Ensuring safe and proper nurse-to-patient ratios with critically ill patients has been a constant struggle at hospitals throughout the country. Nursing leaders are trying to improve staffing, but many leaders are not working with direct-care nurses to find a solution. Collaboration between nursing leadership and direct-care nurses on the front lines is essential to improving the work environment and developing sustainable processes for safe and proper staffing.

In 2018, the American Association of Critical-Care Nurses (AACN) came together with the American Nurses Association (ANA), the American Organization of Nurse Leaders (AONL), the Healthcare Financial Management Association (HFMA), and the Institute for Healthcare Improvement (IHI) to partner on nurse staffing issues. In 2022, the National Nurse Staffing Think Tank was formed with these same organizations to identify high priority areas to focus on to address the national nurse staffing shortage. Priority areas identified by the think tank were healthy work environments; diversity, equity, and inclusion; work schedule flexibility; the stress injury continuum (ie, decreasing burnout and supporting nurse well-being); and innovative care delivery models.1  The recommendations from this group were published and are available online.1 

Later in 2022, the group—now known as the Nurse Staffing Task Force—met again to develop long-term solutions to address the national nursing shortage. The group defined appropriate staffing as “a dynamic process that aligns the number of nurses, their workload, expertise, and resources with patient needs in order to achieve quality patient outcomes within a healthy work environment”2(p3) and suggested 5 imperatives of appropriate staffing, with recommendations.2  The 5 imperatives of appropriate staffing outlined by the group include “reform the work environment, innovate the models of care delivery, establish staffing standards that ensure quality care, improve regulatory efficiency, and value the unique contribution of nurses.”2(p2) The purpose of both of these groups was to bring together direct-care, frontline nurses; health care executives; nurse leaders; nurse scientists; quality and safety experts; patient and family advocates; and other subject matter experts to address the nurse staffing crisis.

AACN has long recognized the significance of nurse staffing being based on the needs of patients and competencies of the nurse. They developed the AACN Healthy Work Environment Standards, of which one standard is appropriate staffing.3  AACN states that for appropriate staffing to occur, “Staffing must ensure an effective match between patient needs and nurse competencies.”3 

Results of the AACN Critical Care Nurse Work Environment Survey conducted in October 2021 (in the midst of the COVID-19 pandemic) showed a significant decline since 2018 on the rating of staffing effectively matching patient needs and nurse competencies (mean of 2.66/4.0 in 2018 to 2.33/4.0 in 2021).4  The same survey also showed that 49% of participants who stated their units were appropriately staffed 75% of the time reported they have no plans to leave their jobs in the next 3 years.4 

In addition, AACN assembled a work group in 2023—comprising frontline nurses and nurse leaders, as well as AACN staff—to develop staffing standards for adult critical care. These standards are due to be published in May 2024.

This column describes an example of leaders and staff working together to address the second healthy work environment standard of appropriate staffing3  by developing unit-specific guidelines based on patient needs and outcomes. The 1-to-1 (1:1) staffing criteria project provided an opportunity for frontline staff to effect meaningful change toward appropriate staffing with the added bonus of potential decreased nurse burnout, improved staff satisfaction/morale, and improved nurse retention.

The journey for a new policy and appropriate staffing began at Harbor UCLA (University of California Los Angeles) Medical Center critical care units. This hospital is operated by the Los Angeles County Department of Health Services (DHS), which serves a diverse ethnic and socioeconomic patient population. This facility has 5 different critical care units, all serving a variety of care needs that include but are not limited to adult cardiothoracic, trauma/surgical, coronary care, medical, and neurosurgical services. Patients in these units are extremely critically ill and require multiple resource-intensive approaches of care throughout their hospital stay. Changes in patient acuity can occur rapidly in these patients, affecting the nurse-to-patient ratios at any time.

Although the hospitals for the Los Angeles DHS system in California required minimum staffing ratios that were 1 nurse to 2 patients and had requirements to staff by acuity as well, there were times when patients needed 1:1 staffing for extended periods of time. There were no guidelines on what constituted the need for 1:1 staffing, providing an opportunity to develop criteria for those patients in order to avoid nurses having to provide care for 2 very critically ill patients simultaneously. Examples of the care provided to these patients include, but are not limited to, administering multiple blood transfusions, actively titrating multiple medication and/or vasoactive infusions, drawing frequent blood samples, replacing electrolytes, and performing continuous renal replacement therapy and frequent assessments. Those tasks frequently required more than 1 nurse at a time to complete. One-to-one nurse-to-patient ratios were determined on the basis of subjective assessments by the charge nurse and the bedside nurse together.

The critical care nurses shared their concerns with the chief nursing officer (CNO) about appropriate staffing. The idea for this project began when one of the critical care nurses approached the CNO with a small list of criteria that the staff had developed. The organization had recently implemented shared governance and shared decision-making between leadership and frontline staff, which is important for a healthy work environment. The CNO was very supportive of staff-driven decisions. The budgets that were developed in previous years were set with a nurse-patient ratio of 1 nurse to 2 patients. Over time, the acuity of the patients increased for a small subset of patients in this busy trauma center, but the staffing budget and process had not changed.

