Anecdotes from front-line caregivers—particularly nurses—over unsafe conditions for patients have emerged throughout the pandemic.
Crystal Johnson, an emergency department nurse at Emanate Health Inter-Community Hospital in Covina, Calif., is an example.
The hospital experienced a surge of COVID-19 during the holiday season and in the weeks after. When she spoke to Modern Healthcare last month, Johnson claimed a waiver from the state allowing hospitals to adopt higher nurse-staffing ratios led to subpar care for patients.
“You’re prioritizing your care based on what is needed at the time,” she said. “It’s completely unsafe.”
California is one of two states with mandated nurse-staffing ratios, but when it was experiencing a surge of COVID-19 in December, Gov. Gavin Newsom instituted a waiver for the second time since the pandemic began allowing hospitals to increase nurse-staffing ratios if they are experiencing a surge of cases, through an expedited process. The waivers allowed ED nurses to care for as many as six patients at once, up from four.
In a statement, Emanate Health CEO Rob Curry said the waiver was a necessary and temporary measure. He also said he’s proud of the response from his staff as the pandemic is nearly a year old. “From the onset of the COVID-19 pandemic, maintaining the safety and health of our patients and staff has been and continues to be our number one priority.”
California suspended all current waivers this month alongside declines in COVID cases except in “unprecedented circumstances,” according to the state.
But Johnson described a challenging experience. “You don’t know what to expect and you don’t know if you’re going to be able to give the care you need to the patients that are coming into your emergency room. It’s very stressful,” she said at the time.
Nurses typically point to poor staffing when discussing subpar care for patients. The American Nurses Association calls it the leading problem nurses face right now, according to Katie Boston-Leary, director of nursing programs at the association.
Nurse staffing has become more of a challenge during the pandemic for a variety of reasons, including an overwhelmed health system, nurses out sick or leaving the workforce temporarily or permanently.
And shortages of nurses could be an even greater problem in the future with reports of nurses leaving the profession. When New York was hit with its first surge of COVID in the spring, older nurses decided to retire early, said Judy Sheridan-Gonzalez, an ED nurse at Montefiore Medical Center and president of the New York State Nurses Association.
The ANA is worried about more nurses leaving the workforce post-COVID, added Boston-Leary.
There is some research showing that better nurse-staffing ratios lead to better patient care. A study published last year in the American Journal of Infection Control found an additional patient with sepsis assigned to a nurse was associated with higher odds of mortality, 60-day readmissions and longer lengths of stay. The study used data from 116 New York hospitals.
“This kind of chronic understaffing of nurses isn’t just a health problem for the public where patients are more likely to die. … But in the long-run it’s a money-losing strategy for hospitals because what we are showing in our research is that hospitals could be realizing some pretty significant cost savings through things like reduced length of stay (and) avoided readmissions,” said Karen Lasater, lead author of the study and assistant professor of nursing at the University of Pennsylvania.
In California, where nursing ratios have been mandated for over two decades, the impact on quality is more unclear. One study from 2012 shows mixed results on the quality of care since the ratio law has been in effect.
Rather than mandated staffing ratios, the American Nurses Association advocates for a transparent approach by hospitals in which leadership actively seeks feedback from nurses and other front-line workers, and then responds to their concerns.
The association points to St. Peter’s University Hospital in New Brunswick, N.J., as an example of maintaining adequate staffing levels without mandating ratios.
The 478-bed teaching hospital is part of a project from not-for-profit Organization of Nurse Leaders of New Jersey focused on establishing councils at hospitals across the state. The councils include front-line nurses and leaders who work together to address staffing concerns at their facility.
St. Peter’s maintained the council even during its surge of COVID patients in the spring, said Linda Carroll, the hospital’s chief nursing officer.
Some nurses did take leaves of absence due to child care responsibilities, but no nurses left St. Peter’s due to poor or unsafe working conditions and staffing ratios haven’t been impacted, Carroll said. The hospital maintained strong staffing throughout COVID-19 because it regularly engaged with staff and implemented suggested solutions.
“Our staff is our biggest voice. They know what is needed at the bedside,” Carroll said.