AACN Guiding Principles for Appropriate Staffing

Added to Collection

September 2018


Nurses are essential to the successful delivery of healthcare, and appropriate nurse staffing is key to optimal patient care and overall patient/family satisfaction.1,2 Nurse staffing has been an enduring challenge, and the prevailing model is outdated and unable to meet the needs of patients, families, and the nurses who care for them.

The American Association of Critical-Care Nurses (AACN) has long been concerned about the nurse staffing challenge and has produced influential resources to advance widespread implementation of appropriate staffing. Two of these resources are the AACN Synergy Model for Patient Care3 and AACN’s Standards for Establishing and Sustaining Healthy Work Environments,4 which defines the standard for appropriate staffing. AACN’s focus on staffing supports our vision, which is to create a healthcare system driven by the needs of patients and families where acute and critical care nurses make their optimal contribution. AACN has not been alone in these efforts, other nursing organizations and thought leaders have endeavored to solve the staffing challenge as well.

Appropriate staffing is a comprehensive, dynamic process that ensures patients receive optimal levels of care. It aligns patient needs, nurse abilities, workload, technology, collaboration with other disciplines, the health of the work environment, and many other factors.4  There is no one-size-fits-all answer, and the staffing challenge has defied systemic solutions. Bold steps are needed to reimagine and transform this enduring and complex issue.


AACN asserts the following principles are essential to chart a clear course toward new staffing solutions. With these principles, we advance a call to action and invite stakeholders with shared missions in patient safety and healthcare quality to join us in forging innovative, collaborative solutions.

  1. Nurses are essential to the successful delivery of healthcare.
    Nurses constitute the largest body of healthcare practitioners and provide more direct care than any other profession. Nurses assess, develop, deliver, and optimize plans of care. They are a linchpin of the hospital healthcare team. Nurses make unique and vital contributions to optimal patient outcomes, higher patient and family satisfaction,1,5 and lower morbidity and mortality.6,7,8,9
  2. Appropriate nurse staffing is crucial for optimal patient care.
    Appropriate staffing ensures the effective match between patient and family needs and nurse knowledge, skills, and abilities. Evidence confirms that the likelihood of serious complications7 or death increases when fewer registered nurses are assigned to care for patients.8,10 A substantial body of evidence indicates better patient outcomes occur when registered nurses provide a higher proportion of care hours in healthy work environments.6,11,12,13
  3. Appropriate staffing is inextricably linked to healthy work environments.
    Healthy work environments are safe, healing, humane, and respectful of the rights, responsibilities, needs, and contributions of all people—including patients, their families, nurses, and other healthcare professionals. Studies show that investing solely in staffing resources in the absence of a healthy work environment is ineffective.9,14,15
  4. Higher nurse job satisfaction, which leads to lower staff turnover, is closely tied to appropriate staffing.
    Nurses can experience intense stress when staffing resources don’t meet patient care demands. Inadequate staffing contributes to nurse dissatisfaction, burnout, compassion fatigue, and turnover.16,17 Collaboration between hospital administrators and the professional nursing staff to achieve appropriate staffing can contribute to less turnover, improved quality of care, greater patient/family satisfaction, increased hospital financial viability, and decreased patient costs.15
  5. The creation of appropriate staffing plans requires a nimble, comprehensive approach.
    The conditions of critically ill patients fluctuate rapidly and continuously. Because of this, it is imperative that nurse staffing decisions go beyond fixed nurse-to-patient ratios. Appropriate staffing requires nurses to be involved in all aspects of staffing, from planning to evaluation. It aligns patient needs, complexity, and acuity with nurse knowledge, skills, and abilities. It also considers numerous human and technological factors and the health of the work environment. Appropriate staffing requires flexible systems and tools, dynamic scheduling options, and influential, educated leaders accountable for the outcomes of staffing decisions.
  6. Progress on appropriate staffing advances national patient safety and quality goals.
    The Institute of Medicine’s landmark report, To Err is Human: Building a Safer Health System, created a national agenda intended to reduce healthcare errors and improve patient safety.18 There has been progress toward these goals, but much more is needed—and appropriate staffing can make a significant impact. Evidence indicates that, in the presence of a healthy work environment, a reduction in registered nurse workload is associated with reduced mortality and failure to rescue,6,12,14 reduced hospital readmission rates,19,20 and fewer other adverse events such as medication errors, hospital-associated pressure injuries, and patient falls with injury.7
  7. The complex challenge of appropriate staffing will require bold and innovative solutions.
    Organizations must embrace dramatic innovation to devise and systematically test new staffing models. This includes allocated time for nurses to collaborate away from direct patient care in order to identify opportunities for improvement and create solutions to care delivery challenges. These models must require methods for ongoing evaluation of staffing decisions in relation to patient and system outcomes.21,22,23 Evaluation is essential to provide accurate trend data for identifying targeted improvement tactics, including technologies to reduce the demand for and increase the efficiency of nurses’ work.
  8. A new paradigm is needed that reflects the full value nurses bring to patient care and recognizes nurse staffing as an investment.
    When hospital operating structures emulate the traditional industrial model and view nurse staffing as an operating cost, hospitals can feel like factories. Nurses are highly skilled, well-educated healthcare professionals, who presently work in a financial model that treats them like hourly laborers. When regarded as an investment, appropriate nurse staffing is recognized as essential to financial viability because it ensures better outcomes, patient safety, and patient/family satisfaction. New ways of thinking and transformative staffing models could fully leverage this vital investment in nurses.

