Nurse to Patient Ratios, Staffing,

and the Impact on Healthcare

Provided

Grace Gindlesperger
Youngstown State University
NURS 6900- Professional Issues
Dr. Valerie O’Dell
February 18th, 2023
 Introduction

Negative Feedback Loop

Staffing shortages and inadequate nurse to patient ratios play a critical role in
patient outcomes, quality of care provided, nursing burnout rates, nursing
retention, and hospital costs.
 Higher patient to nurse ratios have consistently been seen to increase mortality and worsen nurse burnout.
Poor staffing/Ratios Higher Burnout
 A 2002 study found that for each additional patient added to a nurse's assignment, there as a 7% increase
in mortality within 30 days of admission (Aiken, 2002).
 A 2020 review looked at the spread of COVID 19 and patient outcomes in nursing homes in California
compared to the staffing ratios of those nursing homes and found that nursing homes with staffing ratios
less than that of the recommended experienced up to twice as many COVID 19 infections in residents
living there (Harrington et al., 2020). Higher Turnover
 Poor staffing and high patient ratios contributes negatively to nursing retention by increasing burnout.
 High burnout contributes to higher turnover which leads to poor staffing ratios and therefore contributing
to burnout- making a negative feedback loop that only continues to worsen the nursing issues at hand.
 A 2002 study found that consistently working with ratios over recommendations lead to a 23% increase in
nurse burnout (Aiken, 2002).
 Introduction cont.

 A reduction in nursing retention as a result of high turnover contributes to increasing healthcare costs and negatively
impacts hospitals financially.
 The cost of a single nurse turnover is around 1.2 - 1.3 times their salary, and when extrapolated this creates a
huge additional cost for hospital systems (Shanafelt et al., 2017).
 Increasing costs of training for hospitals is passed down to patients as increased healthcare, often with poorer
quality care provided.
 Lower retention results in overall unit nurse experience and contributes to poor outcomes as well as higher turn
over as nurses do not feel supported or safe while practicing.
 Significance to Nursing

Historical Impact and Significance in Nursing

 Staffing shortages and poor ratios have been rooted into nursing practice consistently since the second World War.
 The US Department of Labor conducted its first study regarding the shortage in 1948.
 Nurses then made very similar complaints compared to the needs and issues of nursing today.
 “It is obvious that a nurse cannot live on the gratitude of patients, she must have sufficient income” (United States Department of
Labor, 1948, pg. 37.)
 While issues have been consistently identified, no sustainable solutions have been utilized.
 Often the answer has been to just increase the number of nurses graduating to oversaturate the market without solving the issues that
prevent them from being retained.
 Lower degrees with faster programs became acceptable to help speed the process to increase numbers.
 Since the early 1900s the number of nurses per 1000 people has grown exponentially, increasing almost 100-fold yet healthcare continue
to struggle with meeting the needs of patients and staffing ratios alike (Whelan, 2016).
 Significance to Nursing cont.

Modern impact and Significance in Nursing

 Staffing shortages and poor patient to nurse ratios directly impact emotional, psychological, and mental health of nurses.
 Depression in nurses is rising and, as of a 2020 study, impacts between 25-45% of all nurses (Melnyk, 2020)
 High ratios and poor staffing limits the quality-of-care nurse can provide and increases incidents of missed care.
 A 2015 study noted that nearly 63% of all preventable nursing errors could be contributed to burnout and its effects on nursing care
quality (Henderson., 2015).
 A 2016 study of a high level NICU noted that 36% of nurses missed vital care actions on any given shift which was directly related to
increased workloads of nurses on the over eight years without subsequent increase in resources or improved ratios (Lake et al., 2018).
 Nurses are more likely to break policy to ensure care is provided and complete tasks as a result of less staff support and higher work loads
per nurse.
 A 2008 study asked 120 nurses how often they felt they were required to violate policy to complete their jobs and 53% of those
surveyed stated they violated patient safety polices to complete needed and often emergent care (Hughes, 2008).
 Significance to Nursing cont.

