The intent of this position statement is to reaffirm the nursing profession’s responsibility to monitor staffing effectiveness for protection of the public from unsafe and ineffective nursing practice.
Competency: “An individual’s capability to perform up to defined expectations” (American Nurses Association (ANA), 2005b, p.35).
Ratio: “The relationship between two counted sets of data, which may have a value of zero or greater” (ANA, 2005b, p.36).
Staffing: “The analysis and identification of a health care organization’s human resource requirements, recruitment of persons to meet those requirements and initial placement of those persons to ensure adequate numbers, knowledge and skills to perform the organization’s work” (ANA, 2005b, p.36).
It is the position of the New York State Nurses Association that
Staffing effectiveness is described by the Joint Commission (2007) as ensuring appropriate skill mix and numbers of competent staff to meet patient’s needs. Research continues to support that while staffing costs are a significant portion of facilities revenue, adequate staffing has a direct impact on quality and safety of care (Joint Commission, 2010, Preface v.).
The continuing staffing shortages impacts many areas in facilities. These shortages contribute to concerns regarding patient safety and issues related to quality care. Factors identified through root cause analysis of sentinel events include competency, staffing numbers, skill mix, supervision, leadership, orientation, and training (Joint Commission, 2007).
In examining trends in the labor shortage the American Hospital Association Strategic Policy Planning Committee, cite increased competition, changes in the attractiveness of healthcare careers, stressful work environments and associated emotional risks/physical risks as altering an individual’s decision about a career in health care (Joint Commission, 2007).
Nursing remains at the front line of patient care, satisfaction and safety by identifying and addressing patient problems in a timely fashion. To maintain the ability of the profession to respond effectively to a dynamic healthcare system, the IOM’s Future of Nursing (2010) indicated the need for nurses to practice to the fullest extent of their education; achieve higher levels of education; and become full partners in the redesign of healthcare (p. 1). The report also calls for a reexamination of the effectiveness of the current healthcare workforce with methodology to determine areas requiring improvements (IOM, 2010).
Needleman et al. (2010) found an inverse relationship between the number of registered nurses and patient mortality in their retrospective observation study. Dall, Chen, Seifert, Maddox and Hogan (2009) found economic advantages for increasing nurse staffing levels including decreased length of stay; hospital acquired conditions and reduced mortality. Aiken, Clarke, Sloane, Sochalski, and Silber (2002) reported in a cross sectional analysis of data from a survey of nurses and surgical patient’s discharged from hospitals that each patient added to nurses’ workloads was associated with increase in mortality following common surgeries. The nurse’s surveys also indicated evidence of nurse burnout and job dissatisfaction, which are precursors of voluntary turnover, increased as nurses’ workloads increased (Aiken et al., 2002). The ANA has resources to support adequate staffing which include the “Principles for Nurse Staffing” (2005a) and the “Utilization Guide for the ANA Principles for Nurse Staffing” (2005b).
The Utilization Guide for the ANA Principles for Nurse Staffing (2005b) offers evidence for application of the nine principles ANA suggests to ensure appropriate staffing. The Guide reaffirms the difficulties in staffing decisions and the need to identify tools and process for better staffing. The guidelines suggest the use of patient classification systems; nursing judgment in regards to the individual needs of the patient population; integration of resources which support the scope and standards of nursing practice; involvement of the nurse in decisions regarding the tools and evaluation of products which may be used to assist in staffing decisions is imperative (ANA, 2005b). Link to these documents are provided in Appendix A.
The New York State Nurses Association (NYSNA) has advocated for the passage of the Safe Staffing for Quality Care Act in New York State for over eight years. The Act would ensure that an adequate number of nurses are present at the bedside. NYSNA’s memorandum of support reviews a number of studies, which indicate that increasing the numbers and hours of registered nurse care per patients, prevents patient deaths, decreased medication errors and incidence rates of bedsores (decubiti) and decreases hospital days. Registered nurses are clearly more effective when not overburdened by unmanageable patient assignments (NYSNA memo of support, 2010, online).
Research by Aiken et.al. (2010) continues to support that staffing ratios are associated with lower mortality, better nursing outcomes and increased nurse retention in states where they exist.
