Health care workers are under tremendous pressure in an incredibly high-stakes environment.

Medical staff balance a variety of competing demands, often in the absence of sufficient resources like staffing, to keep patients alive and healthy. Research has shown that health care providers prioritize organizational needs, efficiency and the quality and safety of care when making decisions. To meet these demands, sacrificing one’s own needs is the rule in health care, not the exception. Making the decision to take a break or leave work on time when a patient needs you feels impossible, unimaginable and borderline unethical. The same people who based their career choice on the desire to help people are not going to rock the boat (or throw a patient overboard) so that they can eat their lunch. So, we scarf down a piece of pizza at the nurse’s station, hold our bladders and carry on.

Until we can’t anymore.

A recent column from Maine Medical Center’s chief nursing officer (“Commentary: No government mandate will fix the challenges Maine’s hospital nurses face,” May 25) highlighted some of these issues and suggested that the nurse ratio bill before the Legislature, L.D. 1639, would not help to alleviate them. In fact, the commentary suggested that the mandated ratios proposed would “harm our patients,” and noted that nurses continue to provide exceptional care despite these pressures (emphasizing if they go above and beyond, they can even receive a flower-shaped pin and certificate as an acknowledgment of this work). The author concluded that the path forward is to provide wellbeing support, increase nurse salaries, train new nurses and fill staffing gaps with travel nurses, while focusing on other priorities like patients’ abuse of nurses.

These assertions are problematic for many reasons. First, there is very little high-quality evidence that mandated ratios negatively impact outcomes. On the contrary, the evidence from both California and Australia tells us that implementing nurse staffing ratios improves hospital mortality rates, decreases length of stay, reduces readmissions to hospital, increases the retention of experienced nurses and even saves hospitals money.

Second, while it is important to train new nurses, it also essential to keep experienced nurses at the bedside. As the saying goes, you can’t fill a leaking bucket. Nurse staffing impacts patient outcomes and neither inexperienced nurses nor travel nurses are a like-for-like substitute for experienced, local staff. Recent research found that the addition of one registered nurse for a 12-hour period decreased individual odds of patient death by nearly 10% on hospital wards treating acutely ill adult patients. Importantly, adding a senior nurse had more than twice the impact of adding a junior nurse, and adding an additional agency (travel) nurse had no impact on patient mortality. These are not figures we can ignore.


Finally, nurse abuse is an important issue to tackle, but it is a completely separate topic and should not be used to distract from the conversation about staffing. Enabling access to wellbeing support and counselling are of course worthwhile endeavors. But, in the conversation about nurse staffing, they are not a solution. Rather than putting the onus on nurses to cope with a traumatic environment, we need to improve the factors causing burnout in the first place.

Nursing shortages cannot be filled by further diluting the skill-level of the workforce. We need to retain experienced nurses at the bedside, which means addressing the reasons nurses say they are leaving. Guilt, self-sacrifice, moral distress and trauma are not acceptable descriptions for any work environment.

We call health care providers “heroes” rather than people and speak of nursing as a “calling” rather than a profession, narratives that perpetuate self-sacrifice. In the long term, self-sacrifice is unsustainable.

In a year that was meant to be “The Year of the Nurse,” and at a time when the world was already facing the largest nursing workforce crisis to date, nurses bore the brunt of the COVID-19 pandemic. In the United States alone, one-fifth of the nursing workforce is expected to leave the profession entirely by 2027.

As a health care safety researcher, I believe that this is one of the most pressing and catastrophic threats to population health that we will see in our lifetime. Nurses play an essential role in the delivery and promotion of equitable, safe, accessible health care. Without nurses, our health system is at risk of collapse. It’s time for policy to reflect the essential role nurses play in patient outcomes and to foster an environment conducive to this work.

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