Future Impact and Significance in Nursing

 The future of nursing is doomed to continue its current downward trajectory without change and intervention.
 Increasing the number of nurses enrolling and graduating each year is not a long-term answer to a long-term problem
 With growth in medicine, patients' acuity will increase as more complex medical conditions are able to be managed and life spans grow.
 Patients today suffer from many more co-morbidities, require more poly-pharmacy management, and live longer with conditions that
were not manageable in previous decades.
 Increasing acuity of the patients while also increasing the number of patients each nurse cares for is going to continue to negatively
affect nurses and their patients.
 Proposal to Resolve Issue

Past Proposals for Resolution

How to fix the nursing staffing shortage and subsequent poor ratios has been debated and studied since the early 1900s.
Primarily the answer has been to increase the number of nurses working
Focusing on increasing numbers without improving working environments, ratios, burnout rates, or concerns expressed by the nursing
profession
Reducing the criteria needed to practice by accepting associate degrees and offering accelerated programs,
Adding skills, that were previously assigned only to nurses, to ancillary staff to offload nurse tasks.
Utilizing the higher rate of graduating nurses to rationalize not promoting retention of experienced staff,
This has so far resulted negatively for nursing and healthcare.
While the number of nurses has increased, the staffing ratios and shortages have continued to worsen as retention rates fall.
These solutions do nothing to help protect patients from poor care and higher mortality risks as a result of poor staffing and ratios.
Becomes a band-aide solution that only temporarily fixes the problem since the focus is still not on increasing retention and improving
working environments.
 Proposal to Resolve Issue cont.

Current Proposals for Resolution

 Modern focus has been on passing legislation and policy to help ensure safe ratios are enforced and followed.
 California became the first state to enforce safe staffing ratios for nurses on a state level in 2002.
The Assembly Bill 394, that was enacted on January 1 st 2002, ensures that there must be a minimum specific number of licensed nurse to patient
ratios set based on nurse classification and type of unit within a hospital (Aiken et al., 2010).
A lot backlash was reported prior and just after implementation due to concerns that some patients may not be able to receive care as units could hit
capacity and leave patients without options.
This policy has resulted in lower mortality rates, higher nurse retention, lower nurse burnout, and better overall job satisfaction reported.
When compared to other states, New Jersey and Pennsylvania, it was found that there would have been a 10-14% reduction in mortality if the California safe
staffing ratios had been applied over the previous two years (Aiken et al, 2010).
 Legislation is not a one-size-fits-all answer
While this regulation has benefited California’s nurses and patients alike, a blanket policy cannot be applied to everywhere and expect the same
results.
Rural areas and small community centers may need more flexibility with ratios due to limited populations and fewer available nurses.
Safety net hospitals may require policy that takes the higher number of patients into account and the fact that many of these patients have no
other options for healthcare and may need more social support than others.
 Proposal to Resolve Issue cont.

Future Proposals for Resolution

 Nurses are the key to solving the shortage and poor staffing ratios that plaque the profession.
 Nurses need to be involved in everything from larger legislation to small unit specific policy.
 On a larger level, nurses need to be involved with larger legislation and the political culture within healthcare.
 Being more politically literate and understanding the current issues at hand to help promote meaningful and long-lasting change.
 Organizing, supporting, and participating in the process of bills, laws, legislation, and policy being brought up to higher levels of
government.
 On a smaller level, nurses need to work with their hospitals and units to identify primary causes of turnover that is specific to where they
work to better their environment.
 Improving policy on hospital or unit specific level can help promote retention and fix the problems that contribute to burnout and thus
feed the negative feedback loop of high turnover and poor staffing.
 Nurses need to be involved with local committees, boards, and unions to see change on a micro-level that helps impact change on a
macro-level.
 Conclusion

 The impact of short staffing and high patient to nurse ratios is seen in poor patient outcomes, higher rates of nurse burnout, lower rates of retention, and
overall increase in healthcare costs.
 Higher rates of mortality, higher turnover, lower job satisfaction.
 A negative feedback loop of poor staffing leading to burnout leading to turnover leading to poor staffing.
 While the issues of short staffing and poor ratios is deeply rooted in healthcare and nursing history, solutions of the past have proven to not be effective.
 Increasing number of nurses graduating and reducing criteria for practicing without focusing on the issues that lead to burnout, turnover, and thus
staffing shortage.
 Staffing shortages and poor ratios negatively impact nurses on both individual a larger levels.
 Increased rates of depression, higher rates of burnout, more medical errors and mistakes, higher rates of ignoring policy to complete tasks.
 Current proposals for new legislation and policy has potential to break the cycle of staffing shortages and poor ratios that have been seen for over 100 years.
 The Assembly Bill 394 in California can be used as a blueprint to build from to help create state and hospital specific legislation and policy to promote
better care and healthier work environments for nurses.
 Nurses need to be involved in the future of staffing shortages if change is to be sustained.
 Participation in local and state level policy is the most important thing a nurse can do to help solve this issue.
 References

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