In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges

Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT | April 24, 2024

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Editor’s note: Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT, is the Director of Nursing Programs at the American Nurses Association and Adjunct Professor at the University of Maryland School of Nursing and the Frances Payne Bolton School of Nursing at Case Western Reserve University. We spoke to her about patient safety amid nursing workforce challenges.

Sarah Mossburg: Welcome Dr. Boston-Leary. Please tell us about yourself and your current role.

Katie Boston-Leary: I am the Director of Nursing Programs at the American Nurses Association (ANA). I have been a nurse for about 30 years and, prior to joining ANA, was Chief Nursing Officer at a couple of hospitals in Maryland. At ANA, I oversee nursing practice and work environment, which includes staffing, well-being, workplace violence, and racism in nursing. After the onset of the COVID-19 pandemic, and with a grant through the Centers for Disease Control and Prevention, we became a clinical practice resource for nurses. I also teach at the University of Maryland School of Nursing in their nursing leadership courses.

Sarah Mossburg: Together with the American Association of Critical-Care Nurses, American Organization for Nursing Leadership, Healthcare Financial Management Association, and the Institute for Healthcare Improvement, the ANA has participated in Partners for Nurse Staffing as well as a related Think Tank and Task Force. Can you tell us about the Think Tank and Task Force and their purpose?

Katie Boston-Leary: Partners for Nurse Staffing assembled well before the pandemic to understand how we can impact staffing. When staffing issues became urgent during the pandemic, we decided to assemble the Nurse Staffing Think Tank, a diverse group of stakeholders from around the country—not just nurses.

The Think Tank’s focus was on short-term actions that could be taken at an institutional level to address the staffing crisis and its implications, including nurse retention, the work environment, and patient outcomes. The Task Force focused on longer-term interventions that could sustain improvement in nurse staffing with stronger policy-making. Both groups included nurses, nurse leaders, and experts from human resources, patient safety, regulatory affairs and patient advocates on finance to name a few. The recommendations were published in a report that’s freely available online.^1,2

Sarah Mossburg: You mentioned ANA’s role during the pandemic. Could you comment further on how the staffing shortage was impacted by the COVID-19 pandemic?

Katie Boston-Leary: COVID-19 exacerbated existing staffing concerns and exposed vulnerabilities in staffing, problems that have long deserved more attention and action at multiple levels. A bed is of no use if it’s not staffed properly or not staffed at all.

Sarah Mossburg: What trends are you seeing in the nursing workforce?

Katie Boston-Leary: We are seeing the average age of nurses coming down. We’re also seeing that nurses are leaving the workforce, and for the first time in 40 years, there was a drop in the nursing workforce.³ When you look at who is leaving, it’s nurses between the ages of 25 and 34—primarily millennial or Gen Z nurses. This is important because the common assumption is that we are losing nurses primarily to retirement. This exodus says a lot—the future of nursing is leaving. For years, nurses have been “grinning and bearing it.” Now they are leaving, not only nursing, but leaving health care overall.

Diversity, equity, and inclusion are still major issues in nursing that need to be addressed. In my opinion, nursing is not as diverse as it should be. It’s 2024, and lack of diversity still impacts the care that we deliver. It also impacts people of color who are delivering care, including nurses.

Sarah Mossburg: What other trends do you see?

Katie Boston-Leary: Labor pools that support nurses, such as nursing assistants or patient care technicians, have felt underpaid for years.^4,5 With low unemployment rates and different benefits offered by the retail and hospitality industry, these healthcare workers are moving to other industries. People are attracted to work that is less physically taxing with more benefits and pay.^6,7

Healthcare is competing for talent; nurses can’t practice alone. Nursing support roles must be in place for nurses to practice optimally and that’s a major challenge as well.

Sarah Mossburg: What solutions are healthcare organizations using to address the staffing challenges that they face?

Katie Boston-Leary: We’re seeing a lot of creative solutions. For example, hospitals are partnering with academic institutions, which are facing their own challenges with retaining and recruiting faculty. American Association of Colleges of Nursing have data from 2010-2023 that show between 50,000 to 70,000 qualified applicants are turned away every year by nursing programs.⁸ There’s a lot of opportunity to partner with hospitals and health systems to build the faculty base.

Some organizations also offer housing for aspiring nurses as they attend school and are partnering with institutions for their clinical and hands-on training.

Sarah Mossburg: You’ve given us some interesting long-term initiatives related to partnering with academic organizations. In the short term, how are healthcare organizations using agency or travel nurses to address the shortages that they’re facing?

Katie Boston-Leary: I’ll start by explaining the terminology.

Agency nurses typically work for local companies or “agencies” that contract with hospitals.

