February 9, 2023

Opinion | Staffing Ratios Are The Wrong Fight For Nurses

Opinion | Staffing Ratios Are The Wrong Fight For Nurses

Disclaimer: The views and opinions expressed in this article are those of the writer and do not necessarily reflect the views or positions of nurse.org

Are staffing ratio’s the solution? In my opinion, no. Staffing ratios continue to keep nurses in an oppressed position and are a perfect example of learned helplessness.  

Have you heard the story of the chained elephant? Well, it goes something like this - a baby elephant is chained for the first few years of its life.  It tries thousands of times to break out of the small circle it has been confined to, but eventually, the day comes when the elephant stops trying. Then the owner removes the chain. The elephant believes escape is impossible – and this belief keeps him imprisoned for the rest of his life.   This is what sociologists call "learned helplessness."

Nurse Oppression

Nurses have been extorted for decades.  They have little control or power over what they need to safely deliver quality care.  They think ratios are the answer because it is a longer chain that will give them more of what they need - but it’s still a chain as long as somebody else besides the nurse decides ratios.

The oppression nurses experience isn’t really about our profession. If we expand our perception, it becomes obvious that this power struggle is really about what our nation values.

In the current business model, the dominant value is profit - and caring is oppressed. Nurses are empathetic healers whose acts of heartfelt service are not reimbursed in the current business model.  

There is No Billing Code For Compassion 

Nor is there no billing code for the vigilant nurse who intervenes in time to prevent a bad outcome or the only nurse who can get a patient to take their meds. These exceptional moments when a nurse saves a life or connects profoundly with his or her patient are free… like pennies on a convenience store counter.  

Because the work we cherish has no monetary “value” in the current business system, our self-esteem decreases, in-group arguing prevails, and we start measuring ourselves using the language of the dominant group: turn-around time, length of stay, and hours of care per patient day. This is why staffing ratios are the wrong fight. It’s still about control – like Rosa Parks fighting for a seat on the 2 a.m. bus. 

Autonomy and Power are The Real Fights

We think we are exerting power, but we are not.  It is pseudo-power designed to give nurses only a little bit of what they need. By fighting for ratios, we are still playing into the values of the dominant group. I want to waive a red flag and yell “Stop! There’s another way! Look!”  

If you are going to fight, fight for the real thing: your own autonomy and power.  

The Charge Nurse’s Role

The only person in an organization who is qualified to decide staffing levels is the charge nurse.  This person knows,

1) the real-time acuity level of every patient

2) the experience and skill level of oncoming staff

The charge nurse (with the support and endorsement of their manager) should get as many nurses as they request. Period. Fight for that!

If you are smart enough to be a charge nurse, run a crash cart, save lives, manage complicated calculations and patients, etc., then you are smart enough to know how many nurses are needed for safe staffing for the next four hours (and yes, staffing must be assessed every 4 hours). Any other option dummies us down.

Staffing Ratios Are a Temporary Solution

Where is the advocacy for our own judgment, power, skill, and knowledge? That’s Nursing unchained.

Staffing ratios are a temporary, stop-gap solution. They will not create the respect and value our profession deserves.  It never dawns on nurses that there shouldn’t be a chain at all - that nurses themselves should have the power to set ratios on an hourly basis. 

By playing into ratios, we are still holding ourselves in an oppressed position because we are discounting our own ability to make this critical decision. And we all know that conditions change quickly.  What if my ratio is 1:4 - then one patient crashes and I can only safely take 3 patients?  

Oops!  The ratio says 4 so sorry.

Only when we are given the resources that we request to do our job will our patients ever be safe. 

Only then, and not until then.

Kathleen Bartholomew, RN, MN uses the power of story and her background in sociology to illuminate the healthcare culture in her presentations, books, and Op-Eds.  For over twenty years she has spoken to nurses, physicians, and leaders about how to nurture relationships that create a culture of safety. Her TEDx talk challenges our covert belief that some people are more important than others.