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Safety Concern: Unsafe Nursing Ratios


Solutions such as newly required nurse-led staffing committees aim to end unsafe nursing ratios that compromise patient safety. At a recent conference, a group of nurse leaders came up with this catch phrase, "You cannot fix it with a pizza day." "It's one of my favorite expressions now because it's just so apt for the way nurses are feeling," said Cindy Bacon, PhD, RN, CNE, NE-BC, Associate Professor and Program Director of MSN Programs at the University of North Carolina Greensboro School of Nursing. The consensus was that free lunches aren't going to cut it anymore. Nurses want a manageable workload with adequate staffing, among other things. "Nurses are taking on more patients and more responsibilities. And they're to the point where -- after two years of COVID -- staffing just continues to deteriorate. They just aren't doing it anymore," said Bacon.

Mandated ratios in just one state

Nearly one-third of nurses said they're considering leaving their direct patient care role, a recent McKinsey study found. The biggest factor driving this decision? Insufficient staffing levels and concerns over unsafe nursing ratios. In fact, the 2022 Nurse Salary Research Report by found that the pandemic led to a precipitous increase in the number of nurses considering leaving the profession. Currently, no federal mandates regulate the number of patients a registered nurse cares for. If passed, the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act would require hospitals to set mandated minimum nurse-to-patient staffing ratios. "Presently, exact ratios are disputed," said Allison A. Norful, PhD, RN, ANP-BC, FAAN, Assistant Professor at Columbia University School of Nursing in New York. Ratios are driven by state-based legislation and in most states are determined by the severity of the patient's condition. California remains the only state with mandated nurse-to-patient staffing ratios, which have been in effect for years. Hospitals were allowed to adjust their ratios because the pandemic put such strain on the nursing workforce. "So while institutions aren't getting slapped on the hand right now, they certainly are having a difficult time adhering to the ratios," said Anita Girard, DNP, RN, President of American Nurses Association - California. Hospitals counter that mandated ratios would fiscally strain organizations. Yet one study found that cost savings (due to fewer admissions and shorter length of stay) were more than double the cost of additional nurse staffing. Another study found that on medical/surgical units, the odds of 30-day mortality increased by 16% for each additional patient added to a nurse's workload. A growing number of states are passing safe staffing laws, with requirements such as nurse-led staffing committees. "Even in those states, nurses are still being overworked," said Jason Ritchie, Associate Director of State Advocacy in ANA's Government Affairs department. You may not even get time to eat or use the restroom during your shift. Then at the end of a shift, you might be required to stay for mandatory overtime. "That's what we've been hearing from nurses over and over," said Ritchie.

'Five nurses away from total chaos'

Nurses are dealing with unsafe patient loads while confronting increasing violence. Some are choosing to leave the profession altogether. "We're left with a revolving door -- we're hemorrhaging nurses. Nurse leaders say that they're five nurses away from total chaos," Bacon said. "And that is very distressing." Though unsafe nurse staffing is now reaching crisis proportions, it's a long-standing problem. "Nurse staffing and workforce projections have been a concern for many years," Girard said. An aging Baby Boomer population and more people suffering from chronic conditions are exacerbating the situation. There could be a shortage of between 200,000 and 450,000 nurses by 2025, according to a May 2022 McKinsey & Company report. This equates to a 10% to 20% gap. Unsafe nurse staffing levels cause the following problems, according to Norful:

  • At the organizational level: an increase in medication errors, increased likelihood of patient deaths; longer hospital stays; and avoidable falls, infection, and injuries
  • For individual nurses: increased burnout, absenteeism, and workforce turnover

"Poor nurse-patient staffing ratios compromise not only patient care but also the health of nurses," warns Norful.

Line item during budget cuts

In most cases, nurses cannot directly bill for their services. "The lack of direct reimbursement for nursing care hinders the ability to understand the organizational value of hiring more nurses," said Norful. Nursing positions are often among the first budget cuts, which could result in unsafe nurse-patient ratios. "There is a great need to explore care delivery models and payment mechanisms that are better aligned with the current landscape of our healthcare system," Norful said. Some financially strapped hospitals are cutting nursing staff to unsafe levels. Nursing staff is the most expensive portion of the hospital's labor budget. "Nurses are treated differently than physicians. If you don't pay nurses enough and you treat them as a line item in the budget, that's going to come back with a shortage," Ritchie said. Hospital leaders have to cut costs somewhere. All too often, cutting nursing staff can be seen as a solution to budget cuts. "It's frustrating, because we've got all this data that shows how important it is to have the appropriate workloads for nurses to improve quality and safety -- but it keeps being cut," Bacon said.

Lobby to change unsafe nursing ratios

An important first step is to know your state laws pertaining to nursing staffing. "Lots of nurses don't even realize that they live in a state that requires staffing committees, where front-line nurses set staffing standards for units," said Ritchie. If your state does, you can volunteer to serve on those committees. If not, you don't need to wait for policymakers to pass safe staffing legislation. You can advocate for the creation of nurse-led staffing committees. "Use your voice as a nurse, so you have an impact on the decisions that your hospital is making," Ritchie urged. Sharing your voice on what matters most is key to driving your career and the nursing profession forward. For information and insights from other practicing nurses, download and review the 2022 Nurse Salary Research Report.