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Negotiating Safety when Staffing Falls Short

Article in Critical care nursing clinics of North America · June 2010

DOI: 10.1016/j.ccell.2010.03.014 · Source: PubMed

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N e g o t i a t i n g Sa f e t y
w h e n S t a ff i n g
Falls Short
Cindy Diamond Zolnierek, MSN, RNa,b,*,
Cynthia M. Steckel, PhD, RNc

KEYWORDS
 Nurse staffing  Nurse/patient ratios  Staffing plans
 Patient safety  Patient assignment  Patient advocacy

Adequate nurse staffing is inextricably linked to patient outcomes,1 and, although

optimal staffing levels for inpatient hospital units are widely debated, staffing stan-
dards for critical care areas such as intensive care units (ICUs) may be less variable.
Yet, even established staffing levels cannot guarantee adequate staffing. The nursing
workforce shortage has affected all areas of nursing practice, but perhaps no area
more severely than critical care. New treatments and procedures increase the number
of individuals requiring intensive inpatient care and emergency rooms receive
increased requests for nonemergent as well as critical care. There are times when
staffing fails to meet desired levels and nurses are challenged to meet their duty to
the patient for safety. The purpose of this article is to identify the safety challenges
posed when staffing levels are less than planned in critical care settings and discuss
individual, organizational, and policy-oriented strategies for protecting patient safety.

BACKGROUND AND SIGNIFICANCE

Nurse staffing gained attention during the 1990s, a decade of turmoil for the health
care industry as managed care introduced new rules for payment and providers strug-
gled to survive. Hospitals shifted services to outpatient settings and looked to cut
operating costs. As the greatest cost center in the hospital budget, nursing labor
was a natural target. New patient care delivery models (eg, patient-focused care),
which made greater use of unlicensed nurse extenders, emerged. Registered nurse
(RN) positions in hospitals were reduced, the nurse shortage abated, and schools of
nursing closed. But all was not well. Nurses argued that new care delivery models

This work received no financial support.

The authors have nothing to disclose.
a
Texas Nurses Association, 7600 Burnet Road, Suite 440, Austin, TX 78757, USA
b
School of Nursing, The University of Texas at Austin, 1700 Red River, Austin, TX 78701, USA
c
Clinical Services, Scripps Memorial Hospital La Jolla, 9888 Genesee Avenue, La Jolla, CA 92037, USA
* Corresponding author.
E-mail address: cindyzoln@yahoo.com

Crit Care Nurs Clin N Am 22 (2010) 261–269

doi:10.1016/j.ccell.2010.03.014 ccnursing.theclinics.com
0899-5885/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
262 Zolnierek & Steckel

did not provide an adequate level of professional nurse staffing, but lacked evidence
to support this belief.
Aware of staffing concerns, Congress directed a study regarding the quality of
nursing care, patient outcomes, and nursing outcomes (eg, work-related stress and
injuries) related to nurse staffing levels and skill mix. The Institute of Medicine pub-
lished its report Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?2 in
1996. The report pointed to the lack of evidence regarding quality and outcomes of
care, and it gave high priority to research that would provide evidence to allow conclu-
sions to be made about nurse staffing levels.
Seminal studies on nurse staffing followed. In 2002, researchers3 reported that
greater hours of care provided by RNs were associated with more positive patient
outcomes of care. Similarly, fewer nurses was found to be related to poorer outcomes
for nurses and patients.4 Further evidence substantiated these early findings. In
a meta-analysis of 28 studies examining the relationship of nurse staffing and patient
outcomes, researchers established that increased RN staffing was related to lower
patient mortality and adverse patient events.1 Additional research highlighted the
importance of the nurse’s practice environment5,6 and educational levels.7–9
There was scientific evidence to support what nurses knew all along: adequate
staffing is necessary for quality patient care. But what is adequate and who decides?
Several states have attempted to address this question within statute and regulations.
In 1999, California became the first state in the nation to address nurse staffing in
hospitals by passing a law requiring defined nurse/patient ratios for various hospital
units (Assembly Bill 394); the legislation was implemented in 2004. Other states (Ore-
gon, 2002 and 2005; Texas, 2002, 2007, and 2009; Illinois, 2007; Ohio, Connecticut,
and Washington State, 2008; and Nevada, 2009) also implemented legislation or regu-
lations addressing hospital nurse staffing, but none adopted the mandated ratio
approach. Instead, hospitals were mandated to establish staffing plans using nurse
staffing committees that include direct care nurses to determine appropriate nurse
staffing levels. Research has not yet shown the effectiveness of either approach in
ensuring patient safety.10–12 The evidence suggests that adequate staffing is complex,
involving the interplay of several factors including nurse, patient, and hospital charac-
teristics.1,13,14 Rischbieth15(p399) considers specific considerations of nurse-patient
allocation in the ICU and proposes skill matching as a more comprehensive and inno-
vative approach to staffing than nurse/patient ratios. Skill matching considers the
nurse’s critical care qualifications, ICU experience, demonstrated skill and competen-
cies, ability to work with minimal supervision, familiarity with technology and equip-
ment, and knowledge of patient acuities and required therapies and treatments. The
specific layout of the ICU, proximity and accessibility of resources, and peer knowl-
edge of the nurse’s preparedness also influence skill matching.15(p399)
Despite mandated attempts to ensure adequate staffing, fluctuations in patient needs
and available staff can result in understaffing. When there is understaffing, nurses are
faced with the dilemma of fulfilling their duty to the patient without adequate resources.
The nurse has an unconditional duty to the patient and their safety, ethically and
legally.16,17 The responsibility is absolute; it cannot be waived by a directive from another
or by facility policy. How does a nurse fulfill this duty to the patient when staffing falls short?

