Nursing is back in the news, causing angst in the world of patient care and affecting patients and healthcare systems across the national spectrum of urban and rural care. First is the issue of safe staffing, and second is the nursing shortage. In past articles we have covered the recruitment shortages of primary care physicians, and how within the next 20 years there will a shortage of 30,000 primary care physicians, but we have yet to address the fact that in the next 10 to 15 years one million nurses will reach retirement. Who will be stepping into to fill and fulfill their incredible mission of leadership and patient care?

In April 2015, U.S. Reps. Lois Capps, D-CA and David Joyce, R-OH, as well as Sen. Jeff Merkley, D-OR, introduced The Registered Nurse Safe Staffing Act (H.R. 2083/S. 1132), but even though it was a year ago, it hasn’t been collecting dust. This bipartisan legislation requires Medicare-participating hospitals to establish a committee composed of at least 55 percent direct care nurses to create nurse staffing plans for each unit. Without optimal RN staffing, patients risk longer hospital stays, increased infections, avoidable medication errors, falls, injuries, and even death.

First Issue at Risk: Safe Staffing

For all of the devout nurses who would prefer to champion patient needs internally and directly, we in healthcare understand it takes a lot to tear a committed nurse from the patient’s bedside or from his/her nursing team, no matter urban or rural. But we also understand that sometimes, to begin making the change, you have to be first voice of experience to leverage the call to action. As the American Nurses Association (ANA) advocacy page puts it, “When nurses talk—Washington listens…take action because your voice matters. Become an advocate.” Words matter, and their power can immobilize for either clarity or confusion, so it is important to note that while there are groups going to the Hill to address patient care, medical errors, and the attention necessary to address the burdens within the system, the reference to “medical error,” cited in headlines as the third leading cause of patient death, is ambiguous and is not our focus. 

While many nurses have been and continue to go to the Hill, write letters, and advocate for positive change and policy support that will help sustain the nursing field for years to come, we will focus on areas impacting safe staffing and the nursing shortage.

The Good & the Bad of Key Impact Drivers Affecting Safe Staffing and Nursing Shortage:

  1. Many health systems across the nation have been making immense reductions in nursing budgets due to multiple reasons including operations, capital needs, and technology.
  2. When combined with the challenges of a rapid growing nursing shortage, the result is far fewer nurses working longer hours and available to care for sicker patients.
  3. This compromises patient care and contributes to the nursing shortage by creating an environment that drives nurses from direct patient care.
  4. Compounding these issues is a smattering of high profile acronyms: The ACA, EHR/MU attestations, ICD 10, PCMHM (Patient Centered Medical Home Models), CINs, and ACOs, to name a few. These mandates and models address areas of increased healthcare expansion (often affordability), opportunities for greater reimbursement, sustainability (margin and operations), transparency, opportunities to create a better flow of patient information to healthcare providers/teams/caregivers, better engagement, and a more cohesive plan of care for the patients. But these areas are also taking extra time and resources outside of direct patient care.
  5. While technology is propelling the delivery of care, lack of certain models within population health, such as precision and personalized health, especially in the management of chronic diseases, is requiring additional time vs. closing the gap of time and solution for healthcare providers in the delivery of patient care.
  6. Expanded demand for “Nursing Informatics” positions for expediency of information and workflow information is not being filled quickly enough in some health systems or, in others, is not in the strategic plan at all.
  7. Expanded legislation of scope of practice for nurses (including within the VA system) creates additional opportunities for nurses in caring for patients and should serve as a recruitment tool, but the retention mandate is not being fully adapted, adopted, and optimized strategically as part of the workforce plan.
  8. There currently is not enough focus on growing your own programs to develop local healthcare into a current and future workforce pipeline to adequately address the needs of the present and the future.
  9. Sign-on bonuses, retention incentives, and expanded education work only to a degree to build a sustainable nurse workforce, but are not the entire answer. In urban areas, while health systems are highly competitive, in rural areas the additional monetary funds don’t exist within a healthcare recruitment fund, foundation planning, or operations budget. 
  10. Nursing is a calling, and that said, the nurse workforce often has little turnover and even less succession planning. 
  11.  Internal mechanisms of support haven’t kept pace with those heightened external and internal mandates to address safe staffing.
  12. Some health systems across the spectrum are experiencing massive layoffs due to a plethora of reasons including operations cost increases, mergers/acquisitions, costly technology purchases, policies, and penalties.

