Professional Documents
Culture Documents
Darcy S. Thompson
Abstract
Favorable outcomes in patient care have been shown to be directly linked to nurse/patient
ratios that support safe delivery of care, in conjunction with high-quality practices. Who
determines these ratios and why there isnt a standardized, universal practice with regards to
mandated ratios is still a perpetuating question, one that is being challenged within the profession
on many levels in hopes that changes in practice will eventually lead to mandatory staffing ratios
in all patient care settings. Mandatory staffing ratios are being discussed at all levels within
hospital administration alongside managers and staff nurses and the overwhelming question from
many professional nurses, why isnt this universal, standardized practice? Because of this, many
hospitals are now examining a more dynamic staffing approach based in large part on the
complexity of the patient focusing on improving safety and ensuring that patient outcomes
Background
We deliver high quality care has become the slogan for professional registered nurses,
and a top priority in healthcare systems nationwide. Achieving these goals has been shown to be
directly linked to nurse/patient ratios and favorable outcomes in patient care. Safe delivery of
care results when high-quality practices are applied in conjunction with appropriate, qualified
staffing ratios within a hospital setting (Cho, Lee, & Kim, 2016). Therefore, developing
appropriate nurse/patient care ratios is essential to optimize the delivery of quality based care and
the achievement of ideal patient outcomes. However, it is paramount to understand that many
factors must be considered beyond the seemingly simple numeric ratios because of their effect
and influence in how nurse staffing needs are created and patterns are implemented.
Unfortunately, continually rising healthcare costs have become the primary focus in this
era of value-based healthcare. These costs, along with many other factors, have prompted the
attention and close scrutiny that has compelled healthcare systems to acknowledge the need to
address staffing ratios within our healthcare system to seek a more financial responsive
alternative. The top priority still remains the ability to deliver high quality care while reducing
the overall cost simultaneously. The technology that the twenty-first century affords our industry
should easily bridge any gaps between high quality care and safety, because undeniably, safely is
a fundamental component of high quality care (Committee on the Quality of Health Care in
America, 2001). More now than ever, many if not most individuals today have access to
healthcare, since The Affordable Care Act was passed in 2010 and this has caused the need to
improve the quality of care while reducing cost long-term and work on goals for the reform of
healthcare in the United States (Cho, Lee, & Kim, 2016). Several models have created
MANDATORY RATIOS 4
reimbursement initiatives aimed to improve quality while reducing the overall cost of
hospitalization.
What is most crucial and paramount to this restructuring is the emphasis on value-based
healthcare. Many programs look to incentivize or penalize hospitals based on their ability to
meet certain quality initiatives, outcomes, while at the same time, finding creative cost reducing
metrics. This has forced hospitals to explore alternative practices which will improve quality and
patient outcomes while simultaneously containing costs. Since work force of nurses is often
among the largest clinical subgroup within hospitals, and a common response to this pressure is
an attempt to cut cost by reducing the number of necessary professional nurse or licensed hours
and their associated costs. As a whole, the nursing profession views this as a very shortsighted
policy; optimal staffing has been consistently documented to be key in providing professional
nursing value.
Examination of current staffing models within hospitals that do not have structured
nurse/patient ratios reveal that these models are often thought to be outdated and inflexible. In
light of research, greater benefit could be gained from utilizing staffing models that consider the
number of nurses and/or the nurse-to-patient ratios and then are adjusted accordingly to account
for the actual patient population and their specific needs as well as the demographic of the staff
makeup for a particular shift. Published studies show that appropriate staffing helps achieve the
clinical outcomes the profession strives for such as higher scores for overall patient satisfaction,
exceptional delivery of care and reduced medication errors, just to name a few. By promoting
nursing safety through these redefined staffing matrixes, nurse retention and overall job
satisfaction could dramatically increase as well. And conversely, as stated by Cho, Lee and Kim
in their research from 2016, those events which indirectly contribute to safer patient care
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experiences and could certainly promote a lower level of patient mortality, hospital
readmissions, length of stay, and preventable events such as patient falls, pressure ulcers, central
line infections, healthcare-associated infections, and other complications that are often associated
with hospitalization.
