Combating Staffing Problems

By Katherine Kany, BS, RN

Katherine Kany is the senior labor relations specialist at the American Nurses Association.

Q. A couple of years ago, our hospital reduced the number of registered nurses and filled their positions with unlicensed assistive personnel. Now, higher acuity levels and the inability to fill vacant RN positions are causing more short staffing. We’re tired and frustrated with staffing problems and concerned about quality of care. What can we do?

A. Every hospital must be licensed and accredited in order to admit patients and to receive reimbursement from insurers. Examining the requirements necessary for accreditation—specifically those having to do with nurse staffing and quality of care—will give you a sense of your facility’s compliance. While most hospitals apply for accreditation by the Joint Commission on Accreditation of Healthcare Organizations, they are still required to meet state standards. You can receive a copy of these standards, usually free of charge, by contacting the appropriate agency in your state (most likely, the Department of Health). Your state nurses association (SNA) can also provide this information.

While you have the right to report unsafe conditions, it’s important to note that you’re not always protected when doing so. Specifically, you may not be protected from negative consequences resulting from reporting unsafe staffing or quality of care concerns to the appropriate state agency, unless whistleblower protections exist in your state. Kentucky, Minnesota, and New Jersey passed whistleblower legislation last year that protects employees who speak out against unsafe patient care practices. Other states have such legislation pending. At the federal level, the Patients’ Bill of Rights includes whistleblower protections and is currently before Congress.

You’re also protected if you have a collective bargaining agreement, which enables nurses nationwide to bring concerns about staffing to their facilities’ attention; to develop new approaches regarding staffing; and to identify strategies to protect quality of care. Such agreements also allow nurses to participate with hospital management in making critical decisions affecting their nursing practice, their patients, and their quality of work life—all with the help of their SNAs and the ANA.

Unfortunately, in the absence of whistleblower legislation or strong contract language, you have little protection against inappropriate staffing. Still, you can take several measures. First, quantify problems in order to present a strong and objective case to those who have the ability to change staffing patterns. Your research might include an assessment of the number of understaffed shifts; any trends in understaffing occurring on specific shifts or days of the week; unanticipated sick or emergency leave not covered; unusual situations that may have occurred and that would have been almost impossible to predict; and a review of how frequently nurses work overtime. You can also include data on the factors that increase the workload of the scheduled staff. For example, has length of stay decreased, or are patient acuities higher than previously experienced?

The ANA recently released staffing principles for nurses, which can be used to support the argument for an increased RN staff (see Issues Update). To prepare the best possible case for staffing changes, share and analyze your collected information with other nurses on your unit, and add their input. Once completed, present all the data to the unit manager. This collaborative approach creates a more thorough analysis and, ultimately, a more solid proposal on your behalf. If you’re unable to bring about change by working through the chain of command within your facility, present the same information to the appropriate accrediting agency. This can be done with support from your SNA and the ANA.

Another important step is to advocate for state and national legislative initiatives that require collection, analysis, and public reporting of quality data. For example, the Patients’ Bill of Rights includes a component on public reporting of quality data. In addition, the Patient Safety Act, which is expected to be reintroduced in Congress this spring, would require public disclosure of staffing levels in order for hospitals to retain their Medicare status. Supporting this type of legislation, working with your SNA, and becoming a member of the ANA’s N-STAT (Nursing’s Strategic Action Team) will, over time, enable you to identify and enforce safe staffing. N-STAT members receive updates on pending federal legislation and have frequent opportunities to participate in guided activities that let members of Congress know what the nursing community needs.

Whether using existing protections or advocating for new ones, nurses can have a strong role in addressing staffing concerns at their facilities.

For information on whistleblower legislation and N-STAT, call (800) 274-4ANA, or to organize, call (877) ANA-ORGANIZE.