SAFE PATIENT TO NURSE RATIOS

Safe Patient to Nurse Ratios

Safe Patient to Nurse Ratios

Introduction

At least two elements contribute to the urgent need to review nurse staffing and its impact on patient safety. First is the increased acuity of patients in acute care settings. This has occurred for several reasons, including the aging of the population, the application of increasingly sophisticated medical technology, and significant reductions in average length of stay of hospital patients.

For example, from 1980 to 2000, average length of stay in the United States decreased from 7.5 days to 4.9 days (National Center for Health Statistics, 2002). Although the proportion of patients who require intensive services and care in our hospitals is increasing significantly (for example, Pennsylvania hospitals saw a 21-percent increase in patient acuity between 1991 and 1996), there is evidence that nurse staffing has remained the same (Unruh, 2003).

Second, hospital restructuring in the 1990s resulted in significant organizational changes. These changes were precipitated by pressure from the government to be accountable and responsive. Cost-savings were to be made by increasing efficiency while maintaining access and quality of services (Leatt, Lemieux-Charles, and Aird, 1994; Ontario Ministry of Health and Long-Term Care Nursing Task Force, 1999). Most of the changes included mergers of several hospitals (as many as eight) into one organization (McCutcheon, Doran, Evans, MacMillan, McGillis Hall, Pringle et al., 2004). This had a significant impact at the unit level, resulting in some combined units being on different floors within hospitals, in different buildings, and/or sometimes in different communities. This newly consolidated organizational structure created dramatic changes to the work environment, including reductions in the number of clinical and management positions, particularly in nursing. Nurses constitute the largest segment of care providers within the healthcare system.

Because they represent the largest proportion of healthcare personnel, their jobs are most vulnerable to pressures to reduce costs. Throughout the 1990s, staff overheads were commonly reduced through 1) early retirement of experienced senior nurses; 2) replacement of registered nurses with licensed practical nurses and nurses' aides (Brannon, 1996; Norrish and Rundall, 2001; CNA, 2005b; Aiken, Sochalski, and Anderson, 1996; O'Brien-Pallas, Giovannetti, Peereboom, and Marton, 1995; Brooten and Naylor, 1995; Jawad, Scalzi, and Sasichay-Akkadechanunt, 2003; Heinz, 2004; Aiken, Clarke, and Sloane, 2000); 3) reductions in nursing staff; 4) the creation of new clinical teams; and 5) increased responsibilities of nurse managers, who were put in charge of several units, sometimes with more than 150 staff members (McCutcheon et al., 2004). Deterioration of the healthcare system throughout the 1990s led to patient safety concerns becoming a prominent issue for Canada as early as 2001 (Storch, 2005), and pressures to improve the system are ongoing (Nicklin, Mass, Affonso, O'Connor, Ferguson-Paré, Jeffs et al., 2004; Page, 2004). Nursing staff are critical to patient safety, as they deliver more individual patient care than any other single healthcare provider (Savitz, Jones, and Bernard, 2005; Alberta Association of Registered Nurses, 2005).

Clearly, nurse staffing decisions should be addressed within the context of patient safety, as well as ...