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Safe Staffing

January 2014

The Issue: 

Ensuring that a sufficient number and mix of registered nurses (and other nursing care personnel) are available to provide direct, hands-on care to patients is an ongoing problem despite established research-based recommendations on minimum staffing levels for specific units. Hospitals refuse to staff to levels supported by research, often citing cost issues as the reason they are chronically understaffed. At the same time, hospitals pay the price by absorbing the cost of readmissions, the cost of "never events" (serious healthcare mistakes that are often avoidable), and the cost of fatigued staff working (often in mandatory situations) in less-than-optimal conditions.

What the Experts Say:

A solid foundation of evidence has been accumulated over the past 20 years that provides a lens through which to see the implications of insufficient registered nurse staffing. While some studies are technically "dated," they are the classic work on which the foundation has been built.

  • Hospitals with higher RN-to-patient ratios and higher percentages of RNs on staff had lower-than-predicted patient mortality rates. (Linda H. Aiken, Herbert L. Smith, and Eileen T. Lake, "Lower Medicare Mortality among a Set of Hospitals Known for Good Nursing Care," Medical Care 32, no. 8 (1994): 771-787.)
  • Nurse staffing shortages are a factor in one out of every four unexpected hospital deaths or injuries caused by errors. (Joint Commission on Accreditation of Healthcare Organizations, 2002.).
  • After adjusting for patient and hospital characteristics, each additional patient per nurse was associated with a 7 percent increase in the likelihood of a patient dying within 30 days of admission and a 7 percent increase in failure to rescue. (Linda H. Aiken, Sean P. Clarke, Douglas M. Sloane, Julie Sochalski, and Jeffrey H. Silber, "Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction," Journal of the American Medical Association 288, no. 16 (2002): 1987-1993.)
  • High patient turnover (patient throughput generated by admissions, discharges and transfers) contributes to increased demands and resources for care. Higher RN staffing was associated with lower failure-to-rescue (FTR) rates. However, when patient turnover increased from 48.6 percent to 60.7 percent in non-intensive care units (non-ICUs), the beneficial effect of non-ICU RN staffing on FTR rates was reduced by 11.5 percent. Therefore, RN staffing should be adjusted according to patient turnover rates because higher turnover rates increase patient care demand beyond that presented by the patient count. (Shin Hye Park, Mary A. Blegen, Joanne Spetz, Susan A. Chapman, and Holly De Groot, "Patient Turnover and the Relationship between Nurse Staffing and Patient Outcomes," Research in Nursing and Health 35, no. 3 (2012): 277-288.)
  • Value-based purchasing is in its infancy. Devising an effective system that recognizes and incorporates nursing measures will facilitate the success of this initiative. A nursing-sensitive value-based purchasing system needs to be designed and incentivized to decrease adverse events, hospital stays and readmission rates, thereby decreasing societal healthcare costs. (Kevin T. Kavanagh, Jeannie P. Cimiotti, Said Abusalem, and Mary-Beth Coty, "Moving Healthcare Quality Forward with Nursing-Sensitive Value-Based Purchasing," Journal of Nursing Scholarship 44, no. 4 (2012): 385-395.)



There are several possible strategies for addressing concerns of determining, implementing and enforcing sufficient RN staffing levels in acute care facilities.

  • Stipulating specific nurse-to-patient ratios across all units is one approach that many states have attempted over the past two decades. To date, only one state has been successful in passing such a bill: California. (In California hospitals, nurse-to-patient ratios are actually used as a safety-net strategy because California state law requires that staffing be determined through the use of patient acuity assessment tools.)
  • However, many states have enacted legislation or established regulations that require minimum staffing levels on certain care units—usually specialty and intensive care units. Often, these staffing guidelines are reflective of recommendations from specialty nursing organizations. Staff level requirements on certain care units have been passed in California, Connecticut, the District of Columbia, Illinois, Maine, Minnesota, Nevada, New Jersey, New York, North Carolina, Ohio, Oregon, Rhode Island, Texas, Vermont and Washington.
  • Another approach to increasing staffing levels is passing legislation requiring the establishment of staffing committees in hospitals, usually with a minimum level of staff nurses required, in order to determine staffing plans and policies. States with laws requiring staffing committees include Connecticut, Illinois, Nevada, Ohio, Oregon, Texas and Washington.
  • And lastly, the following five states have laws in place that require hospitals to provide some form of public reporting on staffing levels: Illinois, New Jersey, New York, Rhode Island and Vermont.

     Staffing Plans and Ratios map

 View larger version of map.

AFT Position Statements:

1996: Staffing

1998: State Legislation of Health Care Staffing

2000: Protecting Patients and Promoting Quality Health Services

2002: Set Limits, Save Lives: The Need for Staffing Ratios and/or Workload Limitations

2006: State and Federal Legislation of Healthcare Staffing


Other Recommendations:

Utilizing existing staffing or quality committees as a vehicle for reviewing nursing-sensitive outcome data collected by the facility, and the trends in those outcomes compared with staffing levels, provides an opportunity to demonstrate the relationship between nurse staffing and patient outcomes and the value of adequate staffing levels.

Many variables beyond simple ratios affect staffing needs. The range of variables that should be considered in the staffing decision-making process can be found in the ANA Principles for Nurse Staffing, a resource developed using subject matter experts and evidence-based research.