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ANA on the Frontline

Appropriate staffing = safe, quality care

ANA, nurses work on range of efforts to address this nursing priority.

When asked why appropriate staffing was so important, Tracy Viers, MSN, RN, CCRN, didn’t hesitate for a second.

“The bottom line is it’s all about patient safety and positive outcomes,” said Viers, an ANA-Illinois member and intensive care unit (ICU) staff nurse at Blessing Hospital in Quincy, Illinois. “Good patient outcomes are dependent upon nurses, who can’t do their best when they have too many patients and tasks.”

And that inability to provide every patient with the best possible care also causes nurses, no matter where they work, incredible physical and emotional stress, she added.

The American Nurses Association (ANA) wants appropriate staffing to be the rule—not the exception— across care settings. To that end, the association continues to increase and widen its efforts, knowing that complex problems require a multipronged approach.

One effort involves pursuing a unified legislative and regulatory approach to achieve ANA’s staffing goal. Another is an educational and outreach campaign launching this fall to provide nurses with guidance and tools to help them make an immediate case for appropriate staffing and implement practical, comprehensive staffing plans. Among these resources is ANA’s Principles for Nurse Staffing, which was recently revised to make it more applicable to all settings and to emphasize nurses’ critical role in ensuring healthcare facilities meet their mission of providing patients and communities with quality, safe, and cost-effective care. (Read more about ANA’s work in this issue’s special section on staffing.)

Assessing the problem

In a 2019 ANA membership survey of more than 6,700 nurses, 93% identified staffing as an important issue, with 72% identifying it as “extremely important.” And when asked to name their top three nursing issues, “early career” nurses (0-4 years of experience) and “up and comers” (5-14 years of experience) named staffing as a priority far more than any other issue.

Texas Nurses Association member Bob Dent, DNP, NEA-BC, FAAN, FACHE, FAONL, who helped revise ANA’s staffing principles, pointed to years of research showing that appropriate nurse staffing leads to better patient outcomes and fewer adverse events. Studies also have linked appropriate staffing to cost-savings that result from preventing complications and readmissions.

Yet findings from an ANA Enterprise HealthyNurse®Survey gathered between February 2017 and May 2019 revealed that more than a quarter of the 18,500-plus respondents said they were often assigned a higher workload than they felt comfortable with. About 52% responded that they frequently must work through their breaks to complete their assigned workload and 53% often have to arrive early or stay late to get their work done.

Speaking to staffing as a national issue, Washington State Nurses Association (WSNA) member and neuro-trauma ICU staff nurse Danielle O’Toole, BSN, RN, CCRN, said, “Nurses are continually being asked to do more and more and more with less.”

She also affirmed the ANA’s survey findings about nurses working nonstop. For years, nurses in her facility didn’t take rest and meal breaks for fear of overburdening their coworkers and putting their patients at risk. “Anything can happen in 30 minutes, especially in an ICU where you have critical I.V. drips,” O’Toole said.

Looking at the principles

Although ANA’s revised principles include additional information, such as referencing the Institute for Healthcare Improvement’s triple aim efforts  to improve health system performance, this resource continues to provide nurses with an important framework to help them develop, implement, and evaluate appropriate nurse staffing plans and activities. It includes core components of appropriate staffing such as:

  • RNs at all levels within a healthcare system must have a substantive and active role in staffing decisions to ensure they have the necessary time to meet patients’ care needs and their overall nursing responsibilities.
  • All settings should have well-developed staffing guidelines with measurable nurse-sensitive outcomes specific to that setting and the healthcare consumer population they are serving that are used as evidence to guide daily staffing.
  • Staffing needs must be based on an analysis of the patient’s or consumer’s healthcare status, such as acuity and intensity, and the environment in which care is provided.

Other considerations include RNs’ competencies, experience, and skill set; staff mix; and previous staffing patterns that have shown to improve care outcomes.

Dent reinforced the importance of nurse involvement and collaboration—such as through the implementation of staffing advisory committees—to attain appropriate staffing and good patient experiences and care.

Bob Dent

“It’s important that nurses aren’t questioning whether they are really making a positive difference for their patients,” said Dent, who recently left his long-time leadership role at Midland Memorial Hospital in Texas and is now vice president and chief nursing officer of three facilities within the Emory Healthcare system. “I’ve found that if nurses have a positive and healthy work environment—and appropriate staffing is a component of that—then their patients are getting good care and having great experiences.”

