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Hospital restructuring policies and an impending nursing workforce shortage have threatened the nation’s emergency preparedness. Current emergency response plans rely on sources of nurses that are limited and overestimated. A national investment in nursing education and workforce infrastructure, as well as incentives for hospitals to efficiently maximize nurse staffing, are needed to ensure emergency preparedness in the United States. This review highlights the challenges of maintaining hospital nursing surge capacity and policy implications of a nursing shortage.
A robust nursing workforce is needed for a hospital to effectively respond to a public health emergency (PHE) such as a terrorist attack, infectious disease epidemic, or natural disaster. Although there has been an uptick in nurse employment as a consequence of the current recession, a shortage of nurses looms in the long run (Buerhaus, Auerbach, & Staiger, 2009). There is no comprehensive national strategy for addressing this challenge to public health preparedness. Although a regional response that calls upon private and public resources is required for a PHE, hospitals that are inadequately staffed with nurses will face unnecessary risks and public health and safety could be needlessly compromised. The purpose of this review is: (1) to outline the challenges facing hospitals in establishing surge capacity for PHEs in the context of a nursing shortage and (2) to highlight the need for a national strategy and identify potential policy approaches to develop a robust nursing workforce supply in support of public health and emergency preparedness.
The Agency for Healthcare Research and Quality (AHRQ) has defined surge capacity as a health care system’s ability to quickly expand beyond normal services to meet the increased demand for medical care in the event of bioterrorism or other large-scale PHE (AHRQ, 2004). The essential elements of surge capacity include the four S’s: staff (trained personnel), stuff (equipment, supplies, and medicine), structure (facilities, space), and systems (policies and procedures) (Barbisch & Koenig, 2006). A public health system’s operational efficiency is dependent on each of these factors and their relationships with one another.
Nurse staffing and supporting systems are weak links in the preparedness chain. The term “going solid,” originating in operations research (Cook & Rasmussen, 2005) to describe systems failures that lead to accidents and errors, is applicable to describe the nurse staffing conditions in present-day hospitals. Organizations “go solid” when their subsystems are stretched to their limits and become “tightly coupled” or dependent on the smooth operation of the other subsystems of the organization in order to operate safely and effectively. This occurs in day-to-day hospital operations when, for example, critical care beds limited by nurse staffing constraints become occupied, resulting in the boarding of emergency room patients awaiting a staffed and open bed, while ambulances and admissions are diverted due to overcrowding (Institute of Medicine, 2006). A tightly coupled system has little buffer for surges in demand and is more prone to errors. The world bore witness to the large-scale difficulties that a tightly coupled health care system faces in managing a PHE following Hurricane Katrina (Franco et al., 2006), and the SARS outbreak of 2003 (Baumann, Blythe, & Underwood, 2006).
Nurses are an integral part of disaster response, necessary to staff surge beds, triage patients, and administer medications and emergency-related vaccines. One of the defining services of public health is to respond to disasters and assist in recovery (Public Health Functions Steering Committee, 1994). In order to do this, the CDC’s National Public Health Performance Standards Program describes the assurance of a competent public and personal health care workforce for the provision of essential public health services as one of the 10 essential services of public health. An effective public health system and PHE response must incorporate hospital-based nursing resources (Institute of Medicine, 2003). The hospital-based workforce, and in particular, hospital nurses, comprise the largest constituency of U.S. health care workers (U.S. Department of Health and Human Services, 2006). They form a substantial element of the frontlines of public health response (Institute of Medicine, 2003), and are among the first responders envisioned by the National Response Framework (U.S. Department of Homeland Security, 2008) outlining national preparedness for PHEs, and the medical surge capacity development encouraged by the Pandemic and All-Hazards Preparedness Act (PL 109–417). However, through recent decades of hospital restructuring, the percentage of nurses who practice in hospitals has declined. Although hospital nursing employment has increased in response to the current recession (Buerhaus et al., 2009), many hospitals, faced with tighter financial constraints, budget fewer nursing positions overall and in some cases have hiring freezes. In many cases, there is little flexibility for unanticipated fluctuations in patient acuity and demand on a daily basis, and an absence of standby capacity for large-scale emergencies. Hospital staffing plans result in sending nurses home when census falls, for example, even though it is hard to find evidence-based examples of “over-staffing.”
