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why laws can't guarantee safe staffing levels

Why laws can’t guarantee safe staffing levels

By: Leah Curtin, RN, ScD(h), FAAN

Is the complexity of nurse staffing compatible with the blunt force of a law?

FEW can doubt that nursing administration knows a great deal more about safe staffing than it did before the 1980s. In fact, so many medical, nursing, and administrative journals have published so much on safe nurse staffing that you’d have to be functionally illiterate to say “we don’t know what’s safe.” In short, Clarke found that “the available evidence indicates that there is a statistically and clinically significant association between RN staffing and adjusted odds ratio of hospital-related mortality, failure to rescue, and other patient outcomes.” And Kane and colleagues noted that “low RN staffing is a serious risk factor for negative outcomes in patients hospitalized in acute care settings.” I might add that research shows that low staffing levels aren’t good for nurses either.

why laws can't guarantee safe staffing levels postThat being said, why isn’t it a good idea to pass laws that mandate nurse/patient ratios? A law is a blunt instrument that doesn’t deal well with a very complicated issue—and nurse staffing is nothing if not complex. Consider these factors:

  • patient acuity
  • presence and number of patient comorbidities
  • patient level of consciousness and physical capability
  • families and their ability to cope
  • nurses’ knowledge and experience
  • presence (or absence) of support personnel
  • hospital management philosophy and organization
  • presence (or absence) of expert backup
  • physical layout of the hospital unit
  • presence (or absence) of various students seeking clinical experience on the unit
  • various and sundry other issues (physician/nurse communication, presence of advanced nurse practitioners, percentage of specialty certified staff, ratio of RNs to nursing assistants, ratio of full-time to part-time staff…and more).

Why do knowledgeable people oppose mandating RN/patient ratios? See all of the above—and add the well-established fact that a legally mandated minimum quickly becomes a de facto maximum.

Why do knowledgeable people support mandating RN/patient ratios? The world of the hospital often leaves nurses understaffed—so mandating ratios seems the lesser of two evils.

For those who are trying to save money on nurse staffing, researchers have several suggestions:

  • Employ sufficient nursing staff to meet patients’ needs without using overtime or excessive capacity expectations that may affect nurse health and patient outcomes.
  • Increase the mix of full-time to part-time employees (part-time staff should be used to cover unexpected or variable demands).
  • Ensure strong, cohesive, and knowledgeable teams to provide continuity of patient care and to create supportive work environments for nurses.
  • Reinvest in appropriately prepared managers and nurse clinical leadership.
  • Examine frontline nurses’ roles and activities to determine ways to increase the time available for patient care.

leah curtin registered nurse faan





Leah Curtin, RN, ScD(h), FAAN

Executive Editor, Professional Outreach

American Nurse Today

Selected references

Clarke SP. Registered nurse staffing and patient outcomes in acutecare: Looking back, pushing forward. Med Care. 2007;45(12):1126-8.

Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nurse staffing andquality of patient care. Evid Rep Technol Assess. 2007;(151):1-115.


1 Comment. Leave new

  • Holly Salayon, BSN, RN
    February 20, 2019 11:50 am

    I found Dr. Curtin¹ raises a compelling question concerning the effects of laws or lack thereof on nurse staffing challenges. As a nurse in administration utilizing and referencing Federal and State mandated regulations, I recognize nurse to patient ratios has been a profound discussion topic for nearly two decades. When discussing the conundrum of nurse staffing, this article demonstrates an excellent list of complexities to consider for legislative process and offers resolutions available to healthcare organizations to cost-effectively allocate the appropriate number of nurses required to improve safety and quality measures.
    While the statement “…a legally mandated minimum quickly becomes a de facto maximum”¹ is profound and highlights how quickly law can adversely affect the nursing professions position for adequate nurse staffing levels in providing quality patient care; the fact remains consumer and public pressures will continue to influence policy makers. This steadfast stance against mandating nurse to patient ratios is precisely why I have chosen to respond to this article. Rightfully, majority of the research available oppose these laws and demonstrate no change in patient or nursing outcomes in states with nurse staffing mandates; perhaps we can also argue the importance for the nursing profession to educate our politicians and consumers to alternative reporting requirements that hold healthcare organizations accountable in sustaining best practice quality care. The Massachusetts Organization of Nurse Executives (MONE), now known as the Organization of Leaders of Massachusetts, Rhode Island, and New Hampshire (ONL), and the Massachusetts Hospital Association (MHA) collectively approached the Massachusetts Nurses Association (MNA) to pursue alternative cost-saving options to the proposed ballot initiative, avoiding potentially catastrophic consequences as hospitals key stakeholders, consumers, and nurse leaders were given the opportunity to educate the importance of incorporating expert medical opinion, tools to measure acuity, and quality measures for reporting in the legislative process of nurse staffing assignments in intensive care units.²
    Therefore, as nurse leaders in a position to advocate for the nursing profession, why not actively participate in the legislative process and work intimately to educate policy makers by providing explicit insight from the perspective of nurses in these specialty areas to the requirements necessary for achieving the goal to provide safe quality patient care. I only aim to offer additional forethought on such a significant and valid concern as we march into the future of nursing.

    Holly Salayon, BSN, RN

    1. Curtin L. Why laws can’t guarantee safe staffing levels. American Nurse Today. 2018; 13(12).88.
    http://eds.a.ebscohost.com.ezproxy.uta.edu/ehost/pdfviewer/pdfviewer?vid=5&sid=d374de2a- b8ac-4910-b37b-c083682a5577%40sdc-v-sessmgr01

    2. Gale S, Noga, PM, Vitello-Cicciu J. Partnership paramount in efforts to influence nurse staffing legislation. Nurse Leader. 2015; 13(5):23-25.
    doi: 10.1016/j.mnl.2015.08.002


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