Let’s talk understaffing…just don’t say “understaffing”

Shutterstock | Anna Jurkovska
Shutterstock | Anna Jurkovska

Last month, an interesting article was published in The New York Times describing the frustration that many nurses know all too well: understaffing.

We’ve seen many nurses express their exasperation over this taboo topic, but we wanted to know whether management has been responding to this critical issue. So we asked you on our Scrubs Magazine Facebook page if opinions on staffing conditions were heard by hospital management—and here’s what you had to say:

“Corporate just wants $$$$. I have taken care of as many as 20+ residents on the Medicare hall. All management says is ‘we’re more than happy to help you,’ but when 5pm rolls around, guess who’s running for the door?” —Lisa M.

“No. Mid mgt. are always looking to keep their jobs, so it’s all about their political nesting and not patient care. Upper mgt. tells them to cut costs (for their fiscal end bonuses) and they obey. They cut nursing care…keeping their mid-level jobs. Results on my end: pt care drops to just standard. On the floors, it’s worse, no fault [of] the nurses. You just can’t be three places at once.” —Sandee S.

“I’ve been a nurse for 30 years, and for almost 25 years of that time I have been the only RN for 20-29 psych patients. Acuity is a joke and counts for nothing. They refuse to hire more nurses, yet the biweekly schedules are posted with up to 20 or more open shifts per unit. They just refuse to hire more nurses and make it a safe place to work…so people continually leave. Very sad!” —Janet K.

“I was forced out of my job by standing up for safe patient ratio—it was an awful experience. I’m hoping one day things will change; however, it starts with us and different legislation.” —Jennifer C.

“Nope. I have 27 pts at any given time. It’s crazy.” —Shelley M.

“I have four aides and 85 alzheimer/dementia/brain trauma every night. Some of the new nurses have admitted they never even put a catheter in when in school. Bottom line is the money. Corporations get the money and don’t care about the patient. One gal I worked with had a miscarriage at work and they wouldn’t let her go home. I need surgery and can’t stand up straight, but I get told if I call in again, I’ll get fired. Don’t tell me they care about the patient one iota.” —Corinna L.

But have hope, nurses. The responses weren’t all negative!

“My unit actually just increased the number of nurses on our grid so that we will have less patients per nurse. I feel like that is unheard of right now, so I feel very lucky!” —Erin V.

Let’s take this conversation one step further, nurses. In a perfect world, what would be the ideal nurse-to-patient ratio for you? Let us know in a comment below.

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27 Responses to Let’s talk understaffing…just don’t say “understaffing”

  1. Cynthia Ejiogu

    On my unit 1-1 during labor. Postpartum 3-1 because 1 or becomes two with the baby and will give you enough to time. Ned surg best 4 to 1 with an aide!

  2. Fullmoon

    If people only knew a 12 hour shift is at least 13 hours maybe 14 or better. As a RN I am forced to clock out for lunch whether I get to eat or not. I have to hold my urine until I cant stand it any more, so now I am prone to frequent UTI ‘s.
    Management doesnt care. The bottom line is, & has been, for about 30years now the dollar sign.
    I possess a BSN & have worked in middle & upper management. You bet your hiney I wanted to protect my position. I worked in nursing more than full time & carried 17 hours in school. That was a killer. Not to mention the Bachelors degree cost me tens of thousands of dollars.
    So I see both positions. But the nursing shortage will get worse. The writing is on the wall so to speak.
    Ownership of facilities & institutions is where part of the solution lies
    R. C. BSN

  3. Amanda Robinson

    I work in a nursing home , I have 35+ residents on any given night most of which are skilled residents, there is a total of 70+ on the floor and 25 in the alz unit. 2techs on the main floor and 1 in the back (night shift skeletal crew) very hard work, techs work very hard and as an RN if I didn’t have them I would cry,I would ❤to have more techs at night, management simply cuts corners to save $… Which leads to job stress….the turnover rate is outrageous. These residents deserve better than what corporate and mgmt provides.

