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Optimal staffing for safe patient care: What will it take?


Optimal staffing for safe patient care continues to be a top concern of the nation’s 2.8 million employed registered nurses (RNs), 58% of whom work in acute care settings. Although there is a growing body of research supporting the relationship between appropriate staffing and clinical outcomes, shrinking financial resources and increased demand for services have created significant challenges to achieving this goal.


One challenge to finding a permanent and long-lasting solution to staffing issues is the rapidly changing healthcare environment. Over the past 2 decades, the average length of stay in hospitals across the nation has decreased from 7.0 days to 5.4 days. This has resulted in more frequent admissions and discharges, with a corresponding increase in nurses’ workload.

Other factors include anticipated changes in U.S. demographics in the coming decades. The aging of America’s citizens will result in greater need for healthcare services, which will occur in conjunction with the aging of the nursing workforce. Together, these factors will contribute to an anticipated 1.13 million vacancies for RNs and advanced practice registered nurses (APRNs) by 2022.

In addition, changes related to the Affordable Care Act and the focus on decreasing hospital readmissions will continue to increase the shift in care delivery for complex, sicker patients from the inpatient to the outpatient setting, which will significantly impact staffing needs in both ambulatory and long-term care settings.

Issues such as these are top of mind as we consider the question: “If staffing in our department or on our unit is not where it needs to be, what can be done to improve it?”

A solution-oriented approach

Optimal staffing for safe patient care is a highly complex and multifactorial issue. The American Nurses Association’s (ANA’s) Principles for Nurse Staffing serves as a guideline for both nurse administrators and clinicians to evaluate current staffing models, and develop new models based on individual unit or departmental needs.


C1_Principles for Nurse Staffing 2012 (12x18-300dpi)[3]
ANA’s Principles for Nurse Staffing includes 5 key components:

  1. The characteristics and considerations of the healthcare consumer
  2. The characteristics and considerations of the registered nurses and other interprofessional team members and staff
  3. The context of the entire organization in which nursing services are delivered
  4. The overall practice environment that influences delivery of care
  5. The evaluation of staffing plans.

Other steps for taking action include:

Adjustable staffing plans

While all approaches to achieve the goal of optimal staffing for safe patient care should be considered, there is no one staffing model that fits all situations. A number of factors impact nurse staffing, including the patient population being cared for, the layout and technology available on the unit, the activity level on the unit, and the skill mix (meaning the various roles of team members needed to provide quality care to a specific group of patients).

Rather than mandatory fixed nurse-to-patient ratios that may lack adequate flexibility, ANA advocates for minimum RN-to-patient ratios that are increased as needed based on these factors. Hospital or department staffing committees that include clinical nurses as full partners in staffing plan development, implementation, and decision-making should establish and implement adjustable staffing plans.

Strategic collaboration and transparency in reporting

Other strategies that have been demonstrated to impact nurse staffing are included in the Registered Nurse Safe Staffing Act, which is being reintroduced in Congress this spring. These are:

  • implementation of staffing committees with at least 55% of committee participants being clinical nurses
  • committee responsibilities that include the establishment of unit-specific staffing plans based on upwardly adjustable minimum ratios of direct RNs to patients for each unit and shift
  • staffing plans that take into account characteristics of the care team (e.g., training and experience of RNs providing care and other healthcare team members)
  • the use of nationally benchmarked nursing-sensitive clinical outcomes such as falls, pressure ulcers, and failure-to-rescue, as well as nurse and patient satisfaction scores, to evaluate the effectiveness of existing staffing models on an ongoing basis
  • the requirement that staffing plans be publicly reported.

There also is growing support for public reporting of staffing measures such as skill mix and hours of care provided per patient per day. In addition to the public’s right to know, transparent reporting of data has the potential to provide nurses and other healthcare researchers with extremely valuable information that would accelerate our understanding of how various types of staffing plans impact clinical care outcomes.

It is critical for clinical nurses and nurse administrators to work together on staffing solutions. Together they can revise or create staffing models that ensure the health and well-being of the nurse, while also meeting the increasingly complex needs of patients to achieve safe, effective, patient-centered, timely, efficient, and equitable care.

