The Case for Evidence-Based Nurse Staffing

Essential for cost-effective, high-quality hospital-based care and patient safety


Registered nurse (RN) staffing makes a critical difference for patients and the quality of their care. We champion the role of direct-care nurses and nurse managers in working with their hospital leadership to define the best skill mix for each hospital unit, recognizing the role of nurses in managing each patient’s treatment plan and continuously assessing each patient’s health status.

The American Nurses Association commissioned a comprehensive evaluation of nurse staffing practices as they influence patient outcomes and health care costs. The resulting white paper, Optimal Nurse Staffing to Improve Quality of Care and Patient Outcomes, authored by consulting firm Avalere, can be found here

Key findings
Best practices consider many variables when determining the appropriate care team in each hospital unit:

  • Patients: Ongoing assessment of patients’ conditions, their ability to communicate, their emotional or mental states, family dynamics, and the amount of patient turnover (admission and discharges) on the unit
  • Care teams: Each nurse’s experience, education, and training; technological support and requirements; and the skill mix of other care team members, including nurse aides, social workers, and transport and environmental specialists

Nurse staffing models affect patient care, which also drives health care costs. Safe staffing affects a range of hospital-based care issues, including:

  • Medical and medication errors
  • Length of stay
  • Patient mortality
  • Readmissions
  • Preventable adverse events, including falls, pressure ulcers, healthcare-associated infections, and other complications
  • Nurse injury, fatigue, and low retention

Findings point to the importance and cost-effectiveness of nurse staffing decisions that are based on evidence rather than traditional formulas and grids. To foster innovation and transparency in staffing models, it is essential to capture and disseminate outcomes-based best practices.

Staffing and cost containment

Nurse salaries and benefits are among the largest components of a hospital’s expenses and thus are an easy target when balancing budgets. However, decisions to cut labor costs are sometimes shortsighted when the long-term impacts on cost and patient care quality are not considered.

Other variables to consider in addressing hospital-based care costs include:

  • High-tech devices and procedures
  • Prescribed drugs and other medicine
  • Clinician and system practice insurance
  • Facility construction, renovation, and maintenance
  • Information technology investments and upgrades

Well-managed hospitals/health systems continuously balance competing needs to keep organizations fiscally sound.


 2007 (August) – Nurse Staffing by Patient Acuity signed into Law

Every hospital is to implement a staffing plan developed, recommended and reviewed by a committee made up of 50% direct-care staff nurses. The plan must consider admissions, discharges, transfers, the complexity of each patient, skill mix of all staff, the experience of staff, use of special equipment or technology needed. A semi-annual evaluation of the plan must also be completed.

2018 – Survey was conducted by ANA-Illinois on Staffing – over 700 respondents

  • Only 27% reported working in a facility that has a Staffing Committee
  • Only 18% reported that the staffing plan is being used on their report
  • 79% reported staffing issues weekly while 25% reported issues daily
  • 33% reported “dangerous staffing” levels in the last 30 days
  • 69% felt “safe” when reporting concerns about staffing
  • Solutions to short staffing –
    • Nurses are assigned more patients – 85%
    • Float nurses are used – 55%
    • Nurses volunteer for overtime – 51%
    • Managers/Supervisors fill in – 25%
    • Agency nurses brought in – 20%
    • Routine care altered – 19%


Some organizations advocate for legislated nurse-patient ratios, believing that strict ratios will ensure patient safety. Based on our experience with unintended consequences, we do not believe that numeric, fixed ratios will solve the problems with staffing and may, in fact, cause new issues in care delivery in other healthcare sectors.

Possible unintended consequences –

  • We know that we currently have regional nurse shortages – we do not know how many nurses facilities in those regions would have to hire to meet the requirements, and we do not know if our current educational system has the capacity to educate the number of new nurses needed secondary to faculty shortages, clinic site limitations, and simulation limits. The bill has an immediate effective date, so there is no time to “ramp” up to meet the required
  • It currently takes 3-6 months to obtain a license from IDFPR
  • Safety Net (SN) and Critical Access Hospitals (CAH) do not have the resources to meet these requirements.
  • Are we robbing Peter to pay Paul?
    • Will this proposal make it even more difficult for SN and CAH to hire or retain staff?
    • Will this cause a shifting of nurses away from Community Settings, where we already have difficulty recruiting nurses because of pay disparities?
    • How will this impact LTC’s ability to recruit RNs?
    • Will this increase our faculty shortages – as faculty retire will we be able to replace them?


Staffing in Illinois is an issue that we cannot ignore. We must enforce adherence to current law and strengthen the language so we can empower nurses to drive the change in their facility.  We know that staffing models require partnerships between nurses and hospital/health system leadership, including those in finance, operations, and clinical areas. Together, we can find pragmatic solutions to complex and pressing issues.