Nurse Staffing: Are the Brits on the Right Track?

By Maureen Shawn Kennedy, AJN editor-in-chief

hazard/jasleen kaur, via Flickr

According to an article at Nursing Times, hospitals in England may be required to publish “nurse-to-bed” ratios as part of an overall “dashboard” of indicators to measure  performance. While some say this is a step forward, UNISON, the public service union that represents nurses, argues that the better ratio to measure is nurse-to-patient and that variables in patient acuity should also be considered.

Nurse staffing has become an issue in National Health Service hospitals and in April UNISON released results of a survey of over 1,500 nurses and other health care workers about their shifts during the 24-hour period of March 6. The vast majority of respondents (73%) felt they did not have “enough time to spend with patients to deliver dignified, safe, compassionate care.” The Royal College of Nursing also supports mandatory safe-staffing ratios that take into account the skill mix of RNs to “health care support workers” or nursing assistants. 

Here in the United States, California is the only state to achieve any legislation for mandatory hospital staffing and it is a “minimum” nurse-to-patient ratio. While similar legislation has been introduced in a few other states and nationally, it hasn’t advanced.

The ANA does not support mandatory minimum ratios per se, noting in its Principles for Nurse Staffing (2nd edition), released earlier this month, “The solution is not as simple as increasing the number of nurses beyond what is minimally necessary.” The ANA advocates for a “nurse-directed” approach that includes minimum ratios but also takes into account patient acuity, the setting, and the skill set and mix of staff.

At the recent House of Delegates meeting, the ANA reaffirmed that safe staffing is a “top priority.” (Read the press release.) And in a December 16, 2011, letter to the Centers for Medicare and Medicaid Services, the ANA advocated for public posting of “hospital staffing plans” that take into account patient acuity, mix of staffing, and other factors, with these staffing plans to be modified as needed according to measurable patient outcomes—but did not necessarily call for staffing ratios.

What do you think? Should nurse staffing details be made public?

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2016-11-21T13:09:48+00:00 June 26th, 2012|Nursing|55 Comments
Editor-in-chief, AJN


  1. Alfredo Wilson April 14, 2015 at 12:29 am

    This is a topic where there are many opinions and many points of views, yet the main priority is patients safety. My question is how many patients is safe for one nurse to provide high quality and safe care? In many hospitals settings a common cause for nurses overworked and nurses turnover is the amount of patients each RN has to take care of. These days the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) has become one of the “top” priorities for hospital corporations. I feel that safety and basic nursing priorities had been replaced by patients and patient’s family satisfaction. I agree that patient acuity must be taken into consideration when doing patient’s care assignments, and distribute the workload evenly among the nurses. I also agree with the ANA advocating for public posting of “hospital staffing plans” , as this may assist the public and nurses in deciding and evaluating the hospitals and the reasons for the outcomes, as well as nurses to be better informed when deciding to switch jobs.

  2. Jonathan Litt April 4, 2015 at 10:14 pm

    The nurse to patient ratio should be a top priority especially within the United States. California has led and succeeded with passing at least the basic legislation in an attempt to not only protect their residents but their nurses as well. Perhaps the reasoning behind the lag in its push by other state legislators is the patient’s outcome. So for instance the elderly patient dies and there is no family witnesses to prove that the nurse was overworked, thus causing their untimely death. So inevitably their death will just be chalked up to old age or it was just their time. While working in this field whether its on a telemetry floor, the emergency room, or medical/surgical unit the nurse is quite aware of how dangerous the lack of nurse-patient ratio law can be. It would be difficult for one to legislate a nurse to patient ratio especially when the ANA isn’t standing behind it. I understand that they suggest acuity levels should be a factor, but when is this going to start because at this time the acuity is not a factor and four out of your five patients that are currently under you care can be critical (which is unsafe). At least this type of legislation could prevent this. England at least is attempting to do what’s in the best interest for their patients and nurses instead of the United States that allows politicians to control everything, even our safety.

  3. Adeline Levy, RN April 15, 2014 at 9:10 pm

    Based on California’s mandated staffing ratios, research has shown a direct correlation between lower patient-to-nurse ratios and significantly decreased patient mortality rates, as well as, other increased positive patient outcomes. In addition, research also shows improved nurse retention and satisfaction with reduced nursing loads. Notwithstanding consideration for the multiple variables that affect nurse staffing at the unit level, I think that it is reasonable to say, that a nurse-to-patient ratio of 1:7 is definitely not commensurate with safe, quality patient care, regardless of patient acuity or staffing skill mix. This predisposes nursing care in such a setting to be more task-oriented rather than relationship-based, and more importantly, predisposes patients, as well as, nurses to increased risks. Unfortunately, this is the norm for many nurses and patients in South Florida.
    That being said, I think nurse staffing details should be made public. I feel that the exposure will force hospitals to reduce nursing loads to be competitive, as patients will seek the services of those hospitals with lower nurse-to-patient ratios. Moreover, this may provide an impetus to further advance legislation mandating minimum staffing ratios in those states which have already introduced legislation.

  4. Trish April 13, 2014 at 7:37 pm

    Working in a hospital setting has many challenges and opportunities for growth, if given the chance. There is always something to learn and improvements to be made. Nurses are capable of bringing about meaningful change and are in the position to impact many people through their innovation and influence. However, with the amount of work given to nurses nowadays, there is hardly any time to complete the basic tasks of an everyday shift much less to find time to revolutionize any quality change. Some tasks are necessary and within the nurse’s scope of practice and must be performed by a nursing professional, however, some can and should be delegated to the proper nursing staff. Overabundance of patients and workload has caused nurses to have little or no desire to go above and beyond basic practice. An increase in staffing would not only increase the amount of RN’s to handle the growing patient load, but also increase the amount of assistive personnel available to do tasks such as taking vital signs on time, doing IV’s, sitting with confused or disabled patients, assisting discharged patients, assisting with toileting, feeding patients and bathing patients. All of these tasks are unavoidable yet may take up a good portion of the RN’s day if appropriate personnel are not available to do them. The RN misses valuable time that they could spend sitting and speaking with the patient undistracted, being able to talk with the patient one on one and being able to explain medications in a comfortable setting, not hurriedly while walking them to the bathroom, while thinking about all the documentation he/she still has to do.

