1. Ashley borowiak, rn Nursing 450 Ferris state university
Staffing Ratios
Ashley borowiak, rn
Nursing 450
Ferris state university

2. Introduction
Nurse ratios are determined by working hours per patient per day.
Nursing ratios are the number of patients assigned to a staff member.
Nurse staffing can have effects on the quality of care patient’s receive, patient safety, and adverse outcomes from the plan of care.

3. Objectives
Identify if a correlation exists between nurse to patient ratios and patient outcomes.
Recognize mandated staffing ratios and the consistency across health care locations.
Identify nursing implications of high and low nurse to patient ratios.
Identify systems used to determine staffing numbers.
Discuss theories related to the subject.

4. Theories Related to Nurse Staffing
Nursing Services Delivery Theory
Recognizes that many different factors affect the work demands in the health care system and nurse staffing.
Input, throughput, and output interact to determine staffing needs and work demands.
Staffing research has shown a correlation with key nurse staffing indicators and patient outcomes.
Meyer & O’Brien Pallas, 2010

5. Theories Related to Nurse Staffing
Maslow’s Hierarchy of Needs
Nurses need to feel safe in the environment they practice, have a sense of belonging to their organization, and to feel empowered. This is achieved through Maslow’s Hierarchy of Needs.
Inadequate staffing raises a nurses stress level, causing job dissatisfaction. These stressors can threaten patient safety and negatively affect the environment in which they practice in.
Nurses are advised to address their basic needs to provide safe and quality care.
Groff Paris & Terhaar, 2011

6. Achieving Self Actualization

7. Assessment of Health Care Environment
Outpatient Environment-Hospice
Guidelines have been in place since 1994.
Varying acuity depending on home care patients or short length of service patients
Often times family present to assist with cares.
Uses an assessment process to estimate staffing levels such as characteristics of the patient population, level of care, length of service (LOS), and the environment.
National Hospice and Palliative Care Organization [NHPCO], 2013

8. Assessment of Health Care Environment
Higher percentage of short LOS which means acuity could be higher in the first week or two of care, and the patient ‘s needs are more resource intensive.
Lower percentage of routine patients who partake in home care, which indicates a higher number of inpatients receiving continuous care.
Issues for nurses to consider when determining staffing:
Psychosocial issues of the complexity of the patient’s needs
Safety issues for the nurse
High intensity of services
NHPCO, 2013

9. Assessment of Health Care Environment
Inpatient Environment-Acute and Long Term Care
Different levels of acuity of patients
Confusion, frequent repositioning and toileting, frequent prn medications
Severity of diagnosis and level of stability
Staffing policies vary between facilities and states
Delegation is often an underutilized tool that can ease the workload of nurses and CNAs.
Ability to pull staff from other units to assist if needed
Census changes throughout the day
Discharges, Admissions

10. Management and Education Services for Healthcare (MESH)
MESH is a patient centered acuity system designed to determine staffing by identifying patient’s distinctive needs.
The Patient Classification and Staffing System Module (PCSS) is one of four modules used within MESH to assist with proper staffing.
Prior to staffing for the next shift, a projected census is formulated to determine staffing needs and patients are categorized into acuity levels.
University of Wisconsin, 2014

11. MESH System
Taking census and acuity information, the system calculates the number of staff needed.
The system will notify the person making staff assignments if the unit will overstaffed or understaffed depending on the data entered.
University of Wisconsin, 2014

12. MESH System
Nurses making staff assignments are able to and encouraged to documents notes regarding projected and actual decisions made in regards to staffing.
All0ws for nurse explanation as why staff decisions were made to allow for better decision making in the future.
University of Wisconsin, 2014

13. Census Grids
Staff is determined solely by number of patients on the unit.
Acuity is normally not a factor in census grids.
Black and white-Nurses do not have ability to make judgments on staffing decisions
Staffing adjustments are made according to the census grid

14. Root Cause Analysis

15. California Assembly Bill 394
In 1994, law was passed that requires acute care hospitals to maintain a minimum nurse to patient ratio.
First state to initiate
Facilities are required to use an acuity classification system
Mandated staffing ratios are unit specific
Facilities required to record and report staffing numbers to ensure compliance with the law.
Agency for Healthcare Research and Quality [AHRQ], 2014

16. California Assembly Bill 394
What were the outcomes of the new legislation?
Higher staffing levels
Nurse hours per patient day increased from 6.03 to 7.11
Reduced Nurse Workload
Average patients per shift decreased to 4.1
Fewer patient deaths
In California, the death rate was percent lower than 2 other states which do not have staffing mandates
Decrease in nurse burnout and high job satisfaction
66 percent of nurses in California agreed they are more likely to remain in their jobs as a result of the legislation
AHRQ, 2014

17. Michigan’s Safe Patient Care Act
Proposed by State Representative Jon Switalski and State Senator Rebekah Warren
Would implement a staffing plan which would have a minimum nurse to patient ratio.
Facilities would create their own staffing plan
Facilities would be banned from using mandatory overtime to compensate for poor staffing planning
Studies show that facilities would benefit due to shorter lengths of stay, a decrease in readmissions, decreased legal liability for all complications that are associated with nurse staffing, and less nurse turnover.
Michigan Nurses Association, 2014

18. Mandated Staffing Ratios
Positives
Ensure safe care if provided
Increased job satisfaction
Increased patient outcomes
Nurse recruitment
Negatives
Reduction in hospital services
Increased emergency room diversions
Increased unit closures
Increased expenses
Nurses in Minnesota from facilities speak out on why staffing mandates would have a negative affect on the care their patients receive.
American Organization of Nurse Executives, 2014

