Flexible Staffing: Ensuring Optimal Patient Care, Nurse Satisfaction and Low Turnover

August 8, 2023
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Talent shortage is an issue that plagues every industry, from education to event planning, auto manufacturing to airlines. While organizations might benefit in the short run by having an excessively lean workforce, not having enough employees limits their ability to grow and thrive. It strains their relationships with clients and customers. It leads to low employee morale and productivity.

However, when it comes to healthcare, the problem of inadequate staffing is of an entirely different magnitude and the consequences far more serious. A shortage of nurses in a hospital unit sets off a chain reaction – declining quality of care, medical errors, patient dissatisfaction, plummeting quality scores for the hospital, high stress and low nurse morale, and ultimately, high nurse turnover. Chronic short staffing also exposes the hospital to risk if a sudden unexpected spike in patient volume occurs such as seen in natural disasters, riots and the COVID-19 pandemic.

Why are hospital units understaffed?

First, there’s the nurse shortage. With an aging baby boomer population requiring more healthcare services and with large numbers of baby boomer nurses retiring each year, the demand for nurses at hospitals and other health centers is far outpacing the supply. The Bureau of Labor Statistics projects 175,900 openings for RNs each year through 2029 when nurse retirements and exits from the profession are factored in.(1)

Second, hospitals tend to be focused on true vacancy, the number of approved FTE positions that are unfilled. However, relying solely on this statistic can lead to poor planning because it does not take into account other factors that impact nurse availability. A more accurate indicator of staffing need is operational vacancy that takes into account the number of unfilled positions as well as the number of nurses unavailable for scheduling because of extended leave, illness, training and orientation.

Then there is an issue that’s endemic to healthcare, one that can throw a wrench into the most carefully thought out staffing schedules – a sudden influx of patients that can happen without much warning, leaving nurse leaders scrambling to find coverage. Today, the COVID-19 pandemic is a telling example.

Impact on patient care

Adequate nurse staffing is critical to ensure optimal care for patients. Many research studies have documented how nurse shortages in hospital units can negatively impact patient outcomes.

A unit-level nurse staffing study conducted by Columbia University School of Nursing(2) and published in the Journal of Nursing Administration found an association between nurse understaffing and Healthcare Acquired Infections (HAIs) in patients. HAIs included in the analysis were urinary tract infections, bloodstream infections, and cases of pneumonia. According to the study’s authors, when a unit is understaffed, nurses experience excessive workloads and are not able to devote the time and attention to recognize the signs and symptoms of infection, and carry out infection prevention practices. HAIs are responsible for increasing healthcare costs by billions annually. Another study(3) by researchers at 161 acute care hospitals in Pennsylvania found fewer urinary tract and surgical site infections in hospitals where nurses cared for fewer patients.

Safe staffing can be a matter of life and death, and achieving the right staffing levels requires nurses and management working together. Adding additional Registered Nurse (RN) hours to unit staffing has been shown to reduce the relative risk of adverse patient events, such as infection and bleeding. Reducing medical errors is also important from a financial perspective, as the Centers for Medicare & Medicaid Services (CMS) has begun to implement value-based care models that incorporate risk-sharing with the potential to withhold payment for preventable hospital-acquired injuries or illnesses; private insurers are expected to follow suit.

—R N Action, advocacy arm of American Nurses Association (ANA)(4)

Impact on nurse morale, wellbeing and turnover

Inadequate staffing in units imposes excessive workloads on nurses. It impacts their physical health and emotional wellbeing. Overworked nurses are likely to experience chronic stress on the job and develop health conditions such as anxiety, depression, hypertension, and musculoskeletal disorders.

In a 2010 study by the University of Pennsylvania,(5) 29% of nurses in California, the only state to pass legislation regulating nurse-to-patient ratios, reported high burnout compared to 34% of nurses in New Jersey and 36% of nurses in Pennsylvania, both states without minimum staffing ratios during the period of research.

