Summary:
The traditional landscape of nurse staffing, a cornerstone of hospital workforce management, is undergoing a significant transformation. Historically, the planning and managing of these vital resources have been guided by conventional strategies that are now revealing their limitations, such as those associated with Nurse-Patient ratios. Although ratio-based health workforce planning may help provide some indication of baseline provider workloads and especially in places where existing health workforce planning capacity is limited or undeveloped, as highlighted by Saville et al. (2019), these methods suffer from ambiguous decision-making support, an unclear definition of "optimal" staffing, and a neglect for the environmental specificity, relevance, and complexity of nursing and/or provider tasks. The lack of empirical validation further exacerbates the issue, casting doubt on the effectiveness of these long-established practices.
Key Challenges:
The traditional landscape of nurse staffing, a cornerstone of hospital workforce management, is undergoing a significant transformation. Historically, the planning and managing of this vital resource have been guided by conventional strategies that are now revealing their limitations. As highlighted by Saville et al. (2019), these methods suffer from ambiguous decision-making support, an unclear definition of "optimal" staffing, and a neglect for the complexity of nursing tasks. The lack of empirical validation further exacerbates the issue, casting doubt on the effectiveness of these long-established practices.
Operational research (OR) stands at the forefront of this evolution, introducing innovative techniques that aim to revolutionize nurse staffing. Munro, Dowd, and Reynolds (2023) emphasize OR's potential, with its blend of problem structuring, advanced mathematical models, and numerical experimentation, to address the intricate nature of nurse staffing more accurately and flexibly.
The importance of adequate nurse staffing is underscored by the well-documented link between higher registered nurse levels and improved patient outcomes. Hong and Cho (2021) affirm that increased staffing correlates with lower mortality rates, reduced hospital stays, and fewer adverse patient events, highlighting the need for methodologies that can precisely determine the necessary staffing levels to align research evidence with clinical practice.
This paper introduces an overview of provider staffing approaches, drawing upon current research on nursing-patient ratios and best practice examples. We delve into the complexities of employment decisions, workload assessment, and the pursuit of optimal staffing—a concept yet to be concretely defined or measured. Echoing Wynendaele, Willems, and Trybou (2019), we propose an evidence-based approach that moves beyond the limitations of ratio-based planning, addressing key shortcomings such as lack of clarity, ignoring the complexity of healthcare, and the absence of validation. By exploring advances in accommodating variable patient demand, modeling skill mix, and balancing risks and benefits, we set the stage for future planning that includes investigating nursing team skill mixes, considering indirect patient care, quantifying staffing level risks and benefits, and validating staffing methods across diverse hospital settings.
Despite the extensive literature on nurse staffing ratios, empirical evidence directly linking these ratios to increased patient safety in acute hospital settings is scarce. The research conducted by Olley et al. (2019) reflects this gap in the literature, highlighting the need for more rigorous studies that can provide concrete data on the relationship between staffing levels and patient outcomes. While many articles propose various staffing models, few offer robust empirical evidence to support the assertion that specific nurse-to-patient ratios enhance patient safety.
However, the available research does suggest that equitable distribution of nurse workloads is achievable. This aspect is crucial as it relates to both the well-being of the nursing staff and the quality of patient care. Equitable workloads help prevent nurse burnout, which is known to negatively impact patient care and increase the likelihood of errors. Therefore, even in the absence of definitive evidence connecting staffing ratios to patient safety, there is value in pursuing staffing practices that promote workload equity among nurses. This approach not only supports a healthier work environment but also sets the stage for potentially better patient outcomes.
The practice of using nurse-to-patient ratios has been a cornerstone of health workforce planning. Ratio-based planning is broadly applied and introduces multiple challenges in service provision and management. Reports suggest that while specific nurse-to-patient ratios may diminish the risk of substandard care, their real-world effectiveness is inconsistent [ref].
Lillehol, B M, Lønning, K, and Andersen, M H (2018) highlight that even when an optimal nurse/patient ratio is achieved, maintaining it over time is challenging due to the dynamic nature of patient acuity levels. The staffing needs in nursing should be adaptable to the ever-changing care requirements, yet financial and human resource constraints often impede such flexibility.