  4. Katherine Whitley

    The worst kept secret in the health care field: intentional short-staffing, which creates even more staffing shortages as nurse become beleaguered, exhausted, frustrated and as always, terrified of losing the license they worked so hard to get, and have to pay to keep.
    There is also the ever-present fear of lawsuits or, God help us, criminal charges for any harm that could come to a patient as the result of a mistake, and the odds of mistakes or oversights happening increase with every shift we work.
    Every time we are given yet more to do… More to be responsible for, and, at times, mandated to work a 16 hour shift because of a call out and no coverage. (This, as we watch our managers and DONs saunter out the door at the end of their day, exempt and protected from such horrors as being required to work an unexpected double.)
    Yes, some managers and DONs pitch in. Not enough do.
    We are made to search for items we need, find creative ways to deal with missing supplies, do treatments, pass meds (in the required compliance time, of course,) yet expected to do admissions, deal with emergencies, follow up on labs, take off orders, fight the (almost always) sucky software systems we’ve all adopted that was supposed to make our jobs easier, but actually makes everything except writing notes, take much longer.
    We are still required to do most of the paper, PLUS put it in the computer… Yeah, makes sense, doesn’t it?
    We run around in a frantic frenzy, with a clock ticking away at the med times we all need to watch and adhere to, or risk being in trouble for giving meds “outside of compliance,” which is pressed into our heads that this is a med error.
    Meanwhile, hospitals are paying and being paid by patient satisfaction surveys, so we are expected to give instant attention and focused care and outstanding customer service to an ever more demanding clientele: the ridiculous amount of patients we must serve.
    Oh, and there is no magic number; acuity counts, regardless of what upper management wishes to believe. 15 very sick, high acuity patients are a hundred times more difficult to care for, than 30 “walking-talkies,” who are coherent and continent, with minimal meds.
    But they (the powers that be) are disinterested in these facts. They do not want to hear this from the floor nurses. They tell us to “manage our time better,” or basically, that nothing can or will be done… “It’s not in the budget.”
    The problem is, that we nurses continue to run ourselves dead, trying to do everything we are asked to do, and manage to “sort of, barely, kind of,” get it done.
    And so, management steps back and says “see? You CAN do it, if you prioritize your time correctly!”
    I am so angry, as I watch the walls being painted and the grounds being landscaped to make to place look like a 5 star hotel… While “that’s from a totally different part of the budget,” is spouted off as an excuse as to why no more nurses will be put on to help.
    Really? Well, that budget began its life as a lump sum of money, and was divided up according to how much the upperclassmen DECIDED they wanted to spend in each area. Staffing is always skeletal, because they have decided that the state’s laws about minimal staffing requirements (which was meant to say that in the event of any emergency, this is the VERY, VERY LEAST amount of nurses you need) ACTUALLY means, “that’s ALL we need.”
    It’s dangerous. It’s frightening.
    It’s bullshit, and it’s unnecessary.
    And until it’s fixed, nurses will always take the fall as the “reason” for care that is lacking.
    A mid-shift nurse, to help with treatments.
    A nurse at the desk who handles ALL admissions, discharges and “paper nursing,” and nurses on. The floor who need ONLY worry about getting meds out in a timely manner, and and doing treatments.
    Or, team nursing, where one nurse on a hall does meds only, and another nurse does everything else.
    Wherever there is one nurse on, there needs to be two.
    Only then will there be exemplary care always, and nurses who are in love with their jobs all over again.

    • Katherine Whitley

      Please forgive my typos, but I am so passionate about wanting a fix for this. I want to give the care to my patients that they deserve. I do the very best I can, but nothing like I wish I could do.
      I became a nurse to help people, not desperately race a clock non-stop, while fearing for my job.

    • Ricky112

      Well said, Katherine. I am now retired but I remember those days well. Have to admit that when I retired, I hated nursing and was so glad to get out but in all honesty, it was management that made me feel that way. Soooo sad.

    • rklovemusic

      Thank you Katherine for your post. You said exactly what I was thinking and feeling.

  5. Maxi72

    I am a nurse but also an administrator. This makes for a tough combo. The reimbursement to facilities has not caught up with out patients sense of entitlement .

