Minimum nurse-to- patient ratios have been mandated in California and are under consideration in several other states. Because it isn't yet clear what staffing levels will have the most favorable effects on patients, hospitals, and nurses, nurse researchers in California conducted a review of 20 years' worth of studies on nurse staffing (conducted between 1980 and 2000).
Forty-three articles met the criteria for inclusion. While the authors weren't able to pinpoint specific staffing levels or mix (mostly because of the poor quality of the available research), they were able to glean some valuable information from the studies.
Patient outcomes.
Articles dealing with patient outcomes yielded the most information. Among surgical patients (but not medical patients), lower nurse-to-patient ratios were associated with lower failure-to-rescue rates. The evidence also partially supported a link between low ratios and lower mortality rates but couldn't support a connection between inadequate staffing and rates of urinary tract infections or pressure ulcers.
"Nurse employee outcomes."
A few of the studies dealt with the job of nursing itself. But there weren't enough data to determine an association between low nurse-to-patient ratios and either back pain or needlesticks (although one study did show a correlation between inadequate staffing levels and both needle-sticks and "near misses"). And while greater numbers of nursing hours spent with patients weren't associated with nurses' burnout, a heavier workload was.
Hospital outcomes.
The authors found that increasing the number of RNs in the "nursing skill mix" (the proportion of RNs to LPNs, LVNs, and aides) didn't affect the number of hours spent with patients, but they surmise that it likely has a favorable impact on the quality of the care delivered. And although the authors found a positive association between "better staffing" and cost savings, the studies involved were too old to be of much use today, in the era of managed care.
The upshot, according to the authors, is that researchers and organizations attempting to determine appropriate nurse staffing levels should examine more than the simple nurse-to-patient ratio; the nursing skill mix and the type of unit must also be considered. More research (and of better quality), as well as research that examines unit-level data rather than hospital-level data, is necessary. -Doug Brandt
Lang TA, et al. J Nurs Adm 2004;34(7/8): 326-37.