Update on Nursing Staff Ratios
HealthMarch 08, 2018

Understanding nursing staff ratio models

What are the latest nursing staff models to keep patients safe and prevent nursing burnout?

The importance of sufficient nurse staffing in hospitals is widely known, and low levels of nurse staffing have been linked to negative outcomes for patients, including increased length of stay, hospital-related complications, and even mortality. In addition, low staffing also affects nurses, leading to job dissatisfaction, fatigue, and staff burnout.

Adequate nurse staffing benefits patients, staff, and the facility, resulting in the reduction of:

  • Medical and medication errors
  • Patient mortality, hospital readmissions, and length of stay
  • Number of preventable events such as patient falls, pressure ulcers, central line infections, healthcare-associated infections (HAIs), and other complications related to hospitalizations
  • Patient care costs through avoidance of unplanned readmissions.

Several models of nurse staffing have been developed to identify safe and optimal staffing levels.

States take the lead with nurse staffing

Identifying and maintaining the appropriate number and mix of nursing staff is critical to the delivery of quality patient care. Numerous studies reveal an association between higher levels of experienced RN staffing and lower rates of adverse patient outcomes.

When health care employers fail to recognize the association between RN staffing and patient outcomes, laws and regulations become necessary. A federal regulation has been in place for some time (42CFR 482.23(b) that requires Medicare-certified hospitals to “have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed".

But this vague terminology doesn't mean much without a Federal law, so it has been up to each state to enact their own nurse staffing regulations. State staffing laws tend to fall into one of three general approaches:

  1. Require hospitals to have a nurse-driven staffing committee which creates staffing plans that reflect the needs of the patient population and match the skills and experience of the staff.
  2. Legislators mandate specific nurse to patient ratios in legislation or regulation.
  3. Requiring facilities to disclose staffing levels to the public and /or a regulatory body.

The American Nurses Association (ANA) supports state and federal regulation and legislation that allows for flexible nurse staffing plans in which nurses are empowered to create staffing plans specific to each unit. Optimal staffing is much more than just numbers, and direct care nurses are well equipped to contribute to the development of staffing plans.

Establishing minimum upwardly adjustable staffing levels will aide in achieving safe and appropriate staffing plans.

States with hospital nurse staffing laws

Fourteen states currently address nurse staffing in hospitals with official regulations: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA.

Seven states require hospitals to have staffing committees responsible for plans (nurse-driven ratios) and staffing policy: CT, IL, NV, OH, OR, TX, WA.

California is the only state that stipulates in law and regulations a required minimum nurse to patient ratios to be maintained at all times by unit. Massachusetts passed a law specific to ICU requiring a 1:1 or 1:2 nurse to patient ratio depending on stability of the patient.

Minnesota requires a CNO or designee develop a core staffing plan with input from others. The requirements are similar to Joint Commission standards. Five states require some form of disclosure and/or public reporting: IL, NJ, NY, RI, VT.

New Mexico charged specific stakeholder groups to recommended staffing standards to the legislature; the department of health is to collect information about the hospitals that adopt standards and report the cost of implementing an oversight program.

Greater job satisfaction for all nurses

Optimal staffing is essential to providing professional nursing value, and flexibility is key. Staffing levels should be flexible and account for changes, including intensity of patient 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. Greater benefit can be derived from staffing models that consider the number of nurses and nurse-to-patient ratios and can be adjusted to account for unit and shift level factors.

Factors that influence nurse staffing needs include: patient complexity, acuity, or stability; number of admissions, discharges, and transfers; professional nursing and other staff skill level and expertise; physical space and layout of the nursing unit; and availability of or proximity to technological support or other resources.

With the increased focus on value-based care, optimal nurse staffing will be essential to delivering high-quality, cost-effective care. Appropriate nurse staffing helps achieve clinical and economic improvements in patient care, including improvements in patient and staff quality of life.

Free webinar recording: The Key to Competency-Based LTC Staffing

Watch the free webinar from Lippincott Solutions on “The Key to Competency-Based LTC Staffing” with guest speaker Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT, Curriculum Development Specialist at the American Association of Directors of Nursing Services (AADNS).

This webinar discusses key considerations when applying competency-based staffing using the facility assessment and an example of a training and education evaluation plan that can assist in identifying site specific training needs. 

Watch the Webinar
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