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HealthNovember 11, 2016

The importance of the optimal nurse-to-patient ratio

What is the national benchmark when it comes to nurse-patient staff ratios? Maintaining appropriate nurse staffing levels does not just promote better care, in most cases, it's the law. But pinning down a specific number is hard to do, given the legal vagaries from state to state.

Federal regulation 42CFR 482.23(b) requires hospitals certified to participate in Medicare to “have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.”

Without giving a clear figure, it is left up to each state to determine how to ensure that staffing is appropriate to patients’ needs.

The right nurse-to-patient staffing ratio

The American Nurses Association (ANA) supports a legislative model in which nurses are empowered to create staffing plans specific to each unit. This method allows hospitals to establish staffing levels that are flexible and account for changes including the intensity of patients’ needs, the number of admissions, discharges and transfers during a shift, level of experience of nursing staff, layout of the unit, and availability of resources, such as ancillary staff and technology.

California is the only state that has legally defined required minimum nurse-to-patient ratios to be maintained at all times by unit. For example, the nurse-to-patient ratio in a critical care unit must be 1:2 or fewer at all times, and the nurse-to-patient ratio in an emergency department must be 1:4 or fewer at all times that patients are receiving treatment, the law states.

California RN-to-Patient staffing ratios

Type of Care
Intensive/Critical Care 1:2
Neo-natal Intensive Care 1:2
Operating Room 1:1
Post-anesthesia Recovery 1:2
Labor and Delivery 1:2
Antepartum 1:4
Postpartum couplets 1:4
Postpartum women only 1:6
Pediatrics 1:4
Emergency Room 1:4
ICU Patients in the ER 1:2
Trauma Patients in the ER 1:1
Step Down, Initial 1:4
Step Down, 2008 1:3
Telemetry, Initial 1:5
Telemetry, 2008 1:4
Medical/Surgical, Initial 1:6
Medical/Surgical, 2008 1:5
Other Specialty Care, Initial 1:5
Other Specialty Care, 2008 1:4
Psychiatric 1:6

Staffing to improve safety for nurses and patients

The National Campaign for Safe RN-to-Patient Staffing Ratios is a nationwide effort to ensure safe staffing for nurses and patients across the country.

Studies have shown that appropriate nurse staffing helps achieve clinical and economic improvements in patient care, including:

  • Enhancement of patient satisfaction and HCAHPS scores
  • Reduction in medication errors, patient mortality, hospital readmissions, and length of stay
  • Improved safety outcomes by reducing incidents of falls, pressure ulcers, and healthcare-associated infections (HAIs)
  • Reduced patient care costs through avoidance of unplanned readmissions
  • Prevention of nurse fatigue.

In addition to supporting models where nurses themselves are empowered to create staffing plans and promoting flexible staffing plans, the ANA and like-minded organizations support public reporting of staffing data to promote transparency, and penalizing institutions that fail to comply with minimal safe staffing standards.

Optimal staffing is essential to providing the best care possible and getting the maximum value from RNs. Greater benefit can be derived from staffing models that consider the number of nurses and/or the nurse-to-patient ratios and can be adjusted to account for unit and shift level factors.

One strategy to meeting the need for additional nursing staff is opening up the path to a degree for aspiring nurses and encourage more people into the field. Companies such as Wolters Kluwer are working closely with healthcare industry partners, nursing programs and individual educators throughout the country to build world-class nursing education solutions that meet the demands of today’s healthcare field.

But as the transformation of the American healthcare system continues apace, many healthcare professionals are being asked to develop a more holistic approach to addressing the increasing complexity of patients’ health needs. Today’s nurses are now expected to acquire knowledge from several non-nursing disciplines in order to treat patients.

In her whitepaper, Effective Interprofessional Education and Collaborative Practice in Nursing Education,” Elizabeth Speakman, EdD, RN, ANEF, FNAP, notes that experts argue that the delivery of high-quality care requires an interprofessional approach, where representatives from multiple departments work together to provide care. Recent studies, however, question whether nurses can adapt, given the shortage of nurse faculty and mentors, as well as research indicating the prevalence of poor communication and collaborative practices across the healthcare professional spectrum.

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