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‘Staffing Is Not a Numbers Game’

‘Staffing Is Not a Numbers Game’

NJSNA: Healthcare Factors Patient Acuity, Nurse Experience

TRENTON, N.J.—February 6, 2018—Healthcare organizations should develop staffing plans based on patient needs and nurse experience, according to the New Jersey State Nurses Association (NJSNA), which represents 125,000 registered nurses and advanced practice nurses as an advocate for the profession.

Judith E. Schmidt, MSN, DHA (c) RN, CCRN and CEO of the New Jersey State Nurses Association

“We all know staffing has to change,” said Judith Schmidt, MSN, DHA (c) RN, CCRN and CEO of the New Jersey State Nurses Association. “The more patients a nurse is responsible for the greater the chance of an adverse event, such as a fall, infection or avoidable errors. Staffing is not a numbers issue because numbers don’t take into consideration the patients acuity or the nurse’s experience. Should the newer nurse be responsible for the sickest patient(s) or the same number of patients as a nurse that has many years of experience?”

Staffing should take into account patient acuity and nurse experience. Without the necessary nurse coverage, patients risk longer hospital stays, increased infections, avoidable medication errors, falls, injuries and even death. Staffing plans should be directed by a committee, which includes a majority of direct care nurses, to ensure patient safety, reduce re-admissions and improve nurse retention.

The New Jersey Legislature has introduced a bill (S-989) to establish staffing standards for nurses in hospitals, ambulatory surgery facilities, and developmental centers and psychiatric hospitals. The proposed bill outlines specific staffing ratios for patient care.

The proposed plan endorses numbers of nurses for various care situations, which is a good start, but does not go far enough. “It does not address some of the key issues that occur with staffing, such as the constantly changing needs of patients,” Schmidt said. “It’s about the accountability of nurses and nurse managers to establish staffing based on the patient needs and nurse skill levels. Staffing is not about a specific number, but the appropriate mix of how sick the patients are, which dictates how much care they need, plus the level of experience of the nurse.”

Schmidt said ratios are rigid and dictate a set number of staff, which is not the best model for optimal patient care, which constantly changes. “We need to give the nurses at the bedside the authority and the accountability for staffing their units as needed,” she said.

“Patient care loads can change in almost an instant,” she added. “When I was in the critical care unit, I was assigned three beds with two patients occupying two beds and one empty bed. One patient was acute but stable and one was unstable and needed a lot of hands-on care. This was the Department of Health and Human Services New Jersey Licensing Standard ratio for Intensive Care Units. An admission came in that was sicker than both of my patients and needed my full continuous attention. My charge nurse was able to adjust the assignments so all the patients could have the level of care they needed. In a ratio situation, where a rigid number is set, I would not have had the support I needed to help the patient. Without staffing flexibility based on patient needs, this situation could have had a very different result.”

Another key issue that is not addressed in the staffing bill is the availability of assistive personnel such as nursing assistants, transporters and technicians.  “With healthcare economics the way they are, hospitals are going to have to eliminate some of the assistive positions,” said Schmidt. “Nurses and their assistants have the most contact, one-on-one time and direct care of patients within the healthcare system.”

Because Congress hasn’t been able enact a federal law that addresses state nurse staffing, such as The Registered Nurse Staffing Act, states like New Jersey have taken action to ensure there is nurse staffing appropriate to patients’ needs and legislation that allows for flexible nurse staffing plans. Every year, NJSNA advocates for this on the national level during the annual Lobby Day on Capitol Hill with nursing associations from around the country.

“Optimal nurse staffing could mean the difference between a patient surviving or dying,” said Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of American Nurses Association, which has been advocating for safe staffing for many years. “Research tells us it’s that crucial. If you or your loved one were in the hospital, you’d want to be certain that the hospital was continually setting, evaluating and adjusting its nursing coverage to meet your changing needs and the conditions of all patients.”


