Appropriate nurse staffing remains one of the top priorities throughout healthcare, yet the solutions are more complex than ever.
AACN co-led a diverse group of professionals from various healthcare backgrounds to create bold and innovative strategies that address the staffing crisis for acute, critical and progressive care nurses.
The Nurse Staffing Task Force was formed to develop evidence-informed, nursing-led solutions addressing the root causes of the staffing crisis, including the shortage of nursing staff. Through extensive collaboration, they developed the Nurse Staffing Task Force Imperatives, Recommendations and Actions to develop a sustainable nursing workforce.
Several members of the Task Force discussed the critical insights they learned during the process and their key takeaways for moving the work forward.
What is your healthcare role and what perspective does it give you on the nurse staffing crisis?
Crystal Tully:
I am the patient support coordinator at Wellstar MCG Health. In my role, I primarily serve Children’s Hospital of Georgia.
I have two daughters with complex medical needs. When I am a parent at the bedside, I notice when there are staffing issues. But I notice even more now in my professional role going from room to room, unit to unit. You can feel it when you go from a NICU room to a PICU room to a post-surgical room to the ED — especially in the ED. You can see it in the faces of patients and their families. It’s the mom who says, “I can’t leave. If I leave, he’ll get the wrong medicine again.” They can’t go home and shower; they can’t go take care of their other kids. It’s not that they don’t trust their nurses. It’s that they know their nurses have so many other things to criss-cross and unravel and plug in that something is bound to get overlooked.
David Wyatt, PhD, RN, NEA-BC, CNOR, FAORN, FAAN:
I am chief nursing officer of a large academic medical center in Dallas, Texas. My relationship to staffing has been much more significant in the past few years than it was in the years prior, because when you are in a shortage, more decisions need to be made in real time. When you are in a smaller institution, you don’t have a lot of places where you can pull staff from, so staffing in a small hospital can be incredibly difficult to manage. We are fortunate to have a lot of resources to help us manage.
The downside of being in a big place, particularly during an experience like the pandemic, is that we are the end of the road. It is so important for us to assist some of the smaller community hospitals in the area that may not have that same capacity to manage large numbers of patients. There is a staffing component to all of that, particularly with complex patients.
Kiersten Henry, DNP, APRN-BC, ACNP, CCNS, CCRN-CMC:
My role is nurse practitioner and chief advanced practice provider in a community intensive care unit in the Washington, D.C. suburbs. As the sole provider at night, I am the clinical leader on the unit. As a clinical leader, I feel that constant stress over whether we have enough staff, whether we can handle the next emergency, whether we can handle the patients’ needs — and if we don’t, how can we adapt within the constraints that we have available to make sure that our nurses feel they are providing safe and adequate care?
Curtis Devos, MBA, BSN, RN, CNRN:
I am the director of a surgical care unit, and things have become more stable where we don’t have to make as many unplanned changes. We are asking questions like whether we have enough charge nurses or enough coverage for progressive care. But that doesn’t mean that staff are plentiful. It’s just more consistent. It’s always a balancing act. You have to look at the needs of the unit as well as the needs of the staff members who just want to work a fair schedule. You don’t want to put staff in situations that are unsuccessful even if it’s what the unit needs.
Kathi Koehn, MA, RN, FAAN:
I am executive director of the Minnesota Organization of Registered Nurses. In this role I don’t have a direct impact on staffing, but I did spend 35 years as a staff nurse and have been through the many ups and downs of staffing. Currently, things have become harder and harder. Patients are coming in sicker, with higher acuity, but for shorter amounts of time. Quite frankly, I believe staffing has become more challenging as hospitals have become corporations. Our ability, as nurses, to impact change has decreased. It has become harder to understand where in the corporate structure decisions are being made. So, I think when the Task Force started, we were at a time when nurses had already been talking about trying new kinds of solutions because the old ones aren’t working.”
Katrina Bickerstaff, BSN, RN, CPAN, CAPA:
My role has always been bedside nurse. One thing about recovery room staffing is that everywhere I’ve worked, they’ve always maintained something like a ratio, where in the first 20 minutes to half hour of a new patient’s experience, there is a maximum of one nurse to two patients. But it backs up elsewhere. It backs up in the operating room or in the emergency department. So even though we have the staffing, there is still a lot of pressure to move the patient along. And when other units are short-staffed, it backs everything up.
How did your involvement with the Nurse Staffing Think Tank and Task Force change your perspective on staffing?
Crystal: Staffing is a difficult issue. It is an issue that presses lots of different buttons for people. So I think it’s really important for people to see that this big, diverse group came together consistently to work on solutions. It is not going to be solved in a single board meeting or event. These folks were willing to come together and have the tough conversations for the sake of the many. If only we could do that with every difficult topic. If there is something I would like people to know that isn’t in the document, whether you are a new nurse or a nurse leader, is that this experience also showed that tough conversations are worth having.
David: During the Task Force I really had to learn to listen to different perspectives. We won’t get anywhere on nurse staffing if we don’t open our minds to listen. So the nurse leader who says, “All I do is focus on the aggregate and all you do is focus on the individual, so I won’t listen to you” is not OK. And the bedside nurse who says, “I don’t care how many other patients you have to take care of in this unit or in the emergency department” — that’s also not OK. We need a way of meeting in the middle and having a dialogue to make the best decisions for all of the patients.
