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Nurses Know Best: Setting Safe Staffing Levels

Thursday, August 27, 2020   (0 Comments)
Posted by: Shanna Howard
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By Cindy Zolnierek, PhD, RN

It’s no secret that safe staffing is one of the main concerns of nurses working in acute care hospitals. Nurses care about their patients’ outcomes, and nurse staffing levels are inextricably linked to such outcomes. In addition, when staffing levels are inadequate, nurses can experience fatigue, and exhausted nurses are more prone to commit errors affecting patient safety. A systematic review and meta-analysis demonstrated that greater nurse-to-patient ratios negatively affected nurse outcomes such as burnout, job dissatisfaction and intent to leave.

Therefore, nurses, hospitals and the public have a vested interest in assuring adequate staffing in hospitals. But what is “adequate” or “safe” staffing, and who should define the criteria for making that determination?

Three approaches

Texas was the first state to actually implement staffing regulatory requirements in 2002; in 2004, Oregon implemented staffing committee legislation and California, its mandated ratio law. Three general approaches have been adopted to address nurse staffing:

  1. Mandated nurse-to-patient ratios.
  2. Required nurse staffing committees who develop staffing plans.
  3. Public disclosure of staffing.

Only California has passed mandated nurse-to-patient ratio legislation in which the number of patients a nurse may be assigned is determined by regulation; although this approach has been introduced in other states, they have not been successful in passing this regulation.

In contrast, the staffing committee approach typically involves direct care nurses (e.g., representatives from various clinical areas) and leadership (e.g., management, infection control, quality, education) collaborating to develop staffing plans to guide patient care assignments. Seven states have passed legislation mandating nurse staffing committees (CT, IL, NV, OH, OR, TX, WA).

The disclosure approach exists in five states (IL, NJ, NY, RI, VT) and requires organizations to post their staffing plans publicly, report them to regulatory agencies or both.

Staffing considerations

While virtually every study conducted has supported the positive influence of nurse staffing on patient outcomes, not one study has suggested an ideal nurse-to-patient ratio. This is because there are a number of other variables – characteristics of the nurse, patient, hospital and practice environment – that affect the “ideal” ratio.

“A nurse is a nurse is a nurse” does not hold true – nurses vary in their experience and expertise, and this will affect their ability to safely manage a patient assignment. Patients also differ in their care requirements – a patient who was just transferred from intensive care will likely need a different level of nursing care than a patient who is ready to be discharged home.

Likewise, hospitals differ – a telemetry unit in a quaternary medical center that provides heart transplants and bypass surgery is much different from a telemetry unit in a small rural hospital that does not provide cardiology procedures. Finally, characteristics of the practice environment will affect efficacious assignments. In order to provide the right staffing levels and mix, all of these components must be considered.

Safe staffing involves a process of matching and providing staff resources for patient care requirements. Staffing is resource intensive, comprising the largest component of hospital operational budgets. In a time of nursing shortage and crisis, safe and appropriate staffing becomes especially challenging. The need to define and ensure effective staffing is of primary concern to nurses and nursing, and it is critical for quality patient care.

Nurse and patient outcomes

The National Database of Nursing Quality Indicators (NDNQI) provided one of the first detailed looks  at patient and nurse outcome indicators. This database includes measures believed to be directly related to nursing care and patient outcomes, such as:

  • Nursing hours per patient day
  • Patient falls (with or without injury)
  • Pressure ulcer prevalence
  • Restraint prevalence
  • RN satisfaction
  • Skill mix (percent of total nursing hours supplied by RNs, LVNs, UAPs, agency staff)
  • Voluntary nurse turnover
  • Nurse vacancy rate
  • Nosocomial infections

Because the NDNQI provides unit level data, it enables comparisons across like units and like hospitals, e.g., a telemetry unit in one small community hospital can compare its pressure ulcer and vacancy rates to a similar unit in another community hospital.

Measures of structures and processes (characteristics of nurses and staffing) are important because they influence patient outcomes. However, the ultimate measure of quality is the patient outcomes themselves. Regardless of what was planned or intended, did it make a difference? Was the goal achieved?

Committees that work

The Texas Safe Hospital Staffing Act provides a structure and process for direct care nurses and managers to work together in designing staffing plans to provide for the unique needs of their patient population. A successful staffing committee will consider data regarding staffing variances, patient outcomes and finances as they engage in a shared decision-making process to determine staffing plans for hospital units. The committee will need to solicit, consider and respond to staffing concerns raised by nurses. Ongoing tracking and consideration of unit-level patient outcome data is necessary to determine and evaluate relationships as well as the effectiveness of the staffing plan.

Safe staffing is more than a number. It is the right number of nurses and the right match of nurse and patient characteristics that makes staffing “safe.” It is the right number of nurses and the appropriate workload. It is the right number of nurses and the right kind of resources to support the nurse in the particular environment. It is the right number of nurses and the right kind of culture — one that supports collaborative, interdisciplinary practice and encourages nurses to identify and report problems and barriers to providing care.

“Adequate Staffing unto itself is a necessary but insufficient condition for safe, high quality and cost effective nursing care. One unanswered question is who is the best nurse for any situation given the needs of the patient and abilities of the nurse?” Quality patient care will result from “right” staffing and “right” assignments tailored to the uniqueness of patients, nurses and hospitals.


Read more about safe staffing and your legal rights.

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