The Ratios

Nurse aide staffing ratios have been a topic of discussion since nurse aides have been utilized in care settings. Federal law does not require a certain number of residents/ patients/ clients per nurse aide (NA) but only requires that NA’s have at least 75 hours training to care for residents. Some states, however, require more hours of training and that certain topics are covered during that training.

The Law and Nurse Aide Staffing Ratios

The federal law states facilities are required “to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident”.

Caregiver assisting with nailcare

Caregiver assisting with nailcare


Nowhere does it say that there are is a maximum number of patients that a NA can safely care for and specific nurse aide staffing ratios are not addressed.

Fortunately, some states have set a maximum standard for care providers in the nursing home setting. An excellent resource for state mandated standards comes from a report released in 2008 called “Nursing Home Staffing Standards in State Statutes and Regulations”. It shows staffing ratios in nursing homes for RNs, LPNs and NAs.

Do nurse aide staffing ratios affect patient care?

Nurse aide staffing ratios affect patient care, in most cases. Any caregiver who has worked in a nursing home knows this but there is also research to back it up.  Understaffed facilities have higher rates of infection and poorer client outcomes to mention a couple of the consequences related to poor staffing. The residents aren’t the only ones who suffer. Nurse aides working in poorly staffed facilities are at higher risk for injuring themselves as well.

Interestingly, recent research is now showing that it may not be all about the staffing numbers for RNs.

“There is some emerging evidence that it can’t all be about the numbers. We know, for instance, that if you have a better-educated work force, that’s a better way to improve your quality of care even if your numbers are a bit lower,”  states Matthew McHugh, associate professor of nursing and Robert Woods Johnson Foundation Nurse Faculty Scholar at the University of Pennsylvania School of Nursing.

There have been occasions, in my experience working as a NA, that I have preferred to work with one “seasoned” hardworking NA instead of two NA’s that have less experience and different work ethic from my own.

Can you have too much staff?

Caregiver assisting with shower

Caregiver assisting with shower

You can, but that’s not usually the problem. When I was an Assistant Director of Nursing (ADON), we had a unit that had more falls and infections than any other unit in the facility.  My staff said it was because they needed another NA and a bath aide on this unit.

I worked the unit myself to see if there was any legitimacy to their request and I was barely able to get my work done. I decided to staff the unit, as requested and monitor it closely for changed outcomes. What I noticed is that the NA’s were sitting around more and patients were not receiving better care. We still had the same amount of falls and infections on the unit but the NA’s just had more free time.

I decided to look at the individual NA’s on the unit and make changes at that level. I made a few employee assignment adjustments and staffed the unit with a bath aide four hours a day. The change in employees and the added four hours of help was what this unit needed. It didn’t need two more nurse aides each shift.

 Nurse Aide staffing is more than just ratios

Caregiver assists client in chair

Caregiver assists client in chair

Facilities must consider the consequences of under-staffing. Nursing homes are putting patients and health care providers at risk every shift they are poorly staffing.  Usually, in the end, this will cost more in workman’s comp cases, patient treatment and liability costs, and bad press than it’s really worth to under-staff.

The issues with nurse aide staffing, however, are more complicated than just the numbers. The quality, education and work ethic of the individual NA’s must be factored in to decisions made about staffing that is safe for both the clients and the nurse aides.

At Occupational Training Solutions, we believe in the importance of proper training, modeling of desired behaviors, and continual reinforcement of proper care techniques.  For more information visit our products page.