Insufficient Staffing




The Effect of Insufficient Staffing


Molloy College


Understaffing is an issue that is significantly affecting every aspect of health care service delivery throughout the care continuum. It poses a significant threat to patient safety as well as job satisfaction in medical staff, especially RNs. Healthcare institutions have to develop innovative ways to handle nurse shortages while ensuring adherence to prevailing minimum staffing requirements for the delivery of effective and quality healthcare. This document looks as at a case study involving a State Psychiatric Hospital that is experiencing a shortage in staff which is not only affecting the patients but the nurses as well. It looks at the theoretical foundations that define this scenario and develops plausible solutions to these challenges.


The State Psychiatric Hospital is currently experiencing an issue with understaffing as a result of the increase in the number of special patients requiring specialized and personalized observation. The case in point, the admission of Albert, a patient with schizoaffective disorder- Bipolar type, cannabis use disorder, and other severe drug and substance use disorders, which highlights the underlying understaffing issue prevailing in the institution. In cases of a Code Red (psychiatric emergency), staff response as per clinical guidelines leaves a shortage in nurses and patient aids. As such, the remaining nurses are required to cover for their colleagues and take up their workload. Special observation patients require a significant amount of individualized care and attention to cater for their daily needs as defined by the institution’s policies and guidelines in handling psychiatric patients, i.e., patient fresh air period at 4 pm and the 6 pm Narcotic Anonymous (NA) meeting, which requires two staff escorts. The scope and intensity of these responsibilities are compounded by the requirements of the basic daily duties of an RN, such as the redirection, supervision, and ongoing patient’s assessment by a single RN and a few PA.

Because of the working conditions that have been set for RNs, it is expected that staff attrition will occur at one point or another. The volume of workload shift assignment has a significant impact on the quality of care owing to the higher predisposition to commit medical errors and mistakes associated with a higher volume of workload. Potential errors and failure of workload completion would significantly reduce the volume and quality of output from RNs and potentially affect patients and their perception of the delivery of care services in the healthcare institution.

There is an evident underlying issue with communication in the healthcare institution. This is evident in the strategies employed by the supervisor in handling the sick call by the RN. Despite receiving the call, the supervisor did not communicate the sick call to the next supervisor. The organization depicts issues in five major areas, i.e., 1) adherence to OMH staffing policy, 2) patient safety, 3) communication, and 4) acuity.


The analysis of the case employed a descriptive and qualitative research methodology, namely a case study. This approach provides a details description of the situations using document review and observation. This type of methodology was especially useful taking into consideration the main objectives of the analysis, i.e., to identify the challenges and underlying problems in order to propose and recommend solutions to aid the State Psychiatric Hospital to deliver quality health care services as required.

The case study methodology is especially well suited for the proposed analysis owing to the flexibility associated with this approach. This is because it can be conducted at a different point in the process of research, allowing for the development of foundational ideas for future research. Additionally, the case study methodology is especially suited for the research owing to its ability to capture reality. Owing to the fact that a case study analysis allows for the analysis of real-world scenarios, it places into context research and allows intentional application of these concepts in order to realize intended change within the organization.

However, it is important to note that there is certain drawback associated with this methodology. It is important to take into consideration the context of the analysis and avoid generalizing the findings. The utility and veracity of case study can ultimately determine their effectiveness and acceptability as a method of discourse and research. Additionally, there is also the question of preciousness where there is a need to conduct an interpretation of the findings of the case study findings in order to give a meaningful presentation of the facts and principles. Case studies are also predisposed to researcher bias that may stem from underlying principles and values that guide decision systems in the researcher. The research can develop a biased interpretation of case study findings because of their worldview and perceptions regarding key issues and principles that underlie the issue at hand.


OMH Staffing Policy

The healthcare institution’s current understaffing is in contravention of the OMH Minimum Staffing Policy. OMH Policy on minimum staffing requires that during the day shift, 2 RNs or 1 RB and 1 LPN are available. Additionally, 6 Mental Health Therapy Assistants (MHTA) have to be on duty. However, during the evening shift 1 RN, 1 LPN, and 3 MHTAs are supposed to be on duty. Alternatively, the night shift can be allocated 2 RNs and 3 MHTAs, or 1 RN and 4 MHTAs. Additionally, all admission wards are expected to be staffed by 2 RNs or 1 RN and 1 LPN, together with 4 MHTAs at all times, i.e., during the day and night shifts. Alternatively, the night shift can be staffed b 1 RN and 3 MHTAs or 2RNs and 2 MHTAs. However, it is important to take into consideration the requirements for one on one observation that is required for special cases, such as the one depicted in the case. As such, there is a need for additional MHTAs to cater to the one on one observation, requiring a minimum of 3 MHTAs in the State Psychiatric Hospital at any given time. The current staffing standards are in contravention of these minimum requirements set by the OMH.


