Who cares for the caregiver? On the job stress in nursing

Nursing students spend years developing clinical skills, critical thinking, and the ability to provide safe, personalized care. Upon entering the workforce, however, they are thrown into wildly understaffed environments where they are expected to handle an excessive number of patients on their first day. While observing during internships, it became clear to me how burdened they are. 

Every Tuesday night, I put on my bright yellow polo, walk into the Medical Intensive Care Unit, and begin assisting nurses. I restock gloves, gowns, and syringes. I run errands for them to the clinical lab, blood bank, and cafeteria. I’m responsible for the jobs that the nurses should have time to do on their own. One evening, while cleaning a patient room after a transfer, a nurse raised his voice at me after I asked where to throw away the used lead wires. “Do I look like I have time for that right now?” He turned around sharply. “You’re a volunteer. You should know these things.”

I didn’t think much of the interaction given the environment of the ICU. I was also told on the first day that if anyone yelled or was forward with me, they didn’t mean any harm. The night continued on and before the shift was up, the nurse came and spoke to me. He calmly explained that he wasn’t upset with me, but that he had two critical patients during the shift and took his stress and frustration out on me. “Look, man, I’m not upset with you. I just had a rough night with these patients, but I appreciate you volunteers for coming in and helping us.” He then went on to explain how he was once a volunteer like me, and that he never means to upset anyone by yelling at them. “I’ll see you next shift; keep up the good work.” I knew that he was busy, but he seemed embarrassed that I was unphased by the encounter.

For a job that is vital to society, it is disheartening to see nurses worked so hard that they experience a loss of who they are. Hospital nurses are constantly rushing from room to room, struggling to complete tasks on time, and relying on others to help cover their patients during emergencies. During nursing school, they typically start with one supervised assignment and work up to two or three patients during clinical rotations. The limited patient load allows student nurses to hone their skills in a less overwhelming environment. However, after they graduate, new nurses are expected to handle more patients than they were originally instructed with. This disconnect between schooling and reality not only sets new nurses up for failure, but also contributes to early career exhaustion. Unsafe staffing has consequently become one of the most pressing problems facing the nursing profession today, leading to burnout among nurses and jeopardizing the safety and quality of patient care. 

Patients who lack proper nurse staffing have a high risk of adverse events. However, solving this problem involves more than just adding an extra nurse per shift; it also has to do with the work environment. Many nurses who try to ensure patients receive adequate care are not given the space and resources to do so, which only furthers career burnout. Hospitals where this occurs are often large and in disadvantaged areas. Additionally, when nurses in poorly-staffed hospitals choose to leave, it further raises the nurse-to-patient ratio and increases the likelihood of patients being negatively impacted [1]. With nurses juggling multiple patients at a time, it means patients must wait longer for basic comfort needs such as warm blankets, bed readjustments, and bathroom assistance. As for the impact on the nurses, this high ratio can lead to depression and physical exhaustion [2]. Another aspect of nursing burnout that can affect patients directly is the depersonalization that nurses encounter when assigned several patients at once. They become stretched so thin that there is no time to develop any connection with their patients. It is important for nurses to feel the sense of belonging and accomplishment that comes from seeing a patient they have connected with begin to heal. With the absence of this connection, nurses may lose their purpose in their work, leading to poorer workplace performance. On top of this, poor nursing schedule management and mandatory overtime due to sudden patient influxes can cause nursing turnover rates to skyrocket. The current resignation and rehire system does not allow for nurses to develop strong bonds with their colleagues, which are known to improve workplace morale [2]. One of the most important aspects of the job I witnessed as a volunteer was when the nurses would tease one another or exchange quick shift details in passing. This outlet of interacting with peers, although brief, is crucial to maintain a positive environment.

In addition to issues with patient care, staffing mishaps create economic drawbacks. When nurses are overworked or there are not enough people present for a shift, the risk of medical error increases. On top of affecting patient health, any mistake regarding a patient or coworker could result in legal trouble for the hospital or the nurses themselves, ultimately costing time and money. Additionally, understaffing forces nurses to work overtime, which increases costs for the hospital and prolongs the workday. All of these extra costs are often driven by longer patient stays caused by inadequate care, creating a positive feedback loop. Costs can be significantly lowered by utilizing unlimited temporary staffing. Temporary (“temp”) workers are trained nurses or unit managers who do an incredible job filling in when needed. The use of temp workers allows hospitals to hire enough workers to match patient influx demands at different times of the year, potentially lowering the cost per life saved by ~$9840 [3]. This can be attributed to the fact that temp workers receive their compensation and benefits from the outside temp agency that employs them instead of the current hospital they are working at. However, having temp workers in a hospital setting comes with its own issues, ranging from inexperience within a given unit, lower pay and benefits, to their fleeting time spent in one unit. Nurses often see the same patients on and off again throughout the week, allowing them to build strong relationships. Temp nurses simply do not have access to this connection. 

