Implementing nurse-to-patient ratios has recently gained renewed interest due to concerns about nurse understaffing, burnout, patient safety, and quality of care.

Research has shown that patient outcomes can suffer when too many patients are assigned to a single nurse.^[1]Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273–282. … Continue reading Overburdened nurses may struggle to provide adequate attention to each patient, leading to medication errors, delayed response times, poor patient outcomes, and increased rates of hospital-acquired conditions.

Advocates for nurse-to-patient ratios argue that mandating specific staffing ratios can help ensure patients receive the appropriate level of care and reduce the risk of adverse outcomes. By setting minimum staffing levels, nurses may have more time to devote to each patient, resulting in improved quality of care, better patient outcomes, and greater job satisfaction for nurses.

Critics of nurse-to-patient ratios argue that such mandates may be too rigid and fail to account for differences in patient acuity, nurse experience, and other factors that can impact staffing needs. They also suggest that such mandates may be costly and lead to staff shortages if healthcare facilities struggle to recruit and retain enough nurses to meet the mandated ratios.

We must consider all nursing care delivery puzzle pieces to develop practical solutions to staffing shortages. Failure to do so will undermine the effectiveness of efforts to address the nursing shortage, improve nurse staffing, and decrease burnout. We must ensure that we are advocating for all of the resources needed to provide safe and effective patient care.

There is more to staffing than patient care

Much of the nurse staffing crisis discussion focuses on the patient care element of nursing. What often gets overlooked in these discussions and the nursing literature is the importance of the non-patient care aspects of the nursing budget in supporting nursing care delivery.

Decades of applying lean methodologies to nursing operations to monitor and increase productivity have given us tunnel vision. This laser-like focus on patient care and maximizing productivity has neglected the importance of traditional non-productive tasks such as time off and education that enable us to provide patient care. The interplay between patient care, time off, and education heavily influences patient outcomes and quality, safety, and financial metrics.

Safe and effective patient care does not come from merely providing enough staff at the bedside. Overworked and burned-out staff due to understaffing and overtime are at risk of making errors. Adequate time off for bedside staff to rest and recharge is essential to nursing care delivery, the mental health of caregivers, and healthy work environments.

The increase in nursing turnover^[2]Nursing Solutions, Inc. (2022). 2022 NSI National Health Care Retention & RN Staffing … Continue reading has contributed to a significant decrease in nurse tenure at facilities.^[3]Johnston Thayer, Joe Zillmer, Neil Sandberg, Anna R. Miller, Paul Nagel, Alissa MacGibbon. (2022). ‘The New Nurse’ Is the New Normal. … Continue reading We must also consider that with the baby boomer nurses retiring, we will be losing “…more than 2 million years of nursing experience each year between 2020-2030.”^[4]Buerhaus, P. I. (2021). Current Nursing Shortages Could Have Long-Lasting Consequences: Time to Change Our Present Course. Nursing Economic$, 39(5), 247–250. … Continue reading Workforce competence is a critical factor in patient safety and positive patient outcomes. We must recognize the importance of education and orientation and how it supports nursing care delivery by maintaining and improving the competency of our workforce.

While implementing nurse-to-patient ratios may be a partial solution to understaffing, it could be a barrier to implementing acuity or workload-based staffing. Arbitrary numbers in nurse-to-patient ratios do not consider the complexity of care needs based on severity, intensity, acuity, and stability of conditions.^[5]American Nurses Association. (2020). ANA’s Principles for Nurse Staffing. Silver Spring, MD.

When designing solutions to our nurse staffing challenges, we must be careful not to select half-measures for expediency. We need a deeper, more holistic understanding of the mathematics of care delivery within the context of optimal resource allocation. We must advocate for all resources required for safe and effective care. This includes staff at the bedside, additional staff to provide adequate time off for employees to reduce burnout, and the resources needed to provide coverage for education and orientation to maintain and improve workforce competency. Mandating nurse-to-patient ratios without ensuring we also have the resources for time off and education will likely result in facilities that are still understaffed and cutting corners on time off and education while still relying heavily on overtime and travel RNs to meet the ratios.

