Nurse-to-Patient Staffing Ratios and Patient Safety

Topic: Nursing
Words: 2177 Pages: 7


Among hospital employees, nurses are by far the biggest segment, and they are entrusted with the vast majority of care coordination and delivery. Patient discontent, greater readmission rates, and increased negative incidents can be caused by a lack of proper staffing levels. Moreover, there is proof that insufficient nurse personnel in hospital settings is connected with negative events like medical error, health-care-associated diseases, and in-hospital deaths. The current pandemic has shown that these adverse consequences are increasing and causing a considerable impact on healthcare systems globally. Thus, it is critical to explore the influence of nurses’ work environment and personnel on quality of care and clinical outcomes to improve these outcomes.


In 1999, IOM’s To Err is Human report found that 98,000 patients die annually due to preventable medical errors (Goldsteen et al., 2016). The report associated some of these errors to poor nurse-to-patient staffing ratios. Several years after the report, it appears that the U.S. healthcare industry is still bedeviled with similar problems. Since the COVID-19 pandemic started, nurses have faced the problem of caring for many patients in the U.S., and this problem has been reported globally. There are numerous advantages to having an excellent nurse-to-patient ratio. A sustainable nursing workforce has proven to be a success for both nurses and patients (Livanos, 2018). Nurse burnout is a problem that occurs when nurses do not receive this help and are subjected to unrealistic demands. With more patients under a nurse’s care, the quality of patient care declines. There should be nationally mandated nurse-to-patient staffing ratios in order to improve patient safety and positive outcomes as well reducing nursing burnout. This essay provides evidence for why insufficient nurse-to-patient staffing rations cause problems like nurse burnout which compromise quality care and why the solution lies in ensuring nurses have manageable patient ratios at a given time.

Nurse-To-Patient Staffing Ratios

Nurses’ ability to maintain patient safety depends on their capacity to remain alert at the bedside. Consequently, raising the proportion of patients that a caregiver must attend to is fundamentally detrimental to their capacity to deliver safe care (Goldsteen et al., 2016). In addition, research has shown that ICU units with positive care outcomes generally have nurses caring for one or two patients maximum (Phillips et al., 2018). Without a doubt, such evidence influenced California’s 2003 nurse-to-patient ratio legislation. The law, which was amended in 2005, established minimum nurse-to-patient ratios based on the unit category. For instance, the ratio between clinical and surgical units is 5:1, while intensive care units have a ratio of 2:1 (Livanos, 2018). This means that one nurse will be allocated five surgical patients, and one nurse will be allocated two intensive care patients.

Numerous studies have been conducted following the enactment of the California law to illustrate the link between higher patient contentment, safety, and results and relatively desirable nurse staffing ratios. For example, Silber et al. (2016) looked at the clinical outcomes of patients with greater nurse-to-bed ratios. They discovered that those who have surgery in facilities with excellent care conditions have better survival rates. This finding specifically pertained to patients with a higher risk of complications, and the hospitals studied were categorized as focal and control hospitals. The former were large with better resources as opposed to the latter. The most exciting aspect of the study was that the hospitals studied had comparable expenses or nonsignificant cost differences ($33 513 vs. $34 375) (Silber et al., 2016). This means that higher nurse-to-patient does not increase the cost of care. On the contrary, it leads to better patient care.

Nurse staffing levels are crucial for refining the patient experience, enhancing quality care, and controlling costs over the long run in the healthcare industry. The American Nurses Association (ANA) and its representatives advocate for numerous changes in the wake of rising nurse understaffing, an aging society, and rising patient acuity. According to the ANA, nurse staffing is influenced by various aspects, including patient acuity, admissions, transfers, discharges, staff ability diversity and experience, hospital environment, and the availability of various resources (American Nurses Association, 2021). Therefore, the body advocates a legislative approach in which caregivers can design staffing plans for each unit. Using this method, it is possible to develop personnel levels that are adaptable and take into account many factors, such as:

  • The severity of the needs of the patient;
  • The frequency of admissions, releases, and transfers throughout the shift;
  • The degree of nursing workforce expertise;
  • The organization of the unit;
  • And the access to resources (for example, technology) (American Nurses Association, 2021).

Judging by recent events, failure to create a conducive work atmosphere for nurses has dire consequences. There has been an increase in labor strikes in the critical care environment as employees feel overworked and deeply worried about wages and understaffing. For example, nurses at St. Vincent Hospital in Worcester, Massachusetts, made headlines after staging the longest nursing strike in three decades. For the nurses, patient safety is a major worry for nurses, and this is attributed to insufficient staffing and high turnover rates. The nurses argue that these factors make it challenging to provide safe care for their patients (Luo, 2021). Similar strikes have been staged across different states, with some lasting for days and others weeks. This series of coordinated strikes results from employees who believe their needs are not being heard, understood, or addressed by healthcare leaders.