Safety is a significant and vital aspect of the delivery of quality health care. As such, safety takes center stage when considering issues associated with staffing shortages in healthcare delivery. Nursing shortage not only increases the burden on the remaining RNs, but it also increases the risk of patients developing injuries and conditions because of the care delivery process. This risk stems from the predisposition to committing medical errors and other forms of mistakes, which lead to malpractice, negatively affecting patient health and well-being. This is because delayed or missed care compromises the quality and safety of patient care. It has been found that nurses are more likely to leave out items undone in their shift when they experience an increase in shift workload as a result of understaffing in the healthcare institution (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014).

Professional nursing is more likely to be breached when there are heavy workload and interruptions to workflow. The more RNS are interrupted in their work as a result of the increase in the responsibilities they play during their shifts, the more likely they are to subvert some of the professional standards that guide nursing practice within the context of the State Psychiatric Hospital (MacPhee, Dahinten, & Havaei, 2017). Additionally, perceptions of frequent heavy workloads are the strongest independent predictor of urinary tract infections and patient falls (MacPhee, Dahinten, & Havaei, 2017). The greater the workload on RNs the higher the likelihood of patients experiencing harm and injury in the process of care delivery in the healthcare institution.

Maslow’s Hierarchy of Needs

In order to place into context the significance of patient safety as a result of understaffing or staffing shortage, one could employ Maslow’s Hierarchy of Needs, a motivation theory commonly employed in psychology. The application of Maslow’s Hierarchy has a significant impact on healthcare by propelling RNs toward the comprehensive care of the whole individual, aiming to restore the functions of mind, body, and spirit of every patient (Jackson, et al., 2014). Abraham Maslow’s Hierarchy of needs provides a useful framework through which the prevailing customs in the State Psychiatric Hospital and potentially improve the quality of life of patients at the healthcare institution. Maslow postulates five levels of needs that reflect the needs of the individual and in this case the needs of the patients, as well as the needs of the nurses.


Figure 1: Maslow’s Hierarchy of Needs

Patient care guideline is currently and mainly focused on the bottom two needs, i.e., physiological and safety needs since they form the fundamental focus of healthcare. A specific focus on the second stage proposed by Maslow, i.e., security can elucidate to the management of the health care institution the vital importance of proper and adequate staffing to patient safety and wellbeing (Jackson, et al., 2014). By adopting better staffing policies, the State Psychiatric Hospital not only improves the patient physiological and safety needs, but also sets the foundations for the fulfillment of the other needs postulated by Maslow, i.e., love and belonging, self-esteem, and self-actualization. The importance and significance of patient safety cannot be understated as up to 25,000 deaths on a yearly basis are attributed to medical errors (Bates & Slight, 2014).

Additionally, the staffing issue can also be viewed from the perspective of the needs of the RN. The most basic needs for RNs, i.e., physiological and safety needs, can be significantly affected by the existing shortage in staff. The safety needs for nurses include a secure and stable working environment that is devoid of fear. However, the current shortage of staff at the State Psychiatric Hospital has created a work environment that is devoid of security. RNs who are forced to contend with the high workload work under the constant fear of failure and committing malpractice. With the increase in the workload, RNs perceive the higher likelihood of committing medication errors and failing to complete the daily tasks, routines, and responsibilities defined for their roles. Additionally, the lack of adequate staffing creates an environment that is unstable owing to the possibility of an unexpected and unplanned psychiatric emergency for which they are ill prepared with regards to the availability of adequate staff. As such, RNs do not feel safe working in the healthcare institution taking into consideration the high likelihood of committing medication errors and uncompleted tasks and responsibilities, which affects the quality of care they deliver to patients.

Safety Culture

Additionally, the shortage of RNs could develop and create a culture that does not place emphasis on patient care. Owing to the staff shortage at the State Psychiatric Hospital, the high workload shift could lead to staff taking shortcuts and ignoring some processes and procedures in a bid to meet all their increased and burdensome obligations. Stretching nurses to the limit could create a culture where patient safety and the quality of care are not major concerns and pillars of healthcare service delivery.


Acuity refers to the measurement of the intensity of nursing care that is required by a patient or patients in a given department. The nature of the conditions, processes, and procedures required for the effective delivery of care in the State Psychiatric Hospital depict high acuity. However, high patient acuity is associated with patient falls and medication errors. A high patient acuity is also significantly correlated with RNs leaving tasks undone. Patient acuity was found to be the strongest independent predictor of medication errors, i.e., the more intense the care patients require the higher the likelihood staff will commit medication errors in the course of care delivery (MacPhee, Dahinten, & Havaei, 2017). The ratio of nurses to patients has received significant attention in patient safety discourse owing to the implications of the availability to staff to cater to patient needs.


While the nursing shortage is an evident challenge faced by the institution, the lack of or poor communication is a factor that has exacerbated these challenges. The organization has depicted aspects of poor communication. Despite knowing the unavailability of the RN, the supervisor failed to communicate this to the next supervisor, creating a situation that further compounded the issue of nurse workload in the institution. Poor communication amongst staff members creates an environment in which nurses are highly likely to make medication errors and uncomplete tasks, roles, and responsibilities assigned during the shift.