SAFETY STRATEGIES
Individual Safety Strategies for the Nurse
Nurses are at the sharp end of errors in health care. Because of their role in coordi-
nating the patient’s care and providing surveillance, as well as their constant presence
 Negotiating Safety when Staffing Falls Short 263

with the patient around the clock, nurses are at the terminal point of the trajectory of
many potential errors, the point where a latent or potential error is actualized. Hence,
nurses play a critical role in patient safety. Patient outcomes are directly related to
adequate nurse staffing and positive practice environments. When nurses are sup-
ported in their work (eg, through adequate staffing, effective operational systems,
and collaborative relationships) they are able to fulfill their protective role and patients
benefit. When staffing falls short, patient safety is threatened.
Perhaps the first and most important strategy for the direct care nurse is to develop
skill in identifying situations of concern, and more specifically, precisely what about the
situation is a concern. What constitutes adequate, appropriate, or safe staffing or
assignments is not clear-cut; it varies according to the characteristics of the patient(s),
nurse, and environment. Generalizations such as ‘‘this is unsafe’’ are too vague to invite
effective problem solving. By identifying exactly what about the current situation is
problematic, the nurse creates opportunities to correct those specific factors.
 Does the number of patients assigned and the level of surveillance required
exceed the nurse’s capability, such as more than 1 immediate postoperative
open-heart patient assigned to 1 nurse? Shifting assignments and reprioritizing
workloads may be necessary to resolve the staffing concern.
 Does the nurse lack specific competencies to provide safe patient care, such as
when nurses float outside their home unit without orientation or when a new
graduate is assigned to a complex and fragile patient? A solution might entail as-
signing a buddy to the nurse who can assist with patient requirements that do not
match the nurse’s competency.
 Does the available technology and geography of the unit affect the nurse’s ability
to monitor patients appropriately? Deployment of assistive staff, such as
a monitor technician, or relocating patients to a common area may address
the nurse’s concern.

The Texas Nurses Association (2008)18 offers the following suggestions to a nurse
who questions an assignment:

1. Clarify the assignment: be certain about what it is you are being asked to do
2. Assess the characteristics of the patients being assigned and the resources
available
3. Consider the geography of the assignment, the duration of the assignment, and
personal competency to manage the patient assignment.