  5. Yvan Tranquille April 10, 2014 at 7:30 pm

    Nurse to patient ratio is very important issue. Many Hospitals all over the US are trying to cut back by having the least staff to do the work. They are disregarding patient safety and satisfaction. In Miami, Florida, some hospitals have nurse with 7 to 8 patients of telemetry. Most of the time, you do not have charge nurses or PCAs. You are on your own without help. When you talk to the manager about the situation, you are told that you are not allowed to refuse patients, you just have to deal with the situation and be a teamplayer. Many places only care about documentation; If you did not document something you are in trouble. If something happen during your shift, you are in trouble. No matter the amount of patients they give you without charges nurse or with a charge nurse that has a full team of their own, without a PCA and no secretary, they expect everything to be done on time and for the patients to be happy. These practices are unsafe. We need rules and regulations regarding staffing and nurse to patient ratio in Florida and other states in the US.

  6. mmcs1998 October 14, 2013 at 2:17 pm

    A proposal should be presented to Medicare as a pilot to demonstrate that increased hours would provide quality of care that would result in decreasing adverse incidents i.e. readmissions, infections, falls etc. RN hours would be used appropriately in educating patients to improve their quality of life & increase their ability to live out of an ER need.

  7. mmcs1998 October 14, 2013 at 2:02 pm

    I believe with all the Medicare concerns re: readmissions, adverse incident i.e. infections, falls,etc that one could propose a pilot program with increased nursing hours to prove why they will decrease costs & improve quality of care. I believe patient education re: their condition, how to manage & discussions re: post hospital care would improve also.

  8. Yuliet M. October 13, 2013 at 10:09 pm

    It is my believe that establishing a minimum nurse-to-patient ratio could help to prevent medical errors, save lives, improve the quality of care and help to address the nursing shortage by creating a work environment that encourages nurses to remain in the hospital workforce. In a survey of almost 220,000 RNs from over 550 hospitals nurses reported to ANA that nurses in adult medical units and emergency rooms do not have sufficient time with patients. Overtime has increased during the past year with 43% of all RNs working extra hours because the unit is short staffed or busy; and that inadequate staffing affected unit admissions, transfers and discharges.

  9. Britney Stark August 2, 2013 at 11:22 pm

    Nurse staffing is a constant issue at my hospital. Between that and asking the notorious question “are we getting an aide?” you’ll be blue in the face by morning. My job is very strict with the budget and keeps close tabs on how many patients vs. nurses are on the floor vs. who is agency or staff. Every night around 9 the nursing supervisors come by on their walk of shame to take a glimpse at the patient board and decide if s/he is going to send a nurse home due to “over-coverage”, move and aide to another unit or send them home. Nine times out of ten this is very frustrating because when the supervisors look at numbers they are not considering acuity. A patient load of four one night can be just as or more rigorous as a load of 7. Only one time have I seen the charge nurse beg and plead with the supervisor and us be able to keep a nurse because the night was so hectic with post-ops that were in fragile states. Nursing staffing should be made public because it would make hospitals more responsible for their utilization of staff. It would also be a good source of reference to consider when HCAPP scores come back low. Many times satisfaction drops under periods of staffing issues. This may motivate hospitals to be more considerate of how many nurse they to ensure satisfactory care and treatment of patients and less budget crazy.

  10. Ileana R August 2, 2013 at 8:16 pm

    Seeing that there is a nursing shortage, and that it is going to continue to worsen; this is an issue that has to be addressed appropriately. Hospitals in England have initiated the nurse-to-bed ratio, which in my opinion would be a complete fail in the United States. Hospitals in the United States already have a nurse-to-patient, which are not always followed because of short staffing. Time is needed to dedicate time to a patient, and when a nurse is overloaded with extra work because of extra patient load, there is not enough time for that to occur. This is when accidents and occurs occur, which in the end cause more money to be spent and wasted. Other states need to follow in California’s minimum nurse-to-patient ratio. This may be what health care truly needs for improvement.

  11. Patricia Santana August 2, 2013 at 6:50 pm

    The publicity of nurse per bed ratio in England indicates one step forward for the improvement of the nursing profession around the world. The “nurse-to-bed” ratio is an issue that affects all hospitals’ quality of care. It becomes overwhelming when nurses have many patients requiring many things at the same time. The proper distribution of patients based on their acuity level potentially influences the delivery of care for the patient. As mentioned in the blog written by Kennedy, California is the only state in the United States with a mandated patient-nurse ratio. Some benefits that California have from the nurse staffing mandating ratio are that their nurses need less ancillary help compared to other hospitals in other estates, their patients are less likely to have a negative outcomes while staying in the hospital, nurses are able to deliver high quality care to all of their patients, and nurses are more likely to stay on their jobs for a long time (Aikan et al., 2010).
    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A.,
    Spetz, J., & Smith, H. (2010, April 9). Implications of the California nurse
    staffing mandate for other states. Health Services Research. Retrieved from

  12. alexis F. August 1, 2013 at 9:00 pm

    In order to educate the public and advocate for the profession I think nursing patient ratios should be made public. Well informed customers make better choices on decisions affecting their health care. The minimum nurse to patient ratio mandates passed by legislation in California have shown positive outcomes in patient safety. Studies and research on this subject have shown a strong correlation between lowering nurse’s workloads and positive patient outcomes. Making current nurse to patient ratios public will encourage health care corporations to implement minimum ratios similar to the standards passed in California. For example, a hospital or health care organization that advertises itself as being responsible towards the health care of their patients will feel pressured to meet these criteria. As it is, those hospitals that don’t meet the ratios give the public a false impression of their commitment to health care.

