Chapter 10 Mandatory Minimum Staffing RatiosCopyrigh

Chapter 10
Mandatory Minimum Staffing Ratios
Copyright © 2016 Wolters Kluwer Health | Lippincott Williams
& Wilkins
Copyright © 2020 Wolters Kluwer • All Rights Reserved
RN Skill Mix
Economics as the driving concern for changes
Trend: reduction in RNs in staffing mix; replacement with less
expensive personnel
Research: number of RNs in staffing mix directly affecting
quality of care and patient outcomes
National movement to mandate minimum staffing ratios
As of 2017, 14 states addressed nurse staffing in hospitals in
law/regulations
California is the only state that stipulates in law; regulations for
required minimum nurse-to-patient ratios to be maintained at all
times by unit
Staffing Ratios and Patient Outcomes
Research findings (see Table 10.1)
Questions about cost-effectiveness of statewide mandatory
nurse staffing ratios
Greater RN skill mix and fewer cases of sepsis and failure to
rescue

Benchmark research
Needleman et al. (2002)
Aiken et al. (2002)
Direct link between nurse-to-patient ratios and mortality from
preventable complications
Mandatory Minimum Staffing Ratios: Needed? #1
ANA with concern related to effect of poor staffing on nurses’
health and safety and patient outcomes
Proponents
Absolutely essential for patient safety and outcomes
Use of standardized ratios for consistent approach
Critics
Exponentially increased cost with no guarantee of quality
improvement or positive outcomes
AONE agrees and does not support mandated nurse staffing
ratios
Question #1
Is the following statement true or false?
Few states have enacted staffing laws.
Answer to Question #1
False
As of 2017, 14 states addressed nurse staffing in hospitals in
law/regulations.

Evidence of benefits mixed, contradictory
No accounting for education, experience, and skill level
Risk of actual decline in staffing—used as a ceiling or absolute
criteria without accounting for patient acuity or RN skill level
Cost as the major deterrent—not financially attractive to
hospitals
Mandate for specific staffing ratios and current shortage leading
to reduction in hospital services, increased emergency room
diversions, increased unit closures, increased expenses
Ohio Hospital Association: benefit of staffing ratios is mixed
and sometimes contradictory
Corbridge (2017): argues that mandating inflexible nurse
staffing ratios or stringent meal and rest break requirements do
not improve patient care or outcomes
Silber et al (2016): better-staffed facilities had a formula for
excellent value as well as better patient outcomes (see Box
10.2)
California Prototype #1
First state to implement mandatory minimum staffing ratios
Maximum number of patients an RN could be assigned to care
for under any circumstances (see Table 10.2)
Issues in determining appropriate ratios
Lack of data about nurse staffing distribution

Patient classification system (PCS) data problematic
Unknown cost
Recommendation: 1 nurse to every 6 patients in med/surg units
Delays in implementation
Problems with interpreting the meaning and intent of language
related to “licensed nurses”
Issues related to cutting nonlicensed staff
Questions if adequate number of RNs available to meet ratios
Emergency regulation in 2004; overturned in 2005
Hospitals and nursing unions’ responses
Struggle to implement
Mandate effective 1/1/2004
Larger hospitals versus smaller hospitals to meet mandate
Need for legal clarification for “at all times” (i.e., breaks,
lunches)
Question #2
California implemented mandatory minimum staffing ratios
fairly quickly.

False
There were significant delays in implementing the California
mandatory minimum staffing ratios.
Improvement in RN staffing and patient outcomes?
Reduction in number of patients per licensed nurse
Increase in number of worked nursing hours per patient day in
hospitals
No significant impact on measures of nursing quality and
patient safety indicators
No increase in adverse outcomes despite increasing patient
acuity
Lower risk-adjusted mortality (Aiken, 2010)
No improvement in quality of care (HC Pro, 2009)
Similar Initiatives: Other States
Minimum standards for licensed nursing in certified nursing
homes but not in acute care hospitals
Several attempts, but none enacted
Adequate numbers requirement for Medicare-certified hospitals
Many states actively pursuing minimum staffing ratio
legislation
Other Alternatives

Pursuit of alternatives to improve nurse staffing without
legislated minimum staffing ratios
Lack of support for legislated minimum staffing ratios
The Joint Commission
ANA against fixed nurse–patient ratios; recommendation of
three general approaches (see Box 10.3)
Question #3
The ANA supports legislation for fixed nurse–patient ratios.
False
The ANA does not support fixed nurse–patient ratios but
advocates for a workload system that takes into account the
many variables that exist to ensure safe staffing.
End of Presentation

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