Académique Documents
Professionnel Documents
Culture Documents
LaDonna D. Henderson
1
STRATEGIES TO IMPROVE STAFFING 2
Nursing today has become more complex as nurses take on greater responsibilities in
caring for a more complicated patient population. This complexity is affected by the nurses
ability to safely carry out patient care. With patient safety at the core of the nursing profession,
identifying and establishing the appropriate nurse-patient ratio is critical in being able to provide
safe quality care and decrease poor patient outcomes. Establishing safe nurse-patient ratios has a
direct effect on the nursing profession, impacting the safety of both nurses and patients.
Clinical Problem
This paper will seek to identify strategies to improve staffing on inpatient medical-
surgical units by exploring the question of how nurse-patient ratios affect patient outcomes.
According to the Agency for Healthcare Research and Quality (AHRQ), Hospitals with low
nurse staffing levels tend to have higher rates of poor patient outcomes. (Stanton, 2004). While
increasing the nurse staffing seems an obvious response, there are actually many factors to
consider. Patient acuity and staffing mix are important aspects of determining nurse-patient
Purpose Statement: The purpose of the study is to identify strategies to improve staffing
PICO Question
O (Outcome): Smaller nurse-patient ratios than those currently established decrease adverse
patient outcomes.
Research was conducted using the Cinahl, Health Source: Nursing/Academic Edition,
MEDLINE, and Ovid databases. Search terms included (nurse AND ratios) AND (patient AND
outcomes), filtering by peer reviewed, English language, 2006-2016, academic Journals, and
USA. A review of the literature was compiled during the dates of September 25 October 5,
2016.
Literature Review
Seven articles were chosen from the literature review to examine the issue of nurse-
patient ratios and their impact on patient outcomes. There is a general consensus in the nursing
field that low nurse-patient ratios are dangerous for both nurses and patients, resulting in adverse
outcomes such as increased infection rates, increased fall rates, and even increased mortality
rates for patients, as well as increased job burnout and career dissatisfaction for nurses. The
literature review was undertaken to explore ways of improving nurse staffing levels and
One attempt to resolve nurse-staffing concerns has been to federally mandate nurse-
patient ratios. In 1999, California because the first state to pass a law requiring specific nursing
ratios in an attempt to ensure patient safety. For medical-surgical units, this ratio was 1:6.
(Kasprak, 2004). By 2013, several studies had been conducted to discover what impact these
STRATEGIES TO IMPROVE STAFFING 4
federally established ratios had on patient outcomes. Research prior to the institution of
patient-nurse ratio and adverse patient events. However, studies focusing in particular on
Californias nurse-patient ratio laws were at best inconclusive and failed to show a significant
correlation and suggested further research was necessary to explore the impact of ratios on
The main problem with comparing the findings from different research studies is in
determining how the nurse-patient ratio is defined. West, Patrician, and Loan cited inconsistent
was discovered in looking at the federally mandated ratios implemented in California, an across-
the-board hard-line approach does not adequately address the issue. Other factors must be at play
that influence the effects nursing ratios have on patient care, such as patient acuity, unit-level and
shift-level needs, and the staffing mix (RNs to LPNs, experience level, and education level).
Key to resolving the nurse-patient ratio issue is the level of involvement nurses have in
making staffing decisions. Staffing committees have been shown to be a successful approach in
developing staffing policies that take into account an organizations particular needs. This
alternative approach is flexible and can address multiple factors rather than adopting a fixed-ratio
mentality. Nurses who participate on these committees can bring more awareness of unit-level
needs to the table. Both bedside nurses and nurse managers have invaluable knowledge regarding
clinical care needs and can be extremely beneficial in determining a reasonable and effective
staffing plan.
STRATEGIES TO IMPROVE STAFFING 5
Practice Recommendations
Many factors must be considered when determining safe nurse-patient ratios. Based on
the literature reviewed, three practice recommendations are suggested. These recommendations
determination of the nurse-staffing ratios that best promote safe patient care. Adequate staffing is
a complex nursing issue that is not easily solved by inflexible government-mandated staffing
ratios (Wallis, 2013, p. 22). Staffing committees that include both nurse managers and direct care
nurses are better equipped to determine safe nurse-patient ratios (Martin, 2015, p. 6) and allow
2. Staffing mix should be taken into consideration when determining safe nurse-patient
ratios. An effective model should take into account the amount of education, years of experience,
and professional knowledge and skills each nurse possesses when looking at safe staffing. More
adverse events occur during shifts staffed with fewer personnel overall and fewer RNs in
particular (Patrician et al., 2011, p. 67). A significant correlation was found between nurse skill
level and adverse patient outcomes with a decrease in nurse staffing levels being associated with
an increase in mortality among specific patient populations. (Schilling, Goulet, & Dougherty,
2011, p. 2937).
3. Total nursing care hours per patient per shift rather than specific nurse-to-patient ratios
should be used when determining safe staffing. A decrease in the number of nursing care hours
per shift increases the risk of adverse patient events. For example, on a unit with 20 patients and
10 nurses each working 8 hours per shift provides 80 nursing care hours. Dividing the number of
hours by the number of patients computes to 4 nursing care hours per shift. Changing the number
STRATEGIES TO IMPROVE STAFFING 6
of patients (either by admissions, transfers, or discharges) on any particular shift decreases the
nursing care hours available per patient thereby increasing the workload. (West, Patrician, &
Conclusion
Determining safe nurse-patient ratios is a complex issue facing todays healthcare world.
It will require a multi-factorial approach for successful resolution. While there is agreement that
lower nurse-patient ratios have unfavorable effects on safe patient care, traditional approaches no
longer sufficiently address this problem. Many have praised the efforts of government regulation
of staffing ratios, but this proposed solution has its flaws as well. More involvement of nurses,
rather than outside agencies, seems to be the direction with the most promise.
STRATEGIES TO IMPROVE STAFFING 7
References
Hinno, S., Partanen, P., & Vehvilinen-Julkunen, K. (2011). Nursing activities, nurse staffing
https://www.cga.ct.gov/2004/rpt/2004-R-0212.htm
Martin, C. (2015). The effects of nurse staffing on quality of care. Academy of Medical-Surgical
Patrician, P. A., Loan, L., McCarthy, M., Fridman, M., Donaldson, N., Bingham, M., &
Brosch, L. R. (2011). The association of shift-level nurse staffing with adverse patient
doi:10.1097/nna.0b013e31820594bf
Schilling, P., Goulet, J. A., & Dougherty, P. J. (2011). Do Higher Hospital-wide Nurse Staffing
Levels Reduce In-hospital Mortality in Elderly Patients with Hip Fractures: A Pilot
doi:10.1007/s11999-011-1917-8
Serratt, T. (2013). Californias nurse-to-patient ratios, part 3. JONA: The Journal of Nursing
Stanton, M. (2004). Hospital nurse staffing and quality of care (Publication No. 04-0029).
Retrieved from
https://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.htm
l#LowerStaffing
Wallis, L. (2013). Nurse-patient staffing ratios: Where are we headed and why? American
West, G., Patrician, P. A., & Loan, L. (2012). Staffing MattersEvery Shift. AJN, American
Appendix A
Appendix B