Nurse-to-Patient Ratios for Patient Safety and Quality Care

For the 19th year in a row, registered nurses (RNs) were named the nation’s most honest and ethical profession. Their presence on floors can bring confidence and comfort, and when there aren't enough of them to adequately care for every patient in a hospital unit, everyone is disadvantaged—patients, nurses, physicians, and the hospital itself.

As a result, nurse-to-patient ratios play a large part in patient safety and quality care. We explore the complexities of setting minimum nurse staffing standards for safety.

Nurse staffing is under the umbrella of workforce management in hospitals, health systems, and other care settings. Because nurses compose the largest provider group that spends the most time in patient-facing roles, nurse staffing must take into consideration many factors. Arguably the most crucial element is a limit on the number of patients a nurse can care for at once, known as the nurse-to-patient ratio. 

Unfortunately, applying a ratio doesn’t automatically produce a safe environment, so acuity-based systems are used to produce staffing patterns based on patients’ conditions and severity (i.e., if a set of patients requires more nursing care, more nurses are added). In addition, there’s growing awareness of the benefits of matching nurses’ skills and competencies to patients' needs. 

Ratios and downstream staffing effects

Nurses are pulled in multiple directions to administer medications, round, and conduct vital sign checks, not to mention answering call buttons, responding to codes, and other tasks. As a result, setting patient limits that account for acuity and other factors makes sense to uphold safety and care quality.

There are downstream effects of failing to staff your nurse workforce to the needs of the patients and to the specific skills of the nurses. In fact, when nurses don’t perform necessary care, it's called "missed nursing care" and it can lead to serious negative outcomes for patients ranging from increased falls to medication errors and pressure ulcers. 

On the other hand, evidence suggests that units with optimal staffing have fewer instances of missed care and incidents. One study concluded that "nurses in inpatient pediatric care settings who care for fewer patients each and practice in a professionally supportive work environment miss care less often, increasing quality of patient care."

Determining safe patient ratios

While staffing sounds like a relatively straightforward concept, determining and maintaining the best nurse-to-patient ratios is challenging. To begin, there are no federal regulations for nurse-to-patient ratios, and just two states have laws that explicitly mandate specific ratios, according to the American Nurses Association:

  • California has set ratios that vary by care setting and patient acuity, but generally range from 1:1 for the operating room and trauma patients in the emergency department to 1:6 for postpartum women and psychiatric patients. Mandated ratios apply even during breaks and meals times.
  • In Massachusetts, a mandated ratio applies only to intensive care units and requires a 1:1 or 1:2 nurse-to-patient ratio depending on a patient's stability.

In addition, ensuring appropriate nurse-to-patient ratios is difficult because it's not easy to predict the hospital census and patient acuity from day to day or even shift to shift. That's why many healthcare organizations use workforce management technology and tools that help leaders make real-time staffing decisions with safety and quality in mind.

As a result of nonexistent federal laws, sparse state laws, and a general lack of hard and fast rules around patient ratios, it's up to hospitals and other healthcare organizations to use evidence-based guidelines to ensure safe patient ratios that take into account factors like the type of unit, the care setting, nurses’ skills sets, and patient acuity.

Fortunately, healthcare organizations aren’t alone in trying to calculate the right patient staffing ratios. The American Association of Critical Care Nurses (AACN), for example, publishes six essential standards that offer evidence-based guidelines for success for patients and nurses, including one on staffing. “[Appropriate staffing] affects everything in your unit, including nurse performance and retention, quality of care, patient outcomes, and hospital costs,” according to the AACN. It adds that staffing must ensure the effective match between patient needs and nurse competencies.

AACN’s staffing guidance includes the following elements:

  1. Ensure staffing policies are grounded in ethical principles and support nurses’ professional obligation to provide high-quality care.
  2. Formally evaluate the effect of staffing decisions on patient and system outcomes, including the analysis of patient needs versus nurse competencies.
  3. Facilitate team members’ use of staffing and outcomes data to develop more effective staffing models.
  4. Offer support services to ensure nurses can optimally focus on the priorities and requirements of patient and family care.
  5. Use technologies that increase the effectiveness of nursing care delivery, and include nurses in selecting, evaluating, and adapting these tools.