  13. Lauren S. August 1, 2013 at 4:55 pm

    I am quite disappointed to hear that the American Nurses Association (ANA) does not publicly support mandatory staffing ratios. As it has been said before, the ratios are not the only issue at hand. Care should be paid to ensure appropriate staffing based on acuity as well, but these staffing mandates are necessary to ensure safety when business takes priority over patient safety, as it so frequently does.
    From a consumer standpoint, I think it is brilliant to draw attention to these numbers as a point of attraction for business. Without legally requiring a ratio, hospitals now have incentive to better staff their units. Improving patient ratios has time and time again been proven to be beneficial to both staff and patients. If a company continues to benefit these two groups, the profits will not follow far behind.

  14. Ian Diaz July 31, 2013 at 5:30 pm

    Mandating a nurse to patient ratio is the best solution for ensuring better patient outcomes. According to Aikan, Sloane, Cimiotti, Clarke, Flynn, Seago, Spetz & Smith 2010 increased nurse to patient workloads had an increase of post-operative mortality by seven percent. Decreasing a nurse’s workload will lead to better quality of care, lower rates of nursing burnout, earlier identification of significant changes in patients and increases the chance a patient will be discharged alive (Aikan et al, 2010). Although the American Nurses Association (ANA) currently does not support a mandatory nurse to patient ratio, they do support a “nurse-directed” approach, which does include minimum staffing ratios. The ANA’s request to post hospitals staffing plans will only slow down chances for improving patient outcomes. Instead there should be a public posting of a side by side comparison of hospitals that have mandated nurse-patient ratios to hospitals that do not, illustrating their patients outcomes. I truly feel that mandated nurse-patient ratios will not only benefit patients but also the nursing workforce.

    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J.,
    & Smith, H. (2010, April 9). Implications of the California nurse staffing mandate
    for other states. Health Services Research. Retrieved from

  15. Yarelis July 28, 2013 at 5:44 pm

    Working at two different hospitals has made me realize the importance of a mandated nurse-patient ratio. Although both hospitals are near each other, the quality of healthcare delivered is exceptionally different. This difference is mostly due to the inequality in the amount of patients a nurse cares for in the emergency room. I believe nurse-patient ratios should not be published, they should not be important to the community. This is mainly because the public does not know how to distinguish the acuity of each patient. In any given emergency room, the door to doctor time is given much importance not the doctor to patient ratio, the same should be for nurses. Staffing of a unit is of ultimate importance, however, I do not wish for a patient to tell me that I should hurry because he/she knows the amount of patients I have at the moment. Unfortunately, California is the only state to have mandated nurse to patient ratios. If this would be the case in Florida I would not find myself practicing nursing differently at these two facilities.

  16. Ashley July 15, 2013 at 1:03 am

    I agree that nurse staffing is very important so that dignified, safe, and compassionate care is provided to patients. It is important to have nurses and patients surveyed in order to collect their feelings on nurse-to-patient ratios. Patient safety is definitely the main concern on this topic but dignified and compassionate care is also essential. California nurses seem to be satisfied with their newly mandated nurse-to-patient ratio laws. They are able to spend more time with their patients and feel they are providing better care because of it. Safe staffing is of high priority and should be mandated appropriately by the government. I do believe that nurse staffing details should be made public so that all consumers are able to view the nurse-to-patient ratios.

  17. janiset April 15, 2013 at 6:36 pm

    I agree that mandated nurse to patient ratios is a necessity in order to provide the best care to patients. However, after reading this article I will have to concur with the ANA opinion. I feel that it is important to take into consideration patient acuity, the setting, and the skill set and mix of staff also. All of these points are key elements to establish a safe health care system. Hospitals are in a constant hiring process, and shortage is one of the issues that our healthcare faces now a day. Safe staffing has become a concern globally in the nursing profession, and it is affecting the quality of care that most patients receive every day. By following the ANA approach to nurse-patient-ratio, I consider that not only it will be an Improvement in patient safety health care delivery but also a reduction of medical errors, and an increase in nursing interests and patient satisfaction.

  18. Georgette Stiban April 15, 2013 at 6:21 pm

    I’m a firm believer in having nurse-patient ratios available to the public; but just as UNISON suggested, factoring in the patient acuities are vital to ensure safe patient loads. Not every intensive care unit has the same patient acuity, and this applies to all areas in hospitals and clinics. Once the acuity and nurse-patient ratio are available to the public, nurses will have realistic expectations of the available employment opportunities to them and patients will be able to research which institutions they prefer ahead of time. This is important to patients because safe and compassionate nursing will not occur in hospitals where nurses are overworked and care for large and unsafe patient loads. If providing staffing and acuity information was required, there will be a greater initiative to correct understaffing and overloaded nursing assignments; this in turn, will decrease burnout rates and offer nurses a safer and more pleasant environment setting to work in.

  19. Victoria Franciscus April 15, 2013 at 4:45 pm

    I believe that nurse/patient ratios should be made public This is an important piece of information for health care consumers and should not be kept a secret. Data is published related to safety issues, medical errors, quality order that the health care consumer is able to make an educated, informed decision. Ratios is another important piece of the puzzle.
    But it is not the be-all and end-all of this dicussion. I agree with the ANA that there is more to this subject than simply ratios but that is still no excuse for their inaction. The ANA represents nurses and it is distressing that they are unwilling to put themselves out on a limb for the very people they represent because the subject is “complicated”.
    We use scales to evaluate fall risk and skin breakdown risk in our patients. A scale to evaluate acuity would not be difficult at all to develop.
    It could be managed in several ways that would provide valuable information.
    It could be done by the nurse during the initial shift assessment. It could be done by the computer itself with a simple program set to calculate the data from the assessment and assign a number for acuity. It could also be done by the charge nurse during her rounds.
    It should include factors such as educational needs, emotional needs, physical needs as well as high risk medications,hemodynamic stability and airway issues.
    With so many options open to us to evaluate acuity, why is it that this is not being implemented? I can sadly only assume that finances are the bottom line and not patient satisfaction and safety.