19. Inferences and Implications
Adequate staffing has been proven to:
Reduce medication errors
Decrease complications relating to patient diagnosis
Decrease patient mortality
Increase patient satisfaction
Reduce nurse fatigue
Decrease nurse burnout
Increase job satisfaction
ANA, 2014

20. Patient Outcomes High Nurse Staffing Reduces UTIs Pneumonia Shock
Upper GI Bleeding
Longer Hospital Stay & Preventable Readmissions
Decreases costs lost by facility for little to no CMS reimbursement
Failure to Rescue
Greater patient and family satisfaction
Failures in the plan of care and meeting outcomes
AHRQ, 2014

21. Nurse Burnout and Turnover Rates
Decreased work conditions and stressful environments have been proven to have direct negative effects on a nurses satisfaction with their job.
Patient satisfaction is much less in facilities where nurse burnout and turnover rates are higher.
Nurses working in direct
patient care areas (especially
those which are short staffed)
have the highest burnout rates.
High burnout and turnover
rates have direct negative
affects on patient care.
McHugh, Kutney-Lee, Cimiotti, Sloane, Aiken, 2011

22. Budgeting
Hospital budgets are one of the main reasons for staffing issues at facilities.
Hospitals spend a large amount of dollars in overtime pay and incentive pays for outside nurses.
Many nurses do not see unit budgets or are aware the amount of funds paid out to employees

23. Centers for Medicare/Medicaid Services (CMS) Reimbursement
Medicare spends $15 billion a year on preventable hospital readmissions.
Hospital Readmissions Reduction Program
Research has proven that hospitals with adequate staffing have a lower level of readmissions.
Government can assist with decreasing readmissions by:
Mandating minimum staffing levels
Using benchmarks and payment incentives based on nurse staffing
Public reporting of nurse to patient ratios
Mitka, 2013

24. Recommendations for Quality and Safety Improvements
Quality and Safety Education for Nurses (QSEN) Competencies
Patient Centered Care
Recognize the patient as a the main source for providing compassionate and coordinated care.
Proper staffing ratios can deliver safe and quality care which the patient is entitled to.
Evidence-Based Practice
Integrate the best current evidence to deliver optimal care.
Continue to study the positive affects that staffing mandates and increase staffing have on patient outcomes.
QSEN Institute, 2014

25. Recommendations for Quality and Safety Improvements
QSEN Competencies
Quality Improvement
Use improvement methods to design changes to improve the quality and safety of health systems.
Discover and test new staffing grids to optimize patient care
Seek out information and formulate a root cause analysis to determine the cause of staffing issues.
QSEN Institute, 2014

26. American Nurses Association (ANA) Standards
Standard Nine: Evidence Based Practice
The nurse will incorporate research into everyday practice.
With this, nurses can discover ways to improve upon staffing issues to deliver quality care and reduce nurse stress.
Standard 10: Quality of Practice
The nurse delivers quality care in his or her nursing practice.
Regardless of staffing issues and/or patient ratios, nurses should deliver safe, quality care, without taking shortcuts to get tasks accomplished that could sacrifice the safety of the patient (i.e. leave catheters in too long, disregard dressing changes)
Standard 16: Environmental Health
The nurse practices in an environmentally safe and healthy manner.
Nurses reach Maslow’s hierarchy of needs and promotes a health environment so patient care can be optimized.
Ferris State University, 2014

27. Summary Nurse to patient ratios vary between environments
Research and studies can improve the way facilities staff their units and improve patient care
Staffing can have both positive and negative affects on patients and the facility
Government mandates are not widely accepted by those in the health care field
Using the standards set by the ANA and QSEN, nurses can continue to deliver optimal patient care.

28. References
Agency for Healthcare Research and Quality (2014). Hospital nurse staffing and quality of care. Retrieved from Agency for Healthcare Research and Quality (2014). State-mandated nurse staffing levels alleviate workloads, leading to lower patient mortality and high nurse satisfaction. Retrieved from American Organization of Nurse Executives (2014). Mandated staffing ratios. Retrieved from Barton, N. (2013). Acuity-based staffing: Balance cost, satisfaction, quality, and outcomes. Nurse Leader, 11(6), Centers for Medicare and Medicaid Services (2012). Design for nursing home compare five-star quality rating system. Retrieved from Ferris State University (2014). Standards of professional nursing practice (ANA). Retrieved from Groff Paris, L., & Terhaar, M. (2011). Using Maslow’s pyramid and the national database of nursing quality indicators to attain a healthier work environment. The Online Journal of Issues in Nursing, 16(1).

29. References
McHugh, M.D., Kutney-Lee, A., Cimiotti, J.P., Sloane, D.M., & Aiken, L.H. (2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30(2), doi: /hlthaff
Meyer, R.M., & O’Brien-Pallas, L.L. (2010). Nursing services delivery theory. Journal of Advanced Nursing, 66(12), doi: /j x
Michigan Nurses Association (2014). MI needs a safe staffing law now! Retrieved from
Mitka, M. (2013). Greater nurse staffing may lower hospital readmissions. The Journal of the American Medical Association, 310(18).
National Hospice and Palliative Care Organization (2013). Staffing guidelines for Hospice home care teams. Retrieved from
QSEN Institute (2014). Pre-licensure KSAS. Retrieved from
University of Wisconsin (2014). Management and education services for healthcare (MESH). Retreieved from