Overcoming Understaffing in Nursing

Inadequate nurse staffing can negatively impact both patients and staff, resulting in poorer patient outcomes, longer hospital stays and even patient death, as well as increased nurse burnout, job dissatisfaction and turnover.

In order to reduce issues associated with understaffing and ensure robust patient safety, states like California have established safe staffing laws that require hospitals to observe minimum nurse-to-patient ratios.

California has taken its law a step further by also requiring hospitals to use a reliable, evidence-based acuity classification system, allowing nurse managers and charge nurses to determine when more staff are required to meet patients’ needs.

Considering Complexity

Mandated or not, many hospitals are already considering staffing ratios and patient acuity as part of their nurse staffing plans.

Although these factors are key to fostering patient safety and limiting staff burnout, they alone do not always provide enough information to accurately estimate patient care time and efficiently anticipate staffing requirements. While assessing acuity is important to determining the required patient care hours each day, it may not provide a complete patient care picture necessary for optimizing staffing resources.


By assessing patient care complexity in addition to acuity, units are better able to align staffing levels as well as staff education and competency skills with patient care needs, leading to more efficient and suitable staffing.

Pomona Valley Hospital Medical Center in California-a 453-bed acute care hospital with more than 1,200 registered nurses-considers both complexity and acuity when allocating nursing staff. For instance, when a patient is identified as high acuity but has a low level of care complexity-such as a patient that requires assistance with time-consuming daily living activities like feeding and hygiene-the organization looks to meet patient care needs using unlicensed staff, such as nurse aides or licensed practical nurses (LPNs).

On the other hand, if a patient is identified as both high in acuity and complexity, such as an ICU patient, most of the care hours will require a RN, driving the unit to adjust its ratios accordingly to meet the critical needs of the patient. In addition, a low acuity patient that has complex care needs due to existing co-morbidities like diabetes and asthma may require care by a RN. Having an appreciation of the complexity as well as the acuity allows the unit to staff more effectively and promotes the effective use of staff expertise.

Leveraging Data-Driven Tools

Organizations must consider many factors when assessing patient acuity and complexity, including patients’ conditions and qualities as well as staff competency skills, education and licensing levels. This can be a complex and tedious process if done manually, particularly in California where patient acuity must be reassessed every shift-or twice per day.

To support an efficient and accurate approach to nurse staffing, Pomona Valley relies on a data-driven staffing management approach. The direct care nurses enter patient information in an acuity classification module, which captures and stratifies patients’ acuity levels and provides a complexity of care measurement to identify the number of staff required to meet the patients’ care needs.

Not only is the number of staff required identified, the complexity of care measurement identifies the RN and non-RN staff requirements. Integrating the acuity system with the hospital’s scheduling software then helps to match nurses’ experience level, education and specific skills with patients’ daily requirements. This provides nurse managers with the information needed to make optimal assignments, matching patient workload and complexity of care needs with staff skill levels and expertise.

Generally, more experienced staff members are assigned more complex workloads. However, the complexity component helps balance staffing assignments to avoid nurse burnout and provide fairer workloads to each team.

The acuity and complexity tools also empower the charge nurse to respond to real-time changes in patient needs. For instance, if a patient goes into cardiac arrest while in the ICU, the charge nurse has the ability to notify the nurse manager or house supervisor to adjust the staffing based on the change in the patient’s acuity and resulting care needs. In addition to streamlining the staffing effort, this technology provides the information needed to improve patient care and boost staff satisfaction.

Preparing for the Future

Soon, safe staffing regulations similar to those in California and other states may be adopted as federal legislation. As such, organizations will need to find ways to better anticipate and respond to staffing needs.

Assessing both patient acuity and care complexity provides a systematic, evidence-based process for staffing that takes into account the experience level, education and specific skills of nursing staff and matches them with patients’ unique conditions and needs.

By leveraging automated staffing tools, hospitals not only can comply with state enforced safe staffing laws, but can also avoid nurse burnout and retain experienced nurses, save invaluable hospital resources and achieve better patient outcomes-ultimately saving lives.

Lolla Mitchell is the director of nursing operations and clinical practice at Pomona Valley Hospital Medical Center.

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