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Practice Matters

Why laws can’t guarantee safe staffing levels

why laws can't guarantee safe staffing levels

Is the complexity of nurse staffing compatible with the blunt force of a law?

FEW can doubt that nursing administration knows a great deal more about safe staffing than it did before the 1980s. In fact, so many medical, nursing, and administrative journals have published so much on safe nurse staffing that you’d have to be functionally illiterate to say “we don’t know what’s safe.” In short, Clarke found that “the available evidence indicates that there is a statistically and clinically significant association between RN staffing and adjusted odds ratio of hospital-related mortality, failure to rescue, and other patient outcomes.” And Kane and colleagues noted that “low RN staffing is a serious risk factor for negative outcomes in patients hospitalized in acute care settings.” I might add that research shows that low staffing levels aren’t good for nurses either.

why laws can't guarantee safe staffing levels postThat being said, why isn’t it a good idea to pass laws that mandate nurse/patient ratios? A law is a blunt instrument that doesn’t deal well with a very complicated issue—and nurse staffing is nothing if not complex. Consider these factors:

  • patient acuity
  • presence and number of patient comorbidities
  • patient level of consciousness and physical capability
  • families and their ability to cope
  • nurses’ knowledge and experience
  • presence (or absence) of support personnel
  • hospital management philosophy and organization
  • presence (or absence) of expert backup
  • physical layout of the hospital unit
  • presence (or absence) of various students seeking clinical experience on the unit
  • various and sundry other issues (physician/nurse communication, presence of advanced nurse practitioners, percentage of specialty certified staff, ratio of RNs to nursing assistants, ratio of full-time to part-time staff…and more).

Why do knowledgeable people oppose mandating RN/patient ratios? See all of the above—and add the well-established fact that a legally mandated minimum quickly becomes a de facto maximum.

Why do knowledgeable people support mandating RN/patient ratios? The world of the hospital often leaves nurses understaffed—so mandating ratios seems the lesser of two evils.

For those who are trying to save money on nurse staffing, researchers have several suggestions:

  • Employ sufficient nursing staff to meet patients’ needs without using overtime or excessive capacity expectations that may affect nurse health and patient outcomes.
  • Increase the mix of full-time to part-time employees (part-time staff should be used to cover unexpected or variable demands).
  • Ensure strong, cohesive, and knowledgeable teams to provide continuity of patient care and to create supportive work environments for nurses.
  • Reinvest in appropriately prepared managers and nurse clinical leadership.
  • Examine frontline nurses’ roles and activities to determine ways to increase the time available for patient care.

leah curtin registered nurse faan





Leah Curtin, RN, ScD(h), FAAN

Executive Editor, Professional Outreach

American Nurse Today

Selected references

Clarke SP. Registered nurse staffing and patient outcomes in acutecare: Looking back, pushing forward. Med Care. 2007;45(12):1126-8.

Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nurse staffing andquality of patient care. Evid Rep Technol Assess. 2007;(151):1-115.


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