Specialty Guidelines for Appropriate Staffing

Hospitals face challenges to address staffing on a daily basis. There is uncertainty about the new federal budget, about executive orders coming from the White House, about the future funding of Medicare and Medicaid. With all of this uncertainty, health care systems are seeking to reduce costs. Because the nursing budget is usually the largest line item in health care system budgets, organizations look at all associated costs for opportunities for reductions. While the role of finance departments and chief financial officers is to maintain a balanced budget, it is important that they work closely with the chief nursing officer, who is responsible for safe staffing.Some states have nursing ratios or regulations related to staffing. In the early 2000s, empirical research found a relationship between licensed nurse staffing and quality patient care.1,2 California implemented nurse staffing ratios in 2004, and since that time more than 10 states have implemented some form of ratio regulations (Table 1).3 Despite numerous states implementing staffing ratios, there have been no studies to validate whether nurse-patient ratios improve care. There are studies, however, that show that a mix of more registered nurses improves care.4 It is important that nurses be aware of the recommendations and regulations to ensure appropriate staffing, especially in their clinical specialty. This column will describe available standards from specialty organizations for staffing in different areas of the hospital.In 2021, the Nurse Staffing Think Tank—made up of representatives from the American Association of Critical-Care Nurses (AACN), the American Organization of Nurse Leaders, the American Nurses Association, the Institute for Healthcare Improvement, and the Healthcare Financial Management Association—met to develop recommendations to improve staffing. One of those recommendations was for specialty nursing organizations to investigate evidence-based practices related to scope of practice and minimum safe staffing levels for patients in their specialty.5 Since then, several specialty organizations have published guidelines for staffing based on patient populations. Some organizations have developed general statements about staffing, whereas other organizations have developed detailed guidelines. Examples of these guidelines are shared below.In 2024, AACN published AACN Standards for Appropriate Staffing in Adult Critical Care, which includes 7 staffing standards (see Table 2).6 In Critical Care Nurse, Delgado7 shared the standards, as well as evidence-based practices to implement these standards.7 The intent of the standards is to be broad enough so most health care systems can apply them within their institutions based on their processes to deliver safe care. The AACN standards do include a minimum nurse-patient ratio in critical care.In addition, Blake et al8 shared a process one organization used involving leadership and staff working collaboratively to develop appropriate staffing guidelines. The article also included the AACN adult critical care guidelines.In 2025, the AACN Standards for Appropriate Staffing in Adult Progressive Care was published.9 These standards define progressive care nursing as providing or influencing care “for acutely ill patients who are moderately stable with an elevated risk for instability.”9 Such patients, the guidelines note, “require a high intensity of care and vigilance.”9 This first 6 progressive care standards are the same as the adult critical care standards (Table 2). The seventh standard, specific to progressive care, is “Organizational staffing plans anticipate that progressive care generally requires a ratio of 1 nurse for every 3 or 4 patients.”9 As an example of a state with specific standards, California stipulates that the maximum number of patients to a nurse in progressive/step-down care is no more than 3.10 A step-down unit in the California code is defined as “a unit which is organized and operated to provide for the care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily life support.”10Although the Association of Medical Surgical Nursing does not yet have detailed standards, they have released a statement for safe staffing, recommending a local approach that takes the following into account: patient acuity, the skills of the nurse, and the physical characteristics of the floor or facility.11 In addition, California law sets the ratio for medical surgical areas at 1 nurse to 6 patients.10In 2021, the American Organization of Operating Room Nurses (AORN) posted a detailed statement for their members on safe perioperative staffing and on-call procedures.12 AORN recommends perioperative staff involvement in staffing planning and consideration of the unique needs of each patient, the procedural complexity and technological demands, professional competency, professional proficiency, skill mix of personnel, professional practice standards and health care regulations, accreditation requirements, and state staffing laws.12 They also provide statements on on-call staffing, recommending provisions for an uninterrupted 8-hour sleep cycle as well as a maximum number of call hours that should be scheduled.12 They further define the minimum staffing requirements: 1 patient per intraoperative circulating registered nurse (RN), 1 nurse to 2 patients during postoperative phase I, and 1 nurse to 3 patients in postoperative phase II.12 California’s staffing ratio for the operating room is similar to AORN’s: 1 nurse to 2 patients in the postanesthesia care unit.10The Society of Pediatric Nurses’ (SPN) board of directors approved a position statement for the safe staffing for pediatric patients in March 2022.13 They recommend use of an acuity tool to objectively measure the patient’s acuity, an assessment of the patient and family needs, an evaluation of published recommendations for staffing ratios, a lower nurse-to-patient ratio than adult nurse-to-patient ratios, and an assessment of RN competency to inform staffing based on other published SPN standards.13 The California nursing staffing ratio in pediatrics is 1 nurse to 4 patients.10In 2022, the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN) released detailed recommendations for their members about staffing in perinatal areas.14 The recommendations are based on the location and acuity of the patient as well as the proficiency of the nurse.14 Patients in active labor who are getting intense nursing care are considered high acuity; for these patients, AWHONN recommends 1 nurse to 1 patient. For couplet care patients (ie, mother and baby pairs) who are stable, AWHONN recommends 1 nurse to 3 couplets, so the nurse can have up to 6 patients in these cases.14 The standards include recommendations for staffing in the antepartum, intrapartum, postpartum, and newborn care areas. California’s code mandates 1 nurse to 2 patients in the labor and delivery department, 1 nurse to 4 patients in couplet care, and 1 nurse to 4 patients in the antepartum area.10There currently are no published ambulatory nursing staffing standards or statements.The Emergency Nurses Association (ENA) recommends that health care organizations determine their own staffing models. They recognize that each emergency department (ED) has its own variables including population served (eg, urban versus rural) and designation as a trauma center, stroke center, or STEMI (ST-segment elevation myocardial infarction) center; ENA believes that staffing should be driven by patient care standards and quality of nurses’ skills as well as the quantity of nurses.15 The California nurse-to-patient ratios for the emergency department are specified at a maximum of 1 nurse to 4 patients.10 California law further defines the ratios as 1 nurse to 2 patients for critical care patients, and 1 nurse to 1 patient for trauma patients.10The American Psychiatric Nursing Association does not recommend or endorse any single staffing model for staffing hospitalized psychiatric patients.16 They state that limited evidence supports existing methods to evaluate staffing and recommend that priorities be defined around patient safety, healthy work environments, and nurses working at the top of their license.16 California law sets staffing in psychiatric inpatient units at 1 nurse to 6 patients.10Among nursing clinical specialty areas, there is a broad range of existing guidance, from none to detailed and specific. It is important for nurses to know what relevant professional nursing associations recommend and what their state laws mandate. In addition, the standards I examined recommend that frontline staff nurses in the clinical areas should be involved in development of staffing guidelines and advocate for safe staffing. I encourage critical care or progressive care nurses to review AACN’s staffing standards, share them with their administrators and if not already in place, and begin collaborative dialogue to determine the staffing guidelines for their units.