  20. Priya Bhatt April 15, 2013 at 8:54 am

    Nurse staffing ratios must be made public. I believe that California would be the most beneficial state to work in due to the minimum nurse to patient ratio. When the nurse to patient ratio information is made public, patients can decide if they prefer hospitals with minimum ratios. With fewer patients, nurses have the opportunity to provide quality care to patients. Studies have shown that smaller nurse to patient ratios, leads to less mortality as well as leads to earlier recovery and discharge. These smaller ratios would allow us to provide safer care to our patients and allow us to give patients the care they deserve.

  21. alvaro April 13, 2013 at 9:36 pm

    Unfortunately, California is the only state to implement a minimum nurse patient ratio law. In Florida, we have hospitals mandating and forcing nurses to take patients more than they can handle. This practice jeopardized the care and quality that can we give to our patients. Nurse needs to be organized and started a petition that will go to our congressman and senators explaining the importance of the staff and patient safety. Nurses work very hard and with this amount of patients, we cannot give a proper care nor an appropriate teaching to our patients. We need to stop the abuse of the facilities, especially the profit hospital which their only concern is their money. We need to put patient ratio into safe practice again. We are working in unsafe, and unfair conditions.

  22. Jessica Messer April 13, 2013 at 3:38 pm

    The nurse-patient ration problem is nothing new, in fact I would imagine the issue has been minimized in recent years due to legality matters, nurse burn-out, and possibly even the popularity of nursing programs. Yes, the hospital is a business, with numbers and money a very important topic so implementing a standard nurse-patient ratio is tricky and probably not popular. I agree that acuity is probably more important to consider. I have personally experienced the benefits of staffing according to the patient acuity. This is much safer and minimizes nurse burn-out, not to mention improves patient satisfaction. Ultimately, patient satisfaction is what truly boosts a hospital’s financial gain, right? Publishing nurse-patient ratios is not really important. Implementing these ratios according to acuity is far more effective. State laws are the best way to accomplish this. Maybe having a grid that takes into account each patient’s particulars would help.

  23. Tanya Karkella-Gjergji April 11, 2013 at 8:42 pm

    Nursing staffing should be public information. I agree that mandated nurse to patient ratios is essential for optimal patient care. With California having this legislation, more time is available for the nurses to spend with the patients; increasing the quality of care. I also feel that it is important to take into account the severity of the patients’ health conditions when assigning the patients. Having a high patient to nurse ratio can lead to more errors and nursing burn out. By lowering the patient to nurse ratio, the quality of care delivered to the patients would be more satisfying. Also, I believe the nursing shortage has a huge effect on the patient to nurse ratio. It is important for nursing schools to have some type of job placement for their students upon graduation. This can help the hospitals keep nurses employed and the patient to nurse ratio at a minimum.

  24. Raquel Diaz April 9, 2013 at 9:56 am

    I believe that any step in the right direction will get us closer to our goal. Nevertheless, I do agree that there is a lot more to nursing ratios that need to be considered. A nurse to bed ratio will reveal some of the nursing issues we currently experience; However, it will not take into consideration the acuity of the patient, whether the beds are occupied, nor how many hours a week the nurse has worked. In order to provide quality care, improve patient outcome, and prevent nurse burnout, nurse-to-patient ratios should be mandated in every country and state. Nurses have the power to affect quality of care and patient outcome in a positive or negative way. Thus, it is in everyone’s best interest that nurses are given a nurse-to-patient ratio that will result in the best quality of care and patient outcome. This should be a top priority because it affects everyone.

  25. Monica Cherhynets November 26, 2012 at 11:03 pm

    Nurse to patient ratios should be mandated. Safety and patient care are determined by the amount and the acuity of patients. The ANA recently stated that ratios should be safe but there is no mention of specific ratios. The ANA also mentioned that staffing safely depends on the acuity of patients. The ANA has not considered that patient care is unpredictable. Patients may become confused, may not swallow their medications without being crushed, they may become unstable, or they may want their nurses attention. It is unlikely for nurses to go through a shift without running into one of these issues.These are some of the examples that take time and dedication. In order to attend to these needs in a safe and proper manner nurses need less patients. Nurses are being overworked in order for hospitals to save on expenditures. Important changes in patients status are being missed, and patients are not able to express themselves without being interrupted. Nurses are being robbed of the time they would like to spend with their patients, and patients are being robbed of quality care. Errors in medication administration, falls, and proper assessments would be accomplished with a safe nurse to patient ratio. Nurses are continuously voicing their need for a mandate without being listened to. A mandate in nurse to patient ratios should be a priority to the ANA.

  26. Yesenia Osle November 26, 2012 at 10:24 pm

    I totally agree that the nursing- patient ratio in hospital should be made public. Reducing nurse – patient ratio is a cause effective way to improve patient outcomes. California unfortunately is the only state that has the legislation for mandatory hospital staffing, and after two years of implementation of this regulation, California has shown mortality reductions in patient care were associated with increase nursing staffing (Aikan, Sloane, Cimiotti, Clarke, Flynn, Seago, Spetz, & Smith, 2010).
    I also believe that accuracy of patients should be taken into account when setting nurse- patient ratio. But who determine in our hospitals the accuracy of patients? In most of the health centers is the administration the one that decides nursing patient ratio. Nurses are the one that take care patients and know them more than anyone and even though, they let the administration to take decisions about patients care. I think nurses have to step up and voice their opinions.
    I work in a trauma center with burned and trauma surgical patients. Last month the administration decided to add another patient to our ratio. During this month, I’ve become myself a task oriented nurse, not being able to be the advocate and the teacher that every patient need. Therefore, I’m really thinking to leave bedside care; first because I think is not safe no more, and second because nursing at hospitals is not patient oriented no more.
    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith,
    H. (2010).Implications of the California nurse staffing mandate for other states. Health Services Research. Retrieved from

