Nursing Staffing

Describing the Strategic and Its Strategic Nature

The issue of nurse staffing has become critical issue in many healthcare organizations. Jacobson (2015) observes that the widespread understaffing of nurses increases the risk to patients. It is indicated that despite there being emerging staffing data that supports the need of attaining nurse-to-patient ratio, but the healthcare facilities seem to reluctant to adopt them.  The health administrators opt to reduce the staff at their facilities as a cost-effective measure. This action is just focused on the direct wages expenses without consideration of the indirect excess costs that result from poor outcomes.

In a survey conducted in 2016 by Avantas, seeking to establish why nurse scheduling and staffing had become a common problem affecting healthcare organizations across the country (Morgan 2016). It was revealed that the issue on nursing shortage had become a chronic problem. A survey carried out in 2002 across the nation revealed at nurse understaffing was among the greatest threats to patient safety in the United States (Morgan 2016). The American Nurses Association made calls for the enactment of laws and regulation. ANA indicated that the healthcare employers had failed to address the correlation between registered nurses staffing and the patients Outcome. California acted on this by creating law that provided a minimum registered nurse (RN)-to-patients ratios for healthcare facilities. Nurse staffing levels have increased between 2004 and 2011 with the total nursing hours per patient (HPPDP) in the general care units increasing by 11.5% and registered nurse hours per patient increasing by 22.9% (He, Staggs, Bergquist-Beringer, Dunton, 2016).

Nurse staffing has been identified as a major issue entailing professional and personal concerns among the nurses. Nursing staffing covers issues such as staffing levels, unit organization, and inequitable assignments. These have specified to among the top reasons why nurses quit their positions which further escalated the problem. In 2013, it was notice that there were more than 120,000 deficiencies of quality in nursing homes. Among the underlying reasons for quality problems has been indicated to be inadequate nurse staffing levels. The nursing home have failed to adhere the requirements provided in the Nursing Home Reform Act of 1987 that required the nurse homes to ensure that they had adequate staff members to meet the needs of the patients. About 41 states have been noted to have established higher staffing standards than the federal regulations. However, despite these regulations, most states have been unable to attain the required nursing staffing levels (Harrington, Schnelle, McGregor, & Simmons, 2016).

The issue of nurse staffing has been largely associated with financial conditions and uncertainty. On this note, it has been indicated that healthcare facilities have been experiencing financial uncertainty resulting from low reimbursements from payers, higher acuity patient, and stiff competition. The situation has seen the hospitals actively seek means of minimizing the costs. A review in the cost centers for a healthcare facility reveal that nurse wages and benefits take up a high a huge portion of overall hospital costs.  This makes the hospital tend to attempt to reduce nursing staffing to reduce costs and increase the profitability of the facility. These moves to reduce the nurse staff are carried out irrespective of availability of empirical studies indicating that adequate nurse staffing enhances better outcomes for the nurses and patients without adversely affecting the financial performance of the facility (Everhart, Neff, Al-Amin, Nogle, & Weech-Maldonado, 2015).  

California State is among the few states that have taken the issue of regulating hospital staffing with a keen interest. It was the only state that set a minimum nurse-to-patient staffing ratios-ceiling that indicate the number of patients that nurse can take for at a time. The California story on nurse staffing connects the adherence to staffing ratio to different improvements in patient care (Jacobson, 2015).

Justification of Nurse Staffing as Strategic Issue


 A major drive for the nurse staffing issue has been noted to be financial uncertainty. This has seen most hospital administrator seeks to reduce the nurse staffing as a means of increasing profitability. The financial uncertainties have been causes by factors such as reduced reimbursements from payers, increased level of acuity patients, and increased competition level from other organizations (Everhart et al. 2013). The result of this has been healthcare facilities continuously seeking to reduce costs. The cuts in the nursing staffing resulted to heavier workloads that brought more concerns adequacy of staffing levels in hospitals.

Another key driver for strategic issue competitive hospital markets is competitive hospital markets. The acute care hospital care hospital market environment has been observed to be characterized by many healthcare facilities that competing for patients, healthcare practitioners, and medical staff. To survive in such kind of environment, the facilities strive to reduce cots and maintain high level of quality. The facilities are expected to differentiate themselves in terms of services offered, quality of care and other services. Operating in these competitive markets face challenges such as competition for scarce resources and the quality of medical staff, including registered nurses, the available for consideration for staffing. These market factors influence the nurse-to-patient ration that can be maintained by these facilities. 

Another driver for nurse staffing is on workload and the work environment. These have been knowing the main factors leading to nursing shortage. Issues on unacceptable and unsafe work environments with incidences such as bullying and harassment affect negatively on the issue of retention. Job workload has been reported by many nurses as being their capacity to take on work. Some nurses have indicated that the main reasons that would affects high rates of turnover are excess workload, lack of recognition for work done, lack of autonomy, low morale, job dissatisfaction, and safety issues (Duffiled, Christine, & O’Brien-Pallas, 2003). 


