Take a gander, if you will, at your state’s legislative body as see if their staffing ratio verbiage says something like, “staffing ratios are determined by the facility to meet adequate needs of patient care…” or, uh, “sufficient staff.” Whatever that means.

I find it really challenging when I am reusing single-use products and having to double as an RN, CNA, Social Worker, Physical Therapist, Psychologist, etc. and having to take time to locate sub-standard medical products to basically “wing it” for patient care. There exists, in this business, the ability to have it all: sufficient profit margins and acceptable or even exceptional care of our patients. So what gives?

What is a “Staffing Ratio”? This phrase refers to how many patients each care taker can safely take care of. For instance, a 1 to 10 nurse to patient ratio means each single nurse has 10 patients she is directly responsible for. Typically for certified nurse aides this number is much higher, and especially in long term care or subacute inpatient settings, these numbers can be greater than 20 for both. Why is that a problem? Simply put, the higher the number of patients each caretaker is responsible for, the higher the likelihood for deficiencies in care, especially when “something goes wrong.”

A healthy, able bodied, able minded individual out in the world is a not a patient, even if this individual is of a less-than-spring-chickenly age. While the acuity (how sick) and type of illness varies, the need for skilled care, period, is an indicator that that individual poses the potential to have something “go wrong” and need medical treatment at the level a licensed nurse can provide, or higher. If your nurse has 10 patients, and 1 of them has something go wrong, the time that nurse has to spend focused on that patient, alone, specifically, becomes however long it takes to get that patient stabilized. During this time, it is unethical and illegal to leave that patient to tend to the remaining patients on his/her case. No nurse is going to say, “well Frank, your time is up, sorry we couldn’t get your breathing under control.” Subsequently, a patient needing more attention is not a legally defensible rationale for other patients on a nurses workload to receive less than their required amount of care time. The ratio is crucial.

If the M.D. is not easy to communicate with or is not present, and/or your peers on the floor are unable to assist, a nurse in this situation can very quickly become overwhelmed and the quality of care rendered to both the patient in acute need and the remaining patients on the caseload will decline. If a second patient of theirs experiences an acute change, and suffers a poor outcome as a result of that nurse and other staff being unable to attend to #2 in a timely fashion, what does that nurse tell her jury of peers? Or that patient’s family? These conundrums are the constant state of nursing and to some degree, this is just how it is. This is why nurses are taught in a focused and repetitive manner to structure and cluster their care, to prioritize, and is why there are so many challenges to becoming a licensed nurse. Decisions made in these moments can make literal life or death differences – and here we are primarily discussing environments of a non-emergent nature. I won’t get into emergency nursing, God Bless Their Souls.

Furthermore, the state of the nursing at present is why adequate new nurse mentorship is critical. Nurses must be competent, efficient, constantly thinking on multiple tiers simultaneously and are often exhausted, overworked, underpaid and/or under recognized – like many of us are in non-nursing roles but whose work performance may not make the difference of life or death. Now situations like I’ve just painted above are not hugely commonplace but they are common enough, and being staffed and tasked as though they could never happen is unacceptable, and normal.

Ok, let me climb down off the soapbox here and make this bite sized. There is a lot of reading to be done out there about this, but I want to use one study performed by the National Institutes of Health in 2021. Using a bank of 87 hospitals across Illinois, researchers with NIH determined: “If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.” (Find the study here). 87 hospitals in one state during the height of COVID crisis pay – the study indicates the average nurse:patient ratio was 1:5, sometimes as many as 7. So fast forward to 2023, when nurses have universally left the profession of nursing in greater numbers than ever seen before during a time when we are seeing a greater influx in patient numbers and acuity than any other time in our history, across all 50 states – in short, this problem isn’t going to fix itself.

Safe Staffing, however, isn’t only about numbers. Continuity and Quality of care are the the Great Equalizers of patient care. Knowing your patients’ baselines and seeing their care through the trajectory of illness is important to quality monitoring and catching changes, which sounds like just a lot of words but it matters. It matters that the subtle changes are caught before they escalate. For those who may be more peripheral the field or more familiar with medical shows, the reality is that most patient’s don’t just suddenly almost die. There is typically an escalation of signs and symptoms that nurses are tracking and addressing. It also really matters if the nurse who is in charge is actually performing at his/her professional best – or not.

Where Do Staffing Agencies Come In? Obviously, my personal interests will make me the hero of my own tale here, but staffing agencies have become increasingly necessary. There are many vulture practices out there – price gouging, not running their businesses intentionally patient-and-nurse-forward (in my opinion). Many have collectively perpetuated the stigma of being an “agency nurse,” by not having or maintaining standards in exchange for having and maintaining warm working bodies. What a good staffing agency should do is supplement staffing needs for facilities with competent and autonomous staff at a rate that reflects the skill and demand placed on the nurse. The facility pays the agency an offset since the agency assumes the risks and costs of doing business instead of the facility, as well as processes the vetting, hiring, and onboarding so that facilities are saved time and money when they need staff in a pinch. ( Summer Slump? Flu Season? ) Staffing agencies also help reduce the fallout (read: financial burden, reputation rebuilding, workplace culture) of mishires and turnover when nurses and nurse aides choose, for whatever of many reasons, not to stay at a place they’ve recently become employed. (See our upcoming article: why don’t nurses stay?) Commonly, staffing agencies can place temps with the ability for the facility to hire him/her on as permanent staff. With the abundance of agencies available to most places, if a facility struggles to hire and retain their own employees outright, there is absolutely no excuse for piss-poor staffing ratios and unsafe working conditions.

Where staffing agencies FAIL: guaranteeing continuity of care and enforcing standardized quality of care. Now, many agency nurses find a couple of facilities they frequent, which is excellent as they become familiar with the patients, policies, and work culture of certain places, but still experience personal control over their schedule and income. Have your cake and eat it too! Many temp nurses also accept extended contracts, which places them in full time roles for a period of time (typically a few months), contributing to that continuity for our patients. However, a fair amount of agency nurses do not have the ability to make these sort of commitments and this presents the problem of reducing that continuity. This does not bring into question an individual nurses competency, but continuity is a proven factor in quality patient care. Determining a change in condition that is subtle, for instance, would be difficult for a nurse who is unfamiliar with the patient’s baseline. (It is worth drawing the linear here: facilities that insist on hiring full natural staff that have a high turnover rate suffer even greater issues with continuity and quality. On average, mishires and high turnover costs facilities 2-3 times more than embedding agency staff. Of course, increasing pay rates and improving working conditions on the whole would really be the answer here). Professionalism and communication really need to be strong suits of the agency nurse, as asking natural staff, reviewing patient history, etc. are all critical components of determining course of action and must be managed in a time-sensitive manner.

It doesn’t really matter where your staff is sourced in the whole big ugly scheme of things, but having staff that is consistent, competent, quality, and professional is the absolutely bread and butter of Safe Staffing and safe staffing is literally the only way to provide actual ethical, practical, and effective patient care. Having poor staff to patient ratios, inconsistent and poor quality staff, a poor or toxic work culture, staff who are exhausted and spread too thin is a recipe for disaster. I do think that until more nurses begin universally refusing assignments that are unsafe and inappropriate, this problem will persist, and perhaps, swell.