To ensure the delivery of safe quality care, healthcare organizations and the nursing profession must collaborate to evaluate and monitor the best possible staffing models and ensure methods to maintain the nurse’s competence. Patients are entitled to safe quality care even during a shortage. The profession has historically accepted and will continue to accept this responsibility (ANA, 1992). The Joint Commission (2007) notes the importance of recruitment and retention in dealing with the workforce shortage. Registered nurses are entitled to a supportive work environment and dedicated measures to alleviate overload and stress. The Code of Ethics for Nurses with Interpretative Statements declares that, “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth” (ANA, 2002, p.18).
In conclusion, coordinated efforts in the healthcare arena to provide quality nursing care and to ensure an ample supply of nurses in the future will serve both the public and nursing’s best interests. It is of utmost importance that professional and regulatory bodies uphold existing professional and legal standards regardless of supply and demand issues and seek ways to improve the work environment to increase registered nurse retention.
Uphold existing professional and legal standards of practice through the following recommendations:
Coordinate efforts to promote the role of the registered nurse and to ensure an adequate supply of nurses in the future through the following recommendations:
Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.
Approved by the Board of Directors, May 18, 1978, September 17, 1987, March 9, 2005, August 25, 2011, and November 16, 2011. Reviewed and revised by the Council on Nursing Practice August 19, 2011. This position statement replaces “Use of Supplemental or Temporary Nursing Services.”
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of the American Medical Association, 288(16), pp. 1987- 1993.
Aiken, L. H., Sloane, D. M., Cimiotti, J. P, Clarke, S. P., Flynn, L., Seago, J. A., Spetz, J., & Smith, H. L. (2010) Implications of the California nurse staffing mandate for other states. Health Research and Educational Trust. DOI: 10.1111/j.1475-6773.2010.01114.x
American Nurses Association. (1992). Position statements: Joint statement on maintaining professional and legal standards during a shortage of nursing personnel. (Archived in members only section of ANA) Retrieved from
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements.
Washington, DC: Author.
American Nurses Association (2005a) Principles for nurse staffing. Washington, DC: Author.
American Nurses Association (2005b) Utilization guide for the ANA principles for nurse staffing.
Washington, DC: Author.
Badzek, L. A. (2010). Provision four. In Fowler, M. D. M. (Ed.). Guide to the code of ethics for nurses: Interpretation and application, (pp. 42-54).
Dall, T. M., Chen, Y. J., Seifert, R. F., Maddox, P. J., & Hogan, P. F. (2009). The economic value of professional nursing. Medical Care, 47(1), 97-104.
Drought, T. S. & Epstein, E. G. (2010). Provision seven. In Fowler, M. D. M. (Ed.). Guide to the code of ethics for nurses: Interpretation and application, (pp. 42-54).
Fowler, M. D. M. (2010). Provision five. In Fowler, M. D. M. (Ed.). Guide to the code of ethics for nurses: Interpretation and application, (pp. 42-54).
Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. [Report Recommendations]. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf
Joint Commission. (2007). Staffing effectiveness in hospitals. Oakbrook Terrace, IL: Joint Commission Resources.
Joint Commission. (2010). Management of human resources. In CAMH: Comprehensive accreditation manual for hospitals (pp. HR-1 - HR-10). Oakbrook Terrace, IL: Joint Commission Resources.
Needleman, J., Buerhaus,P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011).
Nurse staffing and inpatient hospital mortality. The New England Journal of Medicine, 364, 1037-1045.
New York State Nurses Association (2010) Memorandum of support of an act to amend the public health law, in relation to enacting the “safe staffing for quality care act” Retrieved from http://www.nysna.org/images/pdfs/advocacy/A2264_mos.pdf
Olson, L. L. (2010). Provision six. In Fowler, M. D. M. (Ed.). Guide to the code of ethics for nurses: Interpretation and application, (pp. 42-54).
Twomey, J. G. (2010). Provision three. In Fowler, M. D. M. (Ed.). Guide to the code of ethics for nurses: Interpretation and application, (pp. 42-54).
ANA Principles of Nurse Staffing (2005a):
Utilization Guide to the ANA Principles of Nurse Staffing (2005b):
For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.