Adequate nurse staffing has been linked to measures for both patient and nurse satisfaction, and quality of care provided to patients. The relationship between nurse staffing and measures of patient outcomes such as failure to rescue, mortality, and falls and nurse outcomes satisfaction and turnover. Studies have revealed that risk adjusted 30-day mortality and failure-to-rescue rates of hospital surgical patients by about 7% for every one patient increase in nurse workload. Establishing a higher proportion of nurse was associated with lower patient mortality rates. Having higher RN staffing is associated with decreased risk of hospital-related mortality, hospital acquired pneumonia and other adverse patient outcomes. It is thus clear that addressing the issue of nurse staffing and patient outcomes influences the levels of nurses’ lead which causes better patient outcomes. (Everhart, Neff, Al-Amin, Nogle, & Weech-Maldonado, 2015).

Nurse working in hospitals with excessive patient workloads and poor workloads in most cases get burnout and job dissatisfaction. It has been revealed that high patient-to-nurse ratio leads to job dissatisfaction and burnout irrespective of the average wage. Excessive workload has been noted to make the staff to have reduced energy thereby making recovery to be impossible. Despite the fact that hiring more staff will directly increase the wage expense, the costs are offset by increased productivity, reduction in nurse’s turnover and retraining costs and eventually enhancing better outcomes (McHugh & Ma, 2014).

In a study that sought to establish the effect of nurse staffing and burnout on healthcare- associated urinary tract and surgical sites infections, revealed that few infections were recorded in healthcare facilities were nurses were responsible for fewer patients. the higher rate of infections experienced in healthcare facilities where nurses dealt with more patients were noted to be associated with high nurse burnout attributed to heavier nurse patient workload. The resulting nurse burnout has been associated with job dissatisfaction and general quality of patient care. Burn-out has bene noted to have the potential of increasing self-reported medical errors among surgeons and practitioner of internal medicine (Cimiotti, Aiken, Sloane, & Wu, 2012). 

In the state of California where, where law on nurse staff were first established, it has been established that there was reported increments in satisfaction of the nurses in the state between 2004 and 2006. Outcomes for nurses and patients in healthcare facilities that uses relied on the California nurse staffing mandates as their benchmarks have been noted to increase. In such facilities, where the staffing ratios are based on the California standards, there have been experienced lower job satisfaction and nurse burnout. With such conditions, it has been indicated that nurses are less likely to report on issues such as poor work environment, need for leave their jobs, or that workload cased them to miss changes in the patient’s conditions (Aiken, Sloane, Cimiotti, Clarke, Flynn, Seago, Spetz, & Smith, 2010). It was also observed that by adhering to the California standards on nurse staffing quality was expected to lead to less complaints from the patients and families.  

Another consequence of nursing staffing has been indicated to be on mortality. One particular study researched on the association between nurse patient staffing levels and failure to rescue or death to be much higher than in surgical patients as compared to medical patients. various studies have highlighted an association between nurse staffing and hospital mortality. some of these studies have recognized high mortality rates among post-surgical patients, others among the patients with acute myocardial infarctions, others with severe complications (Needleman & Beurhaus, 2003). 


Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., … & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health services research45(4), 904-921.

Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care–associated infection. American journal of infection control40(6), 486-490.

Duffield, C., & O’Brien-Pallas, L. (2003). The causes and consequences of nursing shortages: a helicopter view of the research. Australian Health Review26(1), 186-193.

Everhart, D., Neff, D., Al-Amin, M., Nogle, J., & Weech-Maldonado, R. (2013). The effects of nurse staffing on hospital financial performance: Competitive versus less competitive markets. Health care management review38(2), 146.

He, J., Staggs, V. S., Bergquist-Beringer, S., & Dunton, N. (2016). Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality. BMC nursing15(1), 60.

Jacobson, R. (2015). Widespread Understaffing of Nurses Increases Risk to Patients. Scientific American.

Mark, B. A., Harless, D. W., Spetz, J., Reiter, K. L., & Pink, G. H. (2013). California’s minimum nurse staffing legislation: results from a natural experiment. Health services research48(2pt1), 435-454.

McHugh, M. D., & Ma, C. (2014). Wage, work environment, and staffing: effects on nurse outcomes. Policy, Politics, & Nursing Practice15(3-4), 72-80.

Morgan, C. (2016). New Survey Shows Hospitals Struggling with Nurse Scheduling and Staffing Due to Use of Outdated Tools. 

Staggs, V. S., Olds, D. M., Cramer, E., & Shorr, R. I. (2017). Nursing skill mix, nurse staffing level, and physical restraint use in US hospitals: a longitudinal study. Journal of general internal medicine32(1), 35-41. 

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