Nurse-Patient Ratios and Safe Staffing: Why You Should Care

By Keith Carlson, RN, BSN

The subject of nurse-patient ratios comes up often in nursing circles, and can often be a topic of discussion in state legislatures around the United States. Ratios are also a topic of conversation and disagreement in other countries. “Safe staffing” is a frequent rallying cry by nurses and non-nurses alike, but what does that really mean and does it make patients and nurses safer?

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Safe Staffing As A Rallying Cry

RNAction.org, an American Nurses Association (ANA) website dedicated to political action and advocacy, states the following about the subject of safe staffing :

“Inadequate nurse staffing levels by experienced RNs are linked to higher rates of patient falls, infections, medication errors and even death. As a result of massive reductions in nursing budgets, combined with the challenges presented by a growing nursing shortage, fewer nurses work longer hours and care for sicker patients. This situation compromises care and contributes to the nursing shortage by creating an environment that drives nurses from the bedside.

“ANA and its Constituent & State Nurses Associations (C/SNAs) in the states are promoting legislation to hold hospitals accountable for the development and implementation of valid, reliable, unit-by-unit nurse staffing plans. These staffing plans, based upon ANA's Principles for Nurse Staffing (member login required), are not mandated ratios. They are created in coordination with direct care registered nurses (RNs) themselves, and based on each unit’s unique circumstances and changing needs.”

Most healthcare providers recognize that safe staffing can impact the safety and quality of patient care. However, there are many forces at play in relation to mandates on nurse-patient ratios, and fights often ensue when attempts are made to enact them.

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Factors Need To Be Weighed

The setting of staffing ratios cannot necessarily occur in the relative vacuum of a legislative session; many factors must be weighed, and various stakeholders must have a seat at the table. The ANA has recommended that hospital committees weighing such decisions must be comprised of a minimum of 55% direct care nurses (or those who represent them). They also take the position that any nurse-patient ratio and staffing plans must include the following recommendations:

  • Establish adjustable minimum numbers of RNs
  • Include input from direct care RNs or their exclusive representatives
  • Be based upon patient numbers and the variable intensity of care needed.
  • Take into account the level of education, training and experience of the RNs providing care
  • Take into account the staffing levels and services provided by other health care personnel associated with nursing care
  • Consider staffing levels recommended by specialty nursing organizations
  • Take into account unit and facility level staffing, quality and patient outcome data and national comparisons as available
  • Take into account other factors impacting the delivery of care, including unit geography and available technology
  • Ensure that RNs are not forced to work in units where they are not trained or experienced.

While legislators may have the power to push through legislation pertaining to patient safety and nurse staffing mandates, it is clear that those with the greatest stake in such decisions be brought into the conversation.

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Ohio Takes Action

In mid-February of 2017, the subject of nurse-patient ratios and nurse workloads made its presence known on the floor of the Ohio state legislature. Democratic State Senator Mike Skindell reintroduced the Ohio Patient Protection Act (Senate Bill 55) , a legislative attempt to impose restrictions on the number of patients for whom Ohio nurses can safely care for.

The bill mandates that a one-to-one nurse-patient ratio would be imposed for patients in the ICU, OR, trauma, critical care, as well as for unstable neonates and patients needing resuscitation. Another provision of the bill places a one-to-three nurse-patient ratio limit for pediatrics and patients who are pregnant.

Interestingly, the bill would require hospitals to publicly post the mandated nurse-patient ratios, and it also forbids the imposition of mandatory overtime to meet staffing demands. The bill also goes so far as to prevent hospitals from utilizing video surveillance as a replacement for the provision of face-to-face nursing care.

An additional stipulation of the Ohio bill requires that nurses be granted the right to refuse to perform certain aspects of patient care if the nurse deems that action as not being in the best interests of the patients.

Apparently, the Ohio Nurses Association does not officially support passage of the bill, while National Nurses United worked closely with the senator to put the bill together. As of this writing, the bill’s viability is in question.

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Beyond the United States

Safe staffing and nurse-patient ratios are not only issues of importance to Americans; in England, the subject frequently comes up for debate.

In discussing Prime Minister Theresa May’s burgeoning political friendship with President Donald Trump, a blogger for The Nursing Times recently opined that “nurses will pay for Theresa May’s mistakes.” The article states:

“In England’s hospitals, a nurse is meant to look after no more than eight medical patients. The ratio can be as low as one to one in neonatal and intensive care units. Analysis of official data….showed almost every hospital in England had insufficient nurses on duty to guarantee safe patient care. 96% of hospitals had fewer nurses covering day shifts in October than planned and 85% were short staffed at night. Indeed, only 27% of NHS (National Health Service) trust chief executives were confident they had the right staff numbers, quality and skill mix to deliver high quality healthcare for patients. Fewer still, 22%, were confident about having the right staffing levels in six months’ time.”

From an American perspective, we can easily see that the struggles of nurses, hospitals, and patients in Great Britain, a close economic and political ally of the United States, are a mirror image of our own.

Turnover, Nurse Attrition, and Retention

If nurses continue to be driven out of the profession by burnout, understaffing, and incivility and bullying, we are no closer to a solution than before.

In 2014, the Robert Wood Johnson Foundation cited a statistic that almost one out of five new nurses leaves the profession within the first year of gaining licensure as a nurse. If that is not worrisome enough, one out of three leave the profession within two years of beginning their nursing career.

While mandating nurse-patient ratios and outlawing mandatory overtime may be prudent actions to stem the tide, the retention of nurses within the profession must also be considered. Nurse turnover is expensive, and shortages of nursing faculty can also limit the number of students accepted into accredited nursing programs.

Nurse burnout, lateral violence, and other factors impacting nurses’ effectiveness and job satisfaction are crucial factors to consider when examining the retention of qualified nurses within the healthcare workforce.

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Make Your Voice Heard

If nurses want their voices to be heard on issues salient to the profession, having a seat at the table is key. The following is a list of actions a nurse might consider taking in order to be a part of the ongoing conversation:

  • Become an active member of your state nursing association
  • Attend trainings and days of action related to lobbying your legislators in regards to issues of interest and importance to nurses and healthcare consumers
  • Gain understanding of the legislative process in your state
  • Become familiar with current legislation being enforced in your state in relation to nurse-patient ratios, mandatory overtime, or patient protection
  • Join workplace committees related to these important issues
  • Discuss ratios and nurse staffing with nurse colleagues and leaders
  • Document situations that illustrate the challenges faced by nurses providing patient care
  • Meet with your legislators to discuss your concerns
  • Meet with the leadership of your hospital, nursing department, or healthcare organization to discuss your observations and concerns

The issue of safe staffing and nurse-patient ratios is not going away. Staying informed, getting involved, and sharing your professional opinion and experience are crucial keys to feeling empowered in this regard. Nurses and patients equally deserve a seat at the table and a safe healthcare environment; find your voice and make your voice heard.

Next Up: 7 Important Elements Of An Inspiring Nursing Career

Keith Carlson, RN, BSN is a Board-Certified Nurse Coach (NC-BC), award-winning blogger, nurse podcaster, speaker, and author. Based in Sante Fe, New Mexico, Nurse Keith’s work has appeared in a variety of online and print publications.

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