By clarifying the circumstances of the assignment the nurse acquires the informa-
tion needed to determine whether the request is achievable (ie, whether the nurse
can safely complete the assignment).
A nurse who questions the safety of an assignment has a responsibility to raise the
concern to those who can address it, such as the charge nurse or supervisor. Patient
safety is the goal, a goal shared by all involved in the patient assignment process.
Others should be involved as necessary to determine what changes can be made
or what resources can be mobilized to provide for patient safety.
In Texas, the nurse making the assignment, as well as the nurse accepting the
assignment, is held to the same standard: ‘‘(the assignment must) take into consider-
ation client safety and (be commensurate) with educational preparation, experience,
knowledge, and physical and emotional ability.’’19 The accountability for safety is
balanced. A supervisor who knowingly makes an unsafe assignment violates the
Texas Standards of Nursing Practice and places their RN license in jeopardy. Yet,
264 Zolnierek & Steckel

there are times when the direct care nurse and the supervisor may legitimately not
share the same perceptions about the safety of a particular assignment or staffing situ-
ation. The Texas Nursing Practice Act20 offers a unique provision for promoting
problem solving when this occurs. Safe Harbor Nursing Peer Review enables a nurse
to invoke safe harbor if they believe a request (assignment) may violate their duty to
a patient. Safe harbor formally alerts the supervisor to the seriousness of the nurse’s
concern and initiates an immediate problem-solving process. The supervisor must
meet the nurse to determine whether the nurse’s concerns can be immediately
addressed and resolved. Safe harbor also sets in motion a peer review process in
which a committee of nurse peers must review the situation within 14 days and deter-
mine whether the request (the assignment) did indeed violate the nurse’s duty to the
patient. The Nursing Peer Review Committee’s decision is reported to the chief
nursing administrator and communicated to the nurse. The nurse requesting safe
harbor is afforded specific protections from the Board of Nursing and the employer
(retaliation is prohibited).
In rare instances, such as when a nurse lacks the basic competency to provide care,
a nurse may determine that they cannot accept an assignment. This decision should not
be made lightly; usually the patient is better off with the nurse than without the nurse and
the patient’s best interest must guide the decision. However, if the nurse lacks compe-
tency to provide even the most basic care (eg, a cardiac critical care nurse is asked to
float to a neonatal ICU where they have never been before) the nurse should probably
refuse the assignment. Texas laws prohibit retaliation toward nurses who refuse an
assignment because of a good faith belief that it would violate their duty to the patient.20
Nurses have a primary duty to patient safety and are obliged to speak up if they
believe in good faith that their patient assignment may compromise patient safety.
Because safe staffing is complex and involves nurse, patient, and hospital factors,
the nurse’s ability to articulate specific concerns about a particular situation contribute
to the resolution of those concerns. All nurses, regardless of roles in the organization,
have a responsibility to work together to ensure that available resources are used most
appropriately to provide patient safety.

Organizational Strategies
The most important organizational strategy is a commitment to a culture of safety and
a positive nursing practice environment. In a culture of safety, everyone in the organi-
zation is invited to identify, report, and participate in resolving potential safety
concerns. Potential problems are anticipated so that strategies to prevent their occur-
rence can be implemented in a proactive manner. In a positive nursing practice envi-
ronment, the efficiency and effectiveness of nursing care are maximized, thus making
the most of a limited resource.
Seven states have legislated nurse staffing committees as an organizational
strategy to achieve safe staffing (Fig. 1). All 7 states require that direct care nurses
compose at least 50% of committee membership; 3 states require direct care nurses
to be selected by their peers. Staffing committees either develop the hospital nurse
staffing plan or play an advisory role. The use of a staffing committee provides the
foundation for a collaborative, shared decision-making process for establishing, moni-
toring, and evaluating hospital nurse staffing. Direct involvement of front-line staff is an
essential foundation of a positive nursing practice environment and improving hospital
performance.21–23
An adequate staffing plan is a necessary but insufficient condition for assuring safe
staffing. Unexpected surges in demand or vacancies of staff can quickly render an
adequate staffing plan an unsafe situation; influenza epidemics can increase patient
 Negotiating Safety when Staffing Falls Short 265

admissions as well as staff sick calls, quickly challenging adequacy of resources to

provide safe care. Hospitals concerned with safe staffing should establish contin-
gency plans that provide alternative although not ideal staffing options. Some exam-
ples include:
 Alternative staffing models:
The second author developed a contingency plan in which licensed vocational
nurses (LVNs) and respiratory therapists (RTs) were used to supplement
RN staffing in the ICU. An RN/LVN or RN/RT pair were assigned to 3 patients
who normally would have been assigned 2 patients to 1 RN. Staff were
educated to their roles in the dyad and oriented to the ICU environment in
advance as part of a contingency plan in the event of RN shortages.