Staffing problems within hospitals have become a nationwide problem and are mainly controlled by government agencies such as the U.S. Centers for Medicare and Medicaid Services (CMS). Between these agencies and state legislatures, multiple changes have been made to hospital staffing requirements in the last few years. In 1999, California passed Assembly Bill No. 394, which requires hospitals to use patient acuity to determine appropriate patient ratios within units [4]. This was a positive development, as it provided time and resources for nurse-to-patient interactions. By basing the law on patient acuity instead of patient numbers, a specific patient’s required degree of care is now a factor in nurse-to-patient ratios, with nurses receiving less patients altogether if they possess higher acuity. After this new legislation, the acceptable ratio in medical-surgical units is no more than 1 nurse per 5 patients. During 2019, California amended this law to increase its enforcement. The law now allows for the California Department of Public Health to make unannounced visits to hospitals to examine current patient ratios. The new amendment also enables the Department of Public Health to administer fines to noncompliant hospitals [1]. By implementing appropriate legislation and ethical staffing standards, we can alleviate fatigue and prolong both nursing careers and patient lives. Measures such as fines and incentives regarding proper nurse-to-patient ratios can encourage hospitals to ensure their staffing follows all guidelines for a healthy workplace. Moreover, funds can be allocated to hospitals to lower the initial cost of staffing a new nurse. It is expensive to hire new Registered Nurses (RN) due to the costs of insurance, training, and onboarding. Finding concrete ways through legislation to bring these costs down would allow for more nurses to be brought in. For example, hospitals could receive state grants reserved for hiring nurses. It becomes more difficult at the federal level to pass bills involving large sums of money, but even an increase at the state level through public health legislation would have an impact.

When trying to solve nursing burnout, nurse-to-patient ratios are the main concern; however, it is difficult to address these problems because the nature of medicine leaves no room for trial and error. This makes it all the more difficult to ascertain what appropriate steps can be made to benefit nurse and patient wellbeing. Instead, hospitals should dive deeper into patient acuity as a metric to determine proper nursing ratios. This way of organizing nursing schedules will cause higher-need patients to have more care from one specific nurse, lowering that specific nurse’s patient ratio. It would be acceptable for a nurse to have five patients at once, if all of those patients were ambulatory and could feed themselves. Nurse leaders can evaluate each patient’s needs to decide which nurses are best suited to handle their care [5]. An observational study by McHugh et al. highlighted how lowering patient-to-nurse ratios by just one patient per nurse leads to improvements in length of stay, mortality, and readmission rates. It was also noted that the return on investment from lower readmission rates easily covers the cost of paying an extra nurse per shift to lower the ratio [6]. If more hospitals were to implement this practice of acuity-based scheduling, the workplace would become less chaotic for the nurses. However, the nationwide shortage of nurses makes it difficult to do so. A systematic scoping review from Griffiths et al. pointed out that even with extensive research into how hospitals should improve these ratios, it is still unknown which methods would be successful without utilizing patient acuity as a resource [7]. In the future, asking nurses their anonymous opinions on their shifts as a way of checking out of work would offer hospitals a way to monitor how the workplace is holding up while basing schedules on patient acuity.

It took extraordinary stress for that nurse to snap at me while on the job, and after that we never had another altercation. The nurses I’ve worked with are wonderful people—full of friendliness and understanding—and work incredibly hard to save lives. I’ve watched as the ICU nurses take the time to get down to the cafeteria to get patients specific treat requests, and even stay late after 12-hour shifts in order to make sure their patients are comfortable for the night. They deserve a workplace that gives back to them. Creating a supportive and sustainable work environment within nursing units will lessen the growing burden of overworked nurses and reinvigorate compassionate patient care.

About the Author: Kaden Brownie

Kaden is a fourth-year undergraduate majoring in Human Biology. He chose this major to build a strong scientific foundation before continuing on to a career in nursing. Through this paper, he hopes to raise awareness about the current challenges faced by healthcare workers, particularly nurses. His goal is to encourage greater public support for healthcare professionals both in everyday life and through civic engagement. Kaden plans to attend a Master’s program in Nursing next year and hopes to eventually become involved in teaching and mentorship within a hospital setting. He currently serves as a team member in the No One Dies Alone program at Woodland Memorial Hospital and is working toward obtaining his CNA license.

Author’s Note

I wrote this paper as part of Professor Scott Herring’s UWP 104F summer course when we were asked to tackle a current issue in the medical field. As a hopeful undergraduate who wants to pursue nursing, I found it difficult to write about the struggles in my future profession. However, as a volunteer at UC Davis Health, I had a behind the scenes look at the worklife of some of the best nurses in the country, and how they deal with a poorly supported workload.

References

1. Bartmess M, Myers CR, Thomas SP. 2021. Nurse staffing legislation: empirical evidence and policy analysis. Nurs Forum [Internet]. 56(3):660-675. doi:10.1111/nuf.12594 
2. Sullivan V, Hughes V, Wilson DR. 2021. Nursing burnout and its impact on health. Nurse Clin North Am [Internet]. 57(1):153-169. doi:10.1016/j.cnur.2021.11.011 
3. Griffiths P, Saville C, Ball JE, Jones J, Monks T. 2021. Beyond ratios—flexible and resilient nurse staffing options to deliver cost-effective hospital care and address staff shortages: a simulation and economic modelling study. Int J Nurs Stud [Internet]. 117:103901. doi:10.1016/j.ijnurstu.2021.103901 
4. California Legislature. (1999-2000). Assembly Bill No. 394 (AB 394): Health facilities: nursing staff. 
5. Kelly LA, Lefton C, Fischer SA. 2019. Nurse leader burnout, satisfaction, and work-life balance. J Nurs Adm [Internet]. 49(9):404-410. doi:10.1097/NNA.0000000000000784 
6. McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. 2021. Minimum nurse-to-patient ratios improve staffing, patient outcomes—but also provide return on investment. AJN Am J Nurs [Internet]. 121(9):57. doi:10.1097/01.NAJ.0000790644.96356.96
7. Griffiths P, Saville C, Ball J, Jones J, Pattison N, Monks T. 2020. Nursing workload, nurse staffing methodologies and tools: a systematic scoping review and discussion. Int J Nurs Stud [Internet]. 103:103487. doi:10.1016/j.ijnurstu.2019.103487