It isn’t about perfect agreement. Many of us who were on the Task Force are still in disagreement about one recommendation or another. Initially, I was frustrated by that, but I had to come to terms with it and say, “That’s OK.” If there was one single data point that could answer this question for everyone, we wouldn’t be in this situation.
I think that through this Task Force I learned how important language is and in particular how important it is to choose words that don’t exclude alternative options or opinions.
Kiersten: The first thing I always tell people about this staffing initiative is that what is so great is that nurses set the table and then invited the people whose support and advocacy we would need to solve this problem. The standards for what’s safe in staffing should be set by the people who already set the standards of practice excellence. That was the first big idea that really resonated for me.
When we got to the Task Force, we decided after a lot of thoughtful discussion that we have to establish staffing standards that ensure quality of care. It may not be as simple as x number of patients for every nurse, but we cannot get away from the fact that there is some minimum number of nurses that you need to provide care in a given practice area.
So it will be about finding new ways to measure acuity, giving nurses in various specialties the language they need to advocate for standards, and ultimately providing nurses with the tools they need to integrate that into the way they are actually staffing. The weight of the Task Force and a national effort should help that along. But it may also require us to think about legislation to support this. How do we make this a benefit to the healthcare system instead of a burden? How do we outline what safe staffing looks like while also understanding that everything can change in the blink of an eye?
Curtis: An idea that we adopted in the Task Force was removing tasks that are not really aligned with evidence or team goals. That has changed my practice; so when a new idea is brought forward and people say, “Nursing can do that,” I say, “What can we take away from nursing?” Can we at least agree that there needs to be a one-to-one exchange? Because there are plenty of situations where five committees have decided that nursing needs to do more without anyone saying that nursing needs to do less. When we ask nurses to do new tasks, we need a clear idea of the value added to their work and a measurable outcome.
Katrina: I think that we have come up with a real structure that shows that these people were serious about addressing staffing. It didn’t feel like another meeting where you say, “Oh and the bedside nurse had some input.”
That’s reflected in our recommendation that staffing committees should be made up of at least 50% front-line staff. It’s necessary for the people who are dealing with the most pressing issues day to day to be working right there with the administration.
One other thing that we talked about in several of our groups was that we need more of a flex role or a short shift for the times of day when things are really happening, and you need that extra set of eyes or hands. Because if the nurse is spinning, they won’t be able to focus on patient care.
What actions will you take as a result of this experience?
Crystal: It is truly amazing how much is documented yet how little of that ends up in the final picture that goes toward reimbursement.
I think about the fact that over the summer, we had a four-week period where we had six pediatric gunshot wounds on top of all the things we usually see: drownings, accidents, cancer and heart care. None of our nurses stopped coming to work. They probably stopped doing a lot of other things that were important to them or good for them, but they never stopped coming to work. That says something about the level of commitment nurses have.
David: I think all of us are going to be thinking about the right skill mix we will need for these new care models, and when someone indicates that things have to be a certain way, we need to be very comfortable stopping and asking, “Why?” Now that the staffing situation is getting a little bit better nationwide, it is the time to start thinking about these models.
Kiersten: I think all of us need to zoom back in and find those one or two actions that we can take to our specific workplace. Not all of these issues are within nursing’s control, so we are going to have to continue to partner with others.
How would you advise other people in the healthcare system to act on the Think Tank and Task Force recommendations?
Crystal: In every room I’m in, one of my messages is that silos in healthcare are feeding our emotional burdens and administrative burdens. It is fuel for them. They prevent us from talking about hard stuff like we did in this task force, and they make problems perpetuate within our institutions.
Here’s one way I started to put the experience of this task force into practice before it was even over. I was designing a training around the AIDET model, while also thinking about things that task force members had said. And it made me realize that it isn’t for the lack of knowledge that some of these principles aren’t being followed. You don’t need to tell nurses how to say thank you.
So in the unit I was working with, we talked about emotional intelligence and the difference between empathy and sympathy, but we did it in a way that was focused on making sure they had the bandwidth to think about those things with patients.
Kathi: I would recommend that people read through the whole report, then look back at the imperatives, recommendations and actions to choose what’s most interesting for them. Do a gap analysis. “Here is where we are; here is how far we need to go.” It may not work for every imperative, but hospitals can do many of these things, asking how you can demonstrate it and be innovative.
Kiersten: These documents can be a part of advocating for yourself and collaborating with your colleagues. It is similar to AACN’s Healthy Work Environment standards, which have been deployed across units and professions in hospitals to improve retention and staff satisfaction. As with the standards, you can’t make all of this happen, but you can find something to start with.
Upon the completion of its work, the Task Force agreed on five guiding principles to serve as guideposts while developing contemporary and progressive pathways toward a new nursing workforce. In addition to their comprehensive publication, members developed the Nurse Staffing Task Force Executive Summary Table, which synthesizes the imperatives and recommendations in a one-page downloadable document.