Travel nurses move from city-to-city, state-to-state, and community-to-community on assignments that may last from a few weeks to over a year. This has become popular with some nurses because the jobs offer mobility and you get to see the country or even the world. Travel nursing also offers good benefits and compensation.

Float nurses are institution- or system-based and move from department to department. Some organizations are setting up programs where nurses “float” to different hospitals within a system.

The cost of these agency and travel alternatives to full-time staff nurses is a major concern. It’s not just the hourly rate, but health systems must also pay a stipend, in some cases upfront, to employ a nurse on contract. There is typically an administrative cost to using agency and travel nurses; the nurses get a set amount, and the company that employs them gets a percentage as well.

These alternatives are not new. But during the pandemic, some organizations doubled and tripled their use of agency, float, and travel nurses, and that added to the cost of delivering care. Ideally, contract nurses should supplement a hospital’s core staff and only be used for a few hard-to-fill positions.

Sarah Mossburg: Can you describe the potential impact that nursing staffing has on patient safety, as we think about having agency, travel, and float nurses in addition to your core staff?

Katie Boston-Leary: The evidence is very clear that there’s a direct correlation between staffing and patient safety. Two systematic reviews have found strong evidence associating better staffing with lower mortality.^9,10 Dr. Linda Aiken from the University of Pennsylvania has done numerous studies on how staffing impacts quality of care. We know that staffing has an impact on patient experience.

Contract nurses face special challenges related to being unfamiliar with the facility and other things, like the electronic health record, medication storage, supplies, or the code cart. Your badge might not let you in to a different unit or even the break room, or you may not have the code to open the bathroom door. All those things make it so much harder for nurses who take on temporary work as agency or travel nurses.

Dedication to providing high-quality patient care is the driver of good nursing practice. Nurses who are committed to saying, no matter what, “As much as these challenges and impediments are in place, I’m still going to deliver the best care possible because that’s what my patients deserve.” As challenging as it may sometimes be, you will still knock on doors, call for help, and hold people accountable to make sure that you deliver the best care for your patient.

Sarah Mossburg: What can healthcare organizations do at a unit or organizational level to foster a team environment, given that teamwork and communication are really important to help improve patient safety?

Katie Boston-Leary: The key thing for any leader is to see everyone who reports to deliver care as a member of their team. It’s key to create a culture where everyone is welcome. We all depend on each other. Instilling a culture that says, “We’re all a team, no matter who’s here,” is the way to move forward.

Sarah Mossburg: What do you see as future priorities for improving patient safety in the face of workforce challenges?

Katie Boston-Leary: I think the top priority is to understand that in some cases, we’ve tried to achieve patient safety and quality on the backs of nurses and people that deliver the care without paying attention to those people. We can’t just leapfrog over those who are delivering care and then say we care about patient care.

If we focus on the most important asset in organizations—the people who are delivering care—the other things will fall in place. I think that’s the number one priority. Let’s look at how nurses go about their day, understand all their pain points, be diligent in our efforts to address them, and include nurses in the process to address those pain points. If we fix the systems that impact the people that deliver care, many things may fall in place in terms of patient quality and safety. If we create an environment where nurses feel seen, safe, and supported, it will help us get the outcomes that we want for our patients.

Sarah Mossburg: Thank you for joining us today.

Katie Boston-Leary: Thank you.

1 https://www.nursingworld.org/~49940b/globalassets/practiceandpolicy/nurse-staffing/nurse-staffing-think-tank-recommendation.pdf

2 Delgado, S. A., & Boston-Leary, K. Nurse Staffing Task Force: Strategies to improve acute and critical care staffing. Nurse Lead. Epub 2024 Mar 29. https://www.sciencedirect.com/science/article/abs/pii/S154146122400048X

3 Auerback, D.I., Buerhaus, P.I., Donelan, K., & Staiger, D.O. (2022, April 13). A Worriesome Drop in the Number of Young Nurses. https://www.healthaffairs.org/content/forefront/worrisome-drop-number-young-nurses.