Why it's important to follow nurse-to-patient ratios

Beyond the direct effects that nurse-to-patient ratios have on patient care quality, they can also:

  • Affect the satisfaction and productivity of nurses and all clinicians
  • Alter patient satisfaction, patient experience, and the market perception of the care the organization provides
  • Affect the bottom line (e.g., avoid over- or under-staffing and preventable overtime)
Clinical outcomes 

As noted, inadequate nurse-to-patient ratios are linked to negative outcomes aside from those stemming from missed nursing care. For example, a systematic review and meta-analysis of 35 articles found a major link between nurse staffing levels and nurse-sensitive patient outcomes in acute specialist units, especially in-hospital mortality.

The analysis also found that "higher staffing levels were associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use, and a greater number of patients receiving percutaneous coronary intervention within 90 minutes."

Patient satisfaction

Nurse-patient ratios can also impact patient satisfaction, with one study showing that just 14% of patients who reported that there were never or rarely enough nurses on the hospital ward rated their care as excellent. That's compared to 57% of patients who reported that there were usually enough nurses and rated their care as excellent.

Such patient feedback is expected. Nurses who are struggling to care for too many patients not only might neglect mission-critical tasks, but also won't be able to perform other "soft" nursing duties like providing patient education or even just talking with patients who are feeling confused or afraid.

Nurse safety and satisfaction

Maintaining safe nurse-to-patient ratios helps nurses, too. The pandemic has made the long-simmering problem of nurse burnout worse. Having unsafe nurse patient ratios on top of that undoubtedly leads to increased feelings of exhaustion, stress, hopelessness, and turnover. There's research to back up this premise, too. High nurse-to-patient ratios have been linked to burnout, job dissatisfaction, higher turnover, and even feelings of betrayal toward their employer.

There's evidence that adequate staffing and appropriate nurse-to-patient ratios can keep nurses physically safer, too. One study found that the California nurse staffing law was associated with 55.6 fewer occupational injuries and illnesses per 10,000 RNs per year, which was about 31.6% lower than the expected rate without the law. For that state’s hospitals, this adds up to shorter lengths of stay, lower readmissions, and reduced nurse turnover, among other advantages.

Finally, workforce management software gives nurse managers and staff advanced mobile technology tools to self-serve for collaborative staffing, self-scheduling, shift trading, and open-shift management. Software makes it simpler to factor in necessary checks and balances—such as ensuring nurses get enough time off between shifts and allowing them to take adequate breaks during their shifts. 

Are federal staffing mandates on the way?

Although there are no federal nurse-to-patient ratio requirements today, that could change if the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2021 becomes law. Citing research showing the success of the California nurse ratio law, as well as other evidence of improved outcomes, the proposed legislation would require hospital staffing plans to stick to set nurse-to-patient ratios that largely echo the ones recommended by National Nurses United.

Visibility into staffing trends 

Rather than waiting for a mandate and scrambling to comply, hospitals, health systems, and other healthcare organizations should take steps now to maintain appropriate nurse-to-patient ratios. Using workforce management technology to do so makes it easier and more efficient to determine appropriate nurse-to-patient ratios while keeping nurses happier and patients safer.

There are several key elements to workforce management technology that make it ideal for managing nurse-to-patient ratios both before and even during nursing shifts. 

  1. First, these tools allow leaders and shift supervisors to see real-time census data and make staffing decisions based on which patients are actually in the hospital, rather than based on predictions and historical data.
  2. Second, these tools give managers insight into patient acuity, which is crucial for instances when nurse-to-patient ratios need to be adjusted based on the patient's stability. A good example of this is in the ICU. Industry recommendations and Massachusetts law say the nurse-patient ratio should be 1:2 or 1:1, depending on the patient's condition.
  3. Third, workforce management technology tools can help enable an enterprise-wide—rather than a unit-based or siloed—approach to staffing. This allows leaders to gain a holistic view of everyone who is available to work within the entire institution, rather than just a single unit. Workforce management technology tools can go a step beyond simply looking at open schedule spots and match nurses with scenarios and patients that match their education, training, certifications, specialties, and scope of practice.
  4. Finally, an enterprise-wide approach to staffing helps managers avoid using costly staffing agencies or having too many disparate float pools throughout the hospital, which is especially relevant since many hospitals in California created float pools and have used travel and staffing agencies to deal specifically with nurse-to-patient ratio requirements.

While establishing and maintaining safe staffing and appropriate nurse-to-patient ratios isn’t always easy, it's an important step for hospitals, health systems, and other healthcare organizations to take, especially in the era of COVID-19 and increased nurse burnout. Luckily, workforce management technology tools can ease those efforts and take the guesswork out of ensuring that every shift in every unit is properly staffed.

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