Mandated staffing ratios

Mandated staffing ratios


Different hospitals have been adopting different nurse staffing systems depending on different factors. Ratio staffing involves specific RN-to-patient ratio.  For instance, 1:2 is a ratio whereby one nurse is assigned to two patients. It has been the core supportive element of RN staffing, but it is rigid because it does not allow for acuity. In October 1999, California was the first state to enact mandatory staffing ratio legislation, which requires minimum, specific, licensed nurse-to-patient ratios for all acute care hospitals (Zimmermann, 2002). This legislation was sponsored by the California Nurses Association. The peak of a nurse’s concern over adequate staffing reached the public, and forced staffing changes for the better. Other states followed suit, introducing bills pertaining to staffing initiatives in their state legislatures.

Minimum ratios for critical care units were already in effect (Perrin & McGhee, 2008). These included hospital, intensive care units and operating rooms. Initially, management of hospitals could staff nurses across units in a flexible manner. A controversy arose regarding the effectiveness of the mandated staffing ratios legislation. This essay analyses the merits and demerits of mandated staffing ratios compared to acuity-based, flexible matrices established, through collaborative governance processes.


Mandated staffing ratios are said to limit hospitals’ flexibility in staffing. They prevent management from customizing staffing levels to patient needs.  Besides, technology advanced hospitals may have difficulties in substituting technology for nurses appropriately. Opponents of the mandated staffing ratios have expressed their fears that the minimum staffing ratios would become the average staffing ratio, as hospitals may be tempted to reduce their staffing to the lowest level required by the legislation (Perrin & McGhee, 2008). The legislation is not empirically supported because previous data of staffing for best practices hospitals does not uniformly indicate that hospitals which are rated highly for quality of patient care have richer staffing than other hospitals (Perrin & McGhee, 2008). Therefore, critics of mandated staffing ratios argue that it is not clearly evident that legislating staffing ratios enhances patient care.

In Massachusetts, the Massachusetts Nurses Associations argues that the safe RN staffing bill in California is working, though they cannot demonstrate that patient outcomes have improved.  Negative consequences have not occurred for the health care system, and a positive effect has been seen on the nursing profession from the mandated ratios (Perrin & McGhee, 2008). There had been no hospital closures in California. In addition, hospitals did not find it as tedious as they estimated, to meet the staffing ratios for the two and half years since the staffing ratios came into effect (Perrin & McGhee, 2008).

Proponents of the mandated minimum ratios claim that RN staffing had fallen behind the needs of the increasing severity of hospitalized patients, and higher RN ratios will increase patient safety and quality of care (Feldstein, 2013).  They also argue that minimum legislated ratios will not become the maximum, but rather the best hospitals will exceed such standards and the worst will be forced to stop assigning eight or more patients to the medical surgical nurse (Dunham-Taylor & Pinczuk, 2010). They believe that failing to set minimum standards will not be impossible because of the shortage, but rather poor staffing is a cause of the shortage, and will continue until staffing is fixed.

Another drawback of the mandated staffing ratios is that staffing levels are determined by the government, away from the bedside. Given that it is only the hospital management that understands health care requirements in its units, it is controversial for the government to determine staffing levels, when the government officials do not have the slightest idea of hospital units. Also, mandatory staffing ratios represent a legislation that will take long to achieve the needed changes because they must go through legislation (Zimmermann, 2002). The minimum levels may become the standardized maximum for most hospitals, leading to deterioration in patient outcomes in hospitals and units where patients are many.

It may be difficult to achieve an agreement concerning what the optimal staffing level should be, among various nursing organizations. Also, the government assumes that a nurse is a nurse. Therefore, it bases the staffing ratios on mere numbers. This may be a misguided focus because the emphasis should be on patient outcomes, and not on mere members. It should be noted that having mandated staffing ratios does not guarantee the outcome of adequate staffing because staffing needs can change instantly, as a patient rapidly deteriorates. As far as different nurses are concerned, staff characteristics such as experience level, influence the patient load that a specific nurse can handle adequately differ significantly (Zimmermann, 2002). Besides, ratios may increase hospital costs (Feldstein, 2013).

The mandated staffing ratio denies nurse managers freedom to increase the number of nurses working on their units. This leads to loss of flexibility to move nurses around a hospital as the administration sees fit (Gordon, 2006). It should also be noted that the cost of compliance with legislative mandate may be excessive. Furthermore, ratios may prevent managers from staffing units with a suitable mix of inexperienced and experienced nurses. Any legislated minimum is likely to become the maximum for most hospital facilities. Nurses are likely to lose their control of their practice, and there may not be enough nurses to meet ratio requirements once the ratios are enacted. Only some hospitals have let RNs provide more care to fewer patients. Instead, they have directed them to give less care to more and sicker patients, as workloads have increased (Gordon, 2006).

Opponents of the mandated minimum ratios are vocal about the ineffectiveness of this approach.  They argue that nurse-to-patient ratios are counterproductive to evident-based decision making, and are inappropriate as a staffing methodology for the complex phenomenon of patient care. Ratios assume that care is constant within each level of care, despite the length of stay, skill mix, care delivery model, cost, competence and geography of the unit (Dunham-Taylor & Pinczuk, 2010).  The assumption contradicts what is known about patients by nurses that patients can all be very different, require very different interventions and have a variety of holistic needs, as much as they may be residing within the same unit. Therefore, adoption of inappropriate standards by units can result into a continuous cycle of unfulfilled expectations.

Some leaders may lower current effective RN staffing to the required minimum, hence reducing the quality of patient care. The legislated minimum in rural areas may be ineffective, as well as, trauma settings that have an extensive variety of patient care requirements (Dunham-Taylor & Pinczuk, 2010). This may lead to failure to rescue patients by nurses, where one nurse should attend to a large number of patients. Therefore, unplanned negative patient consequences occur.

Mandated staffing ratios do not consider the range of patient care acuity and fluctuations in daily care. It is assumed that nurses are always available. Unfortunately, minimum ratios could become the maximum ratios. The staffing ratios reflect the differing skills of nurses, and may force closure of hospital beds in the annual budgeting process. In addition it devalues the role of nurse critical thinking and judgement. The mandated staffing ratios assume a manufacturing model is appropriate for patient care, which is never the case. It removes staff accountability from the organization and transfers it to the government. it is imperative to note that patient care is widely varied in required hours and caregiver skill level (Dunham-Taylor & Pinczuk, 2010)………………………………………………………….

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