Our Call to Action

Meaningful and sustainable change to traditional staffing models is a moral imperative that requires urgent collaborative action. Nurses, interdisciplinary teams, healthcare executives, safety leaders, payers, and patients must come together to create new and dynamic ways to approach appropriate staffing. This is a high-stakes, high-urgency issue but, because staffing issues are so complex, there is a tendency toward the status quo. Collaborative action can produce optimal patient outcomes, lower nurse turnover, higher patient and family satisfaction, and improved financial viability for hospitals.


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  2. Martsoff GR, Gibson, TB, Benevent R, et al. An examination of hospital nurse staffing and patient experience with care: differences between cross-sectional and longitudinal estimates. Health Serv Res. 2016;56(6):2221-2241.
  3. AACN Synergy Model for Patient Care. American Association of Critical-Care Nurses website. https://www.aacn.org/nursing-excellence/aacn-standards/synergy-model. Accessed September 9, 2018.
  4. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016.
  5. Aiken LH, Sloane DM, Ball J, Bruyneel L, Rafferty AM, Griffiths P. Patient satisfaction with hospital care and nurses in England: an observational study. BMJ Open. 2018:8(1):e019189.
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  8. Driscoll A, Grant MJ, Carroll D, et al. The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. Eur J Cardiovasc Nurs. 2018;17(1):6-22.
  9. McHugh MD, Rochman MF, Sloane DM, et al. Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Med Care. 2016;54(1):74-80.
  10. Chung W, Sohn M. The impact of nurse staffing on in-hospital mortality of stroke patients in Korea.
    J Cardiovasc Nurs. 2018;33(1):47-54.
  11. Aiken LH, Shang J, Xue Y, Slone DM. Hospital use of agency-employed supplemental nurses and patient mortality and failure to rescue. Health Serv Res. 2013;48(3):931-948.
  12. Cho E, Sloane DM, Kim E, et al. Effects of nurse staffing, work environments, and education on patient mortality: an observational study. Int J Nurs Stud. 2015;52:535-542.
  13. McHugh M, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Med Care. 2013;51(1):52-59. 
  14. Aiken LH, Sloane DM, Clarke S, et al. Importance of work environments on hospital outcomes in nine countries. Int J Qual Health Care. 2011;23(4):357-364.
  15. Silber JH, Rosenbaum PR, McHugh MD, et al. Comparison of the value of nursing work environments in hospitals across different levels of patient risk. JAMA Surg. 2016;151(6):527-536.
  16. McHugh MD, Ma C. Wage, work environment, and staffing: effects on nurse outcomes. Policy Polit Nurs Pract. 2014;15(3-4):72-80.
  17. Liu X, Zheng J, Liu K, et al. Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: a structural equation modeling analysis. Int J Nurs Stud. 2018;86:82-89.
  18. Kohn LT, Donaldson MS, Corrigan JM, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
  19. Lasater KB, McHugh MD. Nurse staffing and the work environment linked to readmissions among older adults following elective total hip and knee replacement. Int J Qual Health Care. 2016;28
  20. Ma C, McHugh MD, Aiken L H. Organization of hospital nursing and 30-day readmissions in Medicare patients undergoing surgery. Med Care. 2015;53(1):65-70.
  21. Weston MJ, Brewer KC, Peterson CA. ANA principles: the framework for nurse staffing to positively impact outcomes. Nurs Econ. 2012;30(5):247-252.
  22. American Nurses Association. ANA's Principles for Nurse Staffing. 2nd ed. Silver Springs, MD: Nursesbooks.org; 2012.
  23. American Nurses Association. Optimal Nurse Staffing to Improve Quality of Care and Patient Outcomes. Silver Springs, MD: Nursesbooks.org; 2015.