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Nurse Staffing Isn't Straightforward. Here's Why.

Analysis  |  By Jennifer Thew RN  
   November 21, 2018

Mandating nurse-to-patient ratios is one solution to nurse staffing, but some favor different approaches to the issue.

In 1999, California became the first state to pass a law mandating nurse-to-patient ratios in hospitals. The requirement went into full effect on January 1, 2004.

At the time, there was speculation in the nursing community that other states would quickly follow suit, and mandatory ratios would spread across the country. That has not been the case.

In fact, this November, Massachusetts voters rejected a law that would establish mandatory staffing ratios in the state. Almost 20 years later, California remains the only state to require nurse-to-patient ratios to such a broad extent.

But why?  

Certainly, some of it is politics and how successfully those for or against ratios lobby lawmakers and the public to support their stance. Another reason is the idea that creating ratios based strictly on mandatory numbers is not enough to address the complexities of staffing and patient care.  

For example, the American Nurses Association says numbers-only ratios are too rigid and don't allow nurses to make staffing decisions that address their individual unit's needs or to account for patient acuity.

According to the ANA's Principles for Nurse Staffing, the following concepts need to be considered to achieve optimal staffing and safe, high-quality care delivery:  

  • Nurse staffing is more than numbers.
  • One size does not fit all.
  • Components such as nurses' experience, patient acuity, workflow, patient volume, and available resources in the delivery of care affect decisions on what is appropriate staffing at any given time.
  • Patient care needs are fluid and vary among hospitals, nursing units, and shifts.
  • Flexibility and teamwork are essential to effectively meet patients ever-changing needs.

Below are five HealthLeaders articles highlighting the spectrum of opinions and issues related to nurse staffing.  

1. Nurse Staffing Affected by Tests, Procedures

When Riverside Methodist Hospital in Columbus, Ohio, experienced a period of multiple changes and high nurse turnover in the 32-bed neurocritical care unit, two of the unit's nurses launched a workflow study to assess relationships between neurological assessment, documentation, traveling with patients for diagnostic tests, and the effects of patient acuity and nurse experience.

The study found that for nurses on neurocritical care units, accompanying patients for imaging scans and other procedures significantly impacted nurse-patient staffing ratios.

Based on these results, the authors recommended a new "circulator" nurse position to travel and assist with patients and to free primary nurses on the unit to stay with their patients. They also recommended three new "one-to-one" staff positions to allow high-acuity patients or those with multiple diagnostic tests scheduled to be assigned to a dedicated nurse. 

2. Do Nurse Staffing Ratios Work? New Research Says No.

Four years ago, Massachusetts passed a law requiring 1-to-1 or 2-to-1 patient-to-nurse staffing ratios in intensive care units, as guided by a tool that accounts for patient acuity and anticipated care intensity.

A recent study by physician-researchers at Beth Israel Deaconess Medical Center found Massachusetts' previous regulations regarding nurse-to-patient staffing ratios in ICUs were not associated with improved patient outcomes.

After comparing outcomes between academic ICUs nationwide and in Massachusetts, the authors found modest increases in ICU nurse staffing ratios—a change from 1.38 patients per nurse to 1.28 patients per nurse— before and after the mandate's implementation. These increases weren't significantly higher than staffing trends in states without state-mandated ICU staffing.  

Additionally, the risk of mortality and risk of complications in Massachusetts' ICUs remained stable after the law's implementation, with no significant difference in trends compared to out-of-state hospitals.

3. Massachusetts Voters Say 'No' to Mandatory Nurse-Patient Ratios

In the November midterm elections, 70% of Massachusetts voters rejected a law seeking to implement nurse-to-patient ratios in hospitals and other healthcare settings. 

For months, the law was hotly debated. Those in favor said it would improve patient safety and care. Those opposed said it didn't account for patient acuity and would create a financial burden on hospitals and healthcare systems.

The Massachusetts Nurses Association, supported the law while the Massachusetts Health & Hospital Association and the American Nurses Association were opposed to it.

While the election is over, all sides say discussions about patient safety and nurse staffing need to continue.

4. Great Nurse Leaders Focus on These 6 Areas

Patricia A. Hickey, PhD, MBA, RN, NEA-BC, FAAN, vice president and associate chief nursing officer, cardiovascular and critical care patient services at Boston Children's Hospital and assistant professor of pediatrics at Harvard Medical School, is internationally known for her work in research and leadership development, care delivery innovation, patient safety, and bridging nursing practice and health policy.

She is a proponent of updating patient acuity instruments which have traditionally been time-based.

"For example, a tool may have allocated 5 minutes to suction a patient. But sometimes it takes 7 minutes," Hickey says.

At Boston Children's Hospital, the CAMEO nursing acuity instrument was developed "as a contemporary tool to measure the cognitive workload and complexity of nursing work. The CAMEO score for each patient is helpful to staffing decisions in combination with the judgment of frontline nurses," Hickey says.


5. Nurse Stressors: It's Not Just Patient Volume and Acuity

Patient volume and acuity aren't the only factors affecting a nurse's ability to deliver high-quality care, finds a new study examining nurses' 'subjective workload.'

Researchers at The Ohio State University found that everything from mental pressures of the job to time constraints can influence whether a nurse can provide optimal care, regardless of how many patients they are assigned.

The study calls for developing broader workload strategies to ease nurses' stress and improve care quality.

The researchers evaluated the relationships between objective and subjective workload measures and quality of care and found the nurses' perceived workloads had a consistently strong influence on missed essential care.

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.


Those in favor of nurse-patient staffing ratios say the ratios promote patient safety.

Those opposed to staffing ratios say the ratios don't account for patient acuity.

Optimal staffing is influenced by many factors, including cognitive workload and nurse experience.

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