Alternative Viewpoints
To date, California is the only state that has adopted the mandated nurse-patient ratio
practice model; however, several states continue to deliberate this type of legislation. Many
nurses are encouraged that the discussion and debate have moved more towards a shared
dialogue surrounding this topic and that both administration and business sectors as well as the
working professional nurses realize that they are equally important stakeholders in this matter.
The relationship between inadequate staffing ratios and negative patient outcomes within
hospital settings has been well documented (Louch, O'Hara, Jame, Gardner, Pater, & O'Connor,
Daryl, 2016). When asked, many nurses felt that they did not have enough time to spend with
patients to deliver appropriate, compassionate care in a safe and dignified manner (Gillen, 2012).
care, and yet surprisingly, not all nurses are in favor of this approach. Some nurses object to the
approach that one-size-fits-all, not because they are advocating for units to be understaffed, but
because they are against the rigidity of such practice. While these dissenters agree, there are
issues that need immediate remediation, including the execution of higher patient safety margins
and quality of care, as well as addressing the workforce burnout and dissatisfaction felt among
many overtaxed nurses, they tend to disagree that these are completely contingent upon staffing
ratios and the regulation of such measures (American Sentinel University, 2015).
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The crux of this argument truly stems from understanding that there is no magic formula
or equation to ensure absolute safety and quality when it comes to staffing ratios. It is, however,
imperative to understand that many factors influence nurse staffing needs including but not
limited to patient stability versus instability; the number of admissions and/or discharges
assigned to the unit, as well as transfers into and out of a particular unit; the skill levels of the
additional staff in the unit and their combined expertise alongside the registered nurse; even the
physical space and layout of the nursing unit needs to be taken into consideration as this can
determine the need for change in the way staffing patterns are created and implemented.
Determining how many patients a nurse can safely manage while still provide high-
quality care really must be based on several factors and cannot be seen as a hard and fast rule.
When specific ratios are mandated by law, hospitals often find there are many issues that can
complicate their compliance. For example, if a unit has a staffing majority of nurses that are
novice, and are by definition, inexperienced nurses, would this be considered a violation when
the majority of the patients have many chronic conditions and could arguably be considered
unstable? Or how does this ratio factor the change in a patients condition unexpectedly? And
how should meal breaks be granted if taking one would cause the staffing ratio to fall below the
allotted levels of necessary personnel to safely run the unit (American Sentinel University,
2015)? Some hospital administrations believe the totality of the environment is more critical to
the quality of nursing care than any one element, including staffing. Linda Aiken concluded in
her 2011 study that adding more nurses to a unit markedly improves patient outcomes in
hospitals with good work environments, slightly improves them in hospitals with average
Because of this, many hospitals are now examining a more dynamic staffing approach
based in large part on the complexity of the patient. A model like this allows for what really
matters: the right number of patient-care hours provided by nurses with the appropriate skill level
for a given situation. It is understood that this is a very fluid equation that should be modified
One theme remains consistent as this discussion continues and that is there is a direct
correlation between poor staffing conditions and less than optimal outcomes for patients, and
mandatory staffing ratios could help make turn those statistics more positive. (Louch, O'Hara,
Jame, Gardner, Pater, & O'Connor, Daryl, 2016) Mandated staffing ratios must make improving
References
American Sentinel University. (2015, January 28). The Sentinel Watch: Nursing. Retrieved from
http://www.americansentinel.edu/blog/2015/01/28/what-have-we-learned-about-nurse-
patient-ratios/
Cho, E., Lee, N.-J., & Kim, E.-Y. (2016). Nurse staffing level and overtime associated with
patient safety, quality of care and care left undone in hospitals. International Journal of
Gillen, S. (2012, April 25). Most nurses are struggling with inadequate staffing, survey shows.
Louch, G., O'Hara, Jame, Gardner, Pater, & O'Connor, Daryl. (2016). The daily relationships