Another fallout from inadequate nurse staffing is high turnover rates that leave hospitals grappling with a myriad of problems. On the one hand, there is the economic impact. The annual fiscal impact of nurse turnover for the average-sized hospital ranges from $5.2 million to $8.1 million.(6) It costs $36,567 for a hospital to hire and onboard a new nurse. Equally significant is the impact of turnover on patient care. When nurses leave, hospitals are left to provide safe care to patients with fewer resources. Avoid overburdening existing staff with excessive workloads and the challenge of recruiting quality candidates to fill vacancies. In 2019, the nurse turnover rate in U.S. hospitals was 15.9%.(7)

Forecasting staffing needs: The role of predictive analytics

Like in other industries, forecasting nurse staffing needs has grown increasingly sophisticated with the advent of AI-enabled predictive analytics. Based on historical and real time data, predictive analytics enables hospital leaders understand future demand for healthcare services and nurse staffing needs. It allows them to ensure optimal coverage by making data-driven plans and shift changes to correct staffing inefficiencies.(8)

Three ways to deliver optimal nurse staffing

1. Permanent staff overtime:

Nurse overtime is a well-established practice in U.S. hospitals. Working beyond normal shift hours boosts income for nurses and gives them more flexibility in managing their shifts. However, this is only a stop-gap measure and far from ideal. Research has shown that nurse overtime is tied to lower levels of collaboration and higher levels of burnout. It has a negative impact on patients as well. A 2011 study of more than 500 hospitals in California, New Jersey and Florida(9) found that patients were less satisfied with their care when there were higher proportions of nurses working shifts of 13 or more hours and were more satisfied when there were higher proportions of nurses working 11 or fewer hours.

2. Unlicensed Assistive Personnel (UAP):

Also known as nurse aides, orderlies, nursing assistants, home health aides, and patient care technicians, UAP support the healthcare team under the supervision of the RN who is ultimately responsible for the coordination and delivery of care. It is estimated that there are more than two million UAP working in the U.S.(10) Employing unlicensed healthcare workers saves money for hospitals as they are typically paid 55%-77% of an RN’s salary. Another benefit of employing UAP is that they perform basic patient care tasks and allow nurses to focus on the more complex patient care activities.

However, UAP are not substitutes for hiring professional RNs as they lack the education, licensing and training to provide independent patient interventions and take on a larger role in patient care. How and when RNs can delegate work to UAP is defined by guidelines developed by the American Nurse Association(11) as well as individual hospitals and health systems.

3. Flexible staffing, the optimal choice for hospitals:

The use of contingent workers allows hospitals to focus on providing high quality patient care. Flexible staffing has demonstrated its value in a variety of situations – while hospitals await the hiring of a permanent staff member; during increase in census; for staff coverage when nurses are out sick or on vacation; and to reduce the costs associated with the use of overtime. Flexible staffing companies give hospitals access to a qualified talent pool. They also offer other benefits such as robust screening, onboarding and ongoing support for clinicians once they begin the assignment. Many contingent nurses end up extending their contracts and even become permanent staff nurses. International nurses, an integral part of the contingent nurse workforce in the country, are educated and highly skilled. They deliver high quality care at rural hospitals and other hard to-staff healthcare organizations, and are more likely to accept long term and permanent position.

Flexible healthcare staffing companies have shown over and over again their ability to respond to changes in the healthcare landscape and evolving client needs with innovative solutions. In recent decades, contingent staffing providers have significantly expanded and streamlined their services. Known as Managed Services Providers (MSPs) these companies offer customized staffing services tailored to the unique needs of hospitals. By taking on the complete responsibility for the hiring of temporary, temporary to permanent, direct hires and vendor management, MSPs allow hospitals to focus on their primary mission – providing the best care to patients.


Adequate nurse staffing is critical in ensuring the best outcomes for patients, as well as nurse morale and satisfaction. Maintaining optimal nurse staffing is a complex task. However, innovations such as predictive analytics have made it easier to forecast demand for healthcare services and make staffing plans for the future. Forward thinking staffing companies have stepped up to fulfill the need for contingent nurses with flexible and innovative solutions so that hospital units can maintain optimal nurse staffing to ensure the best patient outcomes and reduce nurse turnover. Managed Service Providers (MSPs) have become staffing partners of choice for hospitals as they provide the full array of screening and hiring services for permanent, contingent, and temporary to permanent healthcare workers.

Similar Resources

Why the World Needs More Healthcare Professionals

Winning the War for Talent in Healthcare

The Ultimate Guide to Healthcare Staffing

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