What's Being Done About Nurse Staffing?

Carolyn Buppert, MSN, JD


April 04, 2017

To submit a legal/professional nursing question for future consideration, write to the editor at syox@medscape.net (Include "Ask the Expert" in subject line.)


An emergency department (ED) nurse asks a question about staffing.

What patient-to-nurse ratios are considered "safe"? At the hospital where I work in the ED, the patient-to-nurse ratio is often 5:1. At another facility where I worked, the ratio was 4:1 unless the patient was critical; then at times it could be 1:1, and a float nurse or the charge nurse would pick up the other patients for the time needed. Is a 5:1 patient-to-nurse ratio in the ED common, and is it considered safe?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

This question is being debated in hospitals, state legislatures, Congress, and among nurses. The basic questions—"What is appropriate staffing and who should make that decision?"—are being asked in all types of units, including EDs.

Nurses in several parts of the country have been protesting inadequate staffing. In January, organized protests took place in California and Pennsylvania. In March, nurses at a Philadelphia-area hospital had a walk-out over staffing issues. Nurses at Kaiser in California and in St. Louis picketed their own hospitals last year to draw attention to staffing levels they said put patients at risk.

Editor's Note: Don't miss our companion article, "Nurses Are Taking Washington, DC," to learn about a rally/march by nurses for safe staffing planned for May 5, 2017.

What Do Nurses Say?

In a Medscape survey conducted in the fall of 2016, drawing up to 6100 responses to one or more of a series of questions, 53% of nurse respondents said that at the end of a typical shift, they did not feel satisfied about the care they had provided. And 57% believe that patient care is suffering. The nurses (who were not limited to a single response) also believe short staffing affects staff, patients, and families in these ways:

  • Nurse morale is lower                     63%

  • Patient satisfaction is lower            54%

  • Nurses transfer or quit                   47%

  • More mistakes are made                39%

  • Physicians/other staff complain      29%

  • Documentation is incomplete         15%

Only 4% reported that short staffing had no effect, and 1% reported that during times of short staffing, patients and families were less demanding on the nursing staff.

When asked, "What typically happens when the unit is short-staffed?" the nurses answered:

  • Agency nurses are called in                                         91%

  • Nurses on duty must take a heavier load                     67%

  • Additional nursing assistants are assigned to unit       46%

  • Nurses are "floated" in                                                 40%

  • Nurses work voluntary overtime                                   34%

  • Routines are altered to reduce workload                     15%

  • Managers, supervisors step in to help                          14%

  • PRN/part-time nurses are called in                               14%

  • Nurses work mandatory overtime                                  12%

  • Patients are discharged/transferred                                6%

  • The unit is closed to admissions                                      6%

  • Procedures are postponed                                              3%

The most recent shift of 75% of the respondents was a 12-hour shift, and 44% had worked overtime, either before or after their scheduled shift. During their most recent shift, 61% handled one to three admissions, discharges, or transfers.

Patients, patients' families, nurses, and hospital administrators experience short staffing in very different ways—something like this:

  • Patient: "I pushed my call button 15 minutes ago. No one has come. My pain is bad. The nurse told me not to get out of bed by myself. I'm trapped in bed. I'm scared."

  • Nurse: "I have six patients. One is just out of surgery and needs frequent vital signs and pain medication. One has a wound infection and needs a complicated dressing change. One needs help getting to the bathroom, and if she doesn't get help, she may fall. One needs to be discharged, and one needs my admission assessment and all of the paperwork that goes along with that. There are new orders on my sixth patient. I have to start an IV and arrange for a psychiatric evaluation. I hear a call bell going off, but I can't leave the patient I am with right now."

  • Patient's visiting family member: "My mother needs to go to the bathroom, but no one is answering her call light. The nurse isn't very good."

  • Hospital administrator: "We need to keep nursing costs down."


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.