Written Assignment

“Minimum staffing ratios in Nursing:Do they matter?

Can Hospitals Implement and Survive in the Current Volatile Fiscal Environment?” Melissa Boyce, RN Professional Nursing Practice

Professor Jose M.Hernandez, MS, BS, RN

NUR 4130

April 9, 2014

Currently there are hospitals under pressure to regulate the cost of medical care, while at the same time improving patient health outcomes.

One of the common denominators related to these two concerns, is the contentious issue of choosing appropriate ratio amongst nursing staff. In October 1999, California became the first state in the United States to adopt legislation mandating unit-based minimum licensed nurse-to-patient ratios in acute care hospitals (Bolton, 2007). Since the initial ratios, particularly those impacting medical-surgical patient care units, came into effect in 2004, many states, considering enacting similar legislation, have been observing the California experience (Bolton, Aydin & Donaldson, 2007). Through the existing challenges that comes with the nursing profession, such as working long hours and caring for severely ill and sometimes dying patients, many experts argue that in order to lessen job-related burnouts and job dissatisfaction, decrease nurse assignments and improved patient safety, there should be more nurses working in hospitals per patient (Kaissi, 2010). Although intentions of this California law exudes hope, implementing this law holds some challenges. In the following, I will discuss the positive and negative viewpoints of minimum staffing ratios in nursing, along with how it can affects hospitals and long-term care facilities.

Nurses perform a vital role in ensuring safe patient care.  Safe patient care ranges from medication administration to implementing fall risk precautions. Concerns have risen, that patients are being harmed by inadequate staffing related to increased severity of illness and complexity of care (Welton, 2007). According to the American Nurses Association (ANA), “Massive reductions in nursing budgets, combined with the challenges presented by a growing nursing shortage have resulted in fewer nurses working longer hours and caring for sicker patients. This situation compromises care and contributes to the nursing shorting by creating an environment that drives nurses from the bedside” (Safe Staffing, 2012). These viewpoints show that effectiveness of nursing care has some correlation with the number of patients the nurse is assigned to and suggests that it is imperative for the nursing ratio to change.

Changing the nursing-ratio would decrease occurrence of patient infections, falls, skin break downs and possibly patient mortalities (Welton, 2007).  These occurrences are seen commonly on geriatric and critical units, due to limited or complete immobility, along with other factors. I believe with appropriate staffing ratios, efficiency in staff functioning and proper medical practice will increase. Appropriate staffing ratio may also assist in the recruiting and maintaining of nurses within the hospital setting. Seemingly, nurses are leaving the profession because of the overwhelming demand of patient care and the work load associated with it.

Heavy patient workloads for nurses have been associated with poor patient outcomes and low job satisfaction.  Yet few states require hospitals to maintain minimum nurse-to-patient ratios, leaving nurses to care for a significant number of patients at a time. Many studies have found links between heavy workloads and poor patient outcomes. Heavier nursing workloads are associated with poor patient outcomes, including more patient deaths, complications, and medical errors (McHugh, Kelly & Sloane, 2011). A meta-analysis of 90 studies found that increased registered nurse (RN) staffing was associated with lower mortality on intensive care, medical, and surgical units; reduced risk of hospital-acquired pneumonia, unplanned extubation, respiratory failure, cardiac arrest, and failure to rescue; and shorter lengths of stay for surgical (31 percent) and intensive care unit (ICU) patients (24 percent) (Kane, Shamliyan & Mueller, 2007).

Certainly, hospital nurse staffing ratios mandated in California are associated with lower mortality rates and nurse outcomes predictive of better nurse retention in California and in other states where they occur (Parks & Stearns, 2010).  However, 5 years later with the continuing rise of patient acuity, the mandatory minimum staffing ratios adopted in California in 2003 were arguably inadequate, especially when hospitals refused to staff above the ratio when census and acuity called for it (Cortez, 2008).

Virtually all investigators acknowledge that adequate nurse staffing is a crucial element of hospital care.  But study findings in recent years have also emphasized that staffing is only one of a complex array of elements within the “practice environment” that ultimately determines the quality of patient outcomes and nurses’ job satisfaction. The most recent of these works was conducted by a team at Center for Health Outcomes and Policy Research within the University of Pennsylvania School of Nursing. Led by professor Matthew McHugh, the study of nearly 100,000 nurses felt “burned out in their current jobs.” Burnout and work environment, The investigators reported that “nurses” assessments of the overall quality of their work environments—including factors such as managerial support for nursing, responsiveness of management to correcting problems in care at the bedside identified by nurses, and doctor-nurse relations—were significantly associated with burnout and job satisfaction.” Although “mandated nursing ratios” is the phrase most associated with hospital strikes, the nursing community does not unanimously support the concept. A 2009 survey published in the journal, Nursing Economics, found that 38 percent of RNs were not in favor of mandated ratios and only 34 percent supported the idea of a national law requiring these ratios (Brin & Levins, 2012).

