Appropriate staffing levels in hospitals and other healthcare facilities are crucial to maintain the highest level of quality patient care. There is a great deal of debate both within the industry and outside about what constitutes "appropriate levels" and by whom they should be determined.

It is indisputable that changes have taken place in the healthcare industry over the past decade and that these changes have altered the way healthcare services are delivered. Fewer patients are admitted to hospitals. Those that are tend to be more acutely ill and stay for shorter periods of time. Hospitals and other healthcare facilities are competing for lucrative insurance contracts, forcing them to cut costs, which often means cutting staff. Yet, by cutting staff levels inappropriately, patients are not receiving the type and quality of care that they need and deserve.

There are several things to keep in mind when determining staffing levels in healthcare:

• The type of healthcare facility and the types of patients it serves. Not only does the type of healthcare facility affect the type of staffing levels that are appropriate, but so also do each facility's location, number of beds (or residents or clients), occupancy rate and teaching status. Each of these factors must be taken into consideration when determining what is a safe and appropriate staffing level.

• The acuity levels of patients. As cost-cutting measures are implemented in every facet of healthcare, more and more services are being performed in non-acute care settings. Surveys of nurses and other healthcare providers attest to the fact that patients in hospitals are more acute than ever before, even though their lengths of stay have decreased. Likewise, patients seen in outpatient settings and in their homes also tend to be more acute.

• The skill mix of those providing services to patients. There is a significant body of research linking staffing ratios of registered nurses to patients with higher quality care. However, it is important not to overlook the important impact that LPNs, nursing assistants, lab techs, X-ray and radiology techs, respiratory therapists, pharmacists and other healthcare workers have on quality outcomes. Not only is it imperative to have adequate nurse staffing, but adequate ancillary staffing is as important.

Given these parameters, AFT Healthcare has adopted the following principles as related to safe staffing in healthcare (also see AFT Healthcare's definition of safe staffing):

• Healthcare facilities should adopt standardized nurse-to-patient ratios that are established in joint labor-management committees in unionized facilities or by the Department of Health and Human Services. These ratios should always take into consideration, and may include actual staffing ratios for, other caregivers and ancillary staff.

In facilities that do not have a union contract outlining staffing levels, the following minimum RN-to-patient ratios should be mandated:

1:4 med surg
1:2 ICU/CCU
1:1 operating room
1:2 neonatal ICU
1:4 intermediate care nursery
1:8 well-baby nursery
1:8 postpartum, with 1:4 couplets and 1:6 in units with mothers only
1:2 labor and delivery
1:2 post-anesthesia care
1:4 emergency, with 1:2 for critical care and 1:1 trauma
1:2 burn unit
1:4 pediatrics
1:4 step-down/telemetry
1:5 specialty care/oncology
1:5 telemetry
1:6 behavioral health psychiatric units

• In addition to minimum ratios, staffing should be determined based on the acuity of patients. Any acuity system developed by an employer should include the input of front-line nurses and other caregivers. Acuity systems should not be changed arbitrarily by an employer that fails to meet its own staffing guidelines. Any changes in such a system should be done in a collaborative fashion between management and its employees through labor-management committees.

• Hospitals and other types of healthcare facilities should disclose to the public their staffing levels for every unit and every shift. This list should include all workers, licensed and unlicensed and the methods used to determine and adjust staffing levels in that facility. It should also disclose patient care incidents such as medical errors, decubiti, and nosocomial infections on a monthly basis. The public should be aware of inadequate staffing levels, and also of proper staffing levels, in order to make informed decisions regarding their own personal heathcare.

• Safe staffing includes not only the number of registered nurses available to care for patients, but also must take into account the education, experience and expertise of the nurses. Safe staffing must include time for proper training and orientation and should forbid mandating nurses to practice in areas outside of each individual’s area of expertise, skill and knowledge.