Optimal staffing for safe patient care continues to be a top concern of the nation’s 2.8 million employed registered nurses (RNs), 58% of whom work in acute care settings. Although there is a growing body of research supporting the relationship between appropriate staffing and clinical outcomes, shrinking financial resources and increased demand for services have created significant challenges to achieving this goal.
One challenge to finding a permanent and long-lasting solution to staffing issues is the rapidly changing healthcare environment. Over the past 2 decades, the average length of stay in hospitals across the nation has decreased from 7.0 days to 5.4 days. This has resulted in more frequent admissions and discharges, with a corresponding increase in nurses’ workload.
Other factors include anticipated changes in U.S. demographics in the coming decades. The aging of America’s citizens will result in greater need for healthcare services, which will occur in conjunction with the aging of the nursing workforce. Together, these factors will contribute to an anticipated 1.13 million vacancies for RNs and advanced practice registered nurses (APRNs) by 2022.
In addition, changes related to the Affordable Care Act and the focus on decreasing hospital readmissions will continue to increase the shift in care delivery for complex, sicker patients from the inpatient to the outpatient setting, which will significantly impact staffing needs in both ambulatory and long-term care settings.
Issues such as these are top of mind as we consider the question: “If staffing in our department or on our unit is not where it needs to be, what can be done to improve it?”
A solution-oriented approach
Optimal staffing for safe patient care is a highly complex and multifactorial issue. The American Nurses Association’s (ANA’s) Principles for Nurse Staffing serves as a guideline for both nurse administrators and clinicians to evaluate current staffing models, and develop new models based on individual unit or departmental needs.
ANA’s Principles for Nurse Staffing includes 5 key components:
Other steps for taking action include:
- Learning more about optimal staffing.
- Attending ANA’s 2016 Conference “Connecting Quality, Safety and Staffing to Improve Outcomes.”
Adjustable staffing plans
While all approaches to achieve the goal of optimal staffing for safe patient care should be considered, there is no one staffing model that fits all situations. A number of factors impact nurse staffing, including the patient population being cared for, the layout and technology available on the unit, the activity level on the unit, and the skill mix (meaning the various roles of team members needed to provide quality care to a specific group of patients).
Rather than mandatory fixed nurse-to-patient ratios that may lack adequate flexibility, ANA advocates for minimum RN-to-patient ratios that are increased as needed based on these factors. Hospital or department staffing committees that include clinical nurses as full partners in staffing plan development, implementation, and decision-making should establish and implement adjustable staffing plans.
Strategic collaboration and transparency in reporting
Other strategies that have been demonstrated to impact nurse staffing are included in the Registered Nurse Safe Staffing Act, which is being reintroduced in Congress this spring. These are:
- implementation of staffing committees with at least 55% of committee participants being clinical nurses
- committee responsibilities that include the establishment of unit-specific staffing plans based on upwardly adjustable minimum ratios of direct RNs to patients for each unit and shift
- staffing plans that take into account characteristics of the care team (e.g., training and experience of RNs providing care and other healthcare team members)
- the use of nationally benchmarked nursing-sensitive clinical outcomes such as falls, pressure ulcers, and failure-to-rescue, as well as nurse and patient satisfaction scores, to evaluate the effectiveness of existing staffing models on an ongoing basis
- the requirement that staffing plans be publicly reported.
There also is growing support for public reporting of staffing measures such as skill mix and hours of care provided per patient per day. In addition to the public’s right to know, transparent reporting of data has the potential to provide nurses and other healthcare researchers with extremely valuable information that would accelerate our understanding of how various types of staffing plans impact clinical care outcomes.
It is critical for clinical nurses and nurse administrators to work together on staffing solutions. Together they can revise or create staffing models that ensure the health and well-being of the nurse, while also meeting the increasingly complex needs of patients to achieve safe, effective, patient-centered, timely, efficient, and equitable care.
American Nurses Association. 2022: Where have all those nurses gone? 2014. www.ananursespace.org/blogs/peter-mcmenamin/2014/03/14/rn-retirements-tsunami-warning?ssopc=1
American Nurses Association. ANA’s Principles for Nurse Staffing. 2nd ed. 2012.
American Nurses Association. Distribution of RN Employment. 2013. www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workforce/Charts-and-Tables-of-RN-and-APRN-Employment-Data.pdf
Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. 2001. http://nationalacademies.org/hmd/reports/2001/crossing-the-quality-chasm-a-new-health-system-for-the-21st-century.aspx
Kane RL, Shamliyan TA, Mueller C, et al. The association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis. Med Care. 2007;45(12):1195-1204.
Needleman J. Nurse staffing: The knowns and unknowns. Nurs Econ. 2015;33(1):5-7.
Mary Jo Assi is the director of Nursing Practice and Work Environment in the Nursing Programs Department at ANA.