Another crucial element is profitability.  The cost of implementing staffing ratios can not be calculated because each institution functions differently and the use of each institutions budget may be calculated differently and could take funds away from varying areas of need depending on the facility. It appears that the facilities that would most likely be affected economically by the staffing ratios are smaller institutions that are unlikely to be able to survive the possible penalty payments for not adhering to staffing regulations (Welton, 2007). Mandated staffing standards affect only low-staff facilities facing potential for penalties, and effects are small. Selected facility-level outcomes may show improvement at all facilities due to a general response to increased standards or to other quality initiatives implemented at the same time as staffing standards (Park & Stearns, 2009) Another major concern with mandatory nurse-patient ratios is ignorance of critical factors, such as nurse education, skills, knowledge, and years of experience. In Bill 394, only 50% of the mandated nurses must be RNs, which implies minimal differentiation between licensed professional nurses and RNs (Chapman, 2009). Mandatory staffing ratios also disregard other unwarranted criteria necessary for adequate staffing decisions, including patient acuity and required treatments, length of stay, team dynamics of staff, physician preferences, environmental limitations, variations in technology, and availability of ancillary staff (Douglas, 2010).

Passing legislation with possible far-reaching effects on nurses, patients, hospitals, and other stakeholders without sufficient evidence is potentially dangerous.  Additionally, once passed into law, legislation is problematic to change if research challenges its effectiveness and public and private support of the nursing profession could be affected negatively (Buerhaus, 2010b). As a unit clerk, I watch the nurses that surround me who are assigned on average 8:1 and notice the lack of interaction and little time available to truly be there for their patients. Some even described themselves as being a pill-popper and personally felt they were losing their interest in the field due to increased stress and fatigue from labored workload. There is hope that further evidence-based research will improve current conditions and set the tone for an improved, flexible minimum staffing ratio, leading our nursing staff to a common goal: preserving the health of our nurses and continuum of patient safety and optimum care.


Bolton, L.B., Aydin, C. E., Donaldson, N., Brown, D. S., Sandhu, M., Fridman, M., et al. (2007). Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Postregulation. Policy, Politics, & Nursing Practice, 8(4), 238-250.

Brin, D.W., & Levins, H. (n.d.). Beyond Nurse-to-Patient Ratios. ldihealtheconomist.com. Retrieved April 5, 2014, from http://ldihealtheconomist.com/he000021.shtml Buerhaus, P.I. (2010b). It’s time to stop the regulation of hospital nurse staffing dead in its tracks. Nursing Economic$, 28(2), 110-113.

Chapman, S.S.(2009). How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders. Journal of Healthcare Management, 54(5), 321-335.

Cortez, Z. (2008). California’s nurse-patient ratio law. Saving lives, reducing the nursing shortage. Available at:http://www.californiaprogressreport.com/2008/01/ californias_nur.html. Accessed Aril 01, 2014.

Douglas, K. (2010). Ratios — If it were only that easy. Nursing Economic$, 28(2), 119-125.

Kaissi, A. (2010, February 16). Nurse-To-Patient Ratios: The Science and the Controversy. Healthcare Hacks. Retrieved April 1, 2014, from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/A/PDF%20AssessingCANurseStaffingRatios.pdf

McHugh, M., Kelly, L.A., Sloane D., et al (2011) Contradicting fears, California’s nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals. Health Affairs., 30(7):1299-1306.

Park, J., & Stearns, S.C. (2009). Effects of State Minimum Staffing Standards on Nursing Home Staffing and Quality of Care. Health Service Research: Impacting Health Practice and Policy Through State-of-the-Art Research and Thinking, 44(1), 56-78. 

Park, J., & Stearns, S. (2010). Implications of the California Nurse Staffing Mandate for Other States. Health Service Research: Impacting Health Practice and Policy Through State-of-the-Art Research and Thinking, 45(4), 904-921. 

Safe Staffing: The Registered Nurse Safe Staffing Act – See more at: http://dpeaflcio.org/programs-publications/issue-fact-sheets/safe-staffing-ratios-benefiting-nurses-and-patients/#sthash.OlFexKrN.dpuf. (n.d.). www.nursingworld.org. Retrieved April 2, 2014, from http://www.nursingworld.org/SafeStaffingFactsheet.aspx#sthash.OlFexKrN.dpuf

Welton, J.M. (2007). “Mandatory Hospital Nurse to Patient Staffing Ratios: Time to Take a Different Approach”. OJIN: Online Journal of Issues in Nursing, 12(3), Manuscript 1.

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