In the longer term, projections indicate that supplies of RNs will not keep pace with demands and many hospitals will struggle to maintain sufficient staffing to provide high-quality care (Buerhaus, 2008; Buerhaus et al., 2009). The United States currently has an estimated shortage of more than 120,000 nurses, which will likely swell to over 250,000 by 2025 (Buerhaus et al., 2009). The shortage of nurses presents a critical test to the country’s readiness to respond to an aging population with complex health care needs (Institute of Medicine, 2008). This strain would be magnified under the urgent demands placed on hospital systems during a PHE.
A variety of factors have converged to contribute to the growing nursing shortage. The nursing workforce is aging and many nurses are leaving the profession due to unfavorable work environments and more satisfying alternative job opportunities (U.S. Department of Health and Human Services, 2002). However, the most significant factor hindering the expansion of the nursing workforce is the bottleneck at nursing schools due to a retiring and aging faculty, and insufficient infrastructure and funding (Kaji, Koenig, & Lewis, 2007). The predominant demand force underlying the nursing shortage is the rising need for health care, particularly among the growing population of older adults (Kuehn, 2007). In order to keep pace with demand and maintain emergency preparedness, a minimum increase in nurse graduations by at least 25% annually is required (Aiken, 2007). Schools of nursing, however, are not currently able to produce this number of nurses because of insufficient nursing faculty, inadequate financial resources, limited physical capacity, and insufficient clinical education sites (Kuehn, 2007). In 2008, as many as 49,948 qualified applicants for baccalaureate and graduate degree programs were denied admission because of the constraints that exist in the nation’s nursing schools (American Association of Colleges of Nursing, 2008a).
PHEs pose a unique challenge for nurse staffing preparedness. By definition, PHEs are relatively rare events that require a response above and beyond what existing resources can handle. Current strategies for nurse staffing in the event of PHEs involve invoking mutual aid agreements, temporary nurses, volunteer nurses, American Red Cross, and other relief agency nurses, retired nurses, National Disaster Medical Assistance Teams (DMAT) or National Nurse Response Teams, Medical Reserve Corps, other Federal resources of the National Disaster Medical System, and displacement of noncritical patients to other regions (American Hospital Association, 2000; Federal Emergency Management Agency, 2008; Hoard & Tosatto, 2005; U.S. Department of Health and Human Services, 2005; U.S. Department of Homeland Security, 2007). These strategies are an essential component of any response to a PHE because of the overwhelming need. In a shortage situation, however, these plans shift thin margins of nursing resources while overlooking the resulting inadequacy for patient care and leaving the shortage unaddressed.
As of 2004, nurses working in temporary positions, a commonly cited resource for additional nurse surge capacity, accounted for approximately 3.2%of all RNs (Health Resources and Services Administration, 2006b). However, over a third (41%) of these nurses held principal jobs as permanent hospital nurses along with their temporary nursing position. The Community Tracking Study found that 75%of the participating hospitals used temporary nurses to supplement their regular staff (May, Bazzoli, & Gerland, 2006). Anticipating that this pool of nurses will be on call for emergencies presumes that they are not required for work in their usual place of employment as a permanent nurse or that they are not needed for minimum staffing requirements in their placements as temporary nurses. This holds true for volunteer nurses as well since many hospitals operate at a deficit in nurse staffing due to budget constraints or a lack of a sufficient pool of qualified candidates to fill nursing positions. Furthermore, as more states explore minimum staffing legislation and use supplemental nurses to meet the terms of these mandates, supplemental nurses may become less available as a resource in emergencies (May et al., 2006). Additionally, the number of supplemental nurses available may be overestimated because nurses often occupy more than one role and may be counted twice. For example, an emergency room nurse may be part of a DMAT or an Army National Guard Unit, but will only be available to fulfill one of those roles.
Unique challenges are presented depending on the context of any one PHE. In a sudden-onset and localized emergency, the rapid mobilization of patients from the initial PHE scene can result in a brisk surge in admissions to nearby hospitals. During the first critical hours, the patients who require the most time-sensitive and critical care will present to hospitals. Eventually, however, a large number of walking wounded, worried well, and injured search and rescuers, inevitably seek hospital care and strain emergency resources (Auf der Heide, 2006).