Fever Pitch of Safe Staffing:

Some nursing groups have noted that the fever pitch is that hospitals, healthcare facilities, and nursing homes are demanding nurses take more patients with fewer resources than nurses can safely manage to deliver the highest possible quality of care vs. efficiencies of overhead and operations costs. Research is showing that nurses in many facilities are being forced to carry eight patients on medical surgical floors (12 over the course of their shift from admissions to discharges), four patients in the ICU, and 40 in long-term care, and the numbers are growing daily across the U.S. Nursing in a critical access hospital facility is even more in need of support because nurses don’t have floors or wings of expertise or lots of backup support. They have to have the full spectrum of immediate capabilities for what might be coming through the door, whether a car accident or baby birth. The overall result is that our nurse leaders and the backbones of our facilities are constantly being asked to do more with less, and the results create nurse barriers and healthcare delivery risks in working beyond capacity. 

Fever Pitch of Workforce Shortages:

The fever pitch is here – with a million nurses existing the workforce in the next 10 – 15 years, we are already reactive in addressing this huge workforce need. The healthcare delivery model we know today will be have to be very different in the future to meet the needs of millions of healthcare patients. We need to think strategically to meet individual and patient masses. Pod care (especially for regional and rural areas), virtual nursing care delivery models, increased telehealth and mobile apps, and other types of intelligence models are all being discussed.

Concerns in Proposed Legislation for Safe Staffing and No Positive Effect on Workforce Shortages: 

At the heart of the issue are two bills in Congress to address safe staffing limits (HR 1602 and S 864). These bills model the nurses’ staff ratios in California, which is the only state in the nation to mandate safe staffing ratios for nurses to patients. While this seems positive on the outside, there are dynamics in play:

  1. Some nursing executives aren’t totally behind the bills or have not yet taken a stand.
  2. Many healthcare systems simply believe this doesn’t address their true needs, and instead creates greater barriers to strategically meeting internal needs.
  3. Many believe the legislation didn’t accurately take into account the acuity of care or type of facility.
  4. Some have noted that most California nurses are unionized and that for many healthcare organizations, no matter the size, the presence of a union would create increased financial barriers and engagement/employment pressures and less flexibility and autonomy in workflow and operational planning. 


  1. Research shows there actually could be a cost savings of nearly $3 billion, the result of more than 4 million avoided extra hospital stays for adverse patient events (Needleman study) and reduction of costly hospital admissions.
  2. Collaborations could be created among regional systems, networks, hospital associations, and other nursing executives to create a positive 360 of needs across the spectrum—nurses, healthcare organizations, and patients.
  3. We could look at those seven states that have already enacted safe staffing legislation and use them as examples of plans to consider.


  1. Since these bills are aimed at Medicare-participating healthcare organizations, would this include critical access hospitals and smaller regional locations? 
  2. Would passage of these bills actually positively improve patient care?
  3. Would passage of these bills take into account factors impacting delivery of care, including technology access and geographical location?
  4. Would all of this structure advance workforce needs or serve as a recruitment/retention tool now and in the future?
  5. Would passage of these bills allow enough input from RNs and other nursing stakeholders?
  6. Will this create cumbersome committees to review plans and slow down action of work?
  7. Would passage of these bills allow healthcare sites to do an internal assessment of need and take into consideration what other locations, national comparisons and personnel providing nursing care provide?
  8. Take into consideration education, training and experience?
  9. Would passage ensure that RNs are not forced to work in units where they are not trained or experienced?
  10. Would passage look at patient numbers and demand, time and intensity of direct care necessary?
  11. Would passage protect whistleblowers and complainants?
  12. Are the politics numbing compassion through a series of mandates vs. organic site-by-site solutions?
  13.  Should Congress even be in the business of mandating these changes?

Both issues are critical, and like all things passed and mandated , would these changes be sustainable? Both areas aren’t just about urban and rural healthcare, patient safety, healthcare costs and workforce training recruitment, nursing plans and training—they are also public health issues. We also need to think about implementing more mind, body, and spirit caregiver programs to support nurses as they deliver care to patients, so they feel less stress and burnout and are more fortified, engaged, and equipped to do all the work they are called to do on a daily basis.

Stay tuned – what seemed like a million miles away is now a million nurses! 

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