4 Dill J, Duffy M. Structural Racism And Black Women's Employment In The US Health Care Sector. Health Aff (Millwood). 2022;41(2):265-272. doi:10.1377/hlthaff.2021.01400

5 ANA Enterprise Leads National Efforts to Achieve Equitable Reimbursement of Nursing Care. [Press release]. https://www.nursingworld.org/news/news-releases/2023/anaenterprise-lead…

6 Qualtrics. (2023, January 18). Patient Experience Impacted as More Healthcare Workers Consider Leaving their Jobs. [Press release]. https://www.qualtrics.com/news/patient-experience-impacted-as-more-heal…

7 Duffy M. Why Improving Low-Wage Health Care Jobs Is Critical for Health Equity. AMA J Ethics. 2022;24(9):E871-E875. Published 2022 Sep 1. doi:10.1001/amajethics.2022.871

8 American Association of Colleges of Nursing (2023, May 2). New Data Show Enrollment Declines in Schools of Nursing, Raising Concerns about the Nation’s Nursing Workforce. https://www.aacnnursing.org/news-data/all-news/article/new-data-show-enrollment-declines-in-schools-of-nursing-raising-concerns-about-the-nations-nursing-workforce

9 Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):404-409. doi:10.7326/0003-4819-158-5-201303051-00007

10 Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195-1204. doi:10.1097/MLR.0b013e3181468ca3

Patient Safety Amid Nursing Workforce Challenges

April 24, 2024

Introduction

Nurses are essential to patient care, and having an appropriate nurse staffing level is critical to patient safety. Nurses are responsible for many tasks related to direct patient care in health care, and research suggests that nurse staffing is highly correlated with patient outcomes. Specifically, having fewer nurses caring for patients is associated with higher patient mortality. In a study controlling for institutional differences across three sites in an academic medical center, patient mortality was higher with low nurse staffing but not correlated to other factors like patient turnover. Additional studies have come to similar conclusions.¹

The high demand for qualified nurses has outpaced supply, causing nursing shortages, which were further exacerbated by the COVID-19 pandemic.² The nursing workforce has increased steadily since the 1970s. In 1982, there were about one million registered nurses (RNs) in the United States; by 2020, that number had grown to 3.2 million.³ Although this shows nursing is a growing profession, it has not been able to keep up with the demand for nursing staff. Data from 2020 to the present show that younger nurses are leaving the profession at higher rates than previously observed, and there has been a decrease in interest among students in pursuing nursing as a career.³ In 2022, there were more job openings for RNs than for any other profession in the United States.⁴ The demand for nurses is increasing as the needs of an aging U.S. population also increase and staffing for other healthcare professionals, like physicians, remains low.³ Moreover, about one-third of the total number of nurses in the nursing workforce is above the age of 50 and likely to retire in the next 15 years.⁴

Nursing Workforce Challenges and Patient Safety

Inadequate nurse staffing can lead to missed nursing care and negative patient outcomes, such as patient mortality. Missed nursing care refers to necessary nursing care that is not completed, often because nurses do not have enough time to provide such care due to low nurse staffing levels. Many patient outcomes and safety outcomes appear to be connected to nursing levels, including length of hospital stay, patient dissatisfaction with care, and hospital readmissions. Although the correlation between patient outcomes, patient safety, and nurse staffing levels is complex, appropriate levels of nurse staffing tend to reduce avoidable patient harm.⁵ Appropriate staffing is not a static number; rather, it takes into account the relative mix of nurses providing care and their workload, expertise, and available resources.⁶

After controlling for patient and hospital characteristics, studies have shown that missed nursing care is correlated with an increased risk of death.⁷ In addition, missed care is consistently shown to be more prevalent with low nurse staffing in the United States and in international contexts.⁷ Research shows that the use of support workers, such as nursing assistants, did not reduce and in some cases worsened missed nursing care, possibly due to nurses having to supervise or double-check the work of support staff.⁷ This research suggests that achieving appropriate levels of nurse staffing is critical for patient safety.

Addressing Workforce Challenges

Nurses are essential to patient care and patient safety, as they are the healthcare professionals with the most patient contact and coordinate care among other healthcare professionals. In recognition of this essential role, some states have instituted minimum statutory levels of nurse staffing. Appropriate levels of nurse staffing vary by setting and even on a shift-by-shift basis depending on the availability of other staff and the mix of nursing skills.

To compensate for nurse shortages and to achieve appropriate nurse staffing, some healthcare systems have turned to temporary nurse staffing. Such staffing includes (1) non-unit-based nursing staff, (2) float nurses who are redeployed from one department in a hospital or health system to another unit on a temporary basis, (3) agency nurses who are hired from temporary staffing agencies that are usually local to the hospital, and (4) travel nurses who are hired from agencies and move from city to city on temporary nursing assignments. Healthcare systems have, at times, attempted to compensate for nurse shortages by using these forms of temporary nurse staffing.

Using agency nurses and nurses that float between departments is not new; such nurses typically represent a small percentage of the nursing workforce. Since the 1980s, agency nurses who are hired through local contracts have accounted for about 3.8% of the nursing workforce. In addition, travel nurses represent, on average, about 3–4% of hospitals’ overall nurse staffing.⁸ In August 2021, agency nurses accounted for 8–10% of hospital staffing.⁸ However, this high utilization of agency nurses may be decreasing, perhaps by as much as one-third.⁹ Although agency nurses are typically paid 3 to 4 times the salary of permanent nurses, they report the highest rates of job dissatisfaction, burnout, and poor work-life balance compared to other types of nurses.^8,10 Given the continued staffing challenges faced by healthcare organizations and the critical role that nurses play in patient care, the patient safety implications of the use of agency nurses warrant further consideration.

