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APNA Position Statement: Staffing Inpatient Units

A Call for New Staffing Models – Position Statement


Ensuring proper Registered Nurse (RN) staffing levels on inpatient psychiatric-mental health units is vital given the increasing severity of illness of hospitalized mental health patients and the mounting evidence that nurse staffing levels influence outcomes. Furthermore, nurses maintain 24-hour accountability for all aspects of inpatient care. Abundant evidence exists that the risk for adverse outcomes rises as the ratio of patients to nursing staff increases.

Therefore, the American Psychiatric Nurses Association (APNA), as the largest professional organization representing psychiatric nurses, convened a work group to make recommendations for determining staffing needs of inpatient psychiatric units that will protect the quality of care and the safety of both patients and staff. This summary highlights the group’s findings and recommendations based on a comprehensive review of the literature.


Because published research of nurse staffing levels is scarce in psychiatric mental health units, knowledge about nurse staffing planning comes primarily from studies of medical-surgical nurses in general hospitals. Studies show that multiple variables affect staffing needs besides the number of patients. Variables include patient complexity, patient flow on each shift (number of admissions, discharges, transfers, and procedures), education and experience of RNs, nursing skill mix, nurse workload, unit physical environment, technology, care delivery model, and finances. These factors influence outcomes for patients, staff, and hospitals. For instance, higher numbers of bachelor’s-trained RNs yield better quality outcomes, including shorter length of stay, which can reduce costs.


It is the position of APNA that the likelihood of adverse outcomes increases with an increase in the number of patients assigned to each nurse. APNA recognizes that psychiatric mental health nurses are critical to ensuring quality, safety, and recovery of mental health patients in hospital settings. Safe staffing is a process that may vary depending upon a multitude of variables that influence staffing decisions. Further research is needed to develop staffing models that promote optimal use of psychiatric mental health nurses in hospital settings. Therefore, recommendations for establishing safe nurse staffing are proposed.

APNA recommends the following for psychiatric inpatient units in determining staffing needs:

  1. A committee that includes direct-care RNs and nursing administrators should develop, implement, and evaluate the staffing plan.
  2. The staffing plan should consider the multiple variables that affect staffing needs.
  3. Evaluation of the staffing plan should be ongoing with the use of identified quality and safety measures.
  4. As leaders and direct care providers, psychiatric RNs should be acknowledged as essential and integral partners within the institution and be authorized to develop policies on quality and safety of patient care.

In addition, APNA encourages nurse researchers to pursue studies of nurse staffing levels to establish specific nurse-to-patient staffing ratios for inpatient psychiatric units and to foster the development of innovative, effective, recovery-oriented and safe staffing models.