Safe Staffing and Lower Morbidity and Mortality

Emerging research suggests that increased personnel in care settings is related to reduced hospital mortality. Appropriate nurse staffing has been theorized to enhance care quality, especially patient monitoring, by enabling clinicians to devote additional time to offering immediate care. Conversely, a low workforce results in time being rationed for treatment, which can significantly impact the delayed care rate (Haegdorens et al., 2019). Perhaps this is a possibility explaining the relationship between nurse staff numbers and clinical outcomes like in-hospital morbidity and mortality. Morbidity is also referred to as illness, whereas mortality refers to death (Bien & Kim, 2021). Thus, an individual might have multiple co-morbidities and, likewise, die due to morbidity or several co-morbidities.

Previous investigative reports and studies have highlighted the fatal consequences of working in bad healthcare systems. According to Goldsteen et al. (2016), at least 98,000 patients die annually due to preventable medical errors. This number was an estimate of IOM’s To Err is Human report. The report determined that these deaths were not the result of incompetent health professionals but instead due to ineffective health systems and processes (Goldsteen et al., 2016). The report confirmed that robust health systems are capable of averting many health complications that lead to life-threatening co-morbidities. Subsequent scientific studies have also echoed these concerns suggesting that not much has changed.

Although the variation was more significant and statistically relevant in higher-risk participants, Silber et al. (2016) discovered that focal patients died less than reference participants in all risk categories. Mortality was 1.6 per cent less at focal hospitals than at reference hospitals in the second-highest risk category (4.2 per cent vs 5.8 per cent). In comparison, mortality was 2.6 per cent less at focal hospitals in the highest-risk category (17.3 per cent vs 19.9 per cent) (Silber et al. 2016). In a comparable Belgian study, the unexpected fatality rate was 1.80 per 1000 patients due to unsafe patient staffing (Haegdorens et al., 2019). Likewise, deaths occurred at a rate of 0.76 per 1000 following CPR and 0.62 per 1000 after an unexpected hospitalization to the ICU. As a result, the average cumulative mortality per 1000 patients was 3.18. (Haegdorens et al., 2019). In other words, the rate of these deaths would be lower if the studied hospitals had adequate nurse staffing. Although the studies do not present data relating morbidity with staffing, they acknowledged that patient illnesses are worsened when there is little nurse vigilance at the bedside.

Unsafe Staffing and Nurse Burnout

There is adequate evidence showing that unsafe staffing ratios and staff burnout are directly connected. COVID-19 has helped to expose the underlying factors that lead to nursing burnout. Many nurses have encountered fluctuating, unexpected, and gruelling work schedules during the outbreak. Administrative pressures and a growing workload have resulted in pervasive exhaustion. Nurses who have been exhausted by the outbreak and are also dealing with ongoing uncertainties about parenting and family responsibilities combine to exacerbate their already tight schedules. While many are looking for more flexible hours and duties, this has not been possible because of how the virus affects many people.

The direct consequences of longer shifts and working overtime have been widely documented. The most common consequence is increased risk of error, including the high-profile cases revealed by the To Err is Human report. Often, when nurses make grave clinical errors, criminal culpability is hard to rule out. According to studies, nurses who work schedules over 12.5 hours successively are thrice more likely to make treatment blunders (Di Muzio et al., 2019). In addition, fatigue causes forgetfulness, decreased attentiveness, impairment of decision-making, and inability to focus.

NursesTakeDC, a non-profit organization dedicated to advocating for safe nurse staffing, is now running a poll. In the poll, nurses are asked to describe their staff numbers and whether they received their rest. 79.43 per cent of the current 2161 participants say unsafe staffing, 70% reported missing their rest, and 85% favored establishing a safe patient ratio (NursesTakeDC, 2021). This survey suggests that the nursing shortage will continue to be a problem in the future because no significant steps have been made to solve the problem. Solutions are needed, without which the ongoing strikes in the healthcare industry will persist as long as the virus is not wiped out. Many nurses have left the profession with others suggesting that if the situation continues, they will quit.

The findings above reflect the sentiments by nurses working in a COVID-19 ICU unit at Osceola Regional Medical Center. According to one of the nurses, all other night shift employees left due to various factors, including a dangerous work atmosphere and a high nurse-to-patient ratio (Catherman, 2021). The nurse reports that sometimes nurses are compelled to attend to more than three patients at a time. There is optimism, says the nurse, because additional nurses may be assigned every shift, improving patient safety and working conditions (Catherman, 2021). Nurses appear to favor some form of minimal requirement based on the number of strikes for workforce ratios and quality care. Nurses are generally the first to see system failures that could have been avoided, so these strikes are justified.

