Running Head: NURSE STAFFING RATIOS 1

Problem-Based Research Paper

Nurse Staffing Ratios

Delaware Technical Community College

NUR 340 Nursing Research

Miranda Jennings

October 8, 2017
NURSE STAFFING RATIOS 2

Abstract

This paper discusses the issue of nurse staffing ratios and the effect they have on patient

outcomes. California mandated nurse-to-patient ratios in 2004 and has since made improvements

to the law. These ratios have been shown to benefit both the nursing staff and patients. The

nursing staff have reported higher job satisfaction, better health, and fewer instances of nursing

burnout. The ratios have also showing fewer instances of nosocomial infections for patients and

lower rates of patient mortality. The issues with the staffing ratios come when hospitals

administration and state legislation tries to find ways to justify the additional costs of hiring more

nursing staff. More research on this topic needs to be conducted before more states will be able

to pass similar nurse staffing laws.

NURSE STAFFING RATIOS 3

Problem-Based Research Paper

Nurse Staffing Ratios

Imagine being told that you will have to work short staffed, have to do the work of two

nurses, and will be responsible for ten acute patients. This is the reality of far too many nurses in

the United States. Explicit guidelines for nurse staffing are not available and/or followed in many

states. In 2004, California passed mandatory nurse-to-patient ratios in their medical-surgical

units of one nurse to six patients (Wallis, 2013). This law was revolutionary and has seriously

improved nursing job satisfaction, reduced nurse burnout, and improved patient safety in the

state. Several studies have also linked a reduction in nursing staff to higher patient mortality

(Thungjaroenkul, Cummings, & Embleton, 2007). With the mandatory nurse-to-patient ratios,

the mortality rates in California have decreased by as much as 13.9 percent (Wallis, 2013). This

is because when nurses are caring for fewer patients, they are able to better monitor the patients

they have for complications.

Problem Identification

The suggested nurse-to-patient ratio varies depending on patient acuity, patient needs,

unit layout, and nurse experience (Weston, Brewer, & Peterson, 2012). Having fewer patients per

nurse helps to decrease errors and improve patient experiences. Major contributors to nursing

errors are nurse fatigue and burn out. The New Mexico Organization of Nurse Executives

(NMCNE) suggested nurse shift length is less than twelve hours and fewer for older nurses to

combat nursing errors and burnout (New Mexico Nurse, 2012). Another factor that affects nurse

burnout is the time between shifts. The NMCNE suggests the minimum number of hours

between nursing shifts to be eight hours (New Mexico Nurse, 2012). The last factor listed for

nurse burnout and errors is the total hours worked per week. The NMCNE recommends nurses
NURSE STAFFING RATIOS 4

work no more than 60 hours in a week (New Mexico Nurse, 2012). To accommodate these

recommendations, hospitals are having to hire more nurses to fill gaps in scheduling.

Mandatory nurse-to-patient staffing ratios sound great in theory; however, the problem

arises when you factor economics into the equation. Decreasing the nurse-to-patient ratio, in turn

causes an increase in the cost of nursing staff. When hiring more nursing staff, the total

compensation including salary and benefits must be considered (Buerhaus, 2010). The costs

related to the higher number of nursing staff may not be offset by the additional payments to

hospitals (Welton, 2007). To cover these additional costs, hospitals need to come up with

alternative strategies to either save money or make additional income. One strategy suggested,

which is not popular among nurses would be to decrease the nursing salary or hire a greater

number of nursing assistants and fewer registered nurses (Buerhaus, 2010). An alternative to cost

cuts would be to increase charges for services. This includes billing for nursing care time to

cover the costs of the additional nursing staff (Welton, 2007). Despite multiple attempts, research

committees have not been able to come up with a solution to accommodate more nursing staff

that is widely accepted.

Literature Review

The first article used in this research is What is the Harm in Imposing Mandatory

Hospital Nurse Staffing Regulations? by Peter Buerhaus (2010). This is a quantitative article

that reviews many resources to discusses limitations to mandatory nurse to patient ratios that the

profession must overcome in order to improve patient care (Buerhaus, 2010). The limitations

listed included the need for additional nursing staff, the possibility of a nursing shortage related

to the additional staff, the lack of available nursing resources and equipment, the issues with
NURSE STAFFING RATIOS 5

affording the additional staff, and the effect of the quality of nursing care related to the additional

staff (Buerhaus, 2010).

The second article used in this paper is Guidelines: Registered Nurse Staffing posted in

The New Mexico Nurse journal (2012). This is a qualitative article that surveyed nurse leaders in

the state of New Mexico about nurse staffing guidelines posted in 2006 by the New Mexico

Organization of Nurse Executives and the New Mexico Center for Nursing Excellence regarding

(New Mexico Nurse, 2012). The article found a strong correlation between appropriate nurse

staffing and positive patient outcomes and patient safety (New Mexico Nurse, 2012). The article

also found a positive relationship between improve nurse staffing and nursing physical and

psychological health and nurses job satisfaction (New Mexico Nurse, 2012). The article goes on

to list the guidelines and the reasoning behind enacting each.