  27. Maria Serna November 26, 2012 at 9:36 pm

    It is good to see the topic of nurse to patient ratios getting world attention. Being a nurse I can cofirm that this is a problem. Having recently taken a class with an assignment regarding this subject I feel that our profession would benefit greatly from implementation of nurse-patient ratios. A recent study done comparing the mandatory ratios of California to Philadelphia and New Jersey provided substantial evidence that the lower patient-nurse ratios in California have resulted in many fravorable outcomes for both nurses as well as patients. Patient survival improved, their satisfaction of service improved, ability to care for themselves post ambulatory was greater, and hosital stays were reduced. The implementation also proved beneficial for nurses with a reduction in employee turnover, a marked lowering in nurse frustration on the job, and the extra nurses helped to lessen nurse burn-out. The California mandates have lead to more states doing the same. It is also very positive to see this becoming a world issue as well. It is through the release of nurse staffing details to the public that can lead to gauging the effectiveness of these studies.
    The study refered to in this post can be retrieved from,

  28. L. Chavez November 26, 2012 at 9:13 pm

    There is no doubt that nurse staffing ratios continue to be an issue worldwide, especially now with the current nursing shortage we are facing, which sadly, it is expected to continue growing. In my opinion, nurse-staffing ratios should be public and mandated, taking into consideration patient acuity because the higher the acuity, the more care that patient requires, therefore the lower the nurse-to-patient ratio should be so that we can provide enhanced quality of care and have better patient outcomes. Additionally, previous studies in this matter, show that lowering nursing staffing ratios indeed decreases nurse burnout and job dissatisfaction which at the same time also improves nurse retention, work environments and workloads, consequently decreasing patient mortality, medical errors, and safety issues (Stanton, 2004). It is a shame that the ANA do not support mandatory staffing ratios especially when California is the only state in the U. S. that implemented nurse-to-patient staffing ratios, and demonstrated that it is a total success (Aiken, et al., 2010).

    Aiken, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H. (2010, April 9). Implications of the California nurse staffing mandate for other states. Health Services Research. Retrieved from

    Stanton, M. W. (2004, March). Hospital Nurse Staffing and Quality of Care. Retrieved November 26, 2012, from Agency for Healthcare Research and Quality:

  29. Marcela A. November 26, 2012 at 4:33 pm

    Nurse-patient ratio implementation is a measure taken towards patient safety and nurse job satisfaction. As nurses, we know how frustrating it is to try to provide the best and safe care possible but sometimes it’s just not possible due to staffing issues. California has been the first state to implement nurse-patient ratio legislation. The Agency for Healthcare Research and quality (AHRQ) found that, in a study between California and two other states without a nurse-to-patient ratio mandate, that California had fewer patient deaths, higher nurse retention on the job, and nurses reported less burnout and higher job satisfaction. Knowing this, I think making nurse staffing issues public would help people make informed decisions when it comes to healthcare.

    AHRQ. Agency for Healthcare Research and Quality. (2012). State-mandated nurse staffing levels alleviate workloads, leading to lower patient mortality and higher nurse satisfaction. Retrieved

  30. Richard Haig November 26, 2012 at 2:09 pm

    After reading the blog by Maureen Shawn Kennedy and the UNISON survey study included in the text, I have came to the conclusion that, although a “nurse to bed” ratio would be a step forward, there are minor tweaks that must be addressed before this system to work. Patient acuity must be taken into consideration. For this I suggest relying on both “nurse to bed” ratios, for the expected acuity for a given unit, and then utilizing “nurse to patient” ratios afterward for special consideration, much like a heavy patient load or high acuity case. This hybrid approach could fill many of the holes that exist in both ratios. In the survey study Adams stated: ” Self-policed minimum staffing ratios may be ignored or overridden, or they may have been arbitrary or intentionally low to begin with. Protocols to address understaffing issues are used by staff, but then ignored by management.”(2012) From this, it is clear that having mandated ratios, much like in California, are the second condition for staff/bed ratios to work. Finally, the skill mix of the given unit must juggle safe care with training new nurses and assistive personnel.

    Gail Adams, (2012). Care in the balance: a unison survey into staff/patient ratios on our wards. Retrieved

  31. Viviana Castillo November 26, 2012 at 12:33 am

    I believe making “nurse-to-bed” ratios part of the public records is a good idea. Patients should have the opportunity to search and decide what hospital they would like to visit; after all, they are clients in the healthcare system. Nevertheless, in acute circumstances one will not have the luxury of deciding where to receive medical treatment. In the case of elective procedures, pre-planned admissions or short stay visits, I believe patients should be able to make educated decisions and attend the best hospital that they can afford. Personally, if I had this data available before being admitted, I would prefer the hospital with the lowest nurse-to-patient ratio. There is extensive literature that supports that lower patients ratios results in better patient outcomes “Each patient added to nurses’ workloads was associated with a 7 percent increase in mortality following common surgeries” (Aikan et al. 2010, p. 2). If this requirement is passed in England, it will be interesting to see the effect this has on patient satisfaction, and if this change will pressure hospitals into re-evaluating their nurse-to-patient ratios.
    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H. (2010, April 9). Implications of the California nurse staffing mandate for other states. Health Services Research. Retrieved from gRatios.pdf

    This articles covers in more detail the effect of lower patient ratios in a study conducted in New Jersey and Pennsylvania hospitals.

  32. asaviklund001 November 23, 2012 at 9:01 pm

    This is a serious issue for the entire world community. The short-staffing of nurses can be quite detrimental to the health of patients, and the professionals that care for them. It increases burn-out and job dissatisfaction, and contributes to poor patient outcomes (Aiken et al., 2010).

    I believe that the nurse staffing details should be made public. While I do agree with some of the above posts, in that nursing to patient/bed ratios do not tell the whole story, I do think that making them public is better than nothing. In preliminary studies, mandating a sensible minimum nurse to patient ratio has been shown to decrease mortality, and increase job satisfaction. In addition, nurses felt like they were able to provide a higher quality of care to their patients (Aiken et al., 2010).

