If you have been following any nursing news this past year, it is clear the hottest topic continues to be the debate for safe staffing. Currently there are two prevailing thoughts on how nurses should be staffed in acute care areas – mandatory minimum ratios versus local staffing committees / plans. In an effort to become better educated in the matter and make appropriate decisions for support, I wanted to share this excellent discussion regarding the current staffing issues.

 Mandated Ratios VS Staffing Plans

By: Cathy Stokes, RN, BSN

The American Nurses’ Association (ANA) does not support the use of set patient ratios. This leads a problem for those of us advocating for mandated patient ratios, whether it be on a state or national level.

Why? It appears that this organization is a politically motivated organization, and that the members are so removed from the bedside that their direction and focus does not support the working bedside nurse. Lay people and even some poorly involved nurses do not recognize these barriers. While the ANA does a lot for Advanced Practice Nurses and administrative nurses, their actual support of the bedside nurse is absent. Sadly, most state nursing organizations follow in suit with the ANA’s agenda.

There is a reason nurses (and whole states – see California!)  left that organization in favor of collective bargaining organizations like National Nurses United. There is a reason we have new advocacy nursing organizations like Show Me Your Stethoscope.

We recognize that we have a challenge with making a change that is necessary to the safety of patients across the country.

As I read through the ANA’s Safe Staffing Literature Review It is evident that they attempt to demonstrate that ratios are not the answer. Anyone can cherry pick through an article to defend his or her stance on a particular issue. In the literature, there is not any hard conclusive evidence that ratios are not the answer either. There are claims and arguments against it but no real evidence. And just as there is research to try to disprove the use of ratios there is now new evidence to prove that mandated ratios are effective.

So what are the arguments against ratios?

  1. Mandatory nurse–patient ratios take away flexibility and negatively impact the health care delivery system

    Not really. Nurses do have the ability to provide input and adjust staffing as long as the minimum ratio is maintained. Set ratios then adjust for acuity. According to Aiken et al. (2010) “Most California nurses, bedside nurses as well as managers, believe the ratio legislation achieved its goals of reducing nurse workloads, improving recruitment and retention of nurses, and having a favorable impact on quality of care”.

  2. Ratios are not cost effective

    Not true either. Studies are showing that hospitals are still making money out in the only state that has mandated ratios…CA. According to Silber et al. “Hospitals with better nursing environments and above-average staffing levels were associated with better value (lower mortality with similar costs) compared with hospitals without nursing environment recognition and with below-average staffing, especially for higher-risk patients” (2016).

    In the article Improving Nurse-to-Patient Staffing Ratios as a Cost-Effective Safety Intervention “Savings from shortened length of stay improve the cost-effectiveness of increased staffing, although the savings only offset half of the increased labor costs. Savings resulting from decreased length of stay would largely accrue to payers, such as health insurers, while hospitals would incur the costs of additional staffing” (Rothberg, Abraham, Lindenauer, Rose 2005).

  3. Ancillary staff with not be used and lose their jobs.

    Well to be honest… that is a problem now and we don’t have mandated ratios. So the argument can still be made that mandated ratios is needed despite this. That said, in some hospitals this is found to occur, but not all hospitals. Ultimately hospitals that already staff appropriately will more than likely not see a decrease in those areas. If anything it needs to be written in the legislation to include ancillary staff. This can be done more easily at the state level.

In the journal article Implications of the California Nurse Staffing Mandate for Other States it is explained:

Other than reports of less support from unlicensed clinical and support personnel, we find little evidence of unintended consequences of the California legislation that are likely to negatively affect the quality of the nurse work environment or patient care, as have been anticipated. The nursing skill mix in California hospitals appeared to improve and there is much research evidence that more RNs relative to others are associated with better patient outcomes. There is the possibility that reductions in ancillary workers will increase nurses’ workloads, but we found no evidence in our study to suggest that was the case. (Aiken et al. 2010)

All of the literature related to safe staffing and nursing care acknowledges that having more nurses does indeed decrease mortality. In reading these pieces of literature, most of them do try to disprove ratios and support staffing plans. However, these articles really do not prove ratios are not the answer. Those opposed to ratios will of course take the arguments and use them to further their agenda. Most of the articles state that ratios are not the answer but that there are limits to this conclusion. It is though they are just trying to play a word game to ????

