Effective Approaches in Leadership to Address Nurse Staffing Ratios

Description of the Selected Issue – Nurse Staffing Ratios

With America’s senior population on the rise – compounded by other factors like poor
pay, cost-cutting decisions by hospitals, increased patent need and complexity, the inability of
nursing schools to expand workforce capacity to meet the increasing need for care, and an aging
nurse population – experts warn that the country’s healthcare system is on the verge of collapse.
Statistics show that the nurse shortage is increasing in the US, with most hospitals and clinics
suffering from an unprecedented surge in nursing staffing ratios; this is significantly hurting the
quality of care, the safety of patients, and the satisfaction scores of nurses and patients.
In its 2021-2031 projections, the Bureau of Labor Statistics expects the RN population to
increase by 6 percent (from 3.1 million to 3.3 million between 2021 and 2031) within the next
ten years, representing an increase of 195,400 nurses (American Association of Colleges of
Nursing, n.d.). BSL also predicts that 203,200 new openings annually would be created through
2031, creating a gap of approximately 2,032,000 positions for the ten years. The difference
between the two creates a gap of roughly 1,836,600 registered nurses. Factors like cost-cutting,
poor leadership in clinical facilities leading to nursing burnout and resignations, staff retirement
due to age, a growing senior population, and an increase in demand for health care are playing a
fundamental role in this growing demand for RNs. With the country’s inability to expand staff
production due to underfunding in nursing schools and lack of interest in students enrolling in
nursing schools due to low wages, it is unlikely that the country would ever meet this demand.
All the factors mentioned above– the aging population, nurse burnout due to an increased
workload, and violence in healthcare settings, among others – often increase nurse turnover, thus
impacting staffing ratios. According to Haddad, Annamaraju, & Toney-Butler (2022), nurse

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shortages can substantially reduce the quality of care and patient safety, leading to medical errors
and an increase in morbidities, mortalities, rehospitalization rates, length of hospital stays, and
costs of care. In facilities with a high patient-to-nurse ratio, evidence suggests that nurses
experience dissatisfaction, burnout, poor quality of life, and low work-life balance. On the other
hand, patients experience higher failure-to-rescue rates, mortalities, rehospitalizations,
dissatisfaction, increased hospital stays, lost working days, and increased costs. All these factors
can also weigh down on healthcare facilities. For example, dissatisfied patients who suffer from
medical errors might sue healthcare facilities for negligence and lost work days; this can
significantly damage the reputation of healthcare facilities besides causing massive financial
losses in litigation fees and fines.
How Professional Standards of Practice Should be Demonstrated to Address the Issue

(Nurse Staffing Ratios) or Maintain Professional Conduct

There are multiple ways in which players in the healthcare industry, including nurse
leaders and managers, can leverage professional standards of practice to address nurse staffing
ratios and maintain a professional conduct. One way is to ensure that healthcare facilities and
departments maintain appropriate and adequate staffing levels set by state regulatory bodies or
recommended by leading nursing agencies and regulatory bodies. Since there is currently no
federal legislation or standard for nurse-patient ratios, hospitals are required to implement the
state nursing ratio requirements. For example, in California (considered the first state to codify
safe nursing ratios), the nurse-to-patient staff ratio varies for pediatric (1:4), psychiatric (1:6),
labor and delivery (1:2), and intensive critical care (1:2) units (Sharma & Rani, 2020). Although
no federal laws have been ratified, the National Nurses United recommends the following

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nursing ratios for safe staffing: pediatrics (1:3), labor and delivery (1:2), rehabilitation (1:4),
psychiatric (1:4), intensive care (1:1), emergency room (1:3), and medical/surgical (1:4).
The Roles of Nurse Leaders/Managers In addressing Nurse Staffing Ratios and Promote

Patient Safety and Quality of Care

Although their roles might differ, nurse leaders and managers play a fundamental role in
addressing nurse shortages and improving the quality of care and patient safety. Nurse leaders
are hands-on and typically supervise nursing teams, ensuring the overall success of individual
members, nursing teams, and the whole organization. In addressing nurse shortages, nurse
leaders can play an integral role in developing policies and shaping the strategic direction their
institution would take to improve healthcare outcomes and promote effective and professional
nursing practices.
For example, nurse leaders can create a positive culture and work setting that appreciates,
supports, and values nurses as a core part of the system. They can leverage participatory and
servant leadership models to create an inclusive environment that fosters effective
communication, teamwork, and shared decision-making. This can improve team morale, reduce
turnover, and improve staffing ratios. Nurse leaders can also work with other leaders to design
approaches to attract and retain staff, such as competitive-payment models and implementing
electronic health records (EHR) and other technologies. Nurse leaders can also leverage their
advocacy skills to champion policy changes at the organizational, state, or federal levels that
address the welfare of nurses and patients (Haegdorens et al., 2019).
On the other hand, nurse managers work behind the scenes to oversee daily operations
and the delivery of safe and quality patient care. For example, nurse managers can implement
strategic evidence-based staffing tools to accurately estimate their staffing needs, hire and train