Selected references

American Nurses Association. 2022: Where have all those nurses gone? 2014. www.ananursespace.org/blogs/peter-mcmenamin/2014/03/14/rn-retirements-tsunami-warning?ssopc=1

American Nurses Association. ANA’s Principles for Nurse Staffing. 2nd ed. 2012.

American Nurses Association. Distribution of RN Employment. 2013. www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workforce/Charts-and-Tables-of-RN-and-APRN-Employment-Data.pdf

Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. 2001. http://nationalacademies.org/hmd/reports/2001/crossing-the-quality-chasm-a-new-health-system-for-the-21st-century.aspx

Kane RL, Shamliyan TA, Mueller C, et al. The association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis. Med Care. 2007;45(12):1195-1204.

Needleman J. Nurse staffing: The knowns and unknowns. Nurs Econ. 2015;33(1):5-7.

Mary Jo Assi is the director of Nursing Practice and Work Environment in the Nursing Programs Department at ANA.

1 Comment. Leave new

  • Rachel Bargeron
    October 9, 2015 4:18 pm

    September 20, 2015

    Lillee Gelinas, MSN, RN, FAAN
    American Nurse Today
    259 Veterans Lane, Suite 103
    Doylestown, PA 18901

    Dear Lillee Gelinas, Editor-in-Chief:

    I am writing in response to Mary Jo Assi’s article titled “Optimal Staffing for Safe Patient Care: What will it Take?” volume 10, issue 4. Assi discussed the increasing amount of research that is supportive of appropriate nurse staffing numbers, and the relation to safe patient care. As a nurse I have experienced how inadequate nurse staffing negatively impacts nurse satisfaction and retention rates, worsening the current staffing issue and further impeding the delivery of safe patient care. Assi stressed the importance of collaborating with nursing leadership and administrators to develop a staffing solution that promotes the well-being of both the nurse and patient. Inadequate nurse staffing is a significant problem resulting in immediate and long term consequences. Nurses are in a unique position to use their knowledge and skills to identify and influence an individualized and unit specific staffing solution. Like Assi, I believe the nursing profession needs a sustainable nurse staffing solution to meet current and future healthcare needs. Nurses should actively participate and drive conversations about mandatory nurse-to-patient ratios, which will promote the safety of both nurses and patients.

    As Assi indicated, mandatory nurse-to-patient ratios remain a highly controversial subject. Flexible and highly individualized mandatory nurse staffing plans created with significant nurse involvement would be the ideal solution for all healthcare organizations looking to achieve a method for safe patient care. According to Weston and colleagues, in their article titled “ANA Principles: The Framework For Nurse Staffing to Positively Impact Outcomes”, in the Journal for Health Care Leaders (2012), volume 30, number 5; a successful staffing plan must consider multiple variables specific to the practice setting. Some variables to consider are patient population, patient acuity levels, census, admissions and discharges, availability of technology, and staff skills and education. According to Weston and colleagues (2012), research has indicated inadequate nurse staffing numbers have a direct correlation to decreased nurse satisfaction and retention rates, with a resulting increase in adverse reactions and mortality rates. Additionally, Weston and colleagues (2012) indicated insurance carriers held healthcare organizations accountable for adverse reactions, hospital acquired infections, and low patient satisfaction scores through decreased or absent reimbursement rates. I believe healthcare organizations should implement nurse staffing ratios in an effort to achieve and maintain patient safety.
    In conclusion, Assi discussed how multiple barriers contributed to suboptimal nurse staffing numbers, and a resulting negative effect on patient safety. I believe it is critical for all nurses to actively participate in the transformation of the nursing profession to include nurse-to-patient ratios; nurse-to-patient ratios would be the vital change needed to prepare for the future of our health care system. As our healthcare system becomes increasingly complex and diverse, we as nurses owe our patients and profession a voice capable of delivering effective change. In collaboration with nursing administrators and policymakers, I believe the nursing profession can address the nurse staffing shortage and implement a successful solution for safer patient care.


    Jennifer, RN, RN-BSN-Student


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