Establishing Criteria for 1:1 Staffing Ratios
R. Colette Hartigan, RN, BSN, MBA, CCRN
Critical Care Nurse, Vol.
20, No. 2, April 2000
The current reality of old and new challenges that nurses will
continue to face in the 21st century include managed care, for-profit HMOs, third
party payers, caring for the chronically ill elderly, aging in the nursing profession,
the impending shortage of critical care nurses, and innovative efforts at reducing
waste and improving efficiency. Mergers and acquisitions have led to unstable working
conditions resulting in the potential of too little time to deliver effective care.
Staff-to-patient ratios are seen as targets for reducing costs; higher ratios mean
less time to complete required procedures and meet patient care and family comfort
needs. Consequently, nurses must take a more patient-centered approach and adopt
a framework of practice that supports our values when we review patient classification
systems and staffing ratios.
Finding a Model
AACN Certification Corporation first described the Synergy
Model (1) of practice that linked 8 patient characteristics
to 8 nurse characteristics in such a synergistic way to achieve optimal patient
Patient characteristics include stability, complexity, vulnerability,
resiliency, and predictability; resources available; and patients' ability to participate
in their care and decision making. Nurse characteristics, or competencies, are evidenced
by sound clinical judgement and ability to advocate and respond to a patient's uniqueness,
collaborate with colleagues, recognize holistic interrelationships, respond to diversity,
show evidence of clinical inquiry, and demonstrate an ability to facilitate learning
The Synergy Model is adaptable to all areas of nursing practice
including determining staffing criteria for intensive care units (ICUs). Many hospital
administrators look only at numbers to determine staffing without factoring in the
severity and complexity of patients. Nurses are constantly asked to justify additional
staff to balance patients' needs with nurses' competencies. Feedback from nurses
shows that traditional ICU staffing does not adequately recognize unique patient
needs but rather focuses on the technical and mechanical assistance patients require.
Using the Synergy Model to determine staffing may result in more patient-centered
care and better use of resources.
refers to a patient's ability to maintain a steady-state equilibrium.
is the intricate entanglement of 2 or more systems (e.g. body, family, therapies).
Vulnerability refers to a patient's susceptibility to actual or potential
stressors that may adversely affect outcomes.
is the patient's capacity to return to a restorative level of functioning by using
compensatory and coping mechanisms.
Predictability is a summative patient characteristic that allows the nurse
to expect a certain trajectory of illness.
Resource availability refers to resources the patient, the family, and the community
bring to a situation; resources are personal, psychological, spiritual, social,
technical, and financial.
Participation in decision-making and
care refers to the degree to which the patient
and the family engage in the plan of care and the outcome.
Judgment includes clinical reasoning and decision making, critical thinking,
and a global grasp of the situation coupled with acquired skills.
is the ability to represent the concerns of the patient, family and community and
to help resolve ethical and clinical issues and concerns.
Response to patient uniqueness involves caring for the whole patient and family while creating
a compassionate and therapeutic environment.
Collaboration promotes and encourages each person's contribution toward achieving
optimal and realistic goals both for patients and colleagues.
Holistic interrelationships that exist across healthcare systems are recognized and appreciated.
Response to diversity is the ability to recognize and appreciate the individual, cultural,
ethnic, spiritual, racial, and socioeconomic beliefs and values of patients, families,
Clinical inquiry is the ongoing process of questioning and evaluating practice
through research and experiential learning.
Facilitator of learning for the patient, the family and colleagues.
Adapted from Biel M. Reconceptualizing Certified Practice.
Aliso Viejo. Calif: AACN Certification Corporation; 1997.
At St. Elizabeth's Medical Center, the critical care acuity
guidelines left much to individual interpretation and, therefore, each ICU had different
criteria for 1:1 staffing. For example, patients on high levels of oxygen or high-PEEP
(positive-end expiratory pressure) and patients on vasoactive drugs could be classified
as requiring 1:1 nursing care. To address this issue, Joan Vitello developed and
chaired the Critical Care Staff Nurse Council (comprising representatives from medical-pulmonary,
surgical, cardiac, post-anesthesia intensive care units, emergency department, neurology,
cardiac catheterization lab, and interim cardiac care unit), which accepted the
challenge of validating the criteria for 1:1 nurse-to-patient staffing ratios.
The council began by describing patients that required 24-hour
nursing care (1:1 care) and could not safely be assigned to a nurse caring for another
patient. Such patients are highly complex, vulnerable, and unpredictable and minimally
stable with low resilience; they require many resources and cannot participate in
their care. We classified them as requiring Level I care (sidebar).
Patients requiring 18 hours of nursing care per day (1:1 care)
may be assigned to a nurse caring for a stable patient who is awaiting transfer
to another unit. These patients are also highly complex and unpredictable but require
fewer resources and can minimally participate in their care. We classified them
as requiring Level II care.
Patients who require 12 hours of nursing care per day (1:2
care) may be assigned to a nurse caring for another patient requiring 12 hours of
care. Such patients may need hourly assessments and/or interventions; they are moderately
complex, moderately stable, and more predictable. They require Level III care. The
council did not establish criteria for Level II or Level III care.
