Shortage of healthcare providers is a global issue that effects patient, provider, and the healthcare system in general. The consequences are far reaching and one to be aware of for healthcare providers (including nurses) so that they understand obligations and limitations of practice under the state board. As staffing shortages become more pronounced, the legal world will need a deeper understanding of staffing, patient care, and how practice is guided by standards and policy and procedure.
There is a cascading effect of staffing shortages in an acute care setting. When an inpatient floor is short staffed, there will be a cap on how many patients can be admitted to the floor. Even if there are open beds/rooms on an inpatient floor, there are safe staffing ratios (patients: nurse) that each unit within a facility has set to promote patient safety (often based on national standards). When the floor is at capacity, there is then a holding pattern in the Emergency Department (ED). Patients needing to be admitted will then be waiting on an ED gurney for a patient upstairs to be discharged so that a bed will open.
The emergency department is generally a healthcare environment with rapid patient turnover and nurses having specialized education and training to quickly identify and prioritize life threatening emergencies. These emergencies are always going to take priority over the routine care practices required by admitted patients. The requirements of this clinical environment lead to admitted inpatients boarding in the ED not receiving the routine care they need such as the frequent ambulation needed to avoid clots and pressure sore, and delays in medication/care (American Nurses Association, n.d.). Beds in the ER that are meant for the rapid turnover of patients are then occupied by patients who will be there for an undetermined amount of time while waiting for an inpatient bed. As a result, ED’s are backing up with acutely ill patients waiting for longer times in the lobby resulting in delayed care and at times leading to longer recovery times because of the delay in diagnosis. The American College of Emergency Physicians has deemed boarding in the ED a “national healthcare crisis” which “harms patients and leads to an increase in worse health outcomes” (2022). Wang, L., et al. (2020) also find increasing poor patient outcome, and ethical dilemmas for nurses as a result of chronic short staffing. So, who ultimately is responsible when it comes to poor patient outcomes as a result of short staffing?
The American Nurses Association (ANA) has encouraged nurses to be proactive in contacting members of congress in supporting safe staffing levels, they also provide guidance into accepting safe assignments. The Federal Office of the Inspector General has announced that inadequate staffing levels resulting in failure to provide standardized care can result in criminal and civil prosecution using the Federal Civil False Claims Act (Lowrie, n.d.). There seems to be indication that this primarily is targeting healthcare facilities and not the direct care team involved in specific patient care.
With increased populations of aging patients diagnosed with chronic health care issues and decreasing number of healthcare providers the ethical and legal ramifications will continue to evolve. It will be vital for care providers, facilities, and legal teams to stay abreast of staffing, standardized care and protocol changes which may alter practice as well as delay care (whether it be increased consequence of facilities as a whole or individuals providing care); unfortunately, the related issues of the short staffing crises will be an ongoing issue for the foreseeable future.
American College of Emergency Physicians. (2022). Talking points: boarding in the er. [blog]. ACEP // Boarding in the Emergency Department: A National Crisis
American Nurses Association. (n.d.) Nurse Staffing Crisis. https://www.nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-crisis/
American Nurses Association. (n.d.) Questions to Ask in Making the Decision to Accept a Staffing Assignment for Nurses. https://www.nursingworld.org/practice-policy/nurse-staffing/questions-to-ask-in-making-the-decision-to-accept-a-staffing-assignment-for-nurses/
Hong KJ, Cho SH. (2021). Associations between Nurse Staffing Levels, Patient Experience, and Hospital Rating. Healthcare (Basel). 9(4):387. doi: 10.3390/healthcare9040387. PMID: 33915753; PMCID: PMC8066393.
Lowrie, L. (n.d.). Ethics and legal issues in nurse staffing [blog]. https://smallbusiness.chron.com/ethics-legal-issues-nurse-staffing-76772.html
Wang L, Lu H, Dong X, Huang X, Li B, Wan Q, Shang S. (2020). The effect of nurse staffing on patient-safety outcomes: A cross-sectional survey. J Nurs Manag.28(7):1758-1766. doi: 10.1111/jonm.13138. Epub 2020 Sep 14. PMID: 32853457.