The third article used is The Impact of Nurse Staffing on Hospital Costs and Patient

Length of Stay: A Systematic Review by Thungjaroenkul, Cummings, and Embleton published

in Nursing Economic$ (2007). This article provides a quantitative review of seventeen studies to

show the relationship between nurse staffing, hospital costs, and patient length of stay

(Thungjaroenkul et al., 2007). The article found that increasing nursing staff will increase

hospital costs and expenditures for nursing salaries, but it decreases the cost of patient care

related to nosocomial infections (Thungjaroenkul et al., 2007). The article also found that

increasing the nursing staff decreased patient length of stay due to improved patient care and

monitoring (Thungjaroenkul et al., 2007).

The fourth article used for research on nurse to patient ratios is Nurse-Patient Staffing

Ratios by Laura Wallis which was published in the American Journal of Nursing (2013). This

article is a general education article that discusses the impact of the California mandatory nurse-
NURSE STAFFING RATIOS 6

to-patient staffing ratios that was passed in 2004 and revised in 2005 and 2008 (Wallis, 2013).

This article was used to gain additional background information that was helpful in guiding the

line of research.

The fifth article used is Mandatory Hospital Nurse to Patient Staffing Ratios: Time to

Take a Different Approach by John Welton published in The Online Journal of Issues in

Nursing (2007). This is a quantitative review of many articles that summarizes the costs

associated with increased nursing staff for hospitals and provides possible alternatives to combat

these costs (Welton, 2007). Welton (2007) proposes billing based on nursing care time, which, in

turn, will justify the need for additional nursing staff.

The sixth article used for this paper was ANA Principles: The Framework for Nurse

Staffing to Positively Impact Outcomes by Weston, Brewer, and Peterson (2012). This article is

a review of the American Nurses Associations Principles for Nurse Staffing, Second Edition.

The Principles for Nurse Staffing defines the number of nurses necessary to care for patients

based on acuity, floor layout, patient needs, and nursing staff experience (Weston et al., 2012).

This article provided information regarding the necessity of increased nursing staff based on

different hospital dynamics.

Analysis

All of the articles used were found on EBSCOhost with the key words of nurse staffing.

A variety of research studies and educational articles were used to gather the necessary data.

Several issues were encountered when finding data to use. First, there are not a lot of available

articles either supporting or against nurse staffing ratios. This seems to be because there have not

been a ton of studies conducted on the topic. Another issue was that there were not a lot of

current articles available. The articles used ranged from 2007 to 2013, but more recent studies
NURSE STAFFING RATIOS 7

were not found. The articles that were found did not have much conclusive evidence for or

against mandatory staffing ratios. This may be because California is the only state with law

mandated nurse-to-patient staffing ratios. Other states have recommendations for nursing staffing

but hospitals are not required to follow the guidelines.

Recommendations

More research needs to be completed on the effects of nurse staffing on patient outcomes

and hospital costs. Of the articles found, there was much variation in the results and the studies

that were quantitative were very vague on the effect of nurse staffing on patient outcomes.

Furthermore, additional states will have difficulty passing nurse-to-patient staffing laws without

the necessary research and further research will be difficult to conduct without more hospitals

using staffing guidelines.

NURSE STAFFING RATIOS 8

Resources

Buerhaus, P. I. (2010, March). What is the harm in imposing mandatory hospital nurse staffing

regulations? Nursing Economic$, 28(2), 87-93. Retrieved from

http://web.b.ebscohost.com.libproxy.dtcc.edu/ehost/pdfviewer/pdfviewer?vid=7&sid=d6

423cb3-7a01-455c-b442-9b3fbe7cedbd%40sessionmgr103

New Mexico Nurse. (2012, April). Guidelines: Registered nurse staffing. New Mexico Nurse,

57(2), 7. Retrieved from

http://web.b.ebscohost.com.libproxy.dtcc.edu/ehost/pdfviewer/pdfviewer?vid=4&sid=d6

423cb3-7a01-455c-b442-9b3fbe7cedbd%40sessionmgr103

Thungjaroenkul, P., Cummings, G. G., & Embleton, A. (2007). The impact of nurse staffing on

hospital costs and the patient length of stay: A systematic review. Nursing Economic$,

25(5), 255-266. Retrieved from

http://web.b.ebscohost.com.libproxy.dtcc.edu/ehost/pdfviewer/pdfviewer?vid=7&sid=a0

3bf253-a258-4a7c-81d1-5b97e9bb4174%40sessionmgr104

Wallis, L. (2013, August). Nurse-patient staffing ratios. The American Journal of Nursing,

113(8), 21-22. doi: 10.1097/01.NAJ.0000432956.03387.bd

Welton, J. M. (2007, September 30). Mandatory hospital nurse to patient staffing ratios: Time to

take a different approach. The Online Journal of Issues in Nursing, 12(3). doi:

10.3912/OJIN.Vol12No03Man1

Weston, M. J., Brewer, K. C., & Peterson, C. A. (2012, October). ANA principles: The

framework for nurse staffing to positively impact outcomes. Nursing Economic$, 30(5),

247-252. Retrieved from

NURSE STAFFING RATIOS 9

http://web.b.ebscohost.com.libproxy.dtcc.edu/ehost/pdfviewer/pdfviewer?vid=1&sid=89

e76a04-c96a-49b4-bf2e-69580765c0e7@sessionmgr103