Nurse Staffing: Ratios, Reimbursement and the Work Environment

By Sarah Delgado, DNP, RN, ACNP Sep 12, 2023

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I attended a middle school open house a few months ago, and the kids had created a wall of "when I grow up" pictures and essays.

I attended a middle school open house a few months ago, and the kids had created a wall of "when I grow up" pictures and essays. One child said they wanted to become a nurse, because nurses "do as much as they can to try to make the situation that you are in better." That definition of nursing really resonated with me. When I worked as a direct care nurse and as a nurse practitioner, I often cared for patients with chronic conditions that weren't curable, and the goal was to make the situation better. Now, working at AACN, one of the situations I try to make better is acute and critical care nurse staffing.

I wrote a blog in 2021 that described some of the challenges we face in nurse staffing and ideas to help move us to a better state. Two years later, as we continue to face persistent and pervasive barriers to appropriate staffing, we are seeing increased attention on safe nurse staffing. A few examples:

  • The National Academy of Medicine's "National Plan for Health Workforce Well-Being" calls out staffing as an action to improve retention of healthcare workers. The document advises hospitals and healthcare systems to "invest in appropriate and flexible staffing plans that allow for safe patient care, including needed backup."
  • The number of states considering legislation related to acute care nurse staffing has increased. Oregon passed legislation that resembles existing California policy in establishing minimum nurse-to-patient ratios for acute care settings. The New York State Department of Health set a ratio regulation for patients who require intensive care.
  • AACN co-convened the Partners for Nurse Staffing Think Tank to identify solutions that can be implemented over a 12- to 18-month period to address the nurse staffing crisis. That work was followed by the Nurse Staffing Task Force, co-led by AACN, which identified imperatives and recommendations to change longstanding barriers to appropriate staffing.

Are we finally generating the momentum we need for honest dialogue and substantive change in acute and critical care nurse staffing?

Ratios matter

A key priority in honest dialogue is to talk about ratios. In some discussions I've had about safe nurse staffing, the word "ratio" is avoided, sort of the way magical people avoid saying the name Voldemort (He-Who-Must-Not-Be-Named) in Harry Potter books. Connecting the word "ratio" with the word "staffing" is erroneously assumed to refer to regulation or legislation that sets mandated nurse-staffing ratios. The fact is that at any moment, in any unit, in any hospital, the most obvious measure of staffing is a comparison between the number of nurses and the number of patients — a ratio. Sometimes we talk about staffing as nursing hours per patient day (NHPPD), and that too is a ratio; it's just different math.

Decades of research — both cross-sectional and longitudinal — show that nurse staffing ratios do matter. Better staffing is consistently associated with better outcomes for patients. Not a huge surprise really, but it's helpful to have an evidence base. Noting the evidence, our Nurse Staffing Task Force included "Establish Staffing Standards that Ensure Quality Patient Care" as an imperative. It's clear that ratios are part of the equation when it comes to appropriate staffing.

Statements from the American Nurses Association (ANA) and the American Organization for Nursing Leadership (AONL) cite the Nurse Staffing Task Force and also present different views on nurse staffing ratios. When I read those statements, I noticed that they seemed to agree on a key point: Nurses must be the ones deciding staffing ratios for the units in which they work. To quote their statements:

ANA: "ANA supports minimum nurse-to-patient ratios enacted by nurse-centered committees dependent upon key factors such as patient acuity, intensity of the unit practice setting, and nurses' competency among other variables."

AONL: "Organizational leaders, nurse managers and direct care nurses, not policymakers, should collaboratively align staffing with patient needs."

AACN's 2018 Guiding Principles for Appropriate Staffing similarly states, "Appropriate staffing requires nurses to be involved in all aspects of staffing, from planning to evaluation." The Nurse Staffing Task Force recommends that staffing plans be developed by empowered committees and that direct care nurses have clinical coverage to attend committee meetings. Nurse-to-patient ratios matter, and nurses' involvement is crucial in establishing ratios that can meet the needs of patients and families.

Cost is also a consideration

In addition to the number of nurses, the cost of hiring nurses is a key consideration. As explained by nurse leader and policy expert Betty Rambur, and economist and nurse staffing advocate Olga Yakusheva, existing reimbursement models do not address the value of nursing care. For hospitals, this means that nurses represent a cost without commensurate revenue. Appropriate staffing does have financial benefits, including shorter length of stay, reduced readmissions and fewer complications, but those savings are not part of hospital budgets.

Recognizing this barrier to appropriate staffing, our Nurse Staffing Task Force included the imperative Value the Unique Contribution of Nurses with recommendations to quantify the impact of nursing care on revenue and cost containment and explore alternative payment systems. I think changing the payment structure for acute care is a key step toward improving nurse staffing. I also know that this type of comprehensive change will take a long time. We must advocate for such change and also recognize that hospital units need better staffing tonight, tomorrow and next month. So what can we do right now?

Ratios are not the whole story

Our Partners for Nurse Staffing Think Tank identified six priorities that can be implemented over the short term to improve staffing in acute and critical care. ANA created a tool to help nurses and the leaders who support them implement the Think Tank recommendations and actions. Interestingly, both our Think Tank (identifying short-term strategies) and our Task Force (seeking to change long-standing barriers to staffing) identify two essential elements of staffing that go beyond the numbers:

  • Care delivery models – how nurses do their work and the teams they work with
  • Work environments – the context of care delivery and the relationships nurses experience

Innovating care delivery

We must leverage innovations such as virtual nursing and create care delivery models that both meet patients' needs and ensure manageable nursing workloads. Nurses in direct care roles are the ideal candidates to build and test innovative care delivery models. Teams of direct care nurses in AACN's Clinical Scene Investigator (CSI) Academy create real change with measurable benefits, because they know their work and their patients better than anyone else. In addition, AACN highlights staffing innovations from our community by publishing nurse staffing stories on our website. Access those stories and other staffing resources.

Improving the work environment

AACN's 2021 Healthy Work Environment Survey again demonstrated that staffing and the overall health of the work environment are inextricably linked. Nurses working in units that implemented the healthy work environment standards also reported a higher percentage of shifts with appropriate staffing. As described by my colleague Kristine Strohbin in her blog "My Work Environment Is Unhealthy, Now What?" AACN offers resources and tools for nurses to build a case for implementing AACN's Healthy Work Environment Standards. The term work environment can sound like an unchanging monument but, in reality, each person's actions and words contribute to the context of our work.

As nurses and leaders, we must work to improve the dire situation with nurse staffing, just as nurses and patients work to improve the situations that illness and injury create. Including direct care nurses in all staffing decisions, acknowledging that ratios matter, advocating for system-level change while innovating care delivery, and improving the work environment are essential steps forward.

What are your ideas for amplifying the voice of direct care nurses in staffing decisions?