The CNO asked the staff to develop objective criteria to identify the subset of intensive care unit (ICU) patients who required this time-intensive level of care. Until that time, nurses were struggling with providing safe patient care and did not feel supported by leadership. After that discussion, the CNO spoke to the director of critical care services and asked for a small work group of staff and leaders to work on these criteria. With the milieu ripe for change, a task force composed of frontline ICU nurses representing each 1 of the 5 adult ICUs, a nurse manager, 2 clinical nurse specialists (CNSs), and the director of critical care services was formed. With nursing leadership in full support of this project, this task force was empowered to meet routinely for several weeks to develop a draft of the 1:1 criteria that would ensure patient safety, safe nursing practice, and efficient use of resources. This CNS-led team of committed ICU nurses was driven to challenge the status quo and make an impactful change in patients’ lives and their working environment. They carefully examined the criteria, engaged in meaningful discussions to understand the different perspectives of their fellow nurses in the various specialty-specific ICUs, and worked as a team to come to consensus in this process. One challenge the task force encountered was the lack of references or data in the literature on 1:1 or 24-hours-of-care staffing in the ICU. None of the other facilities in their health care system had a 1:1 staffing policy either, so once the first draft was developed, it was important to include nurses from the other DHS hospitals before the list was finalized for the system and ready for review by leadership. The task force also incorporated other facility-specific criteria. The process that was followed to formulate the work is outlined in the Table.

Table:

Process Used to Develop the Staffing Policy

Process Used to Develop the Staffing Policy
Process Used to Develop the Staffing Policy

Once the guidelines were developed and approved (see the Figure for the guidelines), the criteria were included in the new Cerner staffing system (Acuity Scheduling and Time Employee Resource [ASTER]), by the Los Angeles General Medical Center, a DHS hospital that was the first to go live on the new system. ASTER allows informed decisions about assignment of ICU patients by offering transparent analysis of staff workloads. The acuity system also considers admissions, discharge, and transfers when it generates the number of nurses needed. The system generally identifies the appropriate acuity for the patient, but in instances where it does not, the charge nurse can trigger the 1:1 criterion by putting a note in the system.

Figure:

ICU 1:1 staffing guidelines proposal. BiS, bispectral index; CRRT, continuous renal replacement therapy; CSF, cerebrospinal fluid; CVVH, continuous venovenous hemofiltration; CVVHD, continuous venovenous hemodialysis; CVVHDF, continuous venovenous hemodiafiltration; DCD, donation after cardiac death; ECMO, extra-corporeal membrane oxygenation; EKOS, EkoSonic endovascular system (Boston Scientific); FiO2, fraction of inspired oxygen; ICP, intracranial pressure; ICU, intensive care unit; IV, intravenous; pCO2, partial pressure of carbon dioxide; PEEP, positive end-expiratory pressure; SISTBICC, Seattle International Severe Traumatic Brain Injury Consensus Conference; TBI, traumatic brain injury; TTM, targeted temperature management.

Figure:

ICU 1:1 staffing guidelines proposal. BiS, bispectral index; CRRT, continuous renal replacement therapy; CSF, cerebrospinal fluid; CVVH, continuous venovenous hemofiltration; CVVHD, continuous venovenous hemodialysis; CVVHDF, continuous venovenous hemodiafiltration; DCD, donation after cardiac death; ECMO, extra-corporeal membrane oxygenation; EKOS, EkoSonic endovascular system (Boston Scientific); FiO2, fraction of inspired oxygen; ICP, intracranial pressure; ICU, intensive care unit; IV, intravenous; pCO2, partial pressure of carbon dioxide; PEEP, positive end-expiratory pressure; SISTBICC, Seattle International Severe Traumatic Brain Injury Consensus Conference; TBI, traumatic brain injury; TTM, targeted temperature management.

Close modal

The guidelines standardized the 1:1 and 1:2 patient assignments across DHS hospitals and decreased subjective assessments. Furthermore, the transparency of equitable assignments increased staff morale by decreasing questions regarding high-acuity assignments. Satisfaction with staffing has improved throughout the system with implementation of the new guidelines.

Nurse staffing is influenced by various critical factors, such as patient acuity, admissions and transfer rates, discharges, and the physical layout of the nursing unit. In general, the 1:1 guidelines are a great objective document to determine those patients who cannot be in a paired patient assignment due to the level of care that is needed. One of the criteria indicating a 1:1 assignment is a patient who is on continuous renal replacement therapy (CRRT), typically because these patients have additional critical care issues and are not stable. However, stable patients on CRRT alone can be in a paired assignment with another patient. This is one of the criteria that is flexible depending on other issues that are happening with the patient.

The staff came forward and established the 1:1 criteria to provide a standardized guideline and workflow for staff to follow. Prior to implementing these criteria, staff satisfaction with appropriate staffing was low; after implementation, staff satisfaction has improved. The process of leadership and staff working together to develop appropriate staffing supports a healthy work environment. This work reflected several of AACN’s Healthy Work Environment Standards3  including true collaboration, effective decision-making, appropriate staffing, and authentic leadership demonstrated by the leaders who supported this staff-driven work.

1
American Nurses Association
.
Partners for Nurse Staffing Think Tank
.
2023
. Accessed February 9, 2024.
2
Nurses and American Nurses Association
; 
Nurse Staffing Task Force
.
Nurse Staffing Task Force imperatives, recommendations, and actions
.
2023
. Accessed February 9, 2024.
3
American Association of Critical-Care Nurses
.
AACN standards for establishing and sustaining healthy work environments: a journey to excellence
.
Am J Crit Care
.
2005
;
14
(
3
):
87
.
4
Ulrich
B
,
Cassidy
L
,
Barden
C
,
Varn-Davis
N
,
Delgado
SA
.
National nurse work environments-October 2021: a status report
.
Crit Care Nurse
.
2022
;
42
(
5
):
58
70
.

Footnotes

The authors declare no conflicts of interest.