Where hospitals are excessively dependent on external resources for nurse staffing in PHEs, critically injured patients face increasing risk for negative outcomes when the demand exceeds the capacity of the facility response. In a sudden-onset PHE, this risk is magnified, particularly if the expected lag time between the onset of the event and the arrival of any external support becomes extended (Barbisch & Koenig, 2006). Mobilization of nursing resources to a PHE hospital, even those considered immediately available to a hospital through staff call-back, mandated overtime, and duty reassignment, depends on a number of variable factors, including transit congestion, infrastructure damage, weather-related delays, communication problems, delays obtaining necessary authorizations, and staff willingness. Preparedness guidelines explicitly note that hospital personnel surge capacity plans must be predicated on the assumption that hospitals will “surge in place” (Joint Commission on Accreditation of Healthcare Organizations, 2007) with existing facility resources while external assets such as mutual aid partners and federal support will not initially be available (Hick, Koenig, Barbisch, & Bey, 2008; U.S. Army Soldier and Biological Chemical Command, 2002). Furthermore, external resources are not intended to supplant local resources and are only envisioned to deal with the needs of a short-term surge (U.S. Department of Homeland Security, 2008). A fundamental risk is exposed in the assumption that hospitals will have adequate facility-based nursing surge capacity when the day-to-day hospital nursing workforce operates on a thin margin or, in many cases, at a deficit.
In the case of a widespread event such as pandemic influenza, external support may not exist because outside localities will not have additional resources to spare (Barbisch & Koenig, 2006). The SARS outbreak of 2003 demonstrated the complications nurses face in a widespread emergency affecting a large population over an extended period of time. Nurses were one of the most likely populations to be infected and were the most commonly infected health care workers (McDonald et al., 2004). The care of patients with SARS highlighted the labor intensiveness of nursing care during a PHE and the need for a low nurse-to-patient ratio in order to limit an outbreak (Loutfy et al., 2004). Furthermore, public health precautions such as social distancing and travel restrictions limited nurses’ movement (Bell & World Health Organization Writing Group, 2006). In a widespread event, nurses, like other health care workers, will also experience absenteeism due to illness, fear of illness, and the need to care for ill family members (Qureshi et al., 2005). The response of nursing resources to a PHE may be further diminished because of the emotional distress that nurses face during a PHE (Benedek, Fullerton, & Ursano, 2007). Nurses have reported concern that the regional response and institutional commitment expected to come with a PHE will be insufficient to protect them from the physical, emotional, and legal dangers to which they are exposed (O’Boyle, Robertson, & Secor-Turner, 2006; Qureshi et al., 2005). Legal issues include jurisdictional licensure restrictions, workers compensation limitations, and civil liability. While there are policy efforts aimed at addressing these issues, such as mutual recognition of licensure across jurisdictions by agreement or pre-registration and various types of volunteer protection laws, these measures have not been fully implemented and tested nationwide (Carpenter, Hodge, & Pepe, 2008; Health Resources and Services Administration, 2006a; Hellquist & Spector, 2004; Hodge, Pepe, & Henning, 2007; Schultz & Stratton, 2007).
Individual hospitals have the burden of establishing the conditions that support the recruitment and retention of adequate staff. Attenuating the emergency preparedness gap left open by inefficient hospital staffing practices and the potential impacts of a nursing shortage will require a shift in the way in which hospitals view and manage nursing resources. As it is now, hospitals vary in their capacity to handle routine surges of patient admissions and many hospitals are understaffed (Institute of Medicine, 2006). This insufficiency of hospitals’ ability to handle expected surges in admissions raises concerns regarding the facility-based surge capacity for PHEs (Hirshberg, Holcomb, & Mattox, 2001; Institute of Medicine, 2006; McCarthy, Aronsky, & Kelen, 2006). A minimum approach for hospitals is to make organizational improvements to reduce variability in demand and provide adequate staff throughout the hospital for the expected peaks in daily occupancy (Litvak et al., 2005). Consistent and adequate staffing based on empirical evidence regarding quality of care would maximize day-to-day resources as well as reasonable self-sufficiency of facility-based surge capacity for “surge in place” strategies in the initial stages of a PHE when the majority of casualties will present and outside resources may not be available. Having adequate facility-based surge capacity also reduces the need for outside resources, minimizes the inefficiencies associated with external resources working in an unfamiliar environment, and limits the chaos associated with convergent volunteerism (Cone, Weir, & Bogucki, 2003). Simultaneously, this approach takes advantage of the daily cost-effective and quality-of-care benefits of adequate nurse staffing (Rothberg, Abraham, Lindenauer, & Rose, 2005). The call for hospitals to act has been in place since the Institute of Medicine’s (1983) report Nursing and Nursing Education: Public Policies and Private Actions, and the subsequent research that has demonstrated the relationships among poor staffing and poor work environments, nurse burnout, turnover, and professional attrition (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Leveck & Jones, 1996; Stone et al., 2007). Evidence supports programs like Magnet Hospital designation, which is given to hospitals that satisfy a set of criteria designed to measure the strength and quality of their nursing, including adequate staffing. Magnet hospitals have been shown to have better patient outcomes, nurse retention, and job satisfaction (Aiken, Smith, & Lake, 1994; Lake & Friese, 2006; Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2007; Upenieks, 2003).
