One sign of quality in an organization is the ratio of staff to the number of people they help. For example, in schools, a low student-to-teacher ratio is valuable. Teachers can provide more individualized instruction and attention to detail when they only work with a few students at a time. The same is true in health care and senior living. When a team of nurses works with only a few residents, they can provide better-quality treatment than if they had to work with many people.
Staffing issues in health care persist, though the connection between adequate staff levels and care quality is evident. If you are trying to solve issues with staffing problems in nursing homes, it helps to understand the causes and effects of short staffing and how to deal with short staffing in nursing.
What Is Understaffing in Nursing?
Ideally, the team of nurses working during a shift or working in a particular area of a senior living facility would be appropriate to the number of residents in that area. Understaffing occurs when the ratio of nurses to residents becomes unbalanced. Quality regulations determine the maximum number of residents per nurse in an area of a senior living facility. When the number of residents exceeds capacity, the quality of care they receive is likely to dip.
Short staffing is a concern across the health care industry. Assisted living and other types of senior living facilities experience it, as do hospitals, clinics, and private physicians' offices.
Short Staffing in Nursing Statistics
In the U.S, 3.9 million people work as nurses, and employment experts project the demand for nurses will remain high over the next few years. According to the Bureau of Labor Statistics, employment opportunities will increase by 7% between 2019 and 2029, much faster than other occupations. Various health care settings, such as hospitals and long-term care facilities, need nurses. But nurses tend to be the staffing category that gets cut first when a facility deals with budget issues.
The Nursing Home Reform Act of 1987 sought to improve the quality of care senior living facility residents receive, reducing incidences of abuse. The act implemented many regulations, such as requiring licensed nurses to be on shift 24 hours a day and mandating a registered nurse on shift for eight consecutive hours, seven days a week. However, it didn't introduce minimum ratios or rules regarding the number of residents who could be under the care of a single nurse.
California is the only U.S. state with a nurse-to-patient ratio requirement. There is no federal mandate regarding nurse-to-patient ratios.
California's law passed in 1999 and focuses expressly on ratios in hospital settings. For example, under the law, a nurse in an intensive care unit can't have more than two patients. A nurse in a psychiatric ward can have up to six patients under their care, and a nurse in a pediatrics setting can have up to four patients. Regarding senior living facilities, California's laws are less direct. The state requires 3.5 nursing hours per resident per day.
Researchers compared the outcomes for patients in California, which has mandated nurse-to-patient ratios, to patients in hospitals in Florida, Pennsylvania, and New Jersey, which don't have required ratios. Their study found that for every additional patient a nurse had under their care, the odds of survival after an in-hospital cardiac arrest were 5% lower.
In senior living facilities, nurse staffing levels remain low. Three-quarters of senior living facilities in the U.S. hardly ever met the staffing levels expected by the Centers for Medicare & Medicaid Services between 2017 and 2018.
Nurses can represent up to 40% of a facility's operating costs. Reducing their hours and shifts can seem like an effective cost-cutting method. But reducing nursing hours too much can have expenses of its own, including increased mortality and poor staff morale.
What Are Some Causes of Short Staffing in Nursing?
Several factors can contribute to understaffing at senior living facilities. Some causes of short staffing can be due to the facility's policies and processes, while others are because of more significant issues with the nursing profession. A few common causes of short staffing in senior living facilities are as follows.
- Budget concerns: Understandably, a facility would want to trim expenses where it can. As staffing often makes up a significant portion of a facility's operating costs, many try to reduce staffing levels to the bare minimum to save money. In addition to reducing staffing levels, a facility might schedule lower-paid nursing staff, such as certified nursing assistants or licensed practical nurses, for more hours than registered nurses to cut costs.
- Aging workforce: Within the next 10 to 15 years, about one-third of the current nursing workforce will likely retire. In the U.S., that means more than 1 million nurses will be leaving the field over the next decade or so and will need younger people to replace them. In addition to a significant number of people retiring from nursing, many people are also retiring in general. There's likely to be an increase in the number of senior living facility residents over the next few years as the baby-boom generation continues to get older.
- Burnout: Burnout, or exhaustion and inefficiency resulting from long-term job-related stress, is a significant concern in the health care industry. It affects about one-third of nurses. Of nurses who report leaving the field, 31.5% said they did so because of burnout.
- Not enough new nurses: The combination of part of the workforce retiring and creating new nursing positions means there will be opportunities for nurses over the next few years. But there might not be enough newly trained nurses to fill those roles, contributing to understaffing. The new nurse shortage issue is a two-part problem. As nursing program faculty members retire, there's a shortage of talented people to replace them, meaning training programs end up turning away qualified applicants. Additionally, there aren't enough students enrolling in nursing programs to fill the roles of nurses expected to retire.
What Are the Effects of Short Staffing in Nursing?
When a shift is understaffed or when there aren't enough people on staff at a senior living facility, the quality of care patients receive can suffer. Some of the effects of understaffing in nursing homes are as follows.
- Increased risk of errors: A commonly cited problem among nurses at senior living facilities is that many of their patients need medication at least once per shift. Some nurses report having to share a cart with another nurse. When a nurse has too many patients under their care, there's a higher risk that they will make a mistake — for example, administering the wrong medication or the wrong dose to a resident. An overtaxed nurse might forget to turn a patient or check their bedpan, as well.
