Cases & Commentaries

Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care

Spotlight Case
Commentary By Victoria Rich, PhD, RN

Case Objectives

  • Understand the context for nurse
    staffing plans and the processes that hospitals use to design
  • Describe the licensing and regulatory
    constraints that shape staffing plans.
  • Appreciate system capacities for
    covering sudden changes and overload situations.

Case & Commentary: Part 1


A 68-year-old man was
admitted to the intensive care unit (ICU) with chronic obstructive
pulmonary disease (COPD) exacerbation and atrial fibrillation with
rapid ventricular response. He was markedly short of breath despite
use of accessory muscles and was only able to speak in short
sentences. He was alert and oriented but frail, and providers were
concerned that he might tire and ultimately require mechanical

In the ICU that evening, two
nurses scheduled to work had called in sick. There was only one
patient care assistant scheduled on this weekend shift. Due to the
short staffing and inability to locate a last-minute replacement,
each existing nurse was assigned three patients rather than the
usual two.

In this case, due to a shortage of nurses in the
ICU, each nurse present had to take care of more patients than
usual. Nurse researchers have long explored the relationship
between registered nurse staffing, skill mix, and hospitalized
patient outcomes (1-3),
a line of inquiry that took on additional momentum with the
publication of a 1996 Institute of Medicine (IOM) report on nurse
staffing in hospitals.(4)
Seminal studies then demonstrated that increases in the number of
RNs caring for patients, as well as their education and experience,
resulted in fewer complications, lower morbidity, fewer medication
errors, and lower costs.(5-8)

Although some efforts to
standardize nurse staffing ratios had begun prior to the 1996 IOM
report, the increased evidence after 1996 linking ratios to
outcomes created substantial momentum in the policy arena. In 1999,
the American Nurses Association (ANA) introduced a nursing quality
report card and the Principles for Nurse Staffing.(8,9) In 2003, another key IOM report prioritized
increased nurse staffing as a key mechanism to decrease medical
errors.(10) In
2004, building on the work of the California Nursing Outcomes
Coalition (CalNOC), the National Database for Nursing Quality
Indicators (NDNQI), and research reports, the National Quality
Forum (NQF) introduced the 15 nursing-sensitive quality measures
that included hours of nursing care and RN staff mix.(11) As
of July 2009, 12 states (CA, CT, IL, ME, NV, NJ, OH, OR, RI, TX,
VT, WA) and the District of Columbia have passed legislation or
regulations to address nurse staffing, and 15 states (CA, CT, IL,
MD, MN, MO, NH, NJ, NY, OR, PA, RI, TX, WA, WV) also restrict
mandatory overtime.(12,13)

Although these laws and
regulations create some external constraints, individual
organizations retain considerable flexibility in their staffing
strategies. Developing these hospital staffing plans requires a
complex dance involving nurse leaders, staff nurses, physicians,
hospital administrators, financial officers, regulators, patients,
and families. This dance is guided by the ANA Principles of Safe
Nurse Staffing.(12)
Staffing plans are developed annually by nurse leaders and
presented to hospital administrators to review, negotiate, and
approve based on numerous indicators, including patient
volume/acuity, regulatory standards, external and internal
benchmarks, and nursing skill mix and experience.

Once the annual budget is
approved, each nursing care unit develops monthly staffing and
scheduling templates to ensure adequate nurse staffing. This
monthly plan uses past experiences to estimate the number of nurses
needed to fully staff each unit. Even after the plan is developed,
it is reassessed frequently (sometimes every hour) based on the
acuity of patients and the competency of nursing staff. Not only do
patients have differing needs, but nurses have different
experiences, competencies, and organizational skills. Both the ANA
and the American Organization of Nurse Executives (AONE) (12,14)
support evidence-based nursepatient
ratios. Specifically, these organizations feel that staffing
patterns should not be mandated or standardized, but determined,
created, and monitored (i) with input from direct care RNs and
based on (ii) number of patients and acuity; (iii) number of
admissions, discharges, and transfers each shift; (iv) RN
experience; (v) factors such as orientation to unit, support staff,
physical design of unit, vacancy, and turnover; and (vi) RN ratios
benchmarked with specialty and hospital organizations. The Labor
Management Institute (15)
and the National Database for Nursing Quality Indicators (16)
are both recognized as valid and reliable sources for guiding
staffing ratios. The standard rule of thumb is to have a
ratio of 1:4-5 on
medical–surgical units, 1:3-4 on intermediate units, and 1:2
in ICUs.