The ANA document also outlines specific principles related to healthcare consumers, RNs and other staff, the organization and workplace culture, the practice environment, and staffing plan evaluation—all of which can guide direct care nurses and those at other levels in making sound staffing decisions and plans.

For example, staffing decisions should take into account factors such as the age and functional ability of patients and healthcare consumers, as well as their cultural and linguistic diversities, scheduled procedures or treatments, and complexity of care needs.

On the other side of the equation, nurses’ level of overall experience (novice to expert), educational preparation, language capabilities, and experience with the population being served should be among the factors considered.

Deborah Maust Martin

“Staffing is complex,” said Deborah Maust Martin, DNP, MBA, RN, NE-BC, FACHE, who also contributed to the revised principles. “We need to look at patient outcomes and how we get the best match of patients and nurses.”

The principles of staffing document also emphasizes other key points, such as calling mandatory overtime an unacceptable solution to achieving appropriate staffing, ensuring that nursing students aren’t counted as staff, creating a workplace culture that leads to retention, and identifying costs of nursing care in patient billing and reimbursement requests to provide visibility to the value of nurses and nursing services.

Maust Martin, a Wisconsin Nurses Association member, noted that the principles are designed to be applicable to nurses working in all settings, from acute care to school and community-based practices. The term “healthcare consumers” instead of “patients” shows the broad reach of nurses’ roles and the populations they serve.

Pursuing other efforts

Danielle O’Toole

Many state nurses associations and specialty-focused organizational affiliates also are engaging in a range of efforts to address this priority issue.

In Washington State, O’Toole testified before legislators about nurses’ inability to take needed rest and meal breaks and the impact it has on nurses and patients. Her advocacy and that of other WSNA nurses and staff led to the passage of a state law providing breaks and overtime protections for nurses, effective in January 2020. Her facility, Tacoma General Hospital, hired “break relief” staff to cover nurses during those times as a result of legal action by WSNA, and the new law reinforces the hospital’s obligation to ensure nurses get breaks.

“I’m taking my first breaks since the law passed,” said O’Toole, who also is chair of her WSNA local. “We also have a robust staffing committee that meets once a month that is 50-50 staff nurses and management to address staffing issues.” The committee additionally reviews the efficacy of every unit’s staffing plan, including negotiated standards, every 6 months to determine if any changes are needed.

ANA-Illinois Executive Director Susan Swart, EdD, MS, RN, CAE, said the association plans to introduce legislation to strengthen the state’s existing staffing law, which went into effect in 2008 and was based on ANA’s earlier staffing principles. The law requires healthcare facilities to have staffing committees made up of at least 50% direct care nurses and that staffing decisions are based on patient acuity, skill mix, and other key factors.

“We want to put some teeth in the law so the committee isn’t advisory but has real pull,” Swart said. “We know from our recent member survey that nurses continue to struggle with staffing and workplace issues that are connected with understaffing.”

ANA-Illinois also is working with the Illinois Hospital Association’s new chief nursing officers group to more immediately strengthen and raise the profile of staffing committees. Part of their strategy is to include information about staffing committees, including their purpose, as a routine part of orientation in all facilities, Swart said.

ANA-Illinois board member and staff nurse Lauren Martin, RN, CEN, also thinks it’s critical that nurses from all shifts are represented on staffing committees.

“Night shifts tend to not be staffed as well as day shifts, and oftentimes it’s new nurses, who are just learning the job, working those shifts,” said Martin, who works in a specialty long-term care facility. “So, we really need to increase nurses’ involvement on committees and in other ways to solve staffing issues. That includes looking at all the factors that are causing inappropriate staffing.”

Both Dent and Maust Martin added that nurses must think about new ways to manage staffing needs— whether it’s adjusting shift length, having long-time nurses support novice nurses through ongoing, virtual mentoring, or piloting new models of care.

Noted Dent, “We all have a piece of the pie when it comes to addressing nurse staffing.”


Susan Trossman is a writer-editor at ANA.


Access ANA’s new staffing webpage for key documents and tools at nursingworld.org/practice-policy/work-environment/nurse-staffing/.


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