    So, while knowing the nursing staff ratio does not guarantee a top-notch experience in the hospital of one’s choice, it can provide the consumer with a reasonable expectation that they won’t be “left to the wolves”, so to speak. In my experience, fewer patients usually means more individual face-time and care. Having the ability to choose a hospital with a smaller nurse to patient ratio can help the consumer to achieve a better patient outcome; all other things being equal. More information has the opportunity to help empower the client in their own healthcare decisions.


    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn,
    L.,Seago, J.A., Spetz, J., & Smith, H. (2010, April 9).
    Implications of the California nurse staffing mandate for other
    states. Health Services Research. Retrieved from

  33. asaviklund001 November 23, 2012 at 8:57 pm

    This is a serious issue for the entire world community. The short-staffing of nurses can be quite detrimental to the health of patients, and the professionals that care for them. It increases burn-out and job dissatisfaction, and contributes to poor patient outcomes (Aiken et al., 2010).
    I believe that the nurse staffing details should be made public. While I do agree with some of the above posts, in that nursing to patient/bed ratios do not tell the whole story, I do think that making them public is better than nothing. In preliminary studies, mandating a sensible minimum nurse to patient ratio has been shown to decrease mortality, and increase job satisfaction. In addition, nurses felt like they were able to provide a higher quality of care to their patients (Aiken et al., 2010).
    So, while knowing the nursing staff ratio does not guarantee a top-notch experience in the hospital of one’s choice, it can provide the consumer with a reasonable expectation that they won’t be “left to the wolves”, so to speak. In my experience, fewer patients usually means more individual face-time and care. Having the ability to choose a hospital with a smaller nurse to patient ratio can help the consumer to achieve a better patient outcome; all other things being equal. More information has the opportunity to help empower the client in their own healthcare decisions.

    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L.,
    Seago, J.A., Spetz, J., & Smith, H. (2010, April 9). Implications
    of the California nurse staffing mandate for other states. Health
    Services Research. Retrieved from

  34. Laurie Collins November 23, 2012 at 2:07 am

    Publicizing staffing ratios is a step in the right direction, considering the fact that hospitals already publicize their accreditation’s, quality standards, state of the art equipment, new operative and diagnostic procedures etc., all in an effort, to bring in more patients. I think publicizing staff ratios in addition to implementing universal staff to patient ratios will benefit the hospital, the patient and the nurse.The hospital can promote this information, as a marketing strategy. The consumer can benefit from this information when it comes to selecting a hospital. The nurse will have a workload that will allow them to provide that excellent care.

  35. C. DelaCruz November 13, 2012 at 11:58 pm

    I believe if the nurse-patient ratio is documented as public information just as how they post hospital ratings, a few patients will take that into consideration in choosing a hospital, a few will be hospitalized and not have a choice and others will hope for the best. If posting the ratios will cause a change for mandates, I support publicly posting ratios. “Excellence is a ‘stretch’ goal, but if everyone stretched a little, the shape and quality of the organization would be transformed” (McBride, 2011, p. 216). With better nurse-patient ratios we can strive for excellence in health-care.
    I currently work at a hospital in Florida which base the staffing on an acuity rating. If only it would capture the true rating of complexity of each patient. I constantly come across patients properly accounted for and only rated 2 out of 5, but in realty need to be at the least a 3 or 4. But in the end, when they don’t have the staff to even help, we work with what we have. The for-profit hospital I work at typically has a 1:4 ratio for a night-shift nurse on a medical/oncology floor. Other local not-for-profit hospitals have a nurse-patient ratio of 1:6 or 7 on a medical floor.
    It is true there are hundreds of graduating nurses every semester, but does the hospital have the budget to hire now? My boss has mentioned in response to the staffing shortage she is waiting on approval from human resources for a nursing position. In the mean time she cuts how many nurse’s aides are on the floor to allow for an additional nurse to work instead. Thus bringing us back to our normal 1:4 ratio.
    McBride, A. B. (2011). The Growth and Development of Nurse Leaders. New York: Springer Publishing Company.

  36. Angel Moreno-Cruz August 6, 2012 at 10:44 pm

    I believe that merely establishing a minimum nurse to patient ratio without taking into consideration the acuity of the patient will do a disservice to those looking to establish criteria for proper patient care. I also believe that the British drive to establish nurse-to-bed ratios is founded on a metric that is flawed at its core. Establishing a recommended nurse-to-bed ratio (as well as establishing a minimum nurse-to-patient ratio) without considering patient acuity will only serve to provide a false sense of progress with respect to patient care. As everyone in the industry knows, some patients require far more care than others. Without establishing a system to classify patients in terms of the amount of care required, a nurse can be overwhelmed, and yet only have to care for one or two patients at a time. Patient care needs, and the amount of time needed to properly care for each patient, rather than a mere ratio, should be used in establishing a proper patient-to-nurse ratio.

  37. Cindy August 6, 2012 at 10:22 pm

    California is on the forefront of safe nurse to patient staffing. The California mandate has decreased the incidence of nurse burnout rates, decreased patient mortality rates and increased nurses job satisfaction. This state serves as an example which will be followed by many states in the future. I don’t see any harm in reporting nurse to patient ratio’s publicly. It provides patients who are researching hospitals a clue in regards to the type of care they will be receiving from the nursing staff. Patients are very knowledgeable and are aware that higher nurse to patient ratio’s will result in a decrease in care. It also serves as a point of reference for nurses who are seeking employment in theses institutions.

    Staffing ratios are an imminent problem the nursing profession faces. This problem must be resolved to decrease the nursing shorting and increase nurses satisfaction. I do also agree with the ANA regarding patient acuity. Patient acuity is a key component and should also be taken into account when creating an assignment. I do believe this problem will be resolved! This topic is brought up at many political encounters and is receiving the necessary attention to see changes happen.

  38. Shelly-ann Commock August 6, 2012 at 10:15 pm

    Nurse-patient ratio is a serious issue. It is important that a nurse should be able to provide the best amount of care possible for patients that they have on their shifts. California alone should not be the only state that made legislation that looks out for both the nurses and the patients’ safety. Other states should take more action. Reason being if a nurse has too large of a patient ratio lives will most definitely be at stake. I think it is even more disturbing that the ANA does not see the priority of have having a nurse-patient ratio. They are going around the most important issue at hand, which is sufficient patient care.

