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Nurse to Patient Ratios and the Affects on Patient Care

Haley VanWormer
Ferris State University


Nurse to patient ratios have been extensively researched throughout the years. This paper looks
into the affects of different nurse to patient ratios on the quality of care the patients are receiving.
Databases are used to search for appropriate articles. Three articles are critiqued in detail. The
articles are also discussed to show the significance of the research findings. Most of the article
findings pointed to a significant impact on patient care depending on the nurse to patient ratio.
The higher the patient load nurses were assigned the lower quality of care was given. After the
articles are discussed the affects of the findings on nursing is discussed in detail. Research has
pointed to a need to standardize the nursing staffing throughout the country. Many states are
already moving towards implementing laws to ensure safe patient assignments for nurses.


Nurse to Patient Ratios and the Affects on Patient Care
The purpose of this paper is to determine how nurse to patient ratio affects \ patient care
being given in the hospital setting. This includes patient outcomes as well as mortality rates.
Many hospitals have very different policies on what is considered to be an appropriate
assignment for a nurse. Some say there should be no more than a four patient maximum and
others have been known to assign upwards of six to ten patients (Ball, 2012, p.119). This paper
will determine how nurse staffing impacts patient care.
Clinical Question
The clinical question being investigated is how does nurse staffing in the hospital setting
affect the quality of care given? There is a wide range of what is considered to be an appropriate
nurse to patient ratios among facilities. The factors that contribute to the number of patients
assigned to a nurse are variable but generally depend on the patient population, the available
staff, and the ability of the facility to employ adequate staff. Generally, units with higher level of
care required, such as the intensive care units and highly specialized units have a higher nursing
concentration which ultimately leads to better quality of care (Ball, 2012, p. 117). In the same
article it was estimated in intensive care units each full time nurse added to the schedule
decreases the mortality rate by 9% (p. 117).
Medical-surgical units are generally far from staffed as adequately as these higher levels
of care units are, however, the patients still deserve the same quality of care. In a study
conducted by four registered nurses in the United Kingdom it was estimated 86% of the nurses
reported having not completed a patient care task due to a lack of time. The study took place on
medical-surgical units where the average patient assignment for each nurse was 7.8-10 (Ball,
2012, p.120). With the nurses taking on such demanding workloads such as this it is inevitable

time will run out. There are only so many things one person can accomplish within a 12 hour
day. This is leaving important patient care aspects undone.
While observing the staff around a hospital a PICOT (Population, Intervention, Control,
Outcome, Time) question was formed. While watching the staff on a busy medical-surgical unit,
it was noted there were many nurses who had more than four patients to take care of. Many of
them had stated they had not seen all of their patients at least once every hour. The same time of
observation was done on an intensive care unit where the nurses rarely were assigned more than
two patients. The nurses all had seen both of their patients multiple times in a one hour time
frame. The question arose, how do the different nurse to patient ratios affects the quality of care
the patients are receiving? Even though the patients in the intensive care unit require more care
and attention, they still need care from the nursing staff just like the patients on the medical-
surgical unit do. What are the affects of multi-patient assignments on the quality of care these
patients are receiving?
Databases were used to obtain literature. PubMed was the first database of choice. A
search was done using the key words nurse patient ratio and quality of care. Filters were set to
only include nursing journals from the last five years that were peer reviewed and in the English
language. This resulted in only 38 results. After looking through the articles found it was
determined these articles contained information significant to the clinical question.
Articles were to be published within the last five years to ensure their accuracy as nursing
research is changing constantly. This made it slightly difficult to find high levels of research
because this clinical question has been researched extensively throughout the last ten years at
least, with the highest concentration of articles being published within the first five years or so.

Articles specific to intensive care units as well as pediatric units were included in this search
because the clinical question included nurse staffing throughout hospitals as a whole, on every
unit. English language as well as articles from other countries were included. All articles had to
have been nursing research, no other disciplines were included. This was important because
nursing research is specific to nursing. Using nursing research alone shows how the research
directly impacts nursing. Having information that is specific to nursing allows other nurses to
have the correct information that is most pertinent to his or her job and care.
Discussion of Literature
Article 1
The first article being discussed was an article published in 2012 in the peer reviewed
journal the BMJ Quality and Safety Journal, the official journal publication of the National
Patient Safety Foundation. The four authors were associated with various nursing schools
throughout London, United Kingdom. The main subject of the article is poor quality nursing care
and what are the causes. The background literature included a systematic review and multiple
articles of lower levels of evidence (levels 5 or 6 according to Melkins pyramid of level of
evidence) that were conducted within the last five years. However, the majority of these studies,
as well as the systematic review, were conducted in other nations besides the United Kingdom.
Much of the research done also did not include the effects of nurse staffing and missed care.
Because of these factors the background literature supports the need for this research. The
problem investigated was the reasons why hundreds of patients experienced poor care at the
Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009, (Ball, p.
116). The purpose of the study was to determine factors leading to poor quality nursing care.