Experiential Communication Theory

The experiential communication theories, such as the one proposed by Virginia Satir hold that communication is a process of giving and obtaining information. As such, in order for the needs of an individual to be met, there is a need for clear communication. While supervisors are aware of the challenge associated with the shortage of staff in the institution, this fact is not communicated clearly to effectively comprehend the magnitude of the problem and the threat it poses to patient safety. Because communication entails a series of interactions and transactions, the organization has failed to make use of these transactions in order to ascertain strategies that can be employed to solve the prevailing staffing issue. As Satir holds, the sender and recipient of the message play a significant role in clarifying the message in order to achieve the intended response or effect. Dysfunctional or ineffective communication depicted in the State Psychiatric Hospital tends to lead to the overgeneralizations that could have adverse effects on patient safety in the short run as well as in the long run.

Proposed Solutions

MHTAs and LPNs to Help Solve the Current Staffing Shortage

While the healthcare institution may be significantly constrained with regards to its ability to recruit and employ new RNs, the organization can change its staffing policy to meet the minimum requirements set about by the OMH minimum staffing policy. The organization can supplement its current RN staff with LPNs and MHTAs in order to meet the minimum requirements described by the OMH minimum staffing policy. Owing to the fact that code red of psychiatric emergencies leads to the development of staffing issues, the institution could ensure that a minimum of four MHTAs and one LPN are on duty in the same shift. This would not only meet the minimum staff requirements, but it would also significantly reduce the workload on the single RN that is left available in psychiatric emergencies.

Switch to Acuity-Based Staffing

While the healthcare institution currently faces an unavoidable shortage in staffing, a switch to acuity-based staffing could significantly improve the quality of patient outcomes and patient safety. By developing and implementing an acuity-based staffing tool, the psychiatric healthcare institution can effectively address the unbalanced nurse-patient assignment’s that characterize the institution during a Code Red situation. Implementing an acuity-based staffing not only addresses the security needs of the patients, but also the security needs of RNs and other staff.

Effective and balanced patient assignments based on an acuity-based staffing tool could significantly improve job satisfaction and security, thereby leading to improved quality of care delivery (Ingram & Powell, 2018). The development of an acuity-based staffing tool should take into consideration the clinical patient characteristics as well as the workload indicators that define the different grades and levels of acuity associated with specific patients. A useful patient acuity tool classifies patients as stable, moderate-risk, complex, and high-risk. High-risk patients as associated with Code Red situations. Additionally, the tool takes into consideration the clinical patient characteristics and nurse workload indicators.


It is highly recommended that the State Psychiatric Hospital switches to an acuity-based staffing model in order to counter the shortages of nurses. The current model is characterized by unequal staff assignments which result in work overload and poses a threat to patient safety in the short-term as well as in the long-term. With an acuity-based staffing model, the healthcare institution can implement a low-cost strategy that is also non-invasive to the workflow of staff within the healthcare institution. Additionally, the implementation of an acuity-based staffing model leads to improved communication between staff and RNs during the handover process during the change in shifts. This tool has been found to improve and augment the shift-to-shift handover report, which can also be employed to assign patients to staff based on the competence and experience levels of nurses and other staff (Ingram & Powell, 2018). The acuity-based staffing model allows for the identification of underlying safety failure and develops appropriate solutions. Additionally, it provides a framework through which nurses can monitor patients by taking into consideration the level of risk associated with each patient. An acuity-based staffing model also allows the healthcare institution to address the underlying multiple critical even occurrences. This model takes into consideration the occurrence of Code Red situations and proposes strategies to effectively handle these situations while adhering to the minimum staffing standards and requirement specified by the OMH. As such, the proposed switch to an acuity-based staffing model that takes into consideration all the staffing resources available to the institution would effectively address the patient activity and nurse staffing in the State Psychiatric Hospital.


Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2014). Care left undone’during nursing shifts: associations with workload and perceived quality of care. BMJ Quality and Safety, 23(2), 116-125. doi:10.1136/bmjqs-2012-001767

Bates, D. W., & Slight, S. P. (2014, August). Medication Errors: What Is Their Impact? Mayo Clinic Proceedings, 89(8), 1027-1029. doi:10.1016/j.mayocp.2014.06.014

Ingram, A., & Powell, J. (2018, April). Patient acuity tool on a medical-surgical unit. American Nurse Today, 13(4). Retrieved October 22, 2018, from

Jackson, J. C., Santoro, M. J., Ely, T. M., Boehm, L., Kiehl, A. L., Anderson, L. S., & Ely, W. E. (2014, February). Improving Patient Care Through the Prism of Psychology: application of Maslow’s Hierarchy to Sedation, Delirium and Early Mobility in the ICU. Journal of Critical Care, 29(3), 438-444. doi:10.1016/j.jcrc.2014.01.009

MacPhee, M., Dahinten, S. V., & Havaei, F. (2017, March). The Impact of Heavy Perceived Nurse Workloads on Patient and Nurse Outcomes. Administrative Sciences, 7(7), 1-17. doi:10.3390/admsci7010007