The Challenges of Understaffing and the Nursing Shortage

The challenges of understaffing and the nursing shortage are daunting. The education pipeline is in shambles, with thousands of qualified students being turned away yearly.^[6]American Association of Colleges of Nursing, “Student Enrollment Surged in U.S. Schools of Nursing in 2020 Despite Challenges Presented by the Pandemic,” Press release, April 1, 2021, … Continue reading Current salaries are a deterrent to nurses becoming educators.^[7]McFadden, Keyt, and Fang, “Special Survey on Vacant Faculty Positions for Academic Year 2021-2022”; National League for Nursing, “Main Difficulty in Recruiting and Hiring Nursing … Continue reading We have a shortage of clinical placement sites, which are critical for training new nurses.^[8]Advisory Committee on Interdisciplinary, Community-Based Linkages, “Enhancing Community-Based Clinical Training Sites: Challenges and Opportunities” (Washington: 2018), available … Continue reading Nursing preceptors also suffer from inadequate training for precepting, heavy workloads, and non-competitive pay.^[9]Zhavoronkova, M., et al. (2022). “How To Ease the Nursing Shortage in America.” Retrieved 5/31/2022, 2022, from … Continue reading The loss of more than 2 million years of nursing experience each year between 2020-2030 represents an unprecedented loss of nursing experience in the workforce.^[10]Buerhaus, P. I. (2021). Current Nursing Shortages Could Have Long-Lasting Consequences: Time to Change Our Present Course. Nursing Economic$, 39(5), 247–250. … Continue reading High vacancy rates^[11]NSI Nursing Solutions, Inc. (2021). 2021 NSI National Health Care Retention & RN Staffing Report. … Continue reading are driving significant, chronic understaffing and contributing to unhealthy working environments that are putting frontline healthcare workers at high risk for burnout, moral injury, and other mental health conditions.^[12]Ulrich, B., Cassidy, L., Barden, C., Varn-Davis, N., & Delgado, S. A. (2022). National nurse work environments – October 2021: A status report. Critical Care Nurse, e1–e18. … Continue reading “More than 600 rural hospitals– nearly 30% of all rural hospitals in the country– are at risk of closing in the near future.” ^[13]CHQPR. (2023). Rural Hospitals at Risk of Closing. https://chqpr.org/downloads/Rural_Hospitals_at_Risk_of_Closing.pdf

Current efforts to address the nursing shortage appear to focus on inpatient acute care while neglecting a coherent strategy for the crumbling post-acute care industry, which is often unsuccessfully competing for the same nursing resources. A recent report revealed that 94% of nursing homes could not meet the proposed minimum staffing requirements for long-term care. Doing so would require up to $10 billion and hiring more than 187,000 nurses and nursing assistants.^[14]Staffing Mandate Analysis In-Depth Analysis on Minimum Nurse Staffing Levels and Local Impact. (2022). Clifton Larson Allen, LLP. … Continue reading

The nursing-as-a-cost reimbursement model for nursing services is a barrier to creating and funding the positions needed at the bedside. This outdated method for reimbursement fails to take into account the highly variable workload of patients, understates the actual cost of nursing care required, and inadequately represents the level of nursing care provided to patients.^[15]Welton, J. M., & Harris, K. (2007). Hospital billing and reimbursement: charging for inpatient nursing care. The Journal of Nursing Administration, 37(4), 164–166. … Continue reading

That’s a sampling of some of the top issues, but not all.

Healthcare at the Crossroads and Opportunities to “Think Different”

“We’re never going to survive unless we get a little crazy.”

– Seal

The above quote inspired the iconic Apple ad campaign for “Think Different.”

Looking at the numbers and efforts to address understaffing, we simply aren’t going to create enough RNs fast enough to fill our increasing needs nor find a surprise stash of nurses between the couch cushions that we can put back at the bedside.

We need more caregivers (people) – not just RNs – at the bedside. That means different models of care, team-based interventions, and better workflows.

We must ensure that we have an accurate estimate of the resources needed to meet our budget assumptions for patient care, time off, and education. We can do this by utilizing care-centric modeling and using the correct formulas in our FTE budget calculations.

We should explore value-based reimbursement models for nursing care to create and fund the positions needed to provide the desired levels of patient care.

We must address our crumbling educational pipeline and develop creative tools, technology, strategies, and programs to educate and train nurses and other bedside caregivers.

We also need technology that acts as a force multiplier, not a hindrance. Utilizing virtual nursing for patient education, admissions, discharges, and telesitting can be valuable tools to enhance our ability to deliver safe and effective care.

We should leverage the expertise of informatics nurses with their deep understanding of the data, processes, and systems around nursing care delivery.

Nursing and healthcare are at a crossroads.

Decisions made now will determine whether and to what extent we can successfully solve the many problems we must tackle to stabilize nursing and position it for the growth needed to replenish the system. Many of the approaches used in the past to address staffing and burnout issues are faltering under the number and size of the problems impacting our workforce. When developing workforce strategies, we must comprehensively assess the entire healthcare system, not just acute care. We must seek out bold, innovative, and possibly crazy ideas that can inform us of the capacity of our workforce to provide safe and effective care, act as force multipliers to enhance the ability of nurses to care for patients, and leverage technology that can improve the knowledge and skills of caregivers and decrease their workload.

We should listen carefully when someone says they have a crazy idea, as it may be what we’ve been looking for.

In Conclusion…

Nurse-to-patient ratios are a popular solution proposed to address nurse understaffing and improve patient outcomes. However, they are an incomplete solution that fails to account for other factors in nursing care delivery that impact staffing needs. Healthcare facilities must advocate for all resources needed to provide safe and effective care. Safe and effective patient care requires not only adequate staff at the bedside but also resources for time off and education. Moreover, the nursing shortage is a complex and multifaceted problem that requires a comprehensive strategy to address the issues. Neglecting a coherent strategy for post-acute care and other critical factors contributing to the nursing shortage may lead to further problems and adverse outcomes. It is crucial to consider all the puzzle pieces of nursing care delivery to develop practical and effective solutions that promote patient safety and positive patient outcomes, improve job satisfaction and working environments for nurses, and decrease burnout.