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Nurse: Patient Ratios

Introduction

Healthcare systems worldwide are stressed by limited resources and increasing demands on their services. Nurses, as the largest group of healthcare professionals, have experienced significant changes in their work life and environment as systems have tried to meet these challenges. As workloads become more substantial and the number of nurses per patient diminishes, patients and healthcare workers across the globe are put increasingly at risk. ^1-3

Research findings

Recently conducted large scale research found that:

In a given unit the optimal workload for a nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission. A workload of 8 patients versus 4 was associated with a 31% increase in mortality. ⁴

Higher nurse staffing levels resulted in reduced numbers of urinary track infections, pneumonia, upper gastrointestinal bleeding and shock in medical patients and lower rates of "failure to rescue" and urinary track infections in major surgery patients. ⁵

Low registered nurse (RN) staffing levels and poor organizational climates have been found to put nurses at greater risk of needle stick injuries. ⁶

These and other recent studies show a significant association between higher nurse: patient ratios and better patient outcomes.

Factors influencing nurse productivity

Determining the minimum nurse staffing level can be a complex process as numerous factors influence the ability of nurses to care for their patients:

Matrix for Staffing Decision-Making *

Items Elements/Definitions

Patients

Patient characteristics and number of patients for whom care is being provided

Intensity of unit and care

Individual patient intensity; across the unit intensity; variability of care; admissions, discharges and transfers; volume

Context

Geographic dispersion of patients, size and layout of individual patient rooms, technology (beepers, computers)

Expertise

Learning curve for individuals and groups of nurses; staff consistency, continuity and cohesion; control of practice; professional expectations; preparation and experience, access to continuing education

The process depends on valid and up-to-date data in order to set nurse-patient ratios and ensure that they are adapted to changing patient and system needs.

Examples of new minimum nurse-patient ratios

Recently, action has been taken in Victoria (Australia) and California (USA) to set mandatory upwardly adjustable minimum nurse: patient ratios. Such ratios are seen as ways to:

Ensure safe and quality patient care

Recruit and retain nurses by the bedside

In 2001 Victoria implemented mandatory minimum nurse: patient ratios in all public sector facilities. The minimum ratios vary to meet the needs of different units and shifts. Healthcare institutions are categorized into different levels according to acuity of care, size and location. For example ⁷ :

Type of Unit

Hospital category

a.m. shift

p.m. shift

General Medical/Surgical Ward

Level 1

1:4 + in charge

1:4 + in charge

Level 3

1:5 + in charge

1:6 + in charge

Ante/Postnatal

All levels

1:5 + in charge

1:6 + in charge

Operating Theatre

3 nurses per theatre (1 scrub, 1 scout and 1 anaesthetic nurse)
This may vary up and down depending on pre-determined factors

Post Anaesthetic Care Unit / Recovery Room

All shifts 1:1 for unconscious patient

Improvements reported since the implementation of the ratios are ⁸ :

More than 3000 extra nurses employed in hospitals

Decreased staff turnover and absenteeism

25% increase in candidates for nursing schools

Public approval of the State government has increased

California passed legislation in 1999 that established minimum nurse: patient ratios to be implemented in January 2004. Again ratios vary depending on the unit. For example ⁹ :

Type of Unit

2004

2005

Medical / Surgical

1:6

1:5

Antepartum

1:4

Operating Room

1:1

Post-anaesthesia recovery

1:2

All ratios are minimums. Hospitals must increase staffing as needed based on patient acuity. Charge nurses and managers are not counted in the ratios.

Before introducing minimum nurse: patient ratios the following questions need to be answered:

How is the implementation of the minimum nurse: patient ratio going to be ensured?

What is going to happen if hospitals cannot recruit the necessary numbers of nurses?

Pros and Cons

Nurse: patient ratios set a safety net for patients and nurses. The pros include:

Safer environments for patients

Incentives for nurses to return to the bedside-work of their profession

Furthering the collection of nursing relevant data in the healthcare system

By fostering the discussion on the subject, showing the complexity of the issue of safe and adequate staffing levels

Cons include:

Tendency to become the norm for nurse: patient ratios

Ratios don't reflect the level of expertise an experienced nurse has obtained

Data collection and comprehensive workload measurement tools are not available or not applied in many cases

Implications for Nurses

With the introduction or re-introduction of nurse: patient ratios several issues need to be systematically monitored:

Impact on patient outcomes and on nurse retention /recruitment

Short and long-term financial effects in relation to patient outcomes

Development of further knowledge on patient safety, nurses workload and skill mix

Improvement of patient outcomes and development of standardized, accessible and timely data on nurse: patient ratio and staffing

Adaptation of basic and continuing nursing education to the changed work environment

Integration of nursing data into healthcare statistic on a local, national and international level

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* Shortened version from Table I in: Principles for Nurse Staffing, 1999, retrieved 15 Aug. 03 from www.nursingworld.org/readroom/stffprnc.htm

1. International Council of Nurses Press Release retrieved 15-Aug-03 from http://www.icn.ch/PR23_02.htm

2. World Health Organization Press Release retrieved 15-Aug-03 from http://www.who.int/mediacentre/releases/pr80/en/print.htm

3. World Health Professions Alliance Press Release retrieved 15-Aug-03 from http://www.whpa.org/pr07_02.htm

4. Aiken, Linda; Clarke, Sean; Sloane, Douglas; Sochalski, Julie; Silber, Jeffrey; Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction, JAMA. 2002; 288: 1987-1993

5. Needlemann, Jack; Buerhaus, Peter; Mattke, Soeren; Steward, Maureen; Zelevinsky, Katya; Nurse-Staffing Levels and the Quality of Care in Hospitals, N Engl J Med. 2002; 346 (22): 1715 – 1722

6. Clarke, Sean P.; Sloane, Douglas M.; Aiken, Linda H.; Effects of Hospital Staffing and Organizational Climate on Needlestick Injuries to Nurses, American Journal of Public Health, 2002; 92 (7): 1115 – 1119

7. Retrieved 15-Aug-03 from www.anfvic.asn.au/news_briefs/news_ratios%20summary.htm

8. Parish, Colin; 2002, Minimum effort: The introduction of minimum nurse-to-patient ratios can have maximum effect on recruitment and morale, in nursing standard, Vol. 16, No 42

9 Retrieved 15-Aug-03 from www.calnurse.org/finalrat/ratiobox.html

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