A random stratified sample of 64 general acute hospitals in England was used. This
included 401 different units. The exclusion criteria was appropriate, as well as the inclusion
criteria. This was a cross-section survey designed study, a level of evidence of 5 according to the
Melnick pyramid of level of evidence, which was appropriate for this type of investigation
because it allows for many responses as well as a wide range of information to be obtained. The
data collected was nominal data and means, standard deviations, frequencies, and percentages
were used to analyze the data. This is appropriate to this level of measurement. In the end 86% of
all respondents reported at least 1 of the 13 care activities listed on the survey were not done on
their last shift due to lack of time (Ball, p. 118). The results were clearly identified, seem valid
and answered the identifying question of the study. This study also indicated there was a
significant correlation between the number of patients a nurse was assigned and the number of
care activities missed. On this unit the average number of patients per nurse during the day was
7.8 and at night the average number was 10.9 patients per nurse. The authors stated As the
number of patients per RN decreases so does the amount and occurrences of missed care, (Ball,
p. 119). However, it could be argued this study could have a threat to validity of testing threat.
The research conducted consisted of surveys which were given to nursing staff. The staff could
have changed the way they answered the questions based on their own biases such as job
dissatisfaction. The threat of instrumentation change could also be considered a threat to this
study. One nurse could interpret the questions differently than another. It is hard to know how
everyone interpreted the questions and how they thought they should be answered. Despite these
threats, the results of this study still seem to be valid.
Article 2

The second article being discussed is an article published in 2012 the Journal of Nursing
scholarship, a well known peer reviewed journal. It was written by five registered nurses
associated with various nursing schools throughout China. The subject of the article was the
quality of care patients throughout China were receiving. Just as in the previous article, though
the background literature included a systematic review and multiple other lower levels of
evidence which took place within the last five years, it was still necessary to conduct the study.
There was little evidence showing how the quality of care in China and the authors wanted to
investigate China specifically. The problem investigated was nurse staffing which is closely
related to patient outcomes. The purpose of this study was to examine the relationship between
nurse staffing and patient outcomes in hospitals in mainland China, (Zhu, p. 266).
A four-stage sampling design was used to come up with a sample for this study. It
included 780 different unites from 181 hospitals. Surveys were handed out to over 10,000 nurses
throughout the units. Patients were also included in the study. Patients who had stayed at least
three nights, were conscious, and able to communicate were randomly drawn by systematic
sampling based on their bed code. 7,295 patients were given surveys. The exclusion criteria was
appropriate, however, the inclusion criteria could have been more inclusive. They should have
included all patients who are conscious and able to communicate regardless of the length of stay.
This was considered a multisite collaborative study which would be a level of evidence of 5 on
the Melkin pyramid of level of evidence. Even though this is a relatively low level of evidence it
was still necessary due to the lack of evidence based in China. The level of measure collected
was level 5 on the Melkin pyramid. Chi-squared tests were used to analyze the data. This
appropriate for this level of measure. The results of this study showed more than one third of the
nurses reported different nurse staffing levels made a difference on the patient outcomes. It also

showed more than 35% of nurses reported having not adequately prepared patients and family
for discharge and more than 20% reported not having completed skin care and pain management
due to lack of time (Zhu, p. 269). The results were comparable with other studies conducted in
other countries like the United States. Because of this these results seem valid. The results also
fulfilled the purpose of this study. There can be several threats to validity that can be argued for
this article. The first being testing, again just as in the last article, the nurses could answer the
surveys differently based on their own biases. This would have changed the results to one way or
the other. The results from the surveys given to the patients could have also been different due to
the patients own biases. This could also make an argument for history being a threat to validity.
A patient or nurse could have had a bad experience before completing the survey which would
have conflicted with their answers. Despite these threats the results of this study still seem valid.
Article 3
The third and final article to be discussed is a systematic review meta-analysis published
in the Western Journal of Nursing Research. This is a well known peer reviewed journal. The
authors were associated with various medical groups throughout Ohio and Massachusetts. Two
authors were associated with the veterans affairs and the other author was associated with case
Western Reserve University. The subject of this study is the relationship between nurse staffing
and patient outcomes. The background literature supported the need for this study because much
of the literature cited was conducted and published well beyond the five year limit. The literature
also suggested there is much conflicting data among the research published. A systematic review
was needed to compile the evidence into one area and compare it completely and accurately. The
problem investigated is there is so much work published on the relationship between nurse
staffing and patient outcomes, yet no evidence-based nurse staffing guidelines exist. The purpose

