Nurse Understaffing Impacts Patient Safety, Practice Management

During the peak of the COVID-19 pandemic when healthcare staff and resources were stretched thin, nurse understaffing may have led to unsafe practice management workarounds, cognitive failures, and decreased patient safety, according to a study published in the Journal of Advanced Nursing.

Researchers collected survey data from 120 frontline nurses in the United States during a six-week period between April and May of 2020, at the height of the pandemic. Nurses completed three surveys over the six-week period. Results revealed that understaffing can have detrimental effects on patient and employee safety, pointing to a need for better practice management strategies in times of crisis.

Epic reported that the nurse staffing demand increased by 245 percent between September and December of 2020, as ICU beds filled and COVID-19 cases surged. The demand was particularly high in metropolitan areas. Research has also shown that reducing nursing staff in order to cut costs can lead to employee burnout and poor patient outcomes, and these factors have only been exacerbated by COVID-19.

The researchers set out to evaluate how personnel and expertise understaffing jointly contribute to near misses, which are “events that have the potential to result in accidents and injuries,” according to the study.

Identifying near misses is crucial to healthcare as many adverse medical events are preventable. Recognizing them allows healthcare organizations to address systemic issues and develop improved practice management strategies to prevent patient harm.

Survey questions addressed personnel understaffing, safety workarounds, cognitive failures, and near misses with targeted questions such as “Over the last two weeks, if work went undone in our unit, it was primarily due to not having enough employees to do it.” Nurses were asked to record their responses on a five-point scale, ranging from “strongly disagree” to “strongly agree.”

The study found a significant correlation between nurse understaffing and safety workarounds, which tend to lead to near misses. Understaffing during the pandemic put additional strain on nurses in addition to existing time pressures and a heavier workload. As a result, cutting corners to get work done quicker became a necessity for many.

But safety workarounds can have detrimental effects on personnel and patient safety, the study explained. As understaffing increased, safety workarounds became more prevalent, and near misses became more common.

The results also indicated that expertise understaffing, which the study defines as “missing key expertise within one’s work group needed to complete group tasks and responsibilities,” is positively related to cognitive failures.

The pandemic forced many healthcare organizations to reassign nurses to work in the ICU, even if they were never trained in that environment. The study found that this resulted in higher stress levels and cognitive failures such as lapses in memory and attention.

“In turn, we argue that the strain of cognitive failures will moderate the relationship between safety workarounds and near misses. Workarounds can sometimes be productive coping behaviors and beneficial when nurses engage in problem-solving and critical-thinking behavior to improve workflow being blocked by a dysfunctional policy or procedure,” the study stated.

“However, if nurses are generally experiencing high levels of cognitive failure while trying to engage in safety workarounds, the workaround may be more ill-conceived or haphazard, increasing the chances of errors or injuries.”

The safety implications of understaffing were not widely known until recently, even though it was an existing issue prior to the pandemic. Staffing shortages can have a significant negative impact on patient outcomes and employee wellbeing and should be considered by healthcare leaders when making staffing decisions.