NJSNA, which was established in 1901, is a constituent member of the American Nurses Association.  The New Jersey State Nurses Association (NJSNA) represents the interests of 125,000 registered nurses and advanced practice nurses as an advocate for the nursing profession. NJSNA’s lobbying arm continues to protect the nursing profession through legislative victories. Its nonprofit foundation, Institute for Nursing, helps nurses further their careers by providing continuing education, scholarships and research grants in addition to invaluable networking opportunities. For more information, nurses can visit www.njsna.org or contact NJSNA at njsna@njsna.org or (609) 883-5335.

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27 comments on “‘Staffing Is Not a Numbers Game’

  1. steven webster says:

    Dear NJNSA,

    Despite saying all the right things to start this article, you offer no other solution to the staffing problems and the ever increasing acuity of the average hospitalized patient. You criticize the upcoming bill, but what is your answer. Nothing changes, the situations continue to deteriorate and the NJNSA does nothing. We bedside nurses are sick and tired of being sick and tired. The professional organizations do nothing to improve the life of the bedside nurse. The Unions, which take our dues and claim to speak for us, play footsie with the legislature and year in and year out, do nothing either. Thank you for pointing out the problem, thank you for pointing out the shortcomings of the current bill, but no bill is perfect, thank you for speaking from your Ivory tower perches, in short thank you for doing nothing.

    • judy says:

      We are sorry you feel that way Steven, we work very hard to advocate for and improve the practice of nursing and our patients. Please visit our news page to see all that we are doing to advocate for nurses in New Jersey and nationwide (http://njsna.org/latest-news/) such as bringing to light issues at the New Jersey Board of Nursing and asking for a study of the impact of gun violence on healthcare. We all agree that staffing is an issue, it is a solution that we cannot agree upon.

  2. Wait a minute…I know a lot of NJ nurses who are in favor of A1470/S989, just not the nurse executives. If you ask a bedside nurse, he or she will tell you that our work has gotten harder, the patients are sicker and the paperwork is endless. I’m not exaggerating. I’ve been a nurse for 20 years, 10 of those in various emergency departments around the state. Never have I been asked to juggle so much, with so little. We have little to no ancillary help. We go 12, 14, sometimes 16 hours with no break. And everything rests on our shoulders, it seems: patient outcomes, patient satisfaction scores, a dozen National Patient Safety Goals.

    Ms. Schmidt wants an nursing assignment algorithm that will change frequently based on acuity and experience. My job already has that. We adjust staffing every 4 hours based on collected data. For example, we have more staff come at 3p because 3p to 7p are usually our busiest times. But there’s no “usual” in medicine. I can’t tell you home many times we’ve sent people home because 3pm was slow and then, in the next hour, 37 patients came. Now you’re short staffed. You think that nurse you sent home is coming back? No way. Every unit I’ve ever worked is staffed like this every day. God forbid someone should sit around for 5 minutes and take a breath.

    There’s also the things that can’t be measured by scores and algorithms, but patients expect nurses to provide them. The doctor isn’t very communicative, they want the nurse to explain what’s going on with their family member. You have a dementia patient who is constantly calling you into the room because they don’t remember you were just there. The patient who is dying: under acuity staffing, they shouldn’t need a lot of “care”, but often that’s when the patient and their family needs you the most. Am I supposed to wait until 7pm when more staff comes in before I go and provide my non-acute emotional support?

    For those of you who count the beans, nurses are worth every cent you spend on them. We are the biggest group of hospital representatives at any institution. When you have enough of us Press Gainey scores improve, outcomes improve, morale improves. These things are proven. Why, then, is it so hard to get a staffing bill passed? Because the nurses who are supposed to be our advocates in government and business are busy trying to divide us.

    Is this staffing bill perfect? No, but it’s a damn good place to start.

    • judy says:

      Thank you for sharing your experience, and yes we agree 110 percent that staffing needs to be fixed. Nurses are absolutely invaluable members of the care team for a patient and we are looking to protect them so they can continue to provide excellent care for patients. We all want safe staffing, we are just not seeing eye-to-eye on how to achieve it.

  3. Kristy says:

    My unit does not do Staffing according to acuity. I can have anywhere from 5-8 patients. All patients can be incontinent complete cares with 3-4 pegs tubes and with a cpap. And there are no adjustments to how sick the patients are and definitely no adjustments whether the nurse has enough experience.