The ANA believes that staffing committees within a hospital are the answer, and that Registered Nurses within those committees should determine the ratios for nurses to patients. On paper it looks like the perfect solution to our staffing problems. However, the problem with these staffing committees is that they are subjective and that management still weighs too heavy on the decision-making and staffing matrix. Poor staffing still occurs in hospitals that use this method. I remember working in a hospital that phrased itself for using that method. ??? Assignments on most floors were completely unsafe and unnecessary deaths did occur. I also constantly see nurses from the state of Texas and Ohio (states that have “staffing plans” as their legislation) discuss their patient loads and the unsafe conditions that occurs.

My humble thoughts:

I make not effort to disguise that something has to be done regarding the current staffing issues in our hospitals. Although, for the most part, at my current position, we are pretty well staffed – I know this is not the norm.

When California enacted their mandated ratios, I thought that everyone would soon follow…. how I was wrong. California enacted their ratios in 2004…still waiting.

Please educate yourself on this issue. The ANA truly wants you to believe they have your best interest at heart, however, nothing could be further from the truth. Their plan is for local committee, which will have a registered nurse. Let’s be honest here – what staff nurse who would actually speak up is going to get appointed that that committee. Not to mention, they are just one vote against the entire management team. We all know how that would turn out…. in fact, it is what we have now – non-medical/health care folks making decisions on how many patients a nurse should care for each shift.

Again, something has to change and now is the time. Please get involved, get educated.

Thanks again to Cathy for sharing her research and thoughts also!

Take care, be safe & wash your hands!

Until next time…

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., … Smith, H. L. (2010). Implications of the California Nurse Staffing Mandate for Other States. Health Services Research, 45(4), 904–921. http://doi.org/10.1111/j.1475-6773.2010.01114.x

American Nurses Association. (2014). Retrieved June 22, 2016, from http://www.nursingworld.org/…/2014-Nurse-Staffing-Updated-L…

Rothberg, M. B., Abraham, I., Lindenauer, P. K., & Rose, D. N. (2005). Improving Nurse-to-Patient Staffing Ratios as a Cost-Effective Safety Intervention. Medical Care, 43(8), 785-791. doi:10.1097/01.mlr.0000170408.35854.fa

Silber, J. H., Rosenbaum, P. R., Mchugh, M. D., Ludwig, J. M., Smith, H. L., Niknam, B. A., . . . Aiken, L. H. (2016). Comparison of the Value of Nursing Work Environments in Hospitals Across Different Levels of Patient Risk. JAMA Surgery JAMA Surg, 151(6), 527. doi:10.1001/jamasurg.2015.4908

Comments (4)

  1. Renee


    A re-cap would be nice since i seemed to have missed so much of the beginning of the blogging site. I would love to know how it got started and if i would be able to spend some alone time reading and trying to understand the site. I love you

  2. Pingback: Nurses Take DC - how you can help! - The Nurse Teacher

  3. Robin Easley


    Thank you so much for this information. I am working on a paper aimed at implementing safe staffing ratios and have been reading about how the ANA advocates for safer nurse workloads. I understand and believe that the ANA’s approach would be most optimal, but I don’t see how these approaches could be actively enforced (besides mandatory reporting). Even so, business find loop holes and ways to navigate grey areas to their financial advantages. From my perspective, mandated minimum safe staffing ratios would be a very good start. This would serve as a minimal set line allowing for less manipulation by the creative minds of the grey palette navigation artists.

    • Joan RN


      Glad you found it helpful – can’t take credit – written by Kathy Stokes who is an organizer with Nurses Take DC. Please check them out – big rally planned again in DC in April to help bring attention to this issue. I agree with you – hospitals currently know what the right thing to do is, however, the motivation for the bottom line often blurs that line and pushes the envelope. What these business minded folks forget is that we are not publishing books or baking deserts where mistakes can be corrected, these are human lives with little margin for error. Thanks for being a part of the conversation & good luck on the paper!!

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