Safe Staffing: Why Ratios Aren’t the Answer
As the nursing community continues its fight for safe staffing mandates, another concept is being brought to light: acuity-based staffing. While every nurse would agree that staffing ratios are a positive change that will increase the safety of patients, many are voicing concern over the neglect of acuity in these new mandates.
The safe staffing legislature would require that nurses on different specialized floors may only have up to a certain number of patients. For example: 1:2 in ICU, 1:6 in med-surg, 1:3 in emergency departments. This is a big step up from the dangerously high ratios some hospitals work under, but it does not address the issue: how sick are these patients?
While it seems like such a fundamental consideration, many departments and units are not taking acuity into consideration when making staffing plans or patient assignments. Numbers aren’t all that matters here. Acuity based staffing protects the patients and the nurses. Creating acuity-based staffing plans allows nurses the chance to care for their patients appropriately. It helps protect nurses from things like burnout and medication errors. It helps hospitals prevent turnover.
Nurses and hospitals are under great pressure to perform well on customer satisfaction surveys like Press-Ganey. How can a nurse provide excellent customer service when they have high-acuity patients in their “ratio”? The important thing to remember here is that sick patients can deteriorate quick. Things can change in an instant. Nurses are the ones responsible for noticing these subtle changes and intervening as soon as possible. While the majority of their assigned patients may be stable and sleeping, the nurse may be faced with that one patient that now demands all of their time. Giving nurses safe patient assignments allows them the maximum amount of time to spend with their patients, which ultimately increases customer satisfaction and patient outcomes.
While acuity is extremely important in units like emergency departments and intensive care, it is necessary to consider in every department. One nurse may have the “easy assignment” with all stable patients, while another nurse is drowning. The care facility is still following its ratios…but are the patients safe?
Acuity-based staffing doesn’t have to be complicated. Some units are even doing it, and it’s entirely charge-nurse driven. Some units do a “shift huddle,” where they discuss the acuity of each patient and if the assignment is appropriate. Sometimes it’s as easy as splitting up a group of patients so one nurse isn’t burdened with it all. Some units have “float nurses,” a common practice in emergency departments, to take care of critical patients who require 1-on-1 care. However, when a department is only looking at nurses as numbers, the adequate number of staff may not be available for this.
Acuity isn’t the only factor to consider, either. Other factors include: access to ancillary staff and resources, average census of unit, location of hospital, and nursing staff experience level. Simply assigning an arbitrary, generic number of patients to nurse neglects these crucial elements, and does the patients an injustice.
Nursing organizations, like the ANA, are pushing for staffing ratio mandates that include nurse input. It’s the nurses who know what resources they have and when, what type of patients they have in a typical shift, and what staffing should look like. We, as nurses, are the ones caring for these patients 24/7, so shouldn’t we have an input on the regulations? Shouldn’t our voice be heard?
Agreed — especially from a legal perspective. Facilities can be sued for failure to ensure adequate staffing, which can put nurses in a hard place sometimes. The core value should be to put patient safety first, even if that is unpopular at some level of leadership. One resource to add support to nursing’s position is risk management. The American Society of Healthcare Risk Management (ashrm.org) is a good place to check as are quality monitoring sites such as Leapfrog.