Suits vs. Scrubs: The Financial Reality of Post-Pandemic Staffing

We've all experienced it. Walking into work and finding your nurse-to-patient ratio maxed out while one of the scheduled nurses was floated or "cancelled". You spend the entire shift running back and forth with ten things to do at all times. It becomes obvious that you aren't going to get around to the Foley care for one of your patients, or you forget to make your other patient NPO after midnight for surgery, or you don't notice the abnormal lab results that snuck in for another. Things slip through the cracks, we cut corners just to finish our work list, we back-chart and end up forgetting exactly how each patient's shift assessment went, we give meds late or not at all, all the while being relentlessly reminded of every tiny procedure, policy, and precaution required for "patient safety."

This has become more and more of an issue lately, and I've seen it first-hand on most shifts. Almost every shift, halfway through they send a nurse home due to "low census", so the rest of us take on extra patients mid-shift that were initially assigned to the one leaving. They call it "optimizing productivity" or other fancy-sounding things, but what they really mean is "saving money", and we owe quite a bit of it to the COVID-19 crisis ratios.

During the pandemic, we were promised the razor-thin ratios were temporary "crisis standards". High patient-to-nurse ratios were unavoidable because of the sudden influx of severely ill patients and the drop in available staffing due to illness and early retirement out of fear. I remember being offered enormous bonuses for picking up, and hospitals spent a fortune on travel nurse contracts. We tolerated it though, for the most part, because we knew this was an unprecedented global emergency no one had control over, and it was all just temporary. Right?

Except it wasn't. What hospital executives learned was just how thin they could stretch the staffing and stay afloat, so the high patient-to-nurse ratios became normalized. While on a spreadsheet of short-term expenses this does appear to cut costs, studies have consistently shown that long-term costs related to worse patient outcomes, training and retention for nurses, lost productivity, etc. increase with skeleton-staffing. Missing that Foley care caused a UTI, forgetting to make that patient NPO resulted in a delay of surgery, missing the abnormal labs resulted in a sudden rapid deterioration that led to an ICU admission. The burnout leads to high nurse-turnover, increasing recruiting and training costs, worsening physical and mental health, lower quality care, and overall poorer outcomes for everybody. And while it saves some money on a year-by-year basis, it costs more money in the longer-term big picture. Unfortunately, hospital administration seems to prefer looking at short-term savings.

Two studies of over 600,000 patients in New York and Illinois examined this concept. In New York, 4:1 patient-to-nurse ratios could have saved 4,370 lives and $720 million in two years. In Illinois, safe ratios could have saved 1,595 lives and $117 million in one year. It has been thoroughly proven that more nurses results in better and safer patient care and reduced long-term costs. And yet, we continue to watch nurses get sent home or cancelled because of "low census", resulting in skeleton crews that are pushed to the limit. This is because many hospital executives don't have clinical backgrounds and don't make decisions from a perspective prioritizing patient care. They apply business models that look good in the short-term without understanding the long-term costs. Worst of all, they make us nurses feel gaslit when we complain while they never step foot on any chaotic med-surg unit to see the madness for themselves.

I could go on and on about sneaky practices, corporate greed, and staffing grievances, but I would rather focus on what we can actually do about it. I want to introduce and encourage the use of Assignment Despite Objection (ADO) forms every time you are given an unsafe patient load. These forms put hospital executives on official notice of the risks they are taking, pressuring them to improve staffing. (Click on the hyperlink to access a guide to filing an ADO.) It is also important to speak up during workplace feedback periods regarding patient ratios, ideally in writing. Protect yourself and your license. Another important action is calling local legislators and telling them you support laws on safe staffing ratios. Frankly, I'd love to call on all suits and staffing executives to spend a day or two shadowing a nurse on an actual hospital unit to see the chaos they are unleashing, but I feel like that's much less likely.

While reporting unsafe staffing may not be an immediate fix, we can't highlight the problem for society without making the issue widely known. In the meantime, we continue to work shifts understaffed in reality, so here are a few tips for surviving those shifts.

1. Nursing priorities are critical. Foley care is more important than helping a patient find the news channel on their TV. Reporting abnormal lab results is more important than getting extra ketchup for the patient's meal. Responding to a bed alarm is more important than calling family for simple updates. If you try to do every little thing patients request, you'll drown and important things will fall through the cracks. And if they complain that you are taking too long to bring them a blanket, let them. They can complain all they want, but the priority must always be patient safety and care. We aren't paid tips based on service like servers at a restaurant. While making patients as comfortable as possible is important, it isn't the priority when staffing is short.

2. Help each other and use your resources. Use the charge nurse, your techs, and other nurses when you're struggling. Don't try to do it all alone if you're drowning. That's how mistakes are made. I understand the feeling that coworkers might be frustrated with you for needing help, but at that point you have to ask yourself what is more important: patient safety and your nursing license, or making sure all your coworkers never have negative thoughts about you. When understaffed, keep the big picture in mind.

3. Find a safe place to vent (like here on our forum!) and release your frustrations. Keeping them pent up hastens burnout. Take care of yourself mentally and physically. Utilize employee health resources and counseling. Use your PTO for recovery time. Follow the tips in my posts about self-care linked at the bottom of this post. Invest in your health and happiness. If we don't take care of ourselves, we can't take care of our patients.

4. Create a list of reminders at the start of your shift of the important safety things you need to do so you don't forget them, such as Foley care, wound care, central line dressing changes, making a patient NPO at midnight, etc. Set reminders on your phone if that helps you.

5. Make sure you take your break! Legally we are all entitled to uninterrupted lunch breaks. Don't let anyone pressure you to skip it. It is your legal right.

6. Cluster care safely. For example, if you bring meds to a patient, do your assessment and wound care while you're in there as well, if you have the time. Clustering care saves time and energy spent on switching frequently between tasks for each patient.

It is unfortunate we have to adapt to understaffing like this, which is why it's so important to also make your voice heard. "Extra staffing" is not "waste" when it comes to nurse-to-patient ratios. Studies have shown repeatedly that extra staffing leads to safer care and greater long-term savings. Do not be afraid to submit ADOs. Protect your license and advocate for your patients' safety. I know it's easier said than done, but if we don't push this, things will never change.

Disclaimer: Not every hospital, healthcare facility, and executive is guilty of these actions. But many are, and it's becoming more and more of an issue.