The council then surveyed their colleagues to solicit criteria
for 1:1 staffing. The criteria were compiled using a medical systems approach, and
a comprehensive, patient-focused list was formulated and further refined to reflect
current practice. We specifically addressed the patient characteristics of stability,
complexity, vulnerability, and resiliency. We agreed that patients requiring 1:1
nursing care would be highly unpredictable, unable to participate fully in decision
making about their care, and resource intensive. Because the Synergy Model reflected
our practice of linking patient characteristics with nursing competencies, criteria
were established under the relevant patient characteristics.
for 24-Hour 1:1 Nursing Care
Stability Level I
Patients with unstable cardiac rhythms that cause hemodynamic
compromise and necessitate frequent assessments, pharmacological interventions,
and/or mechanical termination of the rhythm and patients who require external cardiac
pacing and/or placement of a transvenous pacemaker
Patients who experience hypertensive or hypotensive crisis
and require rapid stabilization of blood pressure
Patients with symptomatic cardiac tamponade who require
immediate intervention on the unit including drainage and stabilization
Patients who experience inadequate myocardial perfusion
who exhibit ongoing symptoms of chest discomfort resulting in decreased cardiac
output and severe hemodynamic instability
Patients who develop symptomatic bleeding and require immediate
Patients who experience cardiac arrest and remain severely
compromised requiring ventilatory and pharmacological support with continuous adjustments
Patients who exhibit symptoms of extreme dyspnea, acute
anxiety, orthopnea, and diffuse pulmonary congestion who are highly complex and
vulnerable in the acute phase of their illness
Patients who require insertion of an intracranial pressure
monitoring device (ventricular drain or camino) and demand continuous intracranial
pressure monitoring with frequent assessment and interventions
Patients with an acute change in neurological status who
require continuous nursing assessment and interventions
Nonventilated patients exhibiting life-threatening airway
compromise who require frequent treatments and continuous observation
Patients in metabolic crisis with multisystem compromise
who require continuous monitoring, assessment, and interventions
Patients who must leave the critical care area for a procedure
or test and require continuous nursing assessment and monitoring for the duration
of the test
Highly Complex Level I
Patients assigned to a research protocol who require initiation
into the study that necessitates documentation every 15 minutes or more often
Patients who require a diagnostic or therapeutic intervention
in conjunction with conscious sedation and recovery
Patients who are potential organ donors who require immediate,
extensive preparation and/or management
Patients who are severely compromised and require continuous
Patients who require pressure control ventilation in the
acute stage of acute respiratory distress or ventilated patients in the critical
stage of acute lung injury with high-PEEP and high oxygen requirements
Vulnerability Level I
Patients whose families require frequent interventions
including complex teaching and help resolving ethical concerns; for example, families
who require counseling because they are considering terminating life support measures
and/or donating organs for transplantation
Patients exhibiting emotional trauma who require intensive
care, collaboration, and coordination with other support services, including but
not limited to victims of sexual assault
Resiliency Level I
Patients in the acute phase of their illness who exhibit
signs of confusion, sensory overload, or psychosis and require continuous assessment
and immediate pharmacological interventions
Patients who require continuous intravenous sedation and/or
neuromuscular blockade for control of anxiety in the acute phase of their illness
and those who exhibit withdrawal symptoms as they are weaned from long-term sedation.
Focusing on Patients
In a highly technical environment it is all too easy to focus
on tubes, machines, monitors, and intravenous medications rather than on the patient
and family. The Synergy Model assists us in exploring our practice and developing
organizational strategies that are driven by the needs of patients, families, and
the healthcare team. (2) The Synergy Model allows
us to standardize the delivery of care from one ICU to another while personalizing
it according to patients' needs. We are currently in the implementation phase of
the model and although we have not yet evaluated its relevancy to practice, the
consensus among our nursing leaders is that this model is reality-based and will
allow for consistency across units. Its efficient framework permits critical care
nurses to anticipate the level of care needed for patients, match patients' need
with nurses' competencies, and thus achieve optimal outcomes and greater satisfaction
for patients, nurses, and the healthcare team.
The ever-changing healthcare system and its challenging reimbursement
regulations, the increasing need to contain costs, the aging population, and the
advancing number of new technologies must not force us to lose sight of patients'
needs. Instead, we must be willing to advocate for sufficient nursing care to ensure
optimal outcomes for all patients and their families.
The author thanks Joan M. Vitello, RN, MSN, the Critical Care
Staff Nurse Council - Karen Curtis, Suzanne Farley-Keane, Kathy Menard-Murray, Chris
Moriarty, Betty Shea, Kellie Smith, Amy Tschudy - and the nursing leadership at
St. Elizabeth's Medical Center for their thoughtful contributions to this article.
1. Curley MAQ. Patient-nurse synergy: optimizing patients'
outcomes. Am J Crit Care. 1998;7(1):64-72.
2. Moloney-Harmon PA. The synergy model: contemporary practice
of the clinical nurse specialist. Crit Care Nurse.