Higher Workloads and Fewer Nurses? Not a Recipe for Patient Protection and Affordable Care


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In further celebration of Nurses Week, it's worth discussing this TIME article about the “Killer Burden on Nurses” under the Affordable Care Act.

The point I'm raising and highlighting here is not meant to be political or partisan, but really one about nursing workloads, management decisions, and what's right for patients.

We've seen recently that American healthcare spending is UP about 10% (the biggest increase in spending since 1980) – mainly due to newly insured patients getting care. The point is to get people care and treatment, but maybe the law should have been called the “More People Getting Healthcare Act?” That's a noble goal.

From the TIME article, an opinion piece written by a nurse from California:

“… I worry that the switch may compromise the quality of the care our patients receive.”

The nurse talks about patients who are sicker due to not getting good healthcare previously. These patients require more attention and more nursing time.

In any workplace, the staffing levels should be set based on the total workload. Using “number of patients” is not a good basis, since the acuity of patients (and the resulting workloads) aren't equal. Not every patient is the same.

Hospitals, due to other industries, do a really poor job of “industrial engineering” work that would establish the right staffing levels based on workloads.

Staffing levels are often set based on:

  • Budgets (how much money is available, instead of what the workload demands)
  • Benchmarks (if every hospital is similarly understaffed, we have a race to the bottom)
  • BS (who knows — wild guesses or staffing based on what we had before)

I fully realize that hospitals are more complex work environments than a car factory. It's relatively easy to determine the staffing levels for a car factory because the work is very repetitive and pretty predictable.

But, if a hospital sees that nurses are having trouble getting their work done… if patient safety and quality really came first, they would react by ADDING staff, at least in the short term.

Sometimes, saving money by keeping staffing levels low might cost us some larger amount down the road. But, the short term costs of increasing today's labor costs are very known. The potential savings is a prediction and is not guaranteed. It's a hypothesis and a bet many leaders are not willing to make.

So the nurse complains:

“During that shift, one of my other patients said, “You must be busy. I haven't seen you all night.” My heart sank. He was fine physically, but I could tell he needed someone to talk to for a few minutes. Unfortunately, I had to get back to my diabetic patient. Preventing her blood sugar from dropping took priority over spending time with my lonely patient. Unfortunately, there were no extra nurses to care for my other patients.

In fact, executives at my hospital recently proposed reducing our inpatient nursing staff. They note that the number of patients admitted for overnight stays has decreased in the last few years.

This new burden is falling heavy on the hospitals and staff. Nurses are working harder than ever with fewer resources.”

The full name of the law was the Patient Protection and Affordable Care Act. I'm pretty sure that overburdened nurses is NOT the way to safer patient care and better outcomes.

We need to, in many cases, add people to a process to make sure it can be done properly. If that's not possible, we HAVE to reduce waste by improving processes and improving systems. If patients are to be protected and costs are to be reduced, we HAVE to free up time… that can have the same effect (more nursing time) as adding more nurses would have… but that's the only affordable and sustainable way to get there… through Lean, waste reduction, and process improvement.

Our patients and nurses deserve it.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. I didn’t read the article but I find your quotes from the opinion piece ironic considering California has legislated minimum staffing levels (4:1) so you can add that to the list of bad ways to set staffing levels.

    I would also be curious to know if any hospital has nurses who feel they are not overwhelmed with work. The collaborative care unit(s) at ThedaCare might be an example. I think the original collaborative care unit had a 4:1 staff level. I know in my own system a nursing unit that dramatically decreased waste on the unit and the time saved was spent on improving nursing care resulting in improved outcomes. Unfortunately, the budget folks at corporate said that they had to increase their patient load so time for patient care is being diluted.

  2. Comments on LinkedIn:

    From an LPN:

    Amanda Stroop “if patient safety and quality really came first” That’s the problem. Management can only see dollar signs, not human beings. It’s sickening!

    From Bob Wheeler:

    I would caution anyone from assuming that the answer to this delimma is to simply “hire more”. The fact is that as we increase the number of patients coming into the system it will ultiamtely take a system wide solution, not just an increase in the number of emplyees. Systems and organizations will need to find efficient ways of working across the board. In some cases monetary savings may in fact end up going to an increase in staff, but in other cases there may not be as great a need for staffing increases once they take a hard look their operations. I do like the authors point about looking at real work load in a manner other than simply number of patients. That is spot on.

    Step one should be to listen to the nurses to find out how their tasks can be streamlined and also to find out how many tasks they perform that aren’t neccessrily part of the position description. You may find that it’s better to hire 4 more housekeepers or 2 more lab techs, as opposed to one more nurse.

    I replied:

    I agree that “hiring more” isn’t the best solution. But, at least it can be a solution if the organization is not practicing Lean and process improvement. Waste reduction is better than adding people. Both are better than doing nothing and letting patients suffer and be harmed.

  3. “Respect for people” in the Lean approach means that nurses should be able to take breaks and not be overburdened.

    “Nurses often work through their breaks, and they stay after their shifts to get charting done,” said David Fleming, a registered nurse who has been at SFGH for 25 years. “I think nurses are getting the job done – but they’re at the edge.”

    Read more

  4. “Sometimes, saving money by keeping staffing levels low might cost us some larger amount down the road.”

    Fair point. When nurses are too stressed and overworked things start to slip through the cracks and patient care suffers. One or two more nurses could make all the difference in keeping the rest of your staff alive and focused!

  5. I enjoyed your article and found many of the nurse’s comments spot on. I once left a system because they saw staffing cuts as THE solution to reimbursement reductions. Sometimes this is the solution… but only if you have the systems in place to support a more efficient workflow. Telling everyone to work harder and faster (with less people) seems to be the overnight solution to revenue declines. Staff shortages make the problem worse. Management sees you ran your unit with less people last year than your productivity target allowed and make that your new standard. Ironically, there is a major nursing shortage that sometimes leaves open shifts by one or more. So they work hard to beat the new target and the madness continues to the point that productivity targets are often completely arbitrary.

    As leaders we cannot give unlimited resources but we can give our staff (and front line leaders) the systems they need to make their workflows more efficient. Before cutting we need to do our job to see that systems are in place to support a smaller workforce. While I don’t agree with everything the nurse said, she is speaking the language of many at the front line – and we need to hear it, even if we don’t like it.


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