  39. Sherald Jordan August 6, 2012 at 5:02 pm

    It is disappointment to know that the American Nurse Association (ANA) does not support
    the nurse-to-patient ratio. The mandated ratio experience has successful and more importantly, no
    patient has been harmed under the California Nurse- to- Patient Ratio law. This law has translated
    into better care and more satisficed nurses.
    Some healthcare organizations cannot find common ground over the decision to introduce this
    law. Many administrators are wary of the financial implications of mandated ratios. Many nurses I have
    spoken to feel that this law of nurse-to patient ratio would provide a benefit , as nurses
    are being asked to look after more and more patients each shift . It is frustrating to hear the patient
    who is in pain, calling for help and you are in another room assisting another patient in the bathroom.
    It is also frustrating for the nurse to have numerous patients demanding your attention while you
    can only perform one task at a time.
    Increasing staffing will lead to a better outcome resulting in less burnout for the nurse,
    enhanced morale which would l improve the number of qualified nurses to remain in the profession.

  40. alberto candelario August 6, 2012 at 4:50 pm

    Safe staffing has become a concern globally in the nursing profession, and it is affecting the quality of care that most patients receive worldwide everyday. Hospitals are in a constant hiring process, and shortage is one of the issues that most acute care settings face nowaday. In several occasions the American Association of Nurses (ANA) has advocated for the nurses and their right to deliver appropriate care to patients, and it has come to the attention of other organizations how this is impacting not only the nursing career, but also the healthcare system and the service that most patients receive. Nurses experience the frustration of not being able to appropriately care for patients because of the nurse-patient ratio that seems to continuously increase in most acute care settings. In most cases, nurses are not even able to make a thorough assessment in patients due to the lack of time and the amount of work as a consequence of an understaffed floor. The nurse-patient ratio is an issue that should be brought to the board of nursing and joint commission on the accreditation of health care organizations (JCAHCO) in order to hold hospitals and other types of health care institutions accountable for providing true quality of care to patients, while preventing nurses from the frustration and burn out experience of having to take care of a number of patients that jeopardize and puts their licenses at risk.

  41. perette August 6, 2012 at 2:21 pm

    Nurse staffing issues I believe will continue to be an argument that may never see much change in the near future. Many people may argue that we need more nurses to cover the sick. However, I tend to have a different point of view. I prefer to continuously promote healthy lifestyles so that less people are admitted to hospitals and require less health assistance. Besides, to be very honest, not everyone has the ability to be a nurse. This is a lifestyle, not job, which really requires skills, such as patience, understanding, critical thinking skills and much more. Nurses also wear very many hats that many people are unable to handle such as caregiver, advocate, interpreter, babysitter, friend, assistant and many more. So maybe the solution to the nurse to patient ratio isn’t only the lack of nurses, but maybe the overwhelmingly supply of sick people. I think more efforts should be made to make the world a much healthier place. For example, here in the United States, and I’m addressing the South Florida area in particular, almost every hospital has a McDonalds in the hospital itself or very nearby. This type of access is the problem. Foods that are not prepared in a healthy manner are too accessible and the healthier choices cost much more. So in the end I believe that further effort most definitely need to take place in making the world healthier and maybe this will contribute to the decrease of patients to nurses.

  42. Mario Del Valle August 6, 2012 at 1:16 pm

    After spending ample time reading this article and reflecting back on it I quickly realized that the American Nursing Association (ANA) has no interest in a set nurse to patient ratio. Out of all 50 states in our nation, only California has passed laws limiting the nurse to patient ratio. The ANA, however, believes that limiting the nurse to patient ratio is not the answer to solving the problem. Furthermore, they believe that patient acuity as well as the skill set of the staff, among other factors, is what truly needs to be taken into account to resolve the issue. Although, skill set and acuity are certainly contributing factors in a hospital setting, lowering nurse to patient ratios will certainly be beneficial to all parties. Lowering nurse to patient ratios will bring better health care to each and every patient while limiting the burnout rate as well as decreasing stress to our fellow nurses. Allowing nurses to have a decreased workload will allow to them function better as well as increasing their overall quality of care to their patients. Mistakes due to burnout will also significantly decrease as a result of lowering the nurse to patient ratios. The issue of nurse to patient ratios is not only an issue in our country but also in many countries around the world. Only time will tell to see how long and how quickly these issues will become resolved to better over all the quality of care of patients.

  43. Mirna Flores-Serrano August 6, 2012 at 11:29 am

    Nurse to patient ratios definitely needs some reinforcement but it is important to take into consideration of the patient acuity. Ratios alone do not stand without acuity. But it is ideal to raise awareness of these ratios to the public in order to enforce a higher nursing care practice. Not only raise awareness to the public but to support the nurses who are voicing their opinions on the nurse-to-patient ratios that are very demanding. For right now California may be the only state with the mandated law but if we, as nurses, fight harder for the patient’s best care possible, we too will be able to accomplish this.

  44. Sudian Hendrickson August 5, 2012 at 7:34 pm

    Nurse-patient staff ratio should be mandated, however that does not mean that acuity should not be addressed. Depending on the unit, patients’ status can change rapidly. Another reason why I feel that nurse-patient staff ratio should be mandated is because the instability of one patient can affect the amount of time the nurse spends with the other patients. Patients are being discharge out of the hospital with limited teaching because nurses have so many tasks with not enough time to complete them. The hospitals have high expectations, but sometimes I feel as if the environment is not set up for those expectations to become reality.

  45. kristina d August 4, 2012 at 12:41 am

    I agree that nurse-staffing ratios need to be improved and assignments should be based on patient acuity. California has done a great job on addressing these issues with their nurse-to-patient legislation. Studies in California proved that since the legislation went into place nurse satisfaction increased and patient outcomes improved. However, mandatory posting of nurse-to-bed ratios is not going to address the real issue a hand. The real issue is that there are not enough nursing school faculty. In turn not enough students are being taken into nursing programs, hence not enough graduating. All of these issues need to be addressed before tackling the issue of nurse-to-patient ratios.