  4. Michelle Medina, CRNA, MS says:

    I am a little confused if this article is in support or against this safe staffing bill. I have been a Registered Nurse for almost twenty years and I strongly feel that staffing is a number issue and I am in complete support of S-989. I am shocked that the CEO of the NJ Nurses Association does not feel this same way. Or maybe she does. I cannot fully understand from the article. This bill (S-989) creates the same staffing ratios that exist in California, which is a much safer place to be a patient than NJ. Your example of having three ICU patients wouldn’t exist because in bill (S-989) a RN is not allowed to have more than TWO patients. I see unsafe staffing every day. And I have seen negative patient outcomes because of this. I also have seen severe job dissatisfaction, burnout and turnover of nursing staff – ALL of which is mentioned in this bill. I agree that staffing should take into account patient acuity and the nurses level of experience. But this is mentioned and included in this bill (pg 4). Nurses continue to eat their young and not stand together, unlike our physician counterparts. We must stand together and we must support this bill S-989.

    • judy says:

      NJSNA is in support of safe staffing, just not a fixed number or ratio. We believe it should be a mix of nurse experience and acuity with nurses helping to make the staffing decisions. Yes, California has a ratio law that applies to all types of acute care units and nurses still strike over unsafe staffing. Have you seen American Nurses Association’s White Paper for Nurse Staffing? It discusses California on page 22. http://bit.ly/2EB1ddq We all want safer staffing, but are not agreeing on how to achieve it.

  5. Rebecca A Smith, APN, CCRN,CCNS says:

    I was one of the nurses advocating for staffing skill mix as opposed to ratios. It was hard to use an elevator speech and speak about the difference between a mandated ratio tied to the number of patients in beds to the true acuity of patient’s needs matched with the skills of nurses to the legislators or their aides.
    I could see the blank look come over the Senator’s face and I realized that without direct influence from working nurses with real solutions we will just fumble the ball again. I have worked in critical care for 30 years, the last 10 as an APN. Part of the problem is nurses have a hard time changing the status quo as far as their units are concerned. Martha Curley ( http://ajcc.aacnjournals.org/content/16/2/158.full?cited-by=yes&legid=ajcc;16/2/158) wrote the Synergy Model in the 1990s. It works very well when actualized but I can honestly say that nursing administration, unit managers, physicians, and the nurses themselves were all barriers to full implementation. I know that it works because I had an informal method of putting it into action as a care manager. I was a staff nurse, care manager and the most experienced and skilled nurse in the group. I would always take the patient that required the most vigilance and position the newest member of the team near me so I was available as a resource for that nurse. I rounded at least twice during the shift to make sure that everyone was safe and that families were confident in our care abilities.
    I have had the most success as an APN in critical care as I know the nurses’ capabilities, provide stat consults at the bedside for the nurses who need help getting the care organized and meet with the families. I have the power to control some of the workflows because I round on the patients, meet the bedside nurse to plan care with respect to his observations and then I write the appropriate orders such as removing catheters, lines, extubating appropriately, meeting with family to address their needs, decreasing unnecessary and wasteful nursing tasks as appropriate. This might include transitioning a patient from a labor-intensive insulin drip to a sliding scale, decreasing hourly vitals signs as appropriate, transferring patients to SDU or telemetry or consulting with palliative care APNs for support in scenarios where I need time to discuss the de-escalation of care when patient status changes. I don’t want to imply that the physician isn’t factored into the day but there is little else that a physician adds in this environment anymore because PICC lines are put in by nurses, most invasives are done in radiology or by the surgery team at the bedside.
    Until nurses can articulate this model, educators teach the model and DNPs influence the care transitions as direct care clinicians, institutions will fumble the concept. The most innovative paper from the nursing realm that I read recently involved dropping the concept of the business unit/nursing unit silos in hospitals and developing a team to follow a group of patients from admission to discharge. Of course, APNs with acute and critical care capabilities would head the team for those patients and midwives, pediatric APNs etc would head up their respective teams. Hospitals will become critical access only as we move towards OP care. I would take that same team concept and follow the patients from facility discharge to home, LTC, hospice, well-care.
    Finally, I would, of course, try this on a unit with like-minded individuals and as a way to provide a residency for new APNs and staff nurses.
    The winners would be patient’s and families and everyone would work to their capabilities and expertise.