  6. icumomof3

    I am an ICU nurse. We should be 1:2 ratio but we are more like 1:3 then when you transfer 2 out you are getting 2 more right in so in the end you have had 5 patients including a open aaa repair and a crani w/ a ventric and icp’s reading in the 20’s. icu, as well as other critical care areas (sicu, micu, etc) should NEVER be more than a 1:2–depending on the critical nature of the patient. Many patients need to be that 1:1. our president makes millions in bonuses, our organization has made a huge profit, at the sake of its staff. if they truly cared about patient satisfaction, they would make sure that employee satisfaction and patient safety were first.

  7. michadryden

    I don’t think you can just give an ideal ratio. It depends on acuity of the residents. Ideal ratios would vary among intermediate, skilled and specialty units.

  8. Amy Gard

    It’s not about numbers, it’s about acuity. Sometimes 7 patients on a medical floor is doable, but if the acuity of the patient is high, then 4 is too many. There has got to be a way to assign a point system (i.e. Feeding tube – 1 pt, total care – 4 pts, etc. then establishing limits, like, no nurse can have more than 20 pts combined.) Just my little idea.

  9. Meghan Robert

    4 to 1 is ideal for acute care and 1 to 1 for labouring

    • purplemommy

      Did you mean 2:1 for critical care? Because 4:1 is not safe. (Assuming you meant critical care by Acute ). If you meant inpatient Acute care = hospital setting then 4:1 is an awfully broad rule of thumb. There’s many different levels if care in a Acute care hospital. 4:1 on tele would be amazing. 4:1 on step down/intermediate PCU floors would be ok. 4:1 when getting chemo or in icu would be horrible. Acuity is the key.

  10. Tammy Stokes

    Our unit is talking about decreasing patient: nurse ratios we will see

  11. Steffy44

    I’m pretty new on the floor so I’m not sure what other nurses face. All I know is that 6 patients on an ortho/urology (post surgery) floor is my limit. I’m still learning and just got off of orientation and it’s routine to get 6 patients on night shift. They seem to think the patients sleep all night. With no tech, tons of pain meds, assessments, 4 hour vitals, ambulating, etc…I might get to actually charting something at midnight. My preceptor got 8 dumped on her once and ended up in tears by the end of the shift. The lack of staffing will end up getting someone hurt. I can only be in one room at a time and the other night I had 2 patients screaming for me for a pee 911!

  12. Sue Fisher Sargent

    I would like to see ER’s go to 3:1. When you throw that 4th pt in there along with at least 3 different doctor’s all wanting something “now” it is sometimes very hard to keep up. Not only that…rooms are not filled by acuity at all. Sometimes it reminds me of a restaurant..if you have a “table” (room) open then the “guest” (patient) gets put there. I’ve actually heard a triage nurse tell me “it doesn’t matter, it’s your turn to get a patient”!!!! Doesn’t matter the acuity. You could have up to 4 critically sick patients at one time! Thank goodness the ER I work in right now has great team work!!

  13. Denise Starcher

    I think on a medsurg floor with an aide a nurse could at most take 8. ICu needs to be 2 pts to 1 nurse unless the pt condition requires 1to1 nursing

  14. Vintagegirl13

    I live in Australia and we have the same issues in our hospitals. Staff patient ratios are just appalling. It is hard to get through to management that they need to take into account the acuity of the patients. I work on an oncology/rehab ward and it can be very heavy and time consuming. I work mainly night shift and we have two staff for up to 24 patients which is so very wrong. I don’t think it’s ever going to change-if anything is getting worse.

  15. Christine Laden

    I would like to thank the hospital that I work for, for recognizing that there is a nursing shortage and major staffing issues. I work in Patient Logistics/ Bed Management…Sometimes finding beds for our complicated network can be very challenging. I want to thank my hospital for placing patient safety and patient care above everything else. Because really….isn’t that WHY we do what we do???

  16. kaur1raj


  17. mommy3lora

    Money is driven by patient satisfaction. We all know that 100% of patients answering “strongly agree” or “always” is never going to happen, since sick people aren’t happy and becoming healthy isn’t always easy or in line with what people WANT to do. Therefor, there will never be 100% reimbursement, so funding will never be enough. Without more money to pay more staff, how can patient ratio improve? Therefor patients will be even less satisfied, and satisfaction scores will continue to fall.
    Patients’ satisfaction should not dictate whether or not their care gets paid for. Value-based care is a nice idea, but hospitals aren’t spas and the motto should NOT be “the customer is always right.” When 100% of patients always comply with medical recommendations 100% of the time and pay 100% of their bills, THAT’S when HCAPS should matter.

