Staffing ratio refers to the number of healthcare providers per patient in a health facility. The term can also be used to define the differences regarding staffing per patient between hospitals. There have been heated discussions on the introduction of staffing ratio mandates nationwide over the last decade. While a universal staffing ratio mandate is yet to be agreed upon, several states have taken the initiative of introducing the said mandates within their precincts.
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California, for instance, was the first state to order staffing ratios mandate through a series of legislation. Other states that have passed staffing ratio mandates are Arizona, Florida, Hawaii, Iowa, Montana, Connecticut, Missouri, New Jersey, New Mexico, New York, Ohio, Virginia, and West Virginia. It is important to note that there still exists a gap between the introduction and legislation of these mandates and their subsequent implementation. Among the stated states, California is the only one that has successfully implemented staffing ratios mandates.
Staffing mandates should be made an absolute necessity. Studies conducted to assess the impact of staffing ratios have proved that there is a causal relationship between the quality of care provided by Health Service Organizations (HSOs) and overall patient outcomes. The essay will prove that having staffing ratios in legislation will provide substantial grounds for the setting of medical standards and auditing.
History of Staffing Ratio Mandates
Staffing ratio mandates can be traced back to the 60s and 70s when nurse staffing requirements were determined through work sampling. Under this system, an independent observer inspected each unit to assess the tasks being done by each nurse. A productivity scale was created for each shift and the performance of the nurses working in that shift rated. After that, the number of hours worked was divided by the average census in that shift to generate hours per patient shift (HPPS). Further, the HPPS was factored by the productivity percentage of each nurse (skill level) and added to a factor of 1.15, which accounted for the personal time, fatigue and delays encountered (PFD).
The system evolved in the 90s to a more broad-based policy that sought to measure the workload of each. After years of sampling and workload measurement with nurses as the agent factor, and the patient’s as the affected factor, it was noted that there was a relationship between patient staffing levels and the outcome of patients. This realization, coupled with labor unions in California, which had located a favorable environment to agitate for job security, gave rise to the staffing mandate discussions statewide.
Current State and Stakeholders
Currently, very few states have passed legislation on staffing ratio mandate with discussions on a possible universal staffing ratio mandate still ongoing (Mandated Nursing Ratios, 2005). On the same breath, there is a national campaign to accurately define the nurse staffing ratios on both federal and state levels. Examples of current legislation under discussion include:
- The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (S.1063) (“Schakowsky and Brown,” 2017) – This bill seeks to have a minimum number of nurse–to–patient ratio for each hospital unite established. Additionally, it outlines requirements to have acute care facilities provide RNs based on the acuity of the patients presented.
- The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (H.R.2392) (“Schakowsky and Brown,” 2017) – The bill recognizes the difficulty nurses face in their workplaces. Arguably, nurses go through tough situations in an attempt to provide optimum care. According to the statement, the solution to this conundrum is to enforce a mandatory staffing ratio to ensure that each nurse works to the best of their ability without being overwhelmed.
Also, the American Nursing Association has proposed Federal RN ratios that should be implemented nationwide to promote quality care (“National campaign for safe RN-to-patient staffing ratios,” n.d).
Legal and Healthcare Relevance
Having a standard nurse staffing ratio is crucial in enforcing legal compliance in most of the healthcare organizations. From a legal perspective, a standard nurse staffing ratio provides both the state and federal governments with the legal grounds to ensure that the right care is provided within health service facilities compliance is a crucial factor concerning medical facilities. On the same note, it also ensures that Americans have access to quality care.
Currently, there are limited legal statutes on the staffing ratio mandates. In turn, the local and national governments are unable to facilitate proper care within HSOs. Federal regulation requires that health organizations certified to provide medical care have adequate numbers of licensed nurses, and other healthcare personnel to provide care to all patients as needed. On the same note, supervisory and staff personnel for each department or nursing unit should be accorded to ensure immediate availability of a nurse for bedside care of any patient when required.
The stated federal requirement can be considered ambiguous given that it does not provide specific parameters with regards to the standard staffing ratios. “Adequate” is a vague term. Each facility can interpret it from a personalized perspective. Thus, a legal conundrum can arise.
Several things can be used to make a legal standard as opposed to the federal blanket requirement. The California legislation on staff to patient ratio can be used as an example. The Health and Safety Code (n.d, 1276.45(A)) states that for long-term units, the ratio for each of the four support staff divisions described, should not be less than 1 to 25 residents. Further, nurse staffing to patient ratios for these specific units ought not to be less than one registered nurse (RN) or at least a psychiatric specialist for each of the patients in the unit during the day. During the night, each of these groups is required to have at least one RN or a psychiatric technician for 12 residents during the night time shifts.
Currently, the intensive and critical care units in Californian healthcare facilities have an RN to patient ratio of 1:2. Additionally, operating rooms are required to have a ratio of 1:1 while antepartum units have ratios of 1:4 (“The importance of the optimal nurse-to-patient ratio,” 2016). The stated is an exact representation of precise legal standards. However, many health facilities in the state do not have the required standard numbers.