Hospitals, however, will need the support of a federally funded, comprehensive program that emphasizes long-term investments in the U.S. nursing profession through expanding nursing faculty and schools, increasing incentives for the nursing profession and nursing education, and increasing incentives to hospitals with favorable nursing practice environments, clinical training sites, and adequate nursing surge capacity. Expansion of educational loan forgiveness programs, training grants, capitation grants to schools of nursing, support for competitive faculty salaries, nursing school infrastructure, development support, and tax-based incentives provide just a few avenues toward remediation of the nursing workforce shortage (Aiken, Cheung, & Olds, 2009).
Policy measures up to this point have been severely underfunded, aimed below the required number of nurses to meet the projected demand, and paid inadequate attention to expanding baccalaureate education and nursing faculty development. The primary mechanism that the federal government uses to fund nursing education is through the Nursing Workforce Development Programs contained in Title VIII of the Public Health Service Act. The FY2009 Budget from the Bush Administration cut funding to these programs by 30% and eliminated the Advanced Education Nursing Grant program, which has been a source of funding for advanced practice nursing and the pool of future nursing faculty (U.S. Department of Health and Human Services, 2008). Other policy efforts such as the Nurse Reinvestment Act of 2002 (PL 107–205) have proved to be limited steps in addressing the nursing workforce shortage due to insufficient scope and funding (Sochalski, 2003). The American Reinvestment and Recovery Act of 2009 (PL 111-5) and the Patient Protection and Affordable Care Act of 2010 (PL 111–148) have just recently begun providing expanded funding in support of developing a sustainable nursing workforce. State-by-state approaches such as unfunded fixed nurse-to-patient ratio mandates, like that implemented in California (Assembly Bill 394), may prove effective in some environments but early evidence is mixed (Conway, Konetzka, Zhu, Volpp, & Sochalski, 2008; Donaldson et al., 2005). Additionally, there may be unintended effects that result in reduced emergency preparedness for some communities as hospitals struggle to meet the ratios in the context of a competitive nursing market where supply is limited (Fields, 2004; Spetz, 2004).
Addressing the nursing shortage requires a response to the total number of nurses but also the level of nurses’ education. The fastest-growing demand for nurses involves increasingly complex patient care, technologies, and a widening scope of knowledge and expertise. This is particularly salient in the context of PHEs that require hospital nurses to be equipped with a specific set of competencies and complex decision-making skills (Center for Public Health Preparedness, 2004; Gebbie & Qureshi, 2002; Nursing Emergency Preparedness Education Coalition, 2003). The Quad Council of Public Health Nursing Organizations (1999) as well as the American Association of Colleges of Nursing (2008b) have identified the baccalaureate as the minimum standard for nurses, and identify competencies in emergency response at this level. Furthermore, advanced practice nurses and faculty can only be drawn from the pool of baccalaureate-prepared nurses. This is important because a principal limitation for expanding nursing education is the inadequate number of qualified master’s and Ph.D.-prepared nurses who can serve in faculty roles. Currently, over 65% of new nurses entering the workforce are graduates of associate degree programs and a relatively few (21%) of these graduates continue on to obtain a baccalaureate degree or higher (U.S. Department of Health and Human Services, 2006). In order to meet the demands for emergency preparedness, the expansion in nursing education must focus at the baccalaureate and graduate levels.
The nursing workforce shortage impacts the nation’s emergency preparedness. This failing is compounded by hospitals’ reliance on external sources of nurses, which may be limited due to the shortage and overestimated in the context of an emergency. Currently, the United States lacks a realistic and comprehensive plan for addressing the shortage of nurses. Furthermore, the shortage has had limited visibility as an emergency preparedness issue despite the nation’s reliance on nurses during past disasters and PHEs (D’Antonio & Whelan, 2004). A national investment in the nursing education and workforce infrastructure sufficient to establish emergency preparedness will require significant political will, financial investment, and visionary leadership.
This author was supported by the National Institute of Nursing Research (T32-NR-007104; Aiken, PI) and the Agency for Healthcare Research and Quality (K08–HS-017551; McHugh, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute for Nursing Research or the Agency for Healthcare Research and Quality.