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Benefits versus Detriments of Mandated Nursing Staff Ratios

Kathryn S. Crim

James Madison University

462: Issues in Contemporary Nursing Practice

Dr. Hui Zhao

November 7, 2021
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Abstract

Mandated nursing ratios is an allocated number of patients per nurse that varies depending on the

specific unit. Mandated nurse-patient ratios are not federally implemented; however, some states

have made legislative laws within the past several years (Pearce et al., 2018). There is lack of

adequate research to identify specific staff numbers and appropriate ratios, a barrier to mandating

ratios (Pearce et al., 2018). The utilization of mandated nurse ratios has the benefit to allow

nursing staff to have the adequate support and time to provide high quality care. However, on the

contrary, it requires an adequate number of financial resources, as well as finding additional

staffing. The following paper will address the process of determining nurse-patient assignments,

the benefits, and detriments of implementing mandated nurse-patient ratios, and a personal

reflection from a novice nurse.

Keywords: nursing, nurse-patient ratio, staffing ratio, mandated ratios

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Benefits versus Detriments of Mandated Nursing Staff Ratios

Nursing staff ratios has been a topic of interest for many years, some comparing ratios of

healthcare professionals to ratios of childcare workers. Despite, the ongoing discussion, research

and comparison, no actual legal standards have been set in place to determine what constitutes as

safe nurse-patient ratios. As the healthcare systems continues to expect high standards from

nursing staff, the concern regarding safe patient ratios remains a top priority. As the nurse,

patient safety, providing quality care, and ensuring your license as a healthcare professional is

not jeopardized are high on the list of daily concerns. There are multitude of factors to take into

consideration; staffing numbers, nurse workload, skill level, and patient acuity, all of which

contribute to whether an assignment is manageable, safe and/or appropriate. Mandated nurse-

patient ratios have the potential to be asset to the nursing profession but can also inflict burden

upon the profession, taking into consideration the benefits (patient safety, job satisfaction,

quality care) and outweighing them against the nationwide nurse shortage and financial burden.

Nursing Staff Ratios

Nurse-patient ratios do not remain constant, it varies based on staffing needs, patient

needs, number of admissions and number of discharges (Saville et al., 2019). There are currently

no federal regulations regarding nurse ratios, which often leaves nurses unable to provide

adequate patient care. Charge nurses are equipped with experience and expertise in determining

nurse-patient ratios for their individual unit. Factors to be considered when determining

appropriate ratios include adequate staff, nurse experience, nurse skill level, nurse qualifications,

competency, physical demand/workload, and patient acuity (Choi & Miller, 2018). While

nursing assignments are done on a unit level, administration/management are involved in the

number of allocated staff available. According to Olley et al., (2019) staffing models are done
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based on an average number of nurses over a given time frame with fluctuating temporary staff

to cover any gaps, allowing the possibility for sudden understaffing and higher nurse-patient

ratio, ultimately affecting patient outcomes. The American Nursing Association (ANA) Staffing

principles supports that a single conventional staffing model does not fit all units, the

involvement in direct clinical care nurses should be a central component when determining

assignments (Pearce et al., 2018). The importance of assignments remains relevant to positive

patient outcomes, not just considering the number ratio, but also incorporating bedside nurses,

patient data, illness, and the physical demand (Olley et al., 2019).

Mandated Ratios

Benefits

Over the years, some states have passed legislative laws with nurse-patient ratios;

however, no movement has been made towards federal laws (Pearce et al., 2018). The population

is rapidly becoming more ill due to increasing co-morbidities, complex medication treatments,

lack of health coverage, increasing pharmaceutical costs, and progressive health disparities

(Pearce et al., 2018). Mandated nursing ratios have the benefit to allow nurses to establish a solid

relationship with their patient which increases medication compliance, adherence to treatment

plan, encourages open communication – all elements of positive patient outcomes (Pearce et al.,

2018). When ratios are high, elements of patient care go omitted or delayed, leading to near

misses or possible sentinel event, a situation that was unintentional and could have been avoided

(Saville et al., 2019). Adequate nursing staffing is regarded highly towards job satisfaction, nurse

retention, positive work environments, and quality patient care (Choi & Miller, 2018). Mandated

ratios come with a whole set of challenges, as it has its unique factors to be considered (unit
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based, nurse skill level, workload, acuity, etc), this is likely a reason why mandating has not

occurred.

