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Running head: MANDATORY RATIOS 1

Mandatory Staffing Ratios for Professional Registered Nurses

Darcy S. Thompson

James Madison University



Favorable outcomes in patient care have been shown to be directly linked to nurse/patient

ratios that support safe delivery of care, in conjunction with high-quality practices. Who

determines these ratios and why there isnt a standardized, universal practice with regards to

mandated ratios is still a perpetuating question, one that is being challenged within the profession

on many levels in hopes that changes in practice will eventually lead to mandatory staffing ratios

in all patient care settings. Mandatory staffing ratios are being discussed at all levels within

hospital administration alongside managers and staff nurses and the overwhelming question from

many professional nurses, why isnt this universal, standardized practice? Because of this, many

hospitals are now examining a more dynamic staffing approach based in large part on the

complexity of the patient focusing on improving safety and ensuring that patient outcomes

remain a top priority.


Mandatory Staffing Ratios for Professional Registered Nurses


We deliver high quality care has become the slogan for professional registered nurses,

and a top priority in healthcare systems nationwide. Achieving these goals has been shown to be

directly linked to nurse/patient ratios and favorable outcomes in patient care. Safe delivery of

care results when high-quality practices are applied in conjunction with appropriate, qualified

staffing ratios within a hospital setting (Cho, Lee, & Kim, 2016). Therefore, developing

appropriate nurse/patient care ratios is essential to optimize the delivery of quality based care and

the achievement of ideal patient outcomes. However, it is paramount to understand that many

factors must be considered beyond the seemingly simple numeric ratios because of their effect

and influence in how nurse staffing needs are created and patterns are implemented.

Unfortunately, continually rising healthcare costs have become the primary focus in this

era of value-based healthcare. These costs, along with many other factors, have prompted the

attention and close scrutiny that has compelled healthcare systems to acknowledge the need to

address staffing ratios within our healthcare system to seek a more financial responsive

alternative. The top priority still remains the ability to deliver high quality care while reducing

the overall cost simultaneously. The technology that the twenty-first century affords our industry

should easily bridge any gaps between high quality care and safety, because undeniably, safely is

a fundamental component of high quality care (Committee on the Quality of Health Care in

America, 2001). More now than ever, many if not most individuals today have access to

healthcare, since The Affordable Care Act was passed in 2010 and this has caused the need to

improve the quality of care while reducing cost long-term and work on goals for the reform of

healthcare in the United States (Cho, Lee, & Kim, 2016). Several models have created

reimbursement initiatives aimed to improve quality while reducing the overall cost of


What is most crucial and paramount to this restructuring is the emphasis on value-based

healthcare. Many programs look to incentivize or penalize hospitals based on their ability to

meet certain quality initiatives, outcomes, while at the same time, finding creative cost reducing

metrics. This has forced hospitals to explore alternative practices which will improve quality and

patient outcomes while simultaneously containing costs. Since work force of nurses is often

among the largest clinical subgroup within hospitals, and a common response to this pressure is

an attempt to cut cost by reducing the number of necessary professional nurse or licensed hours

and their associated costs. As a whole, the nursing profession views this as a very shortsighted

policy; optimal staffing has been consistently documented to be key in providing professional

nursing value.

Examination of current staffing models within hospitals that do not have structured

nurse/patient ratios reveal that these models are often thought to be outdated and inflexible. In

light of research, greater benefit could be gained from utilizing staffing models that consider the

number of nurses and/or the nurse-to-patient ratios and then are adjusted accordingly to account

for the actual patient population and their specific needs as well as the demographic of the staff

makeup for a particular shift. Published studies show that appropriate staffing helps achieve the

clinical outcomes the profession strives for such as higher scores for overall patient satisfaction,

exceptional delivery of care and reduced medication errors, just to name a few. By promoting

nursing safety through these redefined staffing matrixes, nurse retention and overall job

satisfaction could dramatically increase as well. And conversely, as stated by Cho, Lee and Kim

in their research from 2016, those events which indirectly contribute to safer patient care

experiences and could certainly promote a lower level of patient mortality, hospital

readmissions, length of stay, and preventable events such as patient falls, pressure ulcers, central

line infections, healthcare-associated infections, and other complications that are often associated

with hospitalization.