    • judy says:

      Thank you so much for sharing your thoughts and ideas, you make some excellent points. We are all working toward a solution that is best for nurses and patients.

  6. Lisa S. says:

    Patient acuity and RN experience is hardly ever taken into full account. Administration gives lip service and knee jerk reactions to staffing issues. For example: the RN is busy in the ER keeping inpatient holds cared for. The RN is all by herself running from room to room. The ER is already short techs. The RN begs for help. The staffing supervisor finds an extra nursing assistant and sends to that RN to help out. After a couple of hours the nursing assistant is pulled because they need her somewhere else. This is day after day…rinse and repeat. It’s exhausting. No wonder staff nurses are leaving floor nursing. It’s stressful and exhausting.

    • judy says:

      And this one scenario illustrates why we are working so hard on the issue. We all want better, safer staffing.

  7. Frances Campo says:

    Staffing is all about numbers!!! The number of patients. The number of nurses. The number of transporters, LPNs, CNAs, surgical techs, and every other person who touches a patient in a hospital. The number of experienced nurses. The number of inexperienced nurses. The number of patients with acuity at each of the levels as defined by the particular acuity system in place in that hospital on that unit. The number of nurses on LOA, vacation, off sick, pulled from their assigned unit. There are infinite possibilities of how to staff a unit in a hospital in 2018. Please, walk a day in the shoes of every nurse, in every hospital unit. And do it in the throes of flu season. You’ll see why we are crying out for safe staffing now! Ty

    • judy says:

      The NJSNA Board is made up of practicing nurses from various areas of practice from bedside to hospice and everything in between. We all want safe staffing, and nurses on both sides of this issue agree that something needs to be done, we are just not agreeing on the how.

  8. Robin L says:

    Judy, when I started reading your article I was optimistic. When you talked about the fact that nursing assignments need to take into account how time consuming the patient is, I can relate completely. In fact I’ve been saying that for years. But you lost me when you started knocking down patient ratios. I agree that we should NOT have minimum ratios for each unit. But we do need MAXIMUM ratios. Currently hospitals such as the one I work at like to use a grid system to decide our staffing ratios. They refuse to take in consideration how time consuming one patient can be. Our administration refuses to use the psych component as part as the acuity. They insist on using the same grid for the ICU and PCU for our inner city hospital that has an open heart program, transplant program and neuro interventional program as other facilities that have none. Infact we get the sickest of the sick from them but our units are expected to have the same grid ratios which include our PRISMA patients to regularly have a 2:1 ratio to start with. The nurses you represent are asking you to back us up when we ask for maximum ratios. This would prevent administrators from pushing the staff to continue unsafe ratios. I agree it is not a perfect fix but it is a start. We are working in unsafe environments. And when something bad happens who do you think will be thrown under the bus?

    • judy says:

      We are so sorry that you are in that situation. We all want to find a solution to this issue that is in the best interest of nurses and their patients. Thank you so much for sharing your thoughts on this, we appreciate each and every nurse that has taken the time to comment on this issue.

    • judy says:

      Everyone on both sides of this issue agree that something needs to be done, we are not seeing eye-to-eye on how.

  9. Rose Connelly says:

    Im so tired as a nurse in new jersey the hospitals beat you down and then blame you when a mistake happens it horrible and i feel it is hopeless

    • judy says:

      We are so sorry you feel this way. Thank you for taking the time to share your thoughts with us and we are working toward change.

  10. P. L. Avila says:

    Please do not misrepresent the bill to the hard working bedside RNs and private citizens of this state. The bill does not state that these numbers represent the mandated minimum daily assignment. Rather, the ratios set the maximum number of patients an RN can have at any one time. The bill also states the assignment will based on patient acuity and RN skill mix. Currently, bedside nurses have no say in bedside staffing levels. I have seen first hand how well this has worked in California. We need this bill to pass. Patients lives depend on it.