Detriments

The benefits of mandated ratios seem appealing; however, there are detriments to

consider. When considering decreasing nurse-patient ratios, it would require obtaining more

nurses to cover the patient load. When increasing nursing staff, it is only necessary to pull

staffing from another area to offset the financial demands (Olley et al., 2019). The number of

registered nurses will increase, but the number of unlicensed personal (nursing assistants),

housekeepers, maintenance, and transporters will decrease leaving nurses with increased

workload (Olley et al., 2019). Hospitals rely on reimbursements to pay salaries, when acquiring

additional nurses, the costs increase for the hospital while no increase in reimbursement occurs

(Olley et al., 2019). For a healthcare system and/or government to support mandated ratios, a

positive financial trend would be needed. Most models for hospital staffing are financially

driven, increasing hospitals are losing funding, which is also affecting staffing numbers, making

adhering to mandated ratios difficult (Olley et al., 2019). A solution for many hospitals is to

obtain external staff, while this may seem like a solution, there has been concerns regarding

patient safety with nurses who are not employed directly through the healthcare system and

familiar with hospital policy (Olley et al., 2019). Finances appears to be the biggest detriment to

mandated ratios, as well as consideration between differentiating states requirements, state laws

and hospitals population/demands.

Personal Perspective

The last year and half of being a novice nurse during a worldwide health crisis has

brought about so many emotions, thoughts, and ideas. The number of patients in the hospital
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increased and the number of nurses decreased, leaving the nurses that remained with high patient

ratios and even higher patient acuity. Mandated ratios could have been useful to have during the

past year – allowing nurses to be able to spend more quality time with patients who near end of

life, being able to connect more with families who aren’t allowed in the hospital and helping

decrease the emotional/physical exhaustion that has overcome the profession. While I support

mandated ratios for the sake of patient care, I do believe that there are downfalls such as

finances, nurse shortage, and the inconsistencies between state policies. Mandated ratios are

multifactorial which is why it hasn’t made federal regulations. In the interim, it is possible that

nurses could partner together to care for a team of patients. For example, two nurses to nine

patients; allowing two nurses to share the workload, integrate critical thinking and combine skill

level. Another option that could be useful is allowing licensed practical nurses to be employed

and assist the registered nurse with medication passes, opening more time for the RN to assess,

provide education and be more involved in the interdisciplinary rounding/care plan.

Conclusion

Mandated nurse ratios have the potential to change the nurse profession; however, there

are positives and negatives. On the positive side, nurses would have the opportunity to provide

high quality, safe patient care, increase communication, develop strong nurse-patient

relationships and be more involved in interdisciplinary collaboration. On the opposite side, the

profession would likely suffer even greater financial hardship by acquiring more nursing staff, as

well as depleting other essential departments to have the funds to obtain nursing staff. States

across the nation all have their own polices which make mandated ratios difficult. Nursing ratios

have been a highly researched topic for years and will continue, as there as numerous barriers

and inconsistencies.
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References

Choi, J., & Miller, P. (2018). Registered nurse perception of patient assignment linking to

working conditions and outcomes. Journal of Nursing Scholarship, 50(5), 530–539.

https://doi.org/10.1111/jnu.12418

Olley, R., Edwards, I., Avery, M., & Cooper, H. (2019). Systematic review of the evidence

related to mandated nurse staffing ratios in acute hospitals. Australian Health

Review, 43(3), 288–293. https://doi.org/10.1071/AH16252

Pearce, P., Morgan, S., Matthews, J., Martin, D., Ross, S., Rochin, E., & Welton., J. (2018). The

value of nurse staffing: ANA principles redevelopment and direction for the future.

Nursing Economics, 36(4), 169-176.

Saville, C., Monks, T., Griffiths, P., & Ball, J. E. (2021). Costs and consequences of using

average demand to plan baseline nurse staffing levels: a computer simulation study. BMJ

Quality & Safety, 30(1), 7–16. https://doi.org/10.1136/bmjqs-2019-010569