Fig. 1. Comparison of staffing plans. Courtesy of Texas Nurses Association; with permission.
Copyright ª 2009.
266 Zolnierek & Steckel

Fig. 1. (continued)

Another alternative approach involved assigning 2 RNs to care for 3 patients

who would normally be assigned 1 patient to 1 nurse. Again, staff were
oriented as pairs ahead of time to ensure a strong working team.
 Floating staff: step-down or telemetry unit staff may be able to assume some of the
care for more stable patients in the ICU, for example a patient waiting for a myocar-
dial infarction to be ruled out. Floating staff should be oriented to the unfamiliar unit
environment and provided with a resource person to go to with questions.
 Mobilizing managers and other nondirect care nurses: contingency plans that
require managers and other unit support staff such as educators and clinical
nurse specialists to maintain basic, direct care nursing competencies enable
these individuals to assist in patient care activities when necessary.
 Controlling demand:
Immediate demand in the ICU may be controlled by engaging the critical care
medical director to assist in objectively evaluating all patients and deter-
mining whether any may be ready for transfer to a less acute unit.
Limiting admissions is a difficult and politically contentious strategy that often
creates a backlog and problems for patients in other departments such as
emergency, postanesthesia care, and interventional areas, so limiting admis-
sions is a brief strategy at best. Delaying or cancelling surgeries and procedures
is equally difficult. These approaches require collaboration among the staff,
 Negotiating Safety when Staffing Falls Short 267

leadership, and physicians. A strategy that is defined in advance and commu-

nicated to all parties facilitates successful implementation when necessary.
The key to contingency plans is planning. A strategy, such as the RN/RT dyad, may
work well in a hospital that has prepared staff for their roles, yet be a disaster in another
facility that attempts to implement it with inadequate preparation. Five of 7 states
mandating staffing committees require the hospital staffing plan to include a contingency
plan for unexpected coverage needs. A well-thought-out contingency plan should
consider specific scenarios and identify options to maintain safe staffing. Direct care
nurses should be involved in developing contingency plans; they are best able to antic-
ipate the challenges to be considered and planned for as they experience it firsthand.
Addressing Safe Staffing Through Policy Initiatives
The most obvious policy initiative addressing safe staffing has been legislation
mandating ratios or staffing plans. Although several studies10–12 have investigated
the effect of mandated nurse/patient ratios in California, no studies have evaluated
the effectiveness of mandated staffing plans and nurse staffing committees. Because
patient outcomes are related to several variables besides the number of nurses (such
as quality of the practice environment5,6 and education levels of nurses7–9) it is unlikely
that a simplistic staffing model will suffice. An ICU in a quaternary medical center pres-
ents different patient needs as well as resources from an ICU in a small rural facility.
Policies that enable localized, hospital-based planning that accommodate differences
in patient acuity, nurse characteristics (such as education, experience, and expertise),
and facility factors (such as geography of the unit, technology and other resources,
and practice environment) as well as provide for flexibility to address the dynamic
nature of the critical care environment best meet staffing for safe patient care.
Policies that support a culture of safety and encourage staff to speak up about ques-
tionable staffing also promote patient safety. A silenced staffing concern or question is
not only a missed opportunity for just-in-time problem solving to promote patient safety
and nurse satisfaction, it is an invitation for recurrence of the problem. Polices that
promote collaboration and shared problem solving best support a culture of safety.

SUMMARY

Patient advocacy is a fundamental role of the nurse. Advocacy for safe nurse-patient
assignments requires the nurse to embrace their responsibility to the patient first and
foremost. To meet this obligation, nurses must develop the knowledge, skills, and atti-
tudes that enable them to be effective in their patient advocacy role. These categories
include an understanding of their state nursing practice act as well as organizational
policies regarding nurse staffing, contingency plans, and internal reporting. In addition,
nurses must develop skill in communicating their concerns proactively and objectively
to those in a position to respond. Individual nurses have a professional responsibility to
be engaged in their workplace, to participate in shared decision making and problem
solving, and to contribute to a positive practice environment. Negotiating safety is
central to the advocacy role of the nurse. Nurses must accept their responsibility to
be active participants in creating safe practice environments for patients and nurses.

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