Nurse Staffing Ratios: Leadership and Management Approaches

Introduction to the Nurse Staffing Ratio Debate

In the medical field, a prominent topic of debate concerns nurse staffing ratios, with many arguing that governments need to intervene by setting minimum staffing laws. Currently, California is the only state to have enacted such a law, and nurse unions in other states are fighting for similar legislation in their workplaces. However, most attempts by other states to implement California's approach have failed, largely because hospitals decline to participate (Schultz, 2013). Hospitals commonly argue that mandatory staffing laws deprive them of the ability to make independent staffing decisions and impose a significant financial burden (Schultz, 2013).

As observed in many nursing unions, hospitals have abused the system by employing too few nurses even as patient loads continue to grow. Inappropriate staffing ratios undermine patient safety, diminish nurse satisfaction, and contribute to the further deterioration of the work environment through job stress and burnout. The nurse staffing ratio debate persists, and the only way to improve the situation is to apply effective leadership and management approaches in the hospital environment — thereby avoiding the negative effects associated with inadequate nurse-to-patient ratios.

Arguments For and Against Mandatory Staffing Ratios

According to Aiken et al. (2002), a positive relationship exists between nurse staffing ratios and preventable patient death. Critics of mandated ratios argue that fixed legislative requirements carry a high risk of creating political and economic devaluation of the nursing profession. Mandatory ratio proponents, on the other hand, contend that legislated staffing levels will improve quality of care, enhance the satisfaction of both patients and nurses, and improve the nursing work environment overall. An improved work environment, in turn, attracts new nurses as well as licensed nurses who are not currently working.

Staffing critics counter that mandating specific ratios in environments where nursing shortages are already severe may lead to the reduction of hospital services, increased unit closures, increased emergency room diversions, and higher hospital expenses due to the additional labor costs associated with temporary agency nurses and overtime pay.

The American Organization of Nurse Executives (AONE) has a responsibility to manage patient care and to ensure a focused environment that prioritizes quality and safety. AONE's position is that staffing ratios are complex, involving multiple variables, and that the mandated staffing ratio approach does not guarantee a healthy working environment for nurses. Furthermore, safety and quality levels alone are insufficient to prevent adverse patient outcomes. AONE asserts that mandatory staffing ratios serve only to increase stress on an already overburdened healthcare system facing an escalating shortage of professionally registered nurses both nationally and internationally, and therefore carry the potential of creating greater risks to public safety (AONE).

Leadership vs. Management in Nursing

According to Hughes et al. (2006), the distinction between leaders and managers can be summarized as follows:

• Leaders develop; managers maintain.
• Leaders originate; managers initiate.
• Leaders innovate; managers administer.
• Leaders challenge the status quo; managers accept it.
• Leaders take a long-term view; managers use a short-term view.
• Leaders inspire; managers control.
• Leaders ask why and what; managers ask when and how.

However, a leader is defined not merely by job title but by behavior. It is expected that a leader will inspire, innovate, challenge, and guide as described above. The underlying question is whether these behaviors and practices are present in today's nursing leaders (Curtis et al., 2011, p. 307).

Nursing staffing ratios directly impact a manager's responsibilities. A shortage of nurses increases the chance of errors due to improper patient treatment and nurse burnout. Nurses are easily overworked or discouraged when handling a large number of patients, and it is in these circumstances that the skills — not merely the financial or technical abilities — of nursing leaders and managers are truly tested. Demonstrated leadership in nursing also fosters leadership in others within the work environment. Characteristics that promote leadership include extroversion, openness, and strong motivation; leadership is further facilitated by experience and age. Effective leaders in healthcare settings are those who maintain direct contact with caregivers. Leadership training programs are likewise effective in producing both short-term and long-term change in the healthcare setting (Curtis et al., 2011, p. 308).

Managers assess work environments and determine better assignment and management of nurses. For instance, by designing effective working schedules, burnout is reduced and nurses who work longer shifts are given sufficient time to recover their strength before the next one. When managers apply these approaches during periods of low nurse-to-patient ratios, the work environment becomes more balanced, costs are reduced, and quality and safety are enhanced — all contributing to the attainment of organizational goals and objectives (Hughes et al., 2006).

In nursing, the role of leadership differs from that of management because leadership can be found in any healthcare personnel regardless of their formal position. Leaders inspire and motivate those around them to achieve both organizational and personal goals. Research has demonstrated the existence of a positive relationship "between relational leadership style model and patient outcomes" (Wong & Cummings, 2013, p. 709).

Conclusion

Nurse staffing ratios create work environments that are not only stressful for nurses but also dangerous for patients. As such, leaders and managers must employ varied approaches to bring order to the workplace and improve the safety and quality of services provided to patients. A relational leadership approach applied to nurse staffing ratios is particularly effective because it is inclusive and focuses on improving motivation levels, which keeps the healthcare environment engaging and rewarding for nurses. Nurses should also be included in decision-making processes, since they directly experience staffing challenges and are central to the organization's functioning. Maintaining high motivation levels during periods of low nurse staffing ratios helps ensure that the work environment remains healthy and safe for both patients and nurses, supporting the achievement of organizational and personal goals alike.

References

Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, 1987–1993.

AONE. Mandated staffing ratios. Retrieved from http://www.aone.org/resources/leadership%20tools/staffingratios.shtml

Curtis, E., Vries, J., & Sheerin, F. (2011). Developing leadership in nursing: Exploring core factors. British Journal of Nursing, 20(5), 306–309.

Hughes, R., Ginnett, R., & Curphy, G. (2006). Leadership: Enhancing the lessons of experience (5th ed.). McGraw-Hill.

Schultz, D. (2013). Nurses fighting state by state for minimum staffing laws. Kaiser Health News.

Uhl-Bien, M. (2006). Relational leadership theory: Exploring the social processes of leadership and organizing. Leadership Institute Faculty Publications, Paper 19.

Wong, C., & Cummings, G. (2013). The relationship between nursing leadership and patient outcomes: A systematic review update. Journal of Nursing Management, 21(5), 709–724.