    • judy says:

      We respectfully disagree about ratios working in California, if they were working, why wouldn’t more states have them? Have you seen the American Nurses Association’s White Paper for Nurse Staffing? It discusses California on page 22. http://bit.ly/2EB1ddq

  11. Jacqui Mikulski says:

    It’s about patient needs, nurse skill levels AND THE NURSE PATIENT RATIO. Does not have to be one or the other. It absolutely has to be both.Matching an acutely ill patient with a seasoned nurse is a no brainer.Problem is, and has beenfor a long time, inappropriate amount of staff. It all trickles down to GREED. 35 dollars and hour for a staff nurse vs. at least a half a million for a hospital president or CEO. UNCONSCIENABLE!!!!!

    • judy says:

      We agree that it needs to be all the things you talk about. Everyone on both sides of this issue agree that something needs to be done, we are not seeing eye-to-eye on how.

  12. Angela P says:

    Nationwide, our nurses are tired, frustrated, and exhausted at the current state of nursing. Too many patients, inadequate staffing, insufficient and unrealistic time provisions to safely and properly perform required job duties in fellow humans. I repeatedly remind executives that we are treating people, not robots. No one can dictate a time requirement for duties when the pt him/herself needs complete care and is not a programmable object. 1 human can not accurately care for the several (Med-Surg 1:6) patients he/she is primary nurse for. We are making the patients and ourselves ill. No time to read charts, document, provide care, use the bathroom, take a REAL&SUFFICIENT UNINTERRUPTED break all the while executives sit back with their backs turned the other way. Insurance companies, executives, legislatures, law makers DO YOU EVEN CARE? Patient care involves duties, talking to patients/families, other professionals within the interdisciplinary team, performance, analyzing, critical thinking and so much more. Citizens are upset, medical professionals are angered. When they(patients/families/friends) mistreat us staff members and complain, I tell them to complain to their local legislators and executives. No amount of scripting (yes, the hospitals/organizations provide scripting and other bits of situational calming techniques) or pacifying will resolve this matter. Just Recently as 3 patients were simultaneously requesting pain medications, those same patients and my others were also ringing call lights to placed on the bedpan, 1 with senile dementia was attempting to ambulatory with recent falls and being combative. 2 patients on isolation. 1 with a sudden onset of chest pain. I am 1 person, I had 1 patient care tech for 10-12 patients and the other staff were busy but trying to help when/where they could but it’s a constant zoo. Tell me, who can be the superman ? I loom around to see thee many nurses obtaining advanced degrees to move away from bedside nursing. It is survival of the fittest; like a game of how much can the staff members do and take. I’m seeing begging, incentves, and bonuses to get staff to work but to no avail.Profits are being held in highest regards over patients and healthcare professionals; the real face of healthcare. THIS MUST END.

    • judy says:

      That is what we are working toward and thank for for being a part of the discussion. We appreciate you sharing your story.

  13. Ann Palermo says:

    Thank you for this comprehensive explanation concerning the nurse/patient ratio bill. I agree with you that locking nurses in to a “number” of patients to care is unwise and does not consider all of the variables that can affect the care that the patient receives. It is imperative that we use our nursing knowledge to evaluate the severity of each patient’s condition and the skill level of the nurse on duty. I feel that the bill sheds a light on a critical situation however this problem cannot be solved by simply attaching a number to a nurse’s patient assignment.

  14. Emily says:

    I am currently a tech in a hospital. I See the nurse to patient ratio issue all the time. I am not a nurse but just being one tech on floor with over 26 patients and doing vitlas every 4 hours blood sugars and changes is next to impossiable especially when the patient acuity are at diffrent levels. Sometimes the nurses have 6 patients a piece and the care for each one is diffrent. How can someone do hourly rounds of theres a patient overload? I hope there is a resolution found for this and is put into place not only for the nurses sanity but for the techs also. We get burned out just as much as the nurses.

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