State nurse licensure boards,
The Joint Commission, and Centers for Medicare & Medicaid
Services (CMS) all have standards designed to help ensure adequate
nurse staffing. Each of these regulatory bodies and appraisers
works to ensure that hospital systems adhere to the ANA guidelines
and provide the necessary financial support to staff their units

According to the 2003 IOM report
"Keeping Patients Safe" (10),
it is vital that we empower staff nurses to regulate their own unit
work flow. In the case presented, RN shortages could have been
addressed by closing the unit to new admissions or by considering
the transfer of a more stable patient to an intermediate level of
care unit. The decision not to take transfers and admissions must
be made in collaboration with and supported by physician staff and
must be based on predetermined admission/discharge /transfer triage
guidelines. If it is deemed appropriate to hold all new admissions,
alternative solutions must be offered to care for the new patients.
These alternative solutions require clinician teamwork and strict
adherence to handoff communication protocols. Many times, the
patient awaiting admission or transfer remains in the original
point of entry (such as the emergency department) and does not
receive the level of care needed (e.g., in the ICU). In these
situations, the ICU RN ratio is maintained at the expense of the
ratio in the unit at the point of entry. This conundrum is
commonplace and is best addressed with an internal resource pool
that creates the capacity for nurses to "float" to units where they
are needed.

In this specific case, it
appears that the nursing staff members were not supported in making
difficult decisions that would protect the patient and themselves.
If "holes" in nurse staffing are allowed to remain unfilled at
times like these, my guess is that such failures are a regular
feature of this hospital, like many others. Ill calls and other
unplanned absences are a regular feature of every hospital.
Accordingly, nurse leaders and their designees must develop
strategies to deal with these absences to ensure patient safety. It
is the responsibility of the board of trustees and senior leaders
to empower the Chief Nurse to design safe nurse staffing patterns
and to provide the resources to carry out these

To navigate this complex,
dynamic system requires real-time, redundant decision-making
processes. In this area, best practices include the following:
First, a centralized staffing office that assists the
nurse leaders in adjusting the daily predicted budgeted staff vs.
the actual, and maintains the data to justify staffing alterations.
Second, a Shift Coordinator who has a hospital-wide
perspective and can reallocate or adjust RN staffing in real time,
minute to minute if necessary. It is important to mitigate the
stressors of short staffing on a shift to shift basis. The
practicing nurse needs to focus on the care of patients. The
empowered Shift Coordinator is best placed to understand the
overall hospital activity and hence is better able to problem-solve
with physicians, patients, and other stakeholders in real time to
maximize safety. Third, an internal resource pool of RNs
available and incentivized to provide the ability to flex up or
down to accommodate variations in acuity and/or volume.(12)

Internal resource pool budgets
are based primarily on the expected nonproductive hours of nurses.
For example, a nursing unit can estimate the expected number of
hours of vacation, education, and unplanned absences for a year and
plan the replacement hours needed to cover. Nonproductive hours
expected for each unit can be averaged on a yearly basis, and
resource pool nurses can be hired to replace these hours. Each
unit's hours can then be tallied, and an internal pool leader can
hire nurses to cover this time.

These strategies allow hospitals
to customize staffing to meet both patient and nurse needs,
decrease time spent by nurse leaders in managing unplanned events,
instill trust in nurses that leadership supports safe patient care,
improve nurse retention, and provide accountability for the
efficient and effective use of valuable

Case & Commentary: Part 2

The nurse assigned to the new admission
reviewed and implemented the initial physician orders as the
patient was stabilized on a diltiazem drip for his atrial
fibrillation. His respiratory status also stabilized, and he
avoided the need for noninvasive ventilatory support and intubation
and began to transition to intermittent, rather than continuous,
nebulizer treatments.

Within 30 minutes of his arrival in the ICU,
a second patient was transferred from the overflowing emergency
department with hemodynamic instability from a massive pulmonary
embolism. Since the patient with COPD just admitted appeared to be
improving rapidly, and the other nurses were caring for more
critically ill patients, the same nurse "volunteered" to admit the
new patient. While she was tending to the orders for the new
admission and discussing the vasopressor medications being ordered
with pharmacy, her patient with COPD began urgently asking for help
to use the bathroom. Rather than using the bedpan, the patient
insisted on getting up and going to the bathroom. The nurse quickly
assisted the patient to the toilet and then called for a patient
care assistant to transfer the patient back to his hospital bed
when he was ready to do so. The nurse then hurriedly returned to
the bedside of the acutely ill patient with the pulmonary

Approximately 5 minutes
later, the patient care assistant arrived at the COPD patient's
bathroom and found him slumped on the floor, unresponsive and
cyanotic with his oxygen detached from his face. A code blue was
called but, despite extensive resuscitation attempts, the
previously "stable" ICU patient was pronounced

While we are not provided with details regarding
the physiologic causes of this tragic outcome—it is possible
that it was unrelated to the staffing—the case highlights the
tensions involved in determining appropriate nurse staffing ratios
and policies that exist or need to exist to ensure patient safety.
The solutions are multifaceted, and all solutions begin with the
nursing culture of the organization and the unit.