- Increased risk of harm or mortality: Research has drawn a connection between the number of patients a nurse has under their care and an increased risk of illness or death. For example, one study found that patients on an understaffed floor had a 15% higher chance of developing a hospital-acquired infection. Another study found that adding a nurse to a shift decreased patients' risk of mortality by 14%. Patients who spent 30 to 40 minutes per day with a nurse were less likely to develop urinary tract infections or pressure ulcers.
- Increased staff dissatisfaction: Job dissatisfaction can be infectious. The fewer people working during a shift, the more work each nurse needs to take on and the more burdened they are likely to feel. They are likely to find aspects of the job to complain about, either to themselves or to their colleagues, potentially leading to a toxic work culture.
- Increased resident dissatisfaction: Understaffing can also affect residents' satisfaction. If they feel they aren't getting the promised quality of care, or if their families notice they aren't getting adequate attention, they might rate the facility poorly or consider relocating, depending on their situation.
- Increased staff apathy: When nurses are overworked and feel underappreciated, they are likely to become apathetic about the job. That can make them more likely to call out, making the staffing problem more severe. If they come to work, they might put in the minimum level of effort, affecting the care they provide residents.
- Increased likelihood of carelessness: Understaffing can put a senior living facility's residents at an increased risk of neglect for a few reasons. One is that there may not be enough people working during a shift to provide residents with the attention they need. Another is that burned-out or dissatisfied employees might be less willing to perform their job duties. They might come to feel resentment toward the people they should be helping.
- Decreased teamwork: Cooperation and teamwork enhance a facility's culture and help improve the quality of care residents receive. When people feel maxed out or pushed to their limit, they can be less likely to collaborate, meaning cooperation suffers.
Methods Used to Determine Adequate Staffing Levels
Determining the appropriate level of staffing in a long-term care facility can be challenging, and states often don't provide adequate guidance or regulation concerning staffing levels. Still, methods and practices are available to ensure adequate staffing, and there are benefits to keeping track of staffing levels. For example, the U.S. Census releases staffing data, collected in payroll-based journals, to help long-term care facilities determine the appropriate amount of personal protective equipment (PPE) to have on hand.
Methods used to determine the appropriate ratio of staff to patients in long-term care facilities include acuity-based staffing and per-patient-day (PPD) calculations.
- Acuity-based staffing: In some cases, a simple ratio isn't enough to ensure a patient gets the level of care they need. A facility where residents need a lot of help and attention should have more nursing staff compared to in a facility where residents are mostly independent. Acuity-based staffing decides how many nurses to have on during a shift based on the type of care and the quantity of care the residents require.
- PPD: PPD is the calculation of how many nurses need to be on a shift during a given day based on the number of residents. Acuity can also influence PPD, as a higher PPD is likely in areas of the facility that require more resident care.
How to Handle Short Staffing Issues in Nursing
Knowing what to do when a ward or unit is understaffed helps reduce the burden on your team. Here are some ways to handle understaffing at your facility.
- Have on-call nurses: When you create schedules, have a few people on call for each shift so you can bring them in to fill in gaps as needed.
- Post open shifts: If you use schedule-optimizing software, you can advertise open shifts to your team, allowing them to claim extra hours as necessary. They earn extra pay while you get the reassurance that enough people are working to cover a shift's needs.
- Use overtime when needed: Overtime can be expensive, but it can also be a necessity for your facility, particularly if you don't have a large team. Consider overtime an "if-necessary" measure.
- Sort assignments: If you know a particular shift will be short-staffed, sort assignments by order of priority, so the areas with a more considerable need for nurses have the necessary coverage.
- Encourage teamwork: Getting everyone on the same page and encouraging them to work together can help your team get through understaffed shifts and foster camaraderie and engagement.
How to Fix Short Staffing in Nursing
In addition to handling understaffing issues as they arise, you can also make some changes to your operations to help prevent short staffing in the future.
- Talk to your team: The best way to find out what your team needs or how many nurses should be working during a shift is to talk to the people who experience the effects of understaffing — your employees. Ask your nursing staff what they think an ideal nurse-to-patient ratio is. Remember, lower ratios equal less nurse burnout and harm to residents, while improving quality of care.
- Empower your nursing staff: In addition to asking your team what they need, give them tools to maximize their schedules. Employee engagement software lets your nursing staff enter time-off requests, claim shifts as necessary, and communicate with you. Giving people a sense of being in control of their schedule and work lives can help them feel more like part of a team, leading to higher levels of engagement and investment in their jobs.
- Establish a clear call-out policy: Almost every nurse will need to call out from a shift on occasion. They might be ill or need to take a mental health day. While you can't avoid call-outs, you can minimize their impact on your staffing numbers. Implement a policy defining acceptable call-out reasons and establishes a time limit for calling out, such as no later than two hours before a shift, except in emergencies.
- Hire more nurses: If possible, hire more nurses to provide adequate cover for each shift. Another option is to work with a staffing agency to bring on nurses as needed. If your facility has a large enough pool, it's unlikely you'll have difficulty getting enough people to work each shift.
Schedule a Demo of SmartLinx Today
Understaffing affects your senior living facility's bottom line, the care it offers residents, and your employees' satisfaction. SmartLinx aims to improve your facility's efficiency and quality of care while saving you money. To learn more, schedule a demo today to see how it works.