Complicating matters further is the concept of nursing intensity (NI), acknowledging the significant variation in direct patient care needs. Since patient conditions are not uniformly severe, traditional nurse ratios fail to accommodate the individual and changing needs of each patient. Therefore, ideal staffing models should consider safe maximum limits tailored to various nursing intensity levels instead of a single uniform ratio – which is very resource intense.
Equitable high-quality nursing care is necessary for all patients, day and night, across all hospital areas. This necessitates a staffing strategy that optimally allocates personnel according to the contextual needs. Disparities in unit occupancy levels, for instance, can result in uneven workloads for nurses.
To sum up, while nurse-to-patient ratios are common to HHR planning, they require careful consideration and innovative thinking. Effective healthcare staffing transcends mere patient-to-nurse numbers; it encompasses a comprehensive system that evaluates patient acuity, health necessities, and demands to guarantee the delivery of the highest standard of care to every patient.
Discussions related to minimum nurse-patient ratios are often framed as benefits for preventing understaffing and its associated risks, but the responsive nature of healthcare requires more precision about the competencies of a given healthcare team: not just sufficient staffing but the right staffing to address both the organization and complexity of patient needs. With the increasing specialization in healthcare, patient needs are becoming more and more diverse and even sophisticated, requiring greater discernment and clinical capabilities from the care team.
Evidence from the University of Pennsylvania’s School of Nursing and CHOPR and others has repeatedly shown that patient outcomes improve with adequate nurse staffing. But this is only one part of the puzzle. The Pennsylvania Patient Safety Act proposes nurse ratios based on the model of care, as determined by each hospital unit – in effect acknowledging that different patient populations need different staffing configurations and competencies of providers.
A comprehensive model takes into consideration the severity of acuity and the responsiveness required by the patient needs and conditions, as the approach to staffing should consider strategic planning for not only the number of registered nurses required but also the appropriate number of certified and licensed providers on any clinical unit or in an entire hospital unit.
Along with registered nurses, the appropriate staff plan must include a minimum number of specialized practitioners – such as critical care nurses, paediatric or neonatal nurse practitioners, respiratory therapists, pharmacists, and the like – working together and making up the entire multidisciplinary and inter-professional team committed to incremental and shared care for patients.
Minimum nurse-patient ratios might be aspirational but it’s even more critical to recognize the role of acuity staffing. A staffing model must include a complementary set of competencies and capabilities necessary for any healthcare setting: not just sufficient staff, but staff capable of ensuring safety and achieving the best patient outcomes possible and without harm.
The use of provider-to-patient ratios are useful for setting a minimum standard for planning and calculating staffing needs, but they do not address the multidimensional reality of care delivery. Issues such as the varying care needs of different patients and the varying individual capabilities of nurses are but two of the many considerations that must be taken into account when planning using ratio-based methods.
Evidence has repeatedly demonstrated that what matters most is a more nuanced approach. As explained by the scholars Wynendaele H, Willems R and Trybou J in 2019:
"In addition to staffing levels, the skill mix (proportion of higher to lower educated staff) within the nursing team is crucial and can affect patient outcomes."
Similarly, Kouatly I A, Nassar N, Nizam M and Badr L K in 2018 explained that:
"Regulation policies tend to focus on staffing decisions through the headcount of patients per nurse, but patient acuity must also be taken into account."
Acuity levels reflect the degree of the patients’ illness and the amount of nursing care required to treat them, which can vary greatly, even among patients in the same unit (Cho, D D., 2023; Musy, S N., 2020).
Griffiths and colleagues (2020 and 2021), argue that evidence needs to focus on developing more complex staffing models that incorporate multiple variables to more effectively predict nursing staffing requirements.
A variety of multifaceted initiatives, such as nurse staffing and education, hospital policies and culture, not simply provider-to-patient ratios, are required to provide optimal staffing and quality care. And, while provider-to-patient ratios are an important element to the staffing equation, they are a very inadequate tool to address the myriad needs of patient care and the satisfaction of the nursing workforce. A robust approach to staffing in healthcare requires balancing skills mix, patient acuity, work environment, and the education of nurses into the nurse-to-patient ratios.
