Nurses are the backbone of the healthcare system.  They are individuals who are provide the CARE in healthcare.   Unfortunately, in our pandemic-ravaged system, nurses are frayed, exhausted, and demoralized. We should be worried about our nurses, and even more our patients.

The heart of nursing practice is care, education, and patient support.  However, nursing time is increasingly dominated by documentation, scheduling, and administrative problem-solving. When patients face challenges in obtaining care, it is frequently our nurses who step up to serve in untold ways and close the gaps in our system for the welfare of their patients. 

As pandemic driven disruptions have strained healthcare systems throughout the country, health system leaders face enormous pressure to hold the line on expenses, particularly labor expenses. To expand nursing staffing, managers must demonstrate an increase in clinical volume and a clear staffing need against established benchmarks, including staffing ratios.  Unfortunately, these metrics often fail to account for the fact that in our current era patients are older, sicker, and complicated in ways that defy our standard metrics.  Repeatedly, it falls to nurses to fill the gaps in care that result from our dysfunctional and fragmented healthcare system. 

The toll on nurses is evident in unprecedented rates of turnover, early retirement, and staffing crises.  Many systems have responded by hiring short term contract nurses (traveling nurses) at much higher costs.   In the past year, it is not unusual for a nurse to leave a position, join a contract nursing organization, and be hired back by the same system at a much higher wage.

The difficulty of this situation is twofold.  When clinics and hospital units are understaffed patients don’t receive the care, they need.  While staffing may be adequate to meet the minimum required standards for patient safety, the details of thoughtful and compassionate care are lost in the crush of meeting the basic clinical needs.  For example, care tasks such as assisting patients out of their beds for toileting in a timely way often requires both a nurse and a patient aide.  With marginal staffing these tasks are delayed or hurried.  Similarly, taking the time to walk patients decreases their length of stay and improves outcomes but requires time and nursing resources.   The additional tragedy is that men and women are drawn to nursing as profession that affords them the opportunity to care for patients with compassion.  When nurses do not have the time to provide real care to their patients, they are deprived of the human connection that is one of the most gratifying element of nursing practice. Without this connection, dissatisfaction and burnout inevitably follow.

As health care leaders, we can ill afford to allow this crisis within nursing to continue to unfold.  While there is no simple fix within our current system of health care financing, there are several things that organizations can do to make a difference in the short term:

1. Physicians need to take a more active role in partnering with nurses.

Although physicians are also under strain and at risk for burnout, we need to manage our share of the clinical workload.  This is most evident in ambulatory clinics where physicians should become very facile with ordering in the Electronic Medical Record (EMR).  Too often, we jump to the next patient and leave order placement to the nurse.  With practice and EMR training, even the busiest physicians can accurately place orders and allow our nurses to focus on patient education and care.

• Health system leaders need to look beyond nurse: patient ratios to determine staffing.

The complexity and demands of clinical care are often not captured accurately in staffing ratios. The ratios need to account for time in education and psychosocial support.  While administrators take pride in maintaining a disciplined staffing plan, ignoring the shortcomings of this approach results in burnout, turnover, and staffing challenges.  These difficulties will be costly for nurses, health systems, and most importantly – for patients.

• Effectively integrate clinical care teams.

All too frequently we find that nurses, physicians, schedulers, social workers and aides are working in siloes.  Each group may be unaware of the challenges faced by the others.  Sharing the awareness of shared challenges often goes far in distributing work that tends to default to the nurses.  One way to do this is institute multidisciplinary team huddles before clinics or at the start of shifts so that all staff members take a proactive role in distributing the planned work.

We will only provide excellent care for our patients with an engaged and inspired nursing workforce.  Long term solutions are also important and will involve reform in our health care system.  Our current system, with its emphasis on episodic, fee-for-service care is inherently fragmented in its organization and delivery.  While we work towards more comprehensive solutions, we must redouble our efforts to support our nursing workforce to insure care that is safe, effective, and compassionate.