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nurses to maintain adequate staffing levels at all times to meet their organizational needs,
develop ethical standards and professional standards to guide the nursing practice, allocate funds
to hire new staff and other initiatives to improve nurse experiences, and work with nurse leaders
and other executives to design flexible work schedules, appropriate compensation schemes, and
provide professional growth opportunities. All these strategies can reduce nurse burnout,
improve morale and job satisfaction, and reduce shortages (Carthon et al., 2020).
Additional Aspects Managers/Leaders Require to Initiate to Ensure Professionalism
Throughout Diverse Healthcare Settings while Addressing the Issue
Besides implementing professional standards and recommendations for safe nursing staff,
nurse managers and leaders can also proactively leverage evidence-based staffing models and
tools to determine the most appropriate staffing ratios that meet their specific needs and
demands. There are presently a variety of models and approaches that nurse leaders or managers
can adopt, including patient classification/prototype, simple volume-based methods, timed-task
approaches, and professional judgment. These tools usually try to match nursing staff to a time
requirement or average demand. For example, the patient or prototype classification model
classifies patients based on their care needs and allocates a certain staffing level for each
(Griffiths et al., 2020). Nurse leaders/managers usually generate bespoke groups (for example,
based on dependency/acuity levels) or existing categorizations (for example, diagnosis-related
groups).
Besides leveraging evidence-based models, nurse leaders/managers can regularly assess
nursing workload and patient acuity levels within their facilities and provide ongoing training
and education. They can additionally maintain professional conduct by sticking to ethical
principles (autonomy, nonmaleficence, beneficence, and justice), practice within their scope, and

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partake in professional development to improve their leadership and management skills and
knowledge. Teamwork, effective communication, consultation with team members, and shared
decision-making can also address the underlying factors predisposing organizations to turnover
and staff shortages, including burnout, demotivation, and a lack of concern from the leadership.

The Leadership Style that Would Best Address the Selected Issue
A participative/democratic leadership style is unquestionably the best leadership
approach that can address nurse staffing shortages. Participative leadership typically means
allowing others to partake or impact organizational decisions. This leadership can be effective in
lowering staffing ratios by bringing nurses on board when making decisions affecting aspects
like workload, payment, work schedules, role assignments, and staffing. Participative leadership
promotes two-way, open communication and collaboration, allowing for the effective sharing of
ideas between the nurse leaders/managers and rank-and-file employees (Ebrahim et al., 2022).
By and large, engaging nurses in decision-making can help leaders gain a more profound
knowledge of the strengths and weaknesses of their organizations and the challenges nurses face,
such as unsafe working conditions, excess workload, or underpayment; these insights can form
the basis of finding effective staffing solutions. Leveraging participative leadership can permit
nurses to continuously diagnose the staffing needs of their organizations, develop appropriate
staffing ratios that address these gaps, and design plans to manage workloads.

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References

American Association of Colleges of Nursing. (n.d.). Nursing shortage.
https://www.aacnnursing.org/news-information/fact-sheets/nursing-shortage
Carthon, J. M., Davis, L., Dierkes, A., Hatfield, L., Hedgeland, T., Holland, S., Plover, C.,
Sanders, A. M., Visco, F., Ballinghoff. J., Guidice, M. D., & Aiken, L. H. (2019).
Association of nurse engagement and nurse staffing on patient safety. Journal of Nursing
Care Quality, 34(1), 40-46. doi: 10.1097/NCQ.0000000000000334
Ebrahim, Z. B., Hafidzuddin, S. A., Sauid, M. K., Mustakim, N. A., & Mokhtar, N. (2022).
Leadership style and quality of work life among nurses in Malaysia during the COVID-
19 pandemic crisis. Proceedings, 82(1), 99.
https://doi.org/10.3390/proceedings2022082099
Haegdorens, G., Van Bogaert, P., De Meester, K., & Monsieurs, K. G. (2019). The impact of
nurse staffing levels and nurse’s education on patient mortality in medical and surgical
wards: an observational multicenter study. BMC Health Services Research, 19(864).
https://doi.org/10.1186/s12913-019-4688-7
Griffiths, P., Saville, C., Ball, J., Jones, J., Pattison, N., & Monks, T. (2020). Nursing workload,
nurse staffing methodologies, and tools: A systematic scoping review and discussion.
International Journal of Nursing Studies, 103. doi: 10.1016/j.ijnurstu.2019.103487
Sharma, S. K., & Rani, R. (2020). Nurse-to-patient ratio and nurse staffing norms for hospitals in
India: A critical analysis of national benchmarks. Journal of Family Medicine and
Primary Care, 9(6), 2631-2637. doi: 10.4103/jfmpc.jfmpc_248_20