'1 size doesn't fit all': A nurse leader's case against staffing ratios

While patient safety should always be a top priority, being forced to abide by nurse-to-patient ratios when scheduling takes away nurse leaders' ability to exercise their own clinical power, Robyn Begley, DNP, RN, CEO of the American Organization for Nursing Leadership, told Becker's. 

"Nurses leaders need to feel empowered enough to empower their team members on the front lines. They need flexibility when it comes to creating appropriate care teams that meet the needs of their patients," said Dr. Begley, who also serves as chief nursing officer and senior vice president of workforce for the American Hospital Association. "The issue of ratios is not just about the nurse and patient — or even the total number of patients in a unit — but it's about the entire team."

Mandated nurse-to-patient staffing ratios removes nurses' ability to use their clinical judgment when it comes to deciding what each particular patient needs at any one time, she said, noting, "this is a situation where one size doesn't fit all."

Many factors, Dr. Begley said, must be used to determine "the best way to ensure a care team provides safe, competent and quality care."

She said nurses must have the ability to consider the ever-changing population of patients on a unit in terms of numbers and type/degree of illness. "Also, what does the overall care team look like on that particular floor or unit at the moment? How many nursing assistants are available to help? There are simply many factors to consider when determining appropriate nurse staffing levels." 

She said the physical layout of a hospital unit needs to be considered, as well. "There are many unit layouts. Is everything in a straight line where you can see everybody all the time? Some units are designed well enough to give nurses a better view of the entire space; others have long hallways where a nurse might have to travel a long distance to get to a patient in need."

Dr. Begley said technology resources that can help nurses monitor patients must also be taken into consideration.

"The need for nurse-patient ratios are based on older models of care. Today, we have the ability to consider using advanced capabilities offered by technology," she said, referring to strategies employed by other hospital teams to coordinate care including respiratory therapists, occupational therapists, speech pathologists, physical therapists, case managers, care managers and others that are using modern tools to support direct delivery of care. 

Dr. Begley said staffing ratios focus on an equation and not the skill levels of the nurses on the floor. "The best nursing is delivered when there's someone always checking in to see how their patients are doing. Finding out if a patient is having a challenging day and being there to help."

The American Nurses Association supports minimum nurse-to-patient ratios based on "patient acuity, intensity of the unit practice setting and nurses' competency among other variables," Jennifer Mensik Kennedy, PhD, RN, president, said in a news release July 13. "Setting specific ratios for nurses should be viewed as only one piece of a much larger solution [for staffing challenges]."

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