Chronic staffing shortages have forced healthcare organizations to rely heavily on third-party agencies and nurse overtime. In fact, a 2023 report found that 43% of nurses regularly work overtime. More than 7% of them put in 12 extra hours every week. So it should come as no surprise that the U.S. annual turnover rate for nurses exceeds 27%.
And since COVID ravaged the ranks of healthcare providers (one in five dropped out of the healthcare workforce during the pandemic), organizations have leaned heavily on staffing agencies. One study found that – between 2020 and 2022 – the use of agency and temporary labor doubled, while overtime hours staff nurses jumped 52% over pre-pandemic levels. And while this works well for hospitals scrambling to plug staffing gaps, it’s dramatically driving up costs. In some cases, it adds as much as 50% to the hourly rate.
Previous research established a link between overall nurse staffing levels and patient safety, but those studies overlooked the ramifications of overtime and agency staffing. A new research project sought to answer that. And it doesn’t look good.
A Dangerous Threshold
The study – appearing in JAMA Network Open – revealed a strong link between agency nurse hours and increased rates of pressure ulcers and perioperative hemorrhage or hematoma. More specifically, exceeding identified safe staffing thresholds led to a 6.44% rise in pressure ulcers for patients treated by agency nurses and a 2.09% increase when overtime nurses were used.
Even so, hospitals routinely exceeded these thresholds by 140% for agency nurse hours and 63.6% for overtime hours.
These results underscore the need for providers to take a closer look at their use of staffing strategies. Instead of seeing all nurse hours as equal, the authors contend, hospital administrators must make an effort to distinguish between regular, overtime, and agency staffing when assessing patient safety risks.
“Our study shows that when hospitals over rely on travel nurses or overtime for the regular nursing staff, patient safety care may be compromised,” Patricia Pittman, lead author and director of the Fitzhugh Mullan Institute for Health Workforce Equity at the GWU Milken Institute School of Public Health, said in a press release. “Hospitals that want to improve safety should closely track their reliance on overtime and especially nurse staffing agencies.”
Methodology
Pittman and her team looked at 70 U.S. hospital records between 2019 and 2022. The sample covered much of the country, included facilities of different sizes, and relied on 10 critical patient safety indicators, such as pressure ulcers, in-hospital falls, post-surgical complications, and accidental punctures.
Working with statistical models, the researchers identified structural breakpoints — specific overtime levels and agency nurse staffing beyond which patient safety risks began to rise.
They also controlled for factors such as hospital size, patient case mix, and the lingering effects of COVID-19 on hospital census data.
The Role of Pressure Ulcers in Patient Safety
The study’s authors identified pressure ulcers early on as a primary concern, especially since they’re broadly accepted as an indicator of nursing care quality. Each year, about 2.5 million pressure ulcer cases crop in U.S. hospitals, leading to as many as 60,000 deaths while piling on to already high healthcare costs.
The Centers for Medicare & Medicaid Services (CMS) has already rolled out policies that scale back reimbursements for severe pressure ulcers.
While some levels of alternative staffing are unavoidable— especially during public health emergencies and seasonal patient surges — the data indicate that surpassing certain thresholds poses a real threat to patient safety.
Rethinking Nurse Staffing Regulations
The study’s conclusions raise important policy questions about how hospitals can – and should – balance their staffing models. Some experts advocate for federal or state regulations that limit mandatory overtime. Others encourage hospitals to simplky maintain adequate levels of regular nursing staff. Existing policies, such as the nurse staffing mandates that have shown up in California and Oregon, could serve as models for other states.
Additionally, some policymakers argue that CMS should enforce minimum nurse staffing levels as a condition for hospitals receiving Medicare funding, similar to existing nursing homes regulations. The authors add that transparency measures, such as public reporting of staffing levels, could also help.
Further Reading
Yes, Nurse Practitioners Deliver Psychiatric Services
Perceived Stress and Stigma Among Nurses
Mental Health Decline Among Healthcare Workers Started During COVID
