Time for a different approach to nurse staffing challenges


John Welton has been a professor of nursing at the University of Colorado College of Nursing at the Anschutz Medical Campus in Aurora for the past 7 ½ years and is currently chair of the Division of Health Systems, Leadership and Informatics. He has more than 40 years of experience in critical-care nursing as a registered nurse with prior clinical experience in critical care and flight nursing as well as more than two decades in nursing academics and research. Welton recently talked with Modern Healthcare Assistant Managing Editor David May about nurse staffing challenges, including the role of California’s mandated minimum nurse staffing ratios.

Nurse staffing has been among the high-profile challenges during the pandemic. What are some general thoughts about nurse staffing issues, especially staffing ratios?

Ratios have really been around since Florence Nightingale. That’s over 150 years as far as looking at nurse staffing. So they’re not a new concept. And they’re generally used as planning numbers, not for individual shifts or especially not for individual assignments of nurses to patients. And I think some of my colleagues across the country have taken it as not so much as law, but this is what we need to do. Every hospital, every place that does shift-level staffing—or even things like home healthcare—they have to adapt their staffing patterns to the individual patients they’re caring for. There’s no such thing as an average patient, although we’re using these average instruments to somehow project or determine staffing needs into the future. So that’s problematic.

Another thing that’s important to say is that really where the rubber meets the road for staffing is the actual individual nurse caring for an individual patient. And if you’re looking at staffing ratios on a typical medical-surgical ward of a typical hospital, a nurse might take care of four, five, six patients. But again, what are the needs of those individual patients? I’ve been doing this for four decades and I spent the first two decades in critical care. Every patient is different, even the same patient over multiple days will likely have different needs. Most patients in the intensive-care unit come in really, really sick, and then you get them stabilized and then you get them off the vent later or address other issues that are going on. That’s the critical condition. But again, those patients have different needs. And any hospital, any healthcare setting, needs to adapt their nursing resources, the actual nurses caring for those patients, based on their needs.

Also, each individual nurse has different capabilities, experience levels. So would you give the brand new grad the sickest patient on the unit for that shift? Of course not. That’s not the right thing to do.

So do you see mandated minimum nurse staffing ratios as an effective way to ensure quality care and patient safety in hospitals?
In my professional opinion, the answer is no. And the literature supports that view. They’re sort of a blunt instrument. When California instituted these mandatory legislative staffing ratios, there was a lot of scrutiny as far as what happened after the first 10, 15 years. And there were really minimal changes as far as the overall quality. The costs of hospital nursing care went up, nurse satisfaction clearly went up because the nurses were saying that they were overworked.

But the problem is, should the state legislatures get involved in this? I think that’s a professional accountability issue. It’s an ethics issue. And that really doesn’t solve the problem as far as matching nursing care, the needs of the patient, and the capability of the nurses.

The other piece that really needs to be addressed is the cost of all this. And I argue that the fundamental problem here is that nursing care is locked in room and board so that nursing presents this huge cost to hospitals. If we really wanted to solve the problem as far as matching a patient need to actual nursing resources, we should cost out nursing care on a per-patient basis, possibly even bill for it. And that way you level the playing field.

Right now, hospitals have a reverse incentive to decrease nursing care to the point where it doesn’t affect quality. So hospitals are trying to decrease nursing care, but they’re not seeing nursing care as an added value to the actual services that they’re providing. My argument would be we need to flip this on the other side and say we really need to understand the cost of the quality, and hopefully the value piece of all of this to better understand it and use the data to help optimize or secure, not create an artificial ratio, but to really match the nurses for the needs of the patient to achieve the best outcome.

Waivers were granted for California’s minimum ratios due to COVID-19. Do you believe those were necessary?

The problem with the pandemic is that COVID patients present in respiratory distress, extreme distress sometimes, and then respiratory failure. That’s the primary issue. And because of the nature of the pandemic, hospitals can’t really plan for how many patients are going to present to the emergency department. The acuity is really, really hard to account for. The thing is the hospitals, at least those that can, are trying to retain their critical nurses because it takes so much time and expertise to get them up to be fully functional in the ICU environment.

But now hospitals are basically paying incredible amounts of money for traveling nurses to come work even just a short-term assignment. So what I’m hearing from my colleagues is that this is a huge issue because nurses are saying, “Hey, I can make a $10,000, $20,000 this month by going to this hospital someplace else.” And that’s a draw that’s creating this really volatile environment for nurse staffing right now that hospitals that maybe can’t afford the critical-care nurses are really beginning to see huge gaps in the nursing labor force. And they’re beginning to pull nurses that don’t have the critical-care credentials into the ICU environment.

I had one student who was in New York last break, and she was in the VA system and was not a critical-care nurse and went to New York City from New England. She was saying that the nurses in the ICU, the experienced ones, were taking care of six, seven patients, ventilated patients. That’s unheard of. That clearly is a quality issue. It’s a staffing issue. That’s the nature of why nurses and many other healthcare professionals are getting burned out. And then she said, well, she was asked to go and staff the ICU. She had no experience in that clinical setting.

Yes, a nurse under those conditions who doesn’t have ICU experience can help to a little bit; they can act as a second set of ears and eyes and things like that. But that’s the problem. The actual environment in acute care can be so volatile and so difficult to address from a nurse staffing standpoint. Everyone’s trying to do the best they can in any emergency. Nurses as well as everyone else step up and help out.

Now we’re a year into this pandemic and people are really beginning to get burned out. And I think one of the intermediate term effects of all this, once we get past the major part of the pandemic, hopefully this year or early next year, is that the older nurses, people like me who have been doing this for a long time, they’re going to retire. We’re going to lose a huge amount of what’s left of the baby boomer generation.

What do you believe would be the single most effective policy approach to grow the nurse workforce?

I’m an outlier in this. I don’t agree that legislative solutions are the best way to handle this. I think we need to use technology, use the data we have to go ahead and allocate nursing costs and time directly to each individual patient like we do for the ancillary charges in hospitals and then bill for the nursing care. This has two effects. One is it aligns the actual care to each patient from a nursing perspective and sends a bill out. But it also puts accountability on not only the hospital, but the nurses as well as far as being able to identify trends and patterns. The sickest patients should have the best nurses and it should be a higher cost.

But part of the problem right now is that hospitals are in a quandary because they don’t know exactly what—based on their billing data, their clinical data, their staffing data—is the optimal way to staff patients. What’s the optimum, the best nursing care to achieve the best outcomes? I’m not talking about the amount of nursing here. We’re talking about the optimum level as far as cost, quality, outcomes and ultimately value.

So my answer would be to use and develop new technologies using the data to create real-time staffing systems, real-time nursing assignment, and then real-time costing and billing for nursing care.


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