1. Sasichay-Akkadechanunt, Thitinut PhD, RN
  2. Scalzi, Cynthia C. PhD, RN, FAAN
  3. Jawad, Abbas F. PhD


Objectives: To examine the association between in-hospital mortality and four nurse staffing variables-the ratio of total nursing staff to patients, the proportion of RNs to total nursing staff, the mean years of RN experience, and the percentage of nurses with bachelor of science in nursing degrees.


Background: Studies suggest that nurse staffing changes affect patient and organizational outcomes, but the impact of nurse staffing on patient outcomes has not been studied sufficiently and the results of the previous studies are equivocal. Additionally, the studies of the relationship between nurse staffing and patient outcomes or the impact of nurse staffing on patient outcomes had not been previously examined in Thailand.


Methods: A retrospective, cross-sectional, observational research design was employed to study the research questions. Data of 2531 patients admitted to seven medical units and 10 surgical units of a 2300-bed university hospital in Thailand was used. All data of patients admitted to this hospital with four common groups of principal diagnoses (diseases of the heart, malignant neoplasms [cancer of all forms], hypertension and cerebrovascular diseases, and pneumonia and other diseases of the lung) was extracted from patient charts and discharge summaries in the calendar year 1999. Nurse staffing variables for each nursing unit in 1999 came from nursing service department databases. Multivariate logistic regression was used to determine the relationship between nurse staffing variables and in-hospital mortality.


Results: The findings of this study revealed that the ratio of total nurse staffing to patients was significantly related to in-hospital mortality in both partial and marginal analyses, controlling for patient characteristics. In addition, the ratio of total nursing staff to patients was found to be the best predictor of in-hospital mortality among the four nurse staffing variables, controlling for patient characteristics. The study did not find any significant relationship between in-hospital mortality and three nurse staffing variables (the proportion of RNs to total nursing staff, the mean years of RN experience, and the percentage of bachelor degree prepared nurses) probably due to the low variation of these variables across nursing units or because they may have correlated with other variables.


Conclusions: The findings of this study add to our understanding of the importance of nurse staffing and its relationship to the patient outcome of hospital mortality. Further, the findings also provide information for hospital and nursing administrators to use when restructuring the clinical workforce, revising hospital policies, or making contractual decisions on behalf of nursing and public beneficiaries.


Organizational change, work redesign, cost containment, and "right sizing" have become recent consequences of the economic crisis in Thailand in 1997-1998. During the 1998 fiscal year (October to September) the central government budget was revised and reduced three times. These reductions in budget have affected public hospitals more than private hospitals because 60% of the operating revenue was obtained from the government's allocation. 1 Many of the middle-class clients have shifted from private hospitals to be treated at the public hospitals. Consequently, the volume of patients in public hospitals has increased, placing on them additional financial strain. Public hospitals had to reduce their operating costs, labor costs, and capital investments to control hospital expenditures. To reduce the labor costs of healthcare personnel, the Cabinet agreed to implement a zero-growth policy for the personnel. All retired posts are now terminated without replacement. The requests for promotions with salary increases are frozen and the requests to create new offices are not approved unless mandated by the new constitution. 2


Nursing services, as the largest percentage of hospital personnel, have experienced several budget cuts. In addition, some RNs have been replaced by assistive personnel with less training. These situations appear to be a global concern, not just a problem in Thailand. 3-5 The main argument against this approach is that the quality of patient care and patient safety will decline if the number of nursing personnel decreases or the skill mix declines. Literature examining the effect of the ratio of RNs to all nursing personnel on mortality rates, as well as factors affecting the retention of RNs, is available. Nevertheless, there is a paucity of recent research on the effects of structural measures, such as specific staffing ratios or staffing patterns, on the quality of patient outcomes when controlling for all other explanatory or confounding variables. 6-13