Alternative Viewpoints

To date, California is the only state that has adopted the mandated nurse-patient ratio

practice model; however, several states continue to deliberate this type of legislation. Many

nurses are encouraged that the discussion and debate have moved more towards a shared

dialogue surrounding this topic and that both administration and business sectors as well as the

working professional nurses realize that they are equally important stakeholders in this matter.

The relationship between inadequate staffing ratios and negative patient outcomes within

hospital settings has been well documented (Louch, O'Hara, Jame, Gardner, Pater, & O'Connor,

Daryl, 2016). When asked, many nurses felt that they did not have enough time to spend with

patients to deliver appropriate, compassionate care in a safe and dignified manner (Gillen, 2012).

Adequate staffing is undoubtedly a necessary element in delivering safe and effective

care, and yet surprisingly, not all nurses are in favor of this approach. Some nurses object to the

approach that one-size-fits-all, not because they are advocating for units to be understaffed, but

because they are against the rigidity of such practice. While these dissenters agree, there are

issues that need immediate remediation, including the execution of higher patient safety margins

and quality of care, as well as addressing the workforce burnout and dissatisfaction felt among

many overtaxed nurses, they tend to disagree that these are completely contingent upon staffing

ratios and the regulation of such measures (American Sentinel University, 2015).

The crux of this argument truly stems from understanding that there is no magic formula

or equation to ensure absolute safety and quality when it comes to staffing ratios. It is, however,

imperative to understand that many factors influence nurse staffing needs including but not

limited to patient stability versus instability; the number of admissions and/or discharges

assigned to the unit, as well as transfers into and out of a particular unit; the skill levels of the

additional staff in the unit and their combined expertise alongside the registered nurse; even the

physical space and layout of the nursing unit needs to be taken into consideration as this can

determine the need for change in the way staffing patterns are created and implemented.

Determining how many patients a nurse can safely manage while still provide high-

quality care really must be based on several factors and cannot be seen as a hard and fast rule.

When specific ratios are mandated by law, hospitals often find there are many issues that can

complicate their compliance. For example, if a unit has a staffing majority of nurses that are

novice, and are by definition, inexperienced nurses, would this be considered a violation when

the majority of the patients have many chronic conditions and could arguably be considered

unstable? Or how does this ratio factor the change in a patients condition unexpectedly? And

how should meal breaks be granted if taking one would cause the staffing ratio to fall below the

allotted levels of necessary personnel to safely run the unit (American Sentinel University,

2015)? Some hospital administrations believe the totality of the environment is more critical to

the quality of nursing care than any one element, including staffing. Linda Aiken concluded in

her 2011 study that adding more nurses to a unit markedly improves patient outcomes in

hospitals with good work environments, slightly improves them in hospitals with average

working environments, and has no effect in hospitals with poor environments.


Because of this, many hospitals are now examining a more dynamic staffing approach

based in large part on the complexity of the patient. A model like this allows for what really

matters: the right number of patient-care hours provided by nurses with the appropriate skill level

for a given situation. It is understood that this is a very fluid equation that should be modified

over the course of a shift when deemed appropriate.

One theme remains consistent as this discussion continues and that is there is a direct

correlation between poor staffing conditions and less than optimal outcomes for patients, and

mandatory staffing ratios could help make turn those statistics more positive. (Louch, O'Hara,

Jame, Gardner, Pater, & O'Connor, Daryl, 2016) Mandated staffing ratios must make improving

safety and patient outcomes its top priority.



American Sentinel University. (2015, January 28). The Sentinel Watch: Nursing. Retrieved from


Cho, E., Lee, N.-J., & Kim, E.-Y. (2016). Nurse staffing level and overtime associated with

patient safety, quality of care and care left undone in hospitals. International Journal of

Nursing Studies, (30) 263-271.

(2001). Committee on the Quality of Health Care in America.

Gillen, S. (2012, April 25). Most nurses are struggling with inadequate staffing, survey shows.

Nursing Standard.(26) 34. 9-10

Louch, G., O'Hara, Jame, Gardner, Pater, & O'Connor, Daryl. (2016). The daily relationships

between staffing, safety perceptions and personality in hispital nursing: A longitudinal

on-line diary study. International Journal of Nursing Studies. (59) 27-37.