  18. Regina Paulenich

    In a perfect world 4-5 ER pts per nurse. Management doesn’t think staffing for”what ifs” is necessary. New norm is 5-7 pts per nurse.
    In a critical care area that is asking for trouble.

  19. Heather Shaw

    I am a mental health psych nurse that does home care visits. Right now we are struggling with this very issue of being understaffed, and having to take on more clients and produce more visits etc. The struggle is that they want us to see 5-6 clients a day, which doesn’t sound like a bad deal, the problem is there are only 8 hours in my day. I have to drive to see each client, and log approximately 2 hours a day of driving time, so that brings me down to 6 hours to see clients. I never know how long each visit is going to take, it depends on what is going on with the client when i get there. Some of them I do med boxes for, or give injections, or have to help them make doctors appointments, or do individual counseling or any other number of things that take time. Some of my clients I know I will be in their home for at least an hour, some it might be only a half hour. So lets say that is 4 hours of my day. Now I have to come home and do my charting, and make phone calls to doctors, or return calls to family, not that I’m not doing that driving from client to client too. I have orders to put in, recertifications so we can continue to see the client to do, admissions, discharges, resumption of care….all with extensive paperwork that can sometimes take 30-45 min or more to complete, per patient. So….if you figure out how much I’m expected to do, not taking into account acuity of the clients, the needs they have, the things that have to be done to maintain their safety….I’m outta hours in my day to get it all done. We have nurses who work their 40 hours, and then end up doing another 10 or more hours without pay, because there just isn’t enough time to get it all done. Management will rarely approve OT, they have gotten rid of our admissions nurses, there are no float nurses to help out, so we’re left being told, that we have to see this client for an admission, when we already have 5 or 6 clients on our schedule already. I’m lucky, I have an amazing manager who has worked in the field, she knows what its like out here, but upper management keeps harping on numbers, and how much money we need to be earning by our visits, and that we need to be more productive. WHEN?? HOW?? Its insane how money hungry medical care has become What happened to giving good care, rather then being waitresses and people pleasers for a buck?? Nurses need to stand up, and say NO MORE! Form unions, get support that will force the large corporations to take a step back, and realize if their nursing staff is happy, the patients will be happy, the patients will be well taken care of and ultimately THATS why we do what we do. Because we care about the patient and want to make a difference.

  20. lynnhaney82@gmail.com

    I worked a cardiac unit and at times had 8:1 with no assistant. We had fresh caths that hopefully would not bleed. Med surge overflow. Lots of bedside procedures. Lots of fresh cardiac surgeries. Lots of preps for upcoming cardiac surgeries. And yes we were expected to give showers and change beds. This was night shift. I finally began to hate nursing and I know nursing is a calling for me not a job. I knew everyday I put those patients and my license in danger. So I left. I have a 1:1 complex peds job now. Don’t chance your livelihood and someone’s life because it will go on as long as we allow it.

  21. J.Andrews

    I am an RN on a busy medical floor in Northern Ontario, Canada. Our medical floor is 35patients, with a mixture of RNs and RPNs(Registered Practical Nurse/ LPN/LVN) working. In Ontario RPNs have a great scope of practice but there are still things that they can not do. I was once working where I was the only RN for the floor, so I had my assignment of 1-4 patients and then we had the RPNs having 1-5 ratio with a PSW (personal support worker) helping us throughout our day. It seemed like a day from h***, almost all of my patients and at least 15 of the other patients needed the care of an RN, I was scrambling to get everything done for them. My floor manager (who holds an RN licence) told me that if I need help to call for a nurse alert (A “code” is called where the available nurses go to the floor to help cover. I called the code after I was in tears on the med cart with a list of 39 procedures, meds, and other things that my RPNs couldn’t do. I had a great group of 6 RNs that sat me at the desk, told me to take a breath and gather myself. Within half an hour, everything that was needed to do for the patients was done. I am so thankful for all of them and when I see them I still say thank you!! My manager then sat me down and told me that I didn’t do my job by calling the nurse alert. When I went to his boss, he was then suspended for two weeks without pay. The scheduler was also given a stern talking to stating that we need more RNs on the floor.

