The Nurse Staffing Conundrum

The Nurse Staffing Conundrum

By Rose O. Sherman, EdD, RN, FAAN


I recently watched a very seasoned Chief Nursing Officer do an excellent job of presenting to a group of staff at a conference on the issue of nurse staffing as part of a  discussion on healthy work environments.  Appropriate nurse staffing is one of the six core standards in the healthy work environment developed by the American Association of Critical Care Nurses.  Staffing should be planned to ensure that there is an effective match between patient needs and nurse competencies.  Yet it became clear from our discussion, that the question about what is “appropriate staffing” and how to achieve it is one of the most complex and controversial issues in nursing today.


The Evidence on Staffing

The current evidence on nurse staffing suggests that an increase in nurse staffing is related to decreases in risk-adjusted mortality, nosocomial infection rates, complications in surgical patients, development of pressure ulcers, readmission rates and failure to rescue.  Poor staffing has also been associated with nursing burnout, stress, work-related injuries and turnover.

What is true of all of the research is that no “ideal staffing” has been identified.  California is the first state to mandate nurse staffing but their ratios were taken from expert consensus and not evidence-based work.

The Conundrum

With changes in reimbursement and the unknowns in healthcare reform, many organizations today are looking to reduce costs.  It is not surprising that nurse staffing is targeted as it is one of the biggest line items in any organizational budget.

Nurse leaders are being challenged to justify their staffing ratios – not only with evidence from the literature but also specific data on how staffing is impacting outcomes within their own organization.  This is not always easy to do because numbers alone don’t tell the whole story.  There are qualitative factors in any organization or on any unit that need to be considered.  Five important ones to consider include the following:

1.  What is the organizational/unit culture?  

The type of organization can make a difference.  Staffing needs may be different in academic setting where nurses work closely with house staff to coordinate care versus a community hospital where there is a stable hospitalist group.  Some organizations foster teamwork as a strong value and staff are expected to work closely with one another to meet the needs of patients.  In other organizations or units, nurses take individual assignments with little support from others.

2.  What is the patient population?

Units or organizations with a larger case mix of older patients may require different staffing than organizations with a younger population even with the same acuity.  Some patient populations are higher risk for falls, infections and pressure ulcers.  If staff nurses are expected to be very involved with discharge planning – the needs of the patient population should be considered.

3.  What is the organizational/unit structure and architectural layout?

How much ancillary support an organization provides will impact the RN staffing needs.  Are nurses expected to answer the phone and/or do transport of patients.  We often don’t think about unit layout.  Patients today expect private rooms but depending on the features and layout of those rooms – it may increase the work of staff and the ability of an RN to assume the care of additional patients.

4.  What is the daily census and unit turnover?

A considerable amount of nursing work is spent on admissions, transfers and discharges yet the work associated with patient throughput is often not reflected in staffing ratios.

5.  What is the staff skill and expertise?

A seldom considered factor is staffing ratios is the competency and expertise of the individual nurse.  Units with higher percentages of new graduates may need to be staffed differently.

To some extent – perception is reality.  You may have two nurses working on a unit and one feels it is very understaffed while the other feels that the workload is very manageable.  Staff involvement in staffing and scheduling is key.  Nurse-Manager staffing and Nurse Productivity committees can be a good way for organizations to evaluate their own unique needs.  There are no easy answers to the staffing conundrum and the answers may not be universal.

I would be interested to hear your thoughts on this topic.

Read to Lead

Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L. & Neff, D.F. (2011).  Effects of nurse staffing and education on patient deaths in hospitals with different work environments.  Medical Care.  49(10), 1047-1053.

American Nursing Association. (2013).  Nurse Staffing.  Web Resources

Schultz, D.  (April 23rd, 2013). Kaiser Health News.  Nurses fighting state by state for minimum staffing laws.

The Wall Street Journal. (June 11, 2013).  NY bill would mandate hospital staffing.

© 2013