Mandated Staffing Ratios

Statement of the Issue
The American Organization of Nurse Executives (AONE) recognizes the need for adequate nurse-staffing levels to ensure the quality of patient care delivered in hospitals and health systems throughout our nation.  The number of patients for which a nurse can provide safe, competent and quality care is dependent upon multiple factors.  Studies have concluded that nurse-staffing levels are a critical determinant of patient outcomes, patient satisfaction, and nurse satisfaction.  Recent research found a significant relationship between nurse-staffing ratios and preventable patient deaths (Aiken, et al. 2002).  However, the researchers concluded, the "results do not directly indicate how many nurses are needed to care for patients or whether there is some maximum ratio of patients per nurse above which hospitals should not venture."  (Aiken, et al., 2002, p.1990).  It is the view of Dr. Peter Buerhaus, the Valerie Potter Professor of Nursing and Senior Associate Dean for Research at Vanderbilt University School of Nursing, and a leading researcher who has studied the relationship between nurse staffing and patient outcomes, that legislation to mandate fixed ratios carries a high potential of leading to the economic and political devaluation of the nursing profession and fails to effectively deal with the issues surrounding nurse staffing.

Proponents for mandatory staffing ratios argue that ratios will not only improve the quality of patient care, but also will improve both patient and nurse satisfaction, thus improving the nursing work environment.  This improvement in the work environment will subsequently attract both new nurses and those licensed nurses not currently working in nursing.  Critics of staffing ratios claim that mandating specific staffing ratios in an environment already experiencing a shortage of nurses will lead to a reduction in hospital services, increased emergency room diversions, increased unit closures, and increased expenses as hospitals pay additional labor costs for overtime and temporary agency nurses.

The appropriate staff mix remains a tremendous concern as hospitals and health systems look to balance costs.  Because most state nurse practice acts require the registered nurse to effectively supervise the nursing care delegated to subordinates, greater responsibility and workplace stress will be placed upon the registered nurse. Many professionals in the field fear that arbitrarily developed staffing ratios will be inappropriately interpreted as the maximum nurse ratio level.  The consequences of inappropriate staffing ratios could have a direct impact on patient safety, nurse satisfaction, and contribute to the further deterioration of the work environment.

Policy Position
AONE, as the voice of nurses who are leaders or who aspire to leadership roles in healthcare, approaches this issue from the perspective of the employer and in the context of our social contract with the community.  From this perspective, AONE members are responsible for managing patient care and assuring that every patient is cared for in an environment that is focused on quality and safety.  Because staffing is a complex issue composed of multiple variables, mandated staffing ratios, which imply a "one size fits all" approach, cannot guarantee that the healthcare environment is safe or that the quality level will be sufficient to prevent adverse patient outcomes.  It is for this reason that AONE does not support mandated nurse staffing ratios.

Furthermore, it is the position of AONE that mandatory nurse staffing ratios will only serve to increase stress on a health care system that is overburdened by an escalating national and international shortage of registered professional nurses and has the potential to create a greater risk to public safety.  Research has shown that professional nurse staffing is a critical component of quality patient care, decreased patient mortality and morbidity.  Mandatory nurse staffing ratios based solely on an arbitrary equation of nurses to patients are viewed as ineffective, inefficient and potentially harmful to patients.

It is the position of AONE that patient care staffing is a management decision based on a complex set of variables under the purview of the registered professional nurse manager.  Nurses functioning as managers must have the flexibility to determine the appropriate level of nurse staffing for patient care needs while considering a constellation of important variables, including the various education and experience levels of the staff, the number of staff in orientation, the number of temporary staff on the unit, the acuity of patients, the particular shift, the physical layout of the unit, the availability of hospital resources, the technology on the unit, and the unit volatility (such as the number of admissions, discharges, and transfers).  Because of the unpredictability of the patient care environment, mandatory staffing ratios are viewed by AONE, as a static and ineffective tool with which to address the demands and constant fluctuations of patient care and nursing care needs.

AONE strongly supports research to identify the components of appropriate levels of nurse staffing.  Hospitals and other health care institutions should look to evidenced-based and outcomes-driven research that includes patient acuity in the development of staffing guidelines.  Institutions should also consider the entire ethical spectrum of the ratio debate and the potential consequences of the growing nursing shortage and the inability to meet or maintain mandated staffing levels.

Aiken L., Clarke S., Sloane D., Sochalski J., Silber, J.  2002.  “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction.”  Journal of the American Medical Association 288: 1987-1993).

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