of this article is to summarize review authors findings and recommendations for future
research focusing particular attention on reasons for inconsistencies across primary studies and
how the inconsistencies have contributed to the lack of establishment of evidence based
guidelines, (Brennen, 2013).
Databases were used to search the keywords nurse staffing and patient outcomes. 29
articles consisting of systematic reviews and literature reviews were used as the sample. The
exclusion and inclusion criteria were appropriate in this case because the authors intended on
conducting a systematic review of reviews. The level of evidence of this design is a level one on
the Melkin pyramid of level of evidence. This means this is the highest level of evidence that can
be conducted. The statistical analysis used was simply a synthesis of data through the analysis of
the three authors. This level of analysis is appropriate for this level of measure and review. The
results compiled resulted in inconclusive results due to multiple discrepancies among data. The
results were clearly stated and answered the purpose statement of why there is no clear evidence
based guidelines for appropriate nurse staffing guidelines.
The findings of these studies may also be conflicting due to other threats to validity such
as instrumentation change. All nurses in the studies may not be as adequately educated as they
should or could be. The sample sizes may also result in conflicting findings as well. Another
possible threat to validity for these results could be selection bias. It is possible these studies
could have manipulated their sampling population to sway the results one way or another.
Significance to Nursing
This information affects every practicing registered nurse working in the hospital setting.
The way the facilities staff the units directly affects not only the nurses working but also the
patients receiving care. It is estimated that a 7% increase in patient mortality rate is associated

with every patient added to a nurses bed assignment (Zhu, 2012, p. 272). It is the duty of the
nurses to ensure good, quality care of their patients, however, it can be difficult to do so when
there are so many patients to be taken care of. Granted, as registered nurses on the floor it is
difficult to control just how much staff is available but the nurses can speak up about their
concerns and the affects it is having on the quality of care the patients in the facility are
receiving. An example of such actions that were heard was experienced in 1999 in California.
Californias Assembly Bill 394 was passed as a result of a vocal association called the
California Nurses Association. The association was responding to claims and research that
pointed to unsafe patient care environments as a result of over-worked nurses (Tellez, 2013, p.
18). Currently California is the only state with legislature supporting an adequate, safe nurse to
patient ratio. In 1999 Assembly Bill 394 was passed in California which had required minimal
nurse to patient ratio. In 2004 it was in full affect. The mandated nurse to patient ratio is no more
than one nurse per five patients on medical-surgical floors in California.
Since the passing and success of this law 17 other states have implemented the legislature
to mandate minimum nurse to patient ratio. For example, in 2010 New Jersey introduced S963
which would introduce similar requirements as Californias Assembly Bill 394 did. The ratios
proposed are as follows: 1:6 in medical-surgical units, which would reduce to 1:5 after the first
year of effectiveness, 1:4 in intermediate care units and non-critical emergency departments, 1:2
for critical care and post-anesthesia patients, and finally 1:1 for patients under sedation
(Tevington, 2011, p. 265).
If more states follow this trend the future of nursing and the quality of care the patients
receive is bound to improve. However, it is expected the healthcare field will experience a
nursing shortage worse than it currently is in (Schmalenberg, 2009, p.

65-71). This could impact the ability of facilities to staff adequately and safely. It is still the
responsibility of the nurses to speak up and let their concerns be heard.
In conclusion, the clinical question of how nurse staffing impacts patient care in the
hospital setting has been answered. The results of multiple studies suggest an increase in patient
to nurse ratio decreases the quality of care the patients receive. This decrease in quality of care
can lead to further negative patient outcomes such as pressure sores and falls. To ensure patients
are receiving the most adequate and complete care a low patient to nurse ratio should be


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left undone during nursing shifts: associations with workload and perceived quality of
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Brennan, C., Daly, B., & Jones, K. (2013, July). State of the science: the relationship between
nurse staffing and patient outcomes. Western journal of nursing research, 35(6), 760
794. doi:10.1177/0193945913476577
Schmalenberg, RN, MSN, C., & Kramer, RN, PhD, M. (2009, October). Perception of adequacy
of staffing. Critical care nurse, 29(5), 65-71. doi:10.4037/ccn2009324
Tellez, M., & Seago, J. A. (2013, January-February). California nurse staff law and RN
workforce changes. Nursing Economics, 31(1), 18+. Retrieved from
Tevington, P. (2011, September). Mandatory nurse-patient ratios. MedSurg nursing, 20(5), 265.
Retrieved July 26, 2014, from PubMed.
Zhu, BSN, X., You, MSN, RN, L., Zheng, PhD, RN, J., Liu, PhD, RN, K., & Fang, PhD, RN, J.
(2012, September). Nurse staffing levels make a difference on patient outcomes: a
multisite study in Chinese hospitals. Journal of nursing scholarship, 44(3), 266-273.
Retrieved July 26, 2014, from PubMed.