Background and Significance
Nurses are in high demand now more than ever due to the escalating trend of nurse burnout and diminishing nurse retention. These have created a critical need for more nurses and have led to challenges in providing optimal patient care. An identified clear relationship between inadequate staffing of registered nurses (RNs) and adverse patient outcomes noted in current literature is alarming. Mandating nurse-to-patient ratios is one way to alleviate the challenges associated with the current state of nurse staffing. California has demonstrated success in implementing state laws mandating nurse-to-patient ratios, illustrating the feasibility and beneficial outcomes associated with mandated nurse-to-patient ratios. Yet challenges exist with mandates as experienced with the recent pandemic in mask use and quarantine mandates.
Review of the literature
A targeted literature review was conducted to determine the effects of patient outcomes related to mandated nurse staffing standards. Of the 22 articles selected, the research contained cross-sectional studies (Aiken et al., 2002; Brooks et al., 2019; McHugh et al., 2016), observational studies (Griffiths et al., 2018; Haegdorens et al., 2019; Lasater et al., 2021a; Lasater et al., 2021b), and regression analyses (Needleman et al., 2002). The research reviewed spans several years primarily from 2002 to 2023, with much of the literature focused on for this article over the last five years (i.e., 2019-2023). Evidence strongly suggests that maintaining adequate nurse staffing per patient has a positive influence on patient outcomes. Specifically, for each additional patient a nurse has to care for is associated with a 16% greater chance of patient mortality and longer hospital stays (Lasater et al., 2021b). Furthermore, literature reveals that advocating for a limited number of patients assigned to each nurse to enhances patient outcomes and alleviates nurse burnout (McHugh et al., 2021).
Recommendation
Maintaining adequate nurse staffing by mandating staffing standards has limitations such as limiting admissions in order to be compliant with mandated nurse staffing ratios, creating bottlenecks. However, studies specific to California found that with adequate staffing and time to transition to mandated ratios, patient wait times and care time decreased. In addition, California is compliant with EMTALA and they are successful in this because there are enough nurses available to meet the patients’ needs. Subsequently, more nurses are needed in rural areas with low nurse-to-patient ratios. However, it’s hard to offer mandates to other states that don’t have the inherent draw to the state like California does. Furthermore, organizing patient assignments by acuity should be taken into consideration for maximum efficiency of mandates.
Suggestions for further study
We recommend that additional research is conducted within the United States to explore the comprehensive effects of mandated nurse-to-patient ratios beyond the state of California. Based on the literature reviewed, however, we support and recommend implementing mandated unit-specific nurse-to-patient ratios to improve patient outcomes, safety, and the working conditions for nurses. n
References
Aiken, L., Clarke, S., Sloane, D. M., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987–1993. https://doi.org/10.1001/jama.288.16.1987
Brooks Carthon, J., Hatfield, L., Plover, C., Dierkes, A., Davis, L., Hedgeland, T., Sanders, A. M., Visco, F., Holland, S., Ballinghoff, J., Del Guidice, M., & Aiken, L. (2019). Association of nurse engagement and nurse staffing on patient safety. Journal of Nursing Care Quality, 34(1), 40–46. https://doi.org/10.1097/ncq.0000000000000334
Griffiths, P., Maruotti, A., Recio Saucedo, A., Redfern, O., Ball, J., Briggs, J., Dall’Ora, C., Schmidt, P. E., & Smith, G. (2018). Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Quality & Safety, 28(8), 609–617. https://doi.org/10.1136/bmjqs-2018-008043
Haegdorens, F., Van Bogaert, P., De Meester, K., & Monsieurs, K. (2019). The impact of nurse staffing levels and nurse’s education on patient mortality in medical and surgical wards: an observational multicentre study. BMC health services research, 19(1), 864. https://doi.org/10.1186/s12913-019-4688-7
Lasater, K. B., Aiken, L., Sloane, D., French, R., Anusiewicz, C., Martin, B., Reneau, K., Alexander, M., & McHugh, M. (2021a). Is Hospital nurse staffing legislation in the public’s interest? Medical Care, 59(5), 444–450. https://doi.org/10.1097/mlr.0000000000001519
Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Martin, B., Alexander, M., & McHugh, M. D. (2021b). Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study. BMJ Open, 11(12), e052899–e052899. https://doi.org/10.1136/bmjopen-2021-052899
McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. Lancet (London, England), 397(10288), 1905–1913. https://doi.org/10.1016/S0140-6736(21)00768-6
McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., Merchant, R. M., & Aiken, L. H. (2016). Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Medical care, 54(1), 74–80. https://doi.org/10.1097/MLR.0000000000000456
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in Hospitals. New England Journal of Medicine, 346(22), 1715–1722. https://doi.org/10.1056/nejmsa012247