Commonly Used but
Inadequate Options

The previous discussion focused on policies at
the hospital level to ensure adequate staffing on each unit. But
even in hospitals with such staffing policies, situations will
arise in which nurses find themselves being stretched to the
limits. How should nurses and the systems in which they operate

The first option for this staff
nurse was to discuss with the nurse manager or charge nurse his or
her specific concerns about caring for three ICU patients and
collaboratively establish a new plan of care for all patients
during that shift. An appropriate leadership intervention would
have been to validate the staff nurse's concerns and develop a
solution. Solutions that are commonly used include: (i) reassigning
a nurse from another comparable unit where acuity is lower, (ii)
reprioritizing and readjusting the workload of all nurses on the
shift, and (iii) having nursing management personnel extend their
hours of work into the shift or come in early to help. In my view,
while these actions appear to solve the problem at hand, these
"fix-the-bridge-as-you-walk-on-it" solutions are not sustainable.
When invoked routinely, they cause increased stress, emotional and
physical fatigue, and compromised patient safety. Staff nurses who
endure such shortages shift after shift do feel that care is
unsafe.(9) A
second option is to refuse transfers from the emergency department
to the unit until a secondary plan can be created. Again, while
this ameliorates the situation in the ICU, it often exacerbates
staffing problems in the emergency department. Over time, if
overcrowding in any venue of care persists, all care providers
become overtaxed and anxious. Disrespect for one another begins to
flourish, and patient care can become secondary to unit and
caregiver needs. Other inadequate options are (i) mandatory or
voluntary overtime and (ii) returning to work on an on-call basis
but still working the next day. This translates to working 16-24
hours at one time. Robust research has demonstrated that these
strategies are associated with poorer patient outcomes.(10)

Best Practice

The best approach to unplanned
staffing deficits is to proactively define the action steps to take
prior to the crisis. This action plan is defined by the
approach articulated in Part 1. Nurse unit leaders must anticipate
changing staffing needs and assess at least 4-8 hours prior to the
next shift if staffing ratios and patient needs can be met. If
unpredictable events occur, staff nurses must feel empowered to
voice concerns and collaborate with nurse leaders, shift
coordinators, and physicians to make decisions that protect
patients first. This commentary has expressed both
proactive and just-in-time approaches to making patients

The budgeted staffing ratios
must be planned with staff nurse input and support, and their
decision making must be respected. Danger points for shortages of
staff are weekend shifts and times of high emergency department
census. Nursing leadership must proactively design incentives for
nurses to work on weekends and plan for adjusting staffing levels
when volume increases before the problem actually

Chief Nursing Officers (CNOs)
must constantly balance the financial management of nurse staffing
against the needs of patients. As budgets tighten, it is vital that
nurse leaders maintain RN ratios when census is high and decrease
RN staffing when census is low. The flexibility of a resource pool
and keen daily budget management enable the CNO and other nurse
leaders to follow budgeted staffing plans and instill trust and
confidence in the staff nurses that patient care ratios will be
protected. When RN ratios are adhered to, patients receive safe,
quality care and nurses are recruited and retained. It is not
rocket science.

Take-Home Points

Best practices in dealing with
nurse staffing ratios include:

  • Conduct failure mode effect analysis on
    nurse staffing for each unit in order to develop strategies and
    options to use when staffing levels are not adequate.
  • Create an internal resource pool for
    flexibility and census adjustments.
  • Communicate all action plans to staff
    nurses on the unit plus interdisciplinary and administrative
  • Empower staff nurses to identify
    solutions for staffing issues. Administer annual nurse satisfaction
    survey such as NDNQI to measure and assess if staffing plan is safe
    and adequate according to nursing staff. Annually involve staff
    nurses in staffing decisions made for budgetary purposes.
  • Benchmark staffing ratios annually with
    other facilities and correlate with patient outcomes, adverse
    events, and root causes. Provide data about quality outcomes as
    evidence to assist in determining future staffing needs. Evaluate
    patient satisfaction feedback closely and correlate with nurse
    staffing plan.


Victoria Rich, PhD, RN
Chief Nurse, PENN Medicine
Associate Professor of Nursing Administration

University of Pennsylvania School of

Faculty Disclosure: Dr. Rich has
declared that neither she, nor any immediate member of her family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, her commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.


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