Healthcare Staffing Ratios
Healthcare staffing ratios refer to the number of patients that healthcare providers care for at a time [1]. Of course, healthcare systems require the labor of diverse staff members to function, but perhaps the most heavily studied healthcare staffing ratio is the nurse-to-patient ratio. Likely as a result of a worldwide nursing shortage and its contribution to what has been termed a “global health emergency,” there is pressure on legislators and policymakers to institute formal nurse-to-patient ratio limits [2]. However, they have largely been successful in fending this pressure off. In the United States, there is no federal legislation mandating particular nurse-to-patient ratios; on the state level, only California has passed such a law [3]. The global outlook is no better, with no more than a handful of countries having passed minimum nurse-to-patient ratio policies [4].
In the United States, the failure to institute mandatory healthcare staffing ratios can be (at least) partially attributed to disapproval from powerful medical groups [5]. For instance, in Minnesota, the Mayo Clinic lobbied and threatened to take back billions of dollars in infrastructure investments in its ultimately successful effort to defeat a planned nurse-to-patient staffing ratio [5]. The American Health Care Association and the American Hospital Association have also voiced their dislike of plans to institute ratio regulations [5]. Opponents continue to insist that healthcare staffing ratios have unproven benefits and, thus, would represent an unjustifiably risky fiscal investment [3].
An overwhelming body of evidence contradicts these common arguments. Jurisdictions with nurse-to-patient ratios report better patient outcomes, increased staff well-being, and economic savings compared to places without such ratios [1]. In California, hospital income rose “from $12.5 billion from 1994 to 2003, to more than $20.6 billion from 2004 to 2010” following the implementation of a mandatory maximum, though this is correlation not causation [1]. More importantly, patients in hospitals instituting mandatory ratios reported lower failure-to-rescue and mortality rates [3]. Similarly, in Queensland, Australia, hospitals implementing a minimum nurse-to-patio ratio reported improved length of stay, readmissions, and mortality rates compared to comparison hospitals [4]. It is easy to see how overwhelmed nurses would lack the capacity to offer each patient optimal care, not to mention the incentives they face to leave their jobs prematurely [2].
When considering the examples from California and Australia, it is important to note that there is no one-size-fits-all ratio. Rather, research indicates that the nurse-to-patient ratio implemented in a given institution should account for a variety of factors, including the total admissions, discharges, and transfers likely to occur during a given shift; the floor plan and arrangement of the healthcare units; and the intensity of patients’ conditions [6]. While Victoria, Australia’s ratio introduces variations depending on what shift nurses work (for instance, a 1:4 ratio for morning shifts versus 1:8 for night shifts), California’s varies according to the institution at hand (i.e., 1:4 for emergency versus 1:2 for critical care units) [6, 7]. Adopting appropriate healthcare staffing ratios may require trial and error which, albeit demanding to identify, appears to be a worthwhile investment.
The essential consideration is this: healthcare systems around the world are bordering on collapse [8]. While healthcare staffing ratios are not a panacea to this issue, they are nevertheless empirically proven to cut costs and promote better patient outcomes. As such, ratios could be an indispensable tool in the move to achieve a more efficient and effective system that places patient welfare above all else.
References
[1] “Safe Staffing Fact Sheet,” The New York Campaign for Patient Safety, Updated 2019. [Online]. Available: https://d3ovkdufrefcl9.cloudfront.net/pco/campaigns/safeStaffing/2019safeStaffingFactSheet.pdf.
[2] E. Baines, “Nurse Shortage Branded a ‘Global Health Emergency’,” Nursing Times, Updated March 23, 2023. [Online]. Available: https://www.nursingtimes.net/news/global-nursing/nurse-shortage-branded-a-global-health-emergency-23-03-2023/.
[3] K. B. Lasater et al., “Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study,” BMJ Open, vol. 11, no. 12, December 2021. [Online]. Available: https://doi.org/10.1136%2Fbmjopen-2021-052899.
[4] M. D. McHugh et al., “Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals,” The Lancet, vol. 397, no. 10288, May 2021, pp. 1905-13. [Online]. Available: https://www.thelancet.com/article/S0140-6736(21)00768-6/fulltext.
[5] R. Numerof, “More States Mandate Nurse-To-Patient Staffing Ratios In Another Desperate Attempt To ‘Fix’ A Broken Healthcare Delivery System,” Forbes, Updated June 27, 2023. [Online]. Available: .
[6] S. K. Sharma and R. Rani, “Nurse-to-patient ratio and nurse staffing norms for hospitals in India: A critical analysis of national benchmarks,” Journal of Family Medicine and Primary Care, vol. 9, no. 6, June 2020, pp. 2631-37. [Online]. Available: https://doi.org/10.4103%2Fjfmpc.jfmpc_248_20.
[7] “What Does the California Ratios Law Actually Require?,” National Nurses United. [Online]. Available: https://www.nationalnursesunited.org/what-does-california-ratios-law-actually-require.
[8] C. Rauh, “Why Health-Care Services Are in Chaos Everywhere,” The Economist, Updated January 15, 2023. [Online]. Available: https://www.economist.com/finance-and-economics/2023/01/15/why-health-care-services-are-in-chaos-everywhere.