  46. Roger Torres August 1, 2012 at 3:43 pm

    I agree that mandated nurse to patient ratios is a necessity in order to provide the best care to patients. However, I also feel that it is very important, as others have already mentioned, to take into account the acuity of the patients assigned. Studies have been conducted addressing the work over load being experienced by nurses today. Also, studies confirm that the high amount of stress, lack of support for the nursing staff, and the high patient to nurse ratio all lead to the increasing amount of nurse burn out and nurse resignation. Many are finding the responsibility overwhelming. A reduction in the amount of patients per nurse could lead to improvements in quality reports, improve patient experiences and satisfaction, and most importantly, the quality of care.

  47. Sindis Rodriguez July 29, 2012 at 1:15 pm

    Unfortunately, California is the only state that currently has a regulation implementing concern for nurse-patient ratio. After two years of implementing new legislation for the minimum requirement of nurse staffing, California’s reports have shown mortality reductions in patient care were associated with increased nurse staffing (Aiken et al, 2010). There is no doubt that safe staffing is a top priority as stated by ANA in the article. In my four years of experience working in the intensive care unit, reducing the nurse to patient ratio has brought many benefits to nurses, patients, and the hospital. Improvement in patient satisfaction, reduction of medical errors, and an increase in nursing interests for working in critical care units have all been success stories attributed from reducing the nurse to patient ratios. However, the ANA did not attest to the fact that staffing ratios were as an important factor as staffing based on patient’s acuity and overall needs. In addition, there will be a push for publically listing hospitals’ future staffing plans as it relates to patients’ needs. This will be beneficial for nurses entering the workforce or looking to switch job locations because publically posted staffing plans will demonstrate hospitals’ commitment towards providing the highest quality of patient care and satisfaction.
    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H. (2010, April 9). Implications of the California nurse staffing mandate for other states. Health Services Research. Retrieved from gRatios.pdf

  48. Lisandra S. July 20, 2012 at 4:22 pm

    This is a topic of which I’ve encountered many times while working in the hospital. It especially becomes a topic of choice when nurses feel like they are being overworked with their patient load. I must say that I agree with the ANA, that we should take into consideration the patient acuity. But this also leaves it up to the charge nurse to attempt to divide the assignment evenly. I remember reading an article by Aikan, which stated that there has been studies that show that there is a direct relationship between the nurse patient ratio and the outcome of the patient. With that being said, I believe nurses should voice their opinion. Nurses are the ones indeed taking care of the patients and know more than anyone how it really is. We also know that Nursing involves many aspects, not just passing out medications. If nurses are being overworked, it makes it harder to provide patients time to communicate, which helps the body heal.

    Here is a link to the article I was talking about. It’s a must read!

    Aikan, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H. (2010, April 9). Implications of the California nurse staffing mandate for other states. Health Services Research. Retrieved July 1, 2012 from

  49. CC July 16, 2012 at 10:00 pm

    The “Nurse-directed” sounds like a nice theory, but if there are beds on your unit patient placement will fill the empty bed despite nurses objection, a nurse’s request to wait until staff arrive, or mention of safe ratios. As a floor nurse I do not get to direct the number of patients I receive. The charge RN assigns patients and if they do not assist you or they also have patients (because you have empty bed)-the mandated ratio would at least keep the ratio more reasonable. We also have a system that assigns patients, ranks acuity, etc., but it seems that it documents that nurse assignment, contact census,and is used for budget and future staffing-it does not keep you from getting a patient when your acuity is high or you have a full load. Mandated ratios may help. Studies show RN-to-patient ratios influence patient outcomes and lead to earlier recovery and discharge.

  50. Sugel July 13, 2012 at 2:55 am

    The study, which was published in Health Sciences Research, compared work conditions and outcomes in California, Pennsylvania and New Jersey. California enacted minimum nurse/patient ratios two years ago; Pennsylvania and New Jersey do not have legally mandated staffing ratios.

  51. las artes July 8, 2012 at 10:46 pm

    The studies discussed have documented the connection between lower levels of nurse staffing and higher rates of adverse events. Complementing those studies are a number of other studies addressing the growing nurse workload and rising rates of burnout and job dissatisfaction. One study, jointly funded by AHRQ and the National Science Foundation, examined the relationship between nurse staffing and hospital patient acuity (the average severity of illness of the inpatient population) in Pennsylvania hospitals.

  52. gold price July 8, 2012 at 10:10 am

    This is why acuity-based staffing models are so popular. A shift’s staffing needs are based on the patients’ level of care complexity. Saint Joseph Hospital in Chicago implemented a software program—Res-Q from Concerro—to track and predict nurse staffing needs based on acuity. The program allows nurses to assign relative weight to patients that indicate how much care those patients need. For example, whether they require ventilation or have a central line.

  53. Michael June 29, 2012 at 7:11 am

    With so many nursing schools on the list and the number of graduates coming out of these accredited nursing schools California increasing every year, the patient to nurse ratio should be much better. If someone is left unattended for the only reason that there is one nurse attending 5 patients and something happens to that patient, then who will be held responsible? The studies reveal that there is a nurse shortage and bound to increase by 20%in 2015 and 29% by 2020. So an analytic patient to nurse proportion needs to be maintained for a smooth functioning of medical functionary.

  54. Highlight Reel: June June 28, 2012 at 2:30 am

    […] at Off the Charts (AJN), should nurse-patient staffing ratios or other criteria be made available for public perusal as […]

  55. Peggy McDaniel June 28, 2012 at 12:51 am

    Hmmm, just as other public reporting stats, these are difficult to do well. If you just post ratios, that may not mean much unless they also address acuity, etc.
    That said, more public awareness to ratios is not a bad thing and may help drive change in a positive direction.
    The new Medicare `grades`on patient satisfaction may reveal some of the issues that come from minimal staffing. It will be interesting to see.

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