Mandated Staffing Ratios and Patient Outcomes

Most researchers agree that different factors influence patient safety globally. According to Phillips et al. (2021), it is essential to recognize human variables, which can either help or hinder nurses from accomplishing their assigned jobs and addressing all of their patients’ needs. Nursing care episodes may be less likely to be overlooked by a nurse who is personally responsible for fostering a safe work environment. This notion reflects ‌Sloane et al. (2018), who found a strong correlation between increased resources and improved patient safety and quality of care. To improve patient outcomes, nurses in transformational leadership structures can operate at their peak performance levels since their bosses promote critical thinking and skill development while raising morale amongst the staff (Phillips et al., 2018). It suffices to say that nurse-sensitive approaches such as those recommended by ANA continue to raise the bar for safety and quality in hospital environments.

On the other hand, poor staffing ratios have also been linked with poor patient outcomes. According to a 2016 research, health care facilities with suboptimal nursing workplace settings had a 16% worse chance of life, and every extra patient per nurse in medical-surgical units has a 5% reduced chance of survival (McHugh et al., 2016). In general, numerous legislative and administrative reforms have impacted healthcare institutions in the United States throughout the last decade. These modifications are intended to improve the overall quality of care and the extent to which an organization’s culture encourages nurses to take actions to increase patient safety. Nurse-sensitive metrics are a way to assess how effectively critical care hospitals perform to provide outstanding care, ensure patient protection, and foster an ethical and secure work culture.


This essay has explained why there should be nationally mandated nurse-to-patient staffing ratios to improve patient safety and positive outcomes and reduce nursing burnout. The ongoing strikes by healthcare workers are not focused on a particular subject. When employees feel their needs are not being acknowledged and addressed by management, they organize a coordinated response. The current pandemic has illuminated the importance of collective bargaining in solving the problems facing modern health systems. This climate necessitates the creation of platforms for workers to be heard and the inclusion of workers in pertinent decisions, such as creating staff involvement and retention solutions. To be seen and heard is the new commodity of leadership in today’s world. The rise in nursing staff strikes has underscored why this motto has to be heeded more than ever before.


‌American Nurses Association. (2021). Nurse staffing advocacy. ANA. Web.

Bien, J., & Kim, P. Y. (2021). Epidemiology morbidity and mortality. StatPearls Publishing. Web.

Catherman, C. (2021). In the COVID ICU, an Osceola nurse warns inadequate staffing threatens patient safety. Orlando Sentinel. Web.

Di Muzio, M., Dionisi, S., Di Simone, E., Cianfrocca, C., Di Muzio, F., Fabbian, F., Barbiero, G., Tartaglini, D., & Giannetta, N. (2019). Can nurses’ shift work jeopardize the patient safety? A systematic review. European Review for Medical and Pharmacological Sciences, 23(10), 4507–4519. Web.

Goldsteen, R. L., Goldsteen, K., & Goldsteen, B. Z. (2016). Chapter 6. In Jonas’ introduction to the U.S. health care system, (8th ed.) (pp. 147–148), Springer Publishing Company.

Haegdorens, F., Van Bogaert, P., De Meester, K., & Monsieurs, K. G. (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), 1-9. Web.

Livanos, N. (2018). A broadening coalition: Patient safety enters the nurse-to-patient ratio debate. Journal of Nursing Regulation, 9(1), 68-70. Web.

Luo, A. (2021). Nurses strike for patient safety. The American Leader. Web.

McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., Merchant, R. M., Aiken, L. H., & American Heart Association’s Get With The Guidelines-Resuscitation Investigators (2016). Better Nurse Staffing and Nurse Work Environments Associated With Increased Survival of In-Hospital Cardiac Arrest Patients. Medical care, 54(1), 74–80. Web.

NursesTakeDC. (2021). Report your current staffing. NursesTakeDC. Web.

Phillips, J., Malliaris, A. P., & Bakerjian, D. (2021). Nursing and patient safety. Patient Safety Network. Web.

Silber, J. H., Rosenbaum, P. R., McHugh, M. D., Ludwig, J. M., Smith, H. L., Niknam, B. A., Even-Shoshan, O., Fleisher, L. A., Kelz, R. R., & Aiken, L. H. (2016). Comparison of the value of nursing work environments in hospitals across different levels of patient risk. JAMA Surgery, 151(6), 527–536. Web.

‌Sloane, D. M., Smith, H. L., McHugh, M. D., & Aiken, L. H. (2018). Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study. Medical Care, 56(12), 1001–1008. Web.

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