President's Column: The Staffing Crisis: An Evidence-to-Practice Gap

Aug 24, 2022

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Every day we hear new stories about the current nurse staffing crisis, but appropriate staffing is not a new problem.

Decades of consistent, high-quality research show us that when nurse staffing is inadequate and the work environment is not optimal, patients suffer harm and nurses experience moral distress and burnout, and they leave the profession at higher rates.

At AACN, we included appropriate staffing in our AACN Healthy Work Environment (HWE) Standards back in 2006, and we've been using our influence to boldly and publicly advocate for appropriate staffing ever since.

The pandemic didn't create the staffing problem, it just exposed its deep roots. AACN has been, and will continue to be, a leader in advocating for healthy work environments. But, in the case of staffing, is advocacy enough? Let's think about that.

In my practice as a CNS, scientist and educator, I work to close the evidence-to-practice gap. That is, I try to make it easy for clinicians to use high-quality evidence in routine care.

Many sources say it takes 17 years for new evidence to make its way into routine care. We all know, withholding that evidence from our patients for 17 years — whether a clinical practice guideline or a new technology to improve patient outcomes — is simply unacceptable. The problem isn't that we don't have the evidence that staffing affects nurse and patient outcomes — we have that evidence in abundance. The problem, as I see it, is acting on it. And we can't wait 17 years.

If we think about the staffing crisis as an evidence-to-practice gap, we can begin to explain why change has happened slowly — or in some cases not at all — despite all of the evidence. Implementation science seeks to explain the factors that make changing practice difficult, and then uses evidence-based strategies to overcome them. While applying implementation science theory to the staffing crisis, there are three important barriers that reveal why change hasn't happened quickly:

  1. Nurse staffing is traditionally maintained at the bare minimum, therefore, any improvements in staffing contradict long-held norms and values. The science tells us that changing a practice that contradicts existing norms and values is extremely difficult.
  2. Improving staffing in the current structure of hospital finances is expensive. Nurses are a significant labor cost, and the way hospitals are paid does not incentivize them to improve staffing. Until there are economic incentives (or penalties) for hospitals related to appropriate staffing, the motivation is not there, which creates a significant barrier.
  3. The attitudes and opinions of leaders matter. It's difficult to imagine how improvements in staffing can occur when leaders and administrators do not view change as favorable or are unwilling to act on the evidence.

Starting Now is AACN's theme for the year — a call to begin building the new, advocating with greater urgency and doing the next right thing. So, Starting Now, what can we do that goes beyond advocacy and drives the implementation of appropriate staffing? The science says that to change practice, we must use specific, evidence-based strategies that overcome these barriers to achieve success. At AACN, we are doing that.

To change the norms and values on staffing, AACN has published our most recent survey findings on the health of work environments — including perceptions of staffing — and we are sharing the findings with the widest audience possible, including the public. We're working to raise awareness of the severity of the problem, so more people know the negative impact the ongoing staffing crisis, if left unchecked, will continue to have on patients and the healthcare system.

As noted above, we know that there are financial implications to improving staffing. That said, there are major implications for not addressing it as well. As a result, we have included the Healthcare Financial Management Association leadership in our Partners for Nurse Staffing work, and we are exploring ways to advocate for a payment structure that would financially incentivize hospitals to improve staffing.

Now more than ever, leaders and administrators are listening to the evidence on staffing because they are interested in retaining their increasingly mobile and marketable nursing workforce. And AACN has provided an online HWE Assessment tool and a toolkit that provides a suite of strategies that leaders can use to improve based on their results.

Like the medication rights we know so well, there are three implementation rights that must exist for change to occur: The right method, for the right setting, at the right time. The truth about the pandemic-induced staffing crisis is that it created an unprecedented opportunity for us to bring the HWE standards to the table in the right setting at the right time. Until now, these important rights have not lined up in this way.

I am hopeful that some good will come from the pandemic and we can finally make progress on this critical staffing issue that has plagued our profession for decades. As Walt Disney once said, "The way to get started is to quit talking and start doing." AACN has made this our number one priority, putting the full strength of our organization behind it to help activate the staffing improvements nurses need now.

What has your hospital done to address the current staffing crisis? What are you doing to spotlight this issue? Please write to me at