188 unit 3 | Professional Issues
Staffing Ratios
Although some state nurses associations are calling
for mandated staffing ratios, the issue is not clear-
cut. What has become clear is that there is no “one
size fits all” solution. In 2004 a review was conduct-
ed of peer-reviewed studies published between
1980 and 2003 of the effects of nurse staffing on
patient, nurse employee, and hospital outcomes.
The literature offered no support for specific nurse-
patient ratios. However, findings from 12 key stud-
ies stood out, citing specific effects of nurse staffing
on patient outcomes: incidences of failure to rescue,
in-patient mortality, pnuemonia, urinary tract
infections, and pressure ulcers. Effects of nurse
staffing levels on nurse employee outcomes includ-
ed needlestick injuries, nursing burnout, and nurs-
ing documentation, whereas hospital length of stay,
financial outcomes, and direct nursing care were
experienced by the hospital. Table 12-3 provides a
matrix for staffing decision making.
Above all, the ANA recommends moving
staffing away from an industrial model of measuring
time and motion to a more professional model that
examines factors needed to provide quality care.
Changes in staffing levels should be based on analy-
sis of nursing-sensitive indicators (nursingworld.org/
readroom/stffprnc).
Using Unlicensed Assistive Personnel
Educational preparation and clinical experiences in
practice for nurses differs for basic registered nurse
(RN) education. The nursing shortage will contin-
ue to force health-care facilities to explore creative
ways of providing safe and effective patient care.
This will most likely include RNs working with not
only licensed practical nurses (LPNs) but also with
unlicensed assistive personnel (UAP). The legal reg-
ulation of nursing practice is defined by each state
nursing practice act; however, the ANA believes that
“curricula for all RN programs should include con-
tent on supervision, delegation, assignment, and
legal aspects regarding nursing’s utilization of assis-
tive personnel” (nursingworld.org/readroom/
position/uap/uaprned).
Hospital workforce issues will continue to be
influenced by economic changes, managed care and
insurance issues, media forces, and the nursing
shortage. Linda Aiken has been researching rela-
tionships between positive patient, nurse, and
agency outcomes and RN staffing, educational
preparation, and organizational culture (Aiken,
2002, 2004). Nurses voice disillusionment with
nursing practice and decreased loyalty to organiza-
tions. Nursing leaders in the 21st century must
demonstrate a respect and value for their nursing
staff, communicate effectively with all levels of the
organization, maintain visibility, and establish par-
ticipative decision making. As you move forward in
your career, be part of the solution, not the problem
(Ray, Turkel, & Marino, 2002).Reporting Questionable Practices
Most employers have policies that encourage the
reporting of behavior that may affect the workplace
environment. Behaviors to report may include
(ANA, 1994):- Endangering a patient’s health or safety
- Abusing authority
3.Violating laws, rules, regulations, or standards
of professional ethics - Grossly wasting funds
The Code for Nurses (ANA, 2001) is very specific
about nurses’ responsibility to report questionable
behavior that may affect the welfare of a patient:
When a nurse is aware of inappropriate or ques-
tionable practice in the provision of health care, con-
cern should be expressed to the person carrying out
the questionable practice and attention called to the
possible detrimental effect on the patient’s welfare.
When factors in the health-care delivery system
threaten the welfare of the patient, similar action
should be directed to the responsible administrative
person. If indicated, the practice should then be
reported to the appropriate authority within the
table 12-3
Matrix for Decision Making: Staffing
Patients Characteristics and number of patients
requiring care
Intensity of Unit Intensity of individuals within and across
and Care the unit; variability of care; admissions,
discharges, transfers, volume
Context Architecture of unit; technology available
Expertise Staff consistency, continuity, and
cohesion; staff preparation and
experience
Other Quality improvement activities; nursing
control of practice
Adapted from nursingworld.org/readroom/stffprnc