Hence, having a national legal requirement that is well defined and clear will be crucial in enforcing federal legal statutes in the country. In essence, the nurse staffing ratio mandates would ensure hospitals adhere to federal regulations strictly. Also, the mandates will provide a legal ground over which audits of the facilities will be conducted from time to time in a bid to enforce compliance.
Empirical evidence shows that a relationship between staffing ratios in healthcare organizations and the quality of care provided therein exists. In facilities with a balanced nurse to patient ratios, the patient outcomes have always been desirable. McHugh and Ma (2014) established a link between the burnout and poor patient outcomes. Nurse burnout is as a result of low staff numbers. The stated leads to straining, lack of rest and subsequently inadequate service provision. It is important to note that burnout can be physical and psychological (compassion fatigue).
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Research conducted in the US showed that 3.7% of inpatient cases occasionally lead to adverse events. Further, the study indicated that there is an error in 1 out of 20 prescriptions (Hall, 2016) due to health care worker negligence. In essence, for a nurse to provide quality and desirable care a broad spectrum of personal factors such as career satisfaction, happiness, and absence of depression should be considered.
It can be argued that hospitals need to improve their staffing ratios. Balanced degrees of the nurse to patient ratios help in job specialization and division of responsibilities. Thus, by facilitating desirable nurse staffing ratios and those of other healthcare workers, healthcare providers will be able to reduce nurse burnout, promote job satisfaction and improve the quality of care within their facilities (Lee, 2017).
Mortality levels have been associated with the level of staffing in medical facilities. According to Shekelle (2014), there is adequate evidence to suggest that a significant number of deaths that occur during hospitalization have been prevented due to the provision of more personalized nursing care. The provision of a more customized care is only possible in organizations with an adequate number of nurses. With a high number of nurses to patient ratios, hospitals can afford to ensure that each nurse is assigned a particular patient.
Suffices to mention, nurse to patient relationships are an essential factor in the healing process. Additionally, patient-clinician relationships are both emotional and cognitive. While emotional care involves mutual trust, respect, empathy and acceptance, cognitive care encapsulates sharing of patient medical, educational and family information, which is all critical for the care process (Kelley, 2014).
Systematic reviews and meta-analyses of randomized controlled trials (RCTs) have shown that a relationship between the patient and the care provider can have a significant impact on the outcomes of the patient. The connections have been instrumental in the reduction of the healing timelines and ensured completion of treatment. Kelley (2014) avers that while the datum derived from these studies is statistically insignificant, it meets the assumptive criteria. The stated personal relationships are easier to create when the number of patients assigned to a nurse is manageable.
Important to state, evidence-based practices (EBPs) are an integral part of modern medicine (Fiset, 2017). However, studies show that the most significant challenge to the application of EBPs in most medical facilities is the inadequate time for medical staff, especially nurses. Going through these EBPs, understanding and implementing them requires time. Due to low nurse staffing numbers, it becomes almost impossible to train the nurses on the EBPs. Therefore, to ensure that medical staff has the time to apply EBPs, their numbers must be improved as they will help ease tasks involved affording every person time.
Nurse staffing ratios have an impact on the quality of healthcare provided in medical facilities. The linkage, therefore, implies that for American medical organizations to realize optimum and ideal healthcare levels, they must ensure there is an adequate number of staff within their facilities. Standard staffing levels help improve the quality of care, reduce mortality rates and facilitate the creation of professional and efficient patient-clinician relationships.
Staffing ratio mandates are an essential part of the American healthcare system. To understand the essence of having a universal staffing ratio mandate, it would be crucial to consider the rationale for some of the global systems within the US such as the Patient protection and affordable care act. One of the reasons for the adoption of the Patient Protection and Affordable Care Act of 2010 was to ensure that there is a universal system that creates a visible pathway to a healthy American society.
With a comprehensive system, it becomes easy to set standards and enforce federal and state statutes. It, therefore, justifies the implementation of a staffing ratio mandate for all healthcare organizations to ensure that the services being provided in these healthcare facilities are within the required standards. A universal staffing system will be instrumental in reducing instances of medical errors, never and adverse events and promote healthy patient-clinician relationships as the members of staff have more time to spend with their patients.
While some states have already implemented these staffing ratios, some are yet to adopt them. Staffing ratio mandates provide legal standards which help govern compliance in medical facilities and promote the quality of healthcare. Staffing ratio mandates can also reduce the high staff turnover ratio by improving job satisfaction and division of labor.
Fiset, V. (2017). Evidence-based practice in clinical nursing education: A scoping review. Journal of Nursing Education, 56(9), 534-541.
Hall, L. H. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PloS One, 11(7), e0159015.
Health and safety code – HSC. (n.d). Web.
The importance of the optimal nurse-to-patient ratio. (2016). Web.
Kelley, J. M. (2014). The Influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials. PloS One, 9(4), e94207.
Lee, A. (2017). Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Annals of Intensive Care, 7, 46.
McHugh, M. D., & Ma, C. (2014). Wage, work environment, and staffing: Effects on nurse outcomes. Policy, Politics and Nursing Practices, 15(0), 72–80.
National campaign for safe RN-to-patient staffing ratios. (n.d). Web.
Schakowsky and Brown reintroduce the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act. (2017). Web.