  22. Trina

    Our ICU usually had telemetry overflow, so 3:1 or even 4:1 could happen and be reasonably handled. However, the tele floor had 29 patients, always full, and some shifts only 1 RN with possibly 2 LPNs and one aide. Then, the supervisor would insist we “move” patients to another floor at 3:00 a.m. so we could get a new admit from ER. Really??? Then a cute little plan developed when they wanted us to have more than 29 patients – they would admit them to the pediatric unit adjacent to the tele unit and assign them to the nurse on the tele unit. Problem: when the patient in the ped room used their call light, it would be answered at the ped nursing station…which might have no nurse that night! On med-surg at that hospital, they had 14 patients…unreal! And when the computer charting breaks down at 3:00 and you have to spend an hour with the “help” desk to get back online???

    The only place I have seen handle adequate staffing issues well is at a union hospital. Always had a reasonable ratio or else a grievance was filed! Go girls!

    I’ve, also, seen wacky practices of staff on night shift: scheduled “nap times” of 2-3 hours for aides who don’t even come out when a code is called during that time; all staff expecting to go out to smoke at the same time except one nurse…say what??; those “nurse locator” clip-ons that nurses are required to wear and when the nurse is at the nursing station charting, the “locator” reports that she is in the “elevator”…for the entire time she is at the station; phlebotomy reporting they can’t get a blood sample from a patient when they really just don’t want to or don’t like the patient, and then the RN is required to do it; aides that get really abnormal vitals on patients and don’t report it to the RN; running out of supplies on nights and it takes an act of God to get what you need; charge nurse writes numbers of that shift’s staff’s hospital phones on wipe board in station and some of those phones have been missing for weeks or months; hospital mandating that RN send request for lab label from computer to a printer that doesn’t exist or hasn’t worked in weeks/months; patient rooms that are so small there isn’t even room for a guest’s chair; working nights with no house supervisor, no secretary, no housekeeping, no aide, no monitor watcher….

    I think my worst experience was an assignment of 4 high-acuity patients on a tele floor, 3 of which were in isolation. Only 2 rooms were adjacent. The other 2 were at opposite ends of the unit! Had no secretary, no aide, and no monitor watcher. Instead, all nurses were given a beeper and when any patient on the unit had an event that made the tele monitors go off, it went to ALL the nurses’ beepers. Well, if you’re gowned and gloved in an isolation room, and that beeper is going off all. the. time. that’s a problem. Well, sucked it up and made it from 7p-11p and then was told I was getting an additional patient for 11-7, who was a very agitated female with dementia…at the OTHER corner of this unit and needed 1:1. Talked to staffing the next morning and they acted like this was no big deal. Well, I was a travel nurse, so they, already, had staffing issues, but after this, I cancelled my contract citing that this situation was unsafe.

    I really don’t think things like this will end until the hospitals are FORCED to change, either by being sued, by staff becoming unionized or legislation is passed.

    It’s sad to say, but I see hospitals that care more about their landscaping than their staff and patient care. Beautiful landscaping, but no one to answer the call light…

  23. Gone fishing

    Acuity is the buzzword…in ICU every patient is sick…on a med surg floor it’s a variable as there new post ops and pending discharges…we had numbers for each patient condition which worked unless previous shift gave low ones to patients and staffing was then scheduled for total numbers…for some reason evening shift nurses often assumed that once they had tucked in a patient for the night and closed the door that all would be quiet…thus lowered staffing for nites…
    No question management does not understand the workload-is under pressure to keep costs down-and considers patients as clients rather than as sick and needy people-no regard for reasons why in hospital to begin with and deal with abstract numbers rather than human beings.
    Even medical care systems that claim non profit are always under pressure to cut something due to rising costs of equipment…salaries…maintenance…nurses had no power until males came on the scene and wouldn’t put up with low wages…it’s a blessing and curse at the same time…make more money and see staffing cut..since nursing is a caring profession striking us always a last resort as patients always suffer.