Based on evidence from a variety of studies spanning 20 years, the effect of agency and travel nurse utilization on patient safety outcomes has been mixed, with agency and travel nurses sometimes correlated with better, worse, or no difference in patient outcomes.⁸ One review suggests that no single clinical area is most vulnerable to differences in patient safety outcomes when agency and travel nurses are used. Rather, by analyzing data in published studies through Donabedian’s model for quality of care, which differentiates structural variables from technical processes, researchers observed that agency and travel nurses tended to improve patient outcomes when staffing levels were better. They also found that, while agency and travel nurses are similarly educated compared to permanent nurses, they often have less experience.⁸

These findings support observations on the effect of teamwork on patient safety—namely, that more effective teamwork and communication mitigate patient safety risks. Although differences have been reported on patient variables like hospital-acquired pressure ulcers, falls, and medication errors on the basis of nurse experience, as well as on agency and travel nurse utilization, no consistent, statistically significant findings show a relationship between these variables.⁸ Work environment, which is another process variable from Donabedian’s model, offers another clue on the patient safety effects of agency and travel nurses. A strong work environment characterized by adequate nurse support and good nurse-physician rapport shows patient safety benefits, regardless of whether agency or permanent nurses are used.⁸ However, care settings with high agency nurse use tend to have lower ratings for work environment.⁸ Electronic health records are another work environment factor that may mitigate patient safety risks. It is possible that standardizing parts of the electronic health record across systems could reduce access issues that may reduce patient safety.

Evidence suggests that the use of agency nurses in and of itself is not sufficient to cause higher rates of unsafe patient care. A range of variables, including the relative experience level of nursing staff, pre-existing staffing levels, and work environments, may work in concert to make the use of agency nurses more or less safe. It is possible to create an environment with the teamwork and infrastructure necessary to achieve patient safety even when utilizing a variety of nursing staff, as noted in a report from the American Association of Critical-Care Nurses (AACN) and American Nurses Association (ANA).⁶ Including nurses and nurse leaders in staffing decisions and governance, modernizing care delivery models so that they are efficient and not burdensome to nurses, and improving regulatory oversight to include appropriate nurse staffing are all actionable interventions that can improve patient safety, even during nurse staffing shortages.⁶

The Future of Nurse Staffing

Although the use of agency and travel nurses increased rapidly during the COVID-19 pandemic, that level is likely unsustainable, given the high labor costs associated with using agency nurses. However, if the use of agency nurses does not decline, research indicates that agency nurses can be deployed safely in hospital units. Despite their initial unfamiliarity in new hospital settings, agency nurses often ensure that high-quality care is provided by preparing for assignments and taking care to effectively introduce themselves as well as prioritizing patient care, according to qualitative research.¹¹ Agency nurses contribute to patient safety and high-quality care as members of a strong healthcare team. High-quality care from nurses is essential for achieving patient safety based on findings from multiple studies that have found higher patient mortality with low nurse staffing.

As the amount and intensity of care increases for an aging U.S. population, the care provided by nurses will likely remain essential to patient safety and quality of care. With nursing shortages projected to last until at least 2030, high turnover and high rates of burnout are likely to continue, along with high demand for nurses. But these issues can be mitigated. Recently, professional organizations such as the ANA have noted and advocated for certain essential needs to generate a sustainable nursing workforce.⁶ These imperatives include supporting the nursing workforce through initiatives that are built for their needs, such as providing safe workplaces, the chance for advancement, and a voice in hospital governance. Such efforts could reduce the pressures that lead to high nurse turnover.

Authors

Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC
Director of Nursing Programs
American Nurses Association
Silver Spring, MD

Merton Lee, PharmD, PhD
Researcher
American Institutes for Research (AIR)
Columbia, MD

Sarah E. Mossburg, RN, PhD
Senior Researcher
American Institutes for Research (AIR)
Columbia, MD

References

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Auerbach DI, Buerhaus PI, Donelan K, Staiger DO. A worrisome drop in the number of young nurses. Health Affairs Forefront blog. April 13, 2022. Accessed February 27, 2024. doi:10.1377/forefront.20220412.311784
Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing shortage. In: StatPearls. StatPearls Publishing; 2024. Accessed February 9, 2024. http://www.ncbi.nlm.nih.gov/books/NBK493175
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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers