby that brings you joy and in which you can take part when you are away from work. Be grateful for your peers and for your ability to make a difference in the lives of others. Champion creative ways to manage your life and your profession.

Sharon M. Weinstein and Dina Readinger are health care executives and authors of Healing Healthcare: Evidence-Based Strategies to Mend Our Broken System.