The More RNs, the Higher the Patient Survival

Margaret R. Nolan, DNP, GNP


August 23, 2016

Staff Ratios and Mortality

Many studies have been done looking at the association between lower numbers of registered nurses (RNs) and increased patient mortality. Survival rates for patients who experience cardiac events can vary as much as 42% among different hospitals with similar patient populations.[1] A new study by McHugh and colleagues[2] examines patient survival rates after cardiac arrest in the context of the work environment and RN staffing ratios.

The investigators directly surveyed bedside nurses using the 31-item Practice Environment Scale of the Nurses Work Index. They found that each additional patient per nurse on a medical-surgical unit was associated with a 5% lower odds of survival and a 16% lower odds of survival for patients in hospitals with poor work environments (both findings were statistically significant.) The conclusion from this study is that better hospital work environments and adequate hospital RN staffing are important strategies in improving patient survival rates.


The relationship between RN staffing and patient outcomes is modified by the characteristics of the working environment. This suggests that merely adding more nurses without improving the environment may not be enough to have an impact on patient survival. Improving the environment involves giving RNs more autonomy, control over practice, resources, and good working relationships and communication with physicians. This study adds to the growing evidence that better RN staffing and work environments can improve patient survival.

An important article, published in the New England Journal of Medicine[3] in 2011, found that below-target RN staffing patterns and high patient turnover increased the risk for patient death. New healthcare financing reforms are designed to reward accountability and efficiency, and to bundle services and costs. The cost of RN staffing must also be taken into account.[3]

Safe staffing has been part of the healthcare conversation for many decades. In 2004, California became the first state to establish minimum RN-to-patient ratios for hospitals. This bill, which was passed in 1999 and implemented in 2003, required California acute care hospitals to meet the new staffing ratios by 2004.[4]

The American Nurses Association (ANA) has supported a safe staffing plan that includes the following[5]:

  • Establish a minimum number of RNs that is adjustable;

  • Solicit input from direct care RNs; staff RNs should be represented on staffing committees;

  • Base RN staffing on census and patient acuity levels;

  • Take into account the experience level of RNs;

  • Consider staffing recommendation from nursing specialty organizations; and

  • Ensure that RNs are not forced to float into areas where they have no experience.

The ANA is concerned that legislating minimum RN staffing levels (nurse-to-patient ratios) can fail to account for unique factors, such as patient acuity, skill mix of the nurses, use of ancillary staff, and even architectural features of the work setting. The ANA is also concerned that legislated ratios lack flexibility, and will lead to a reduction in ancillary staffing to meet the RN staffing requirements.[3]

In New York State, where I practice, the state assembly passed the Safe Staffing for Quality Care Act on June 15, 2015.[6] Support for this safe staffing bill was generated by petitions and patients' rights groups, all citing studies that show an increase risk for patient death for each new patient assigned to a nurse. The legislature has included the establishment of safe patient workloads, using nurses trained specifically to the unit on which they work, making it necessary for hospitals to be forthcoming about their staffing patterns and setting a maximum of patients that any nurse can care for.[6] This bill now needs to pass in the state senate and be signed by the governor. The senate already showed support for the bill for safe staffing throughout New York State hospitals in January 2015.[7]

Studies show that Magnet facilities have higher nurse-to-patient ratios and professional practice environments that result in fewer complications, lower mortality rates, and shorter stays.[7] Hospitals applying for Magnet status can improve the work environment for their nurses. Magnet recognition by the American Nurses Credentialing Center requires a culture shift throughout a healthcare organization and takes a constant effort by hospitals to be maintained.[7] Staffing ratios play an important role in patient survival in the hospital, but good working environments prove to be just as important and will need to be addressed by hospitals and nursing leaders throughout the country if we are to have an impact on patient survival.


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