Acute care facilities try to maintain low costs and employ quality nurses. Within this statement is a double standard. How can we have quality nurses and cut costs at the same time? This is where the skill mix comes into play. In the skill mix, there are Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and unlicensed staff. If the lesser skilled staff free RNs they can be better able to perform their nursing duties and assessments. If acute care facilities can agree on an appropriate number of each type of staff member within the facility, they might be better able to accomplish safe patient outcomes while keeping costs down.
Determining nurse-to-patient ratios is a complex issue where one solution is not sufficient to cover all circumstances. The American Nurses Association assembled a panel of nursing and health professionals to research appropriate staffing levels. The panel developed the following Matrix for Staffing Decision-Making (Table 1) in three major areas.
Table 1. Matrix for Staffing Decision-Making
Matrix for Staffing Decision-Making
Patient characteristics and number of patients for whom care is being provided
Intensity of unit and care
Individual patient intensity; across the unit intensity (taking into account the heterogeneity of settings); variability of care; admissions, discharges and transfers; volume
Architecture (geographic dispersion of patients, size and layout of individual patient rooms, arrangement of entire patient care unit(s), and so forth); technology (beepers, cellular phones, computers); same unit or cluster of patients
Learning curve for individuals and groups of nurses; staff consistency, continuity and cohesion; cross-training; control of practice; involvement in quality improvement activities; professional expectations; preparation and experience
Source: American Nurses Association (2005), 2005 Principles for Nurse Staffing, Retrieved December 6, 2006 at http://www.nursingworld.org/readroom/stffprnc.htm
Nurse Safety / Job Dissatisfaction
While nurse safety is a big concern, its goal is mostly to decrease the workload so the nurse can effectively care for patients. Aiken, Clarke, Sloane, Sochalski, and Silber (2002) reported that each additional patient assigned to a nurse was associated with a 23% increase in the odds of job burnout and a 15% increase in the possibility of job dissatisfaction. They also reported that 40% of hospital nurses experience burnout levels that surpass the average for health care workers and that higher nurse-to-patient ratios are directly attributed to elevated emotional exhaustion and job dissatisfaction among nurses. Their research results further indicate that nurses working in hospitals with higher ratios are more than twice more likely to experience job burnout and dissatisfaction than nurses at hospitals with the lowest ratios. Likewise, Sheward, Hunt, Hagen, Macleod and Ball (2005) found that high patient to nurse ratios were associated with increased risk of emotional exhaustion and dissatisfaction with current job. Nurses who continuously work overtime or work without adequate backup incur greater absenteeism and poorer health.
Consensus / Professionalism
High patient to nurse ratios impede collaboration that has been proven to have an important positive impact on patient outcomes. Knaus, Draper, Wagner, & Zimmerman (1986) found that in hospitals where both the nurses and physicians agreed that their communication and collaboration were positive, deaths were 41% lower than ICU predictive tools had forecast. Conversely, they also discovered that in hospitals where nurses and physicians reported that there was little communication and collaboration, 58% of patients died even though the predictive tool had forecast that they would live.
Malila & Von Reuden (2002) have also found that a collaborative approach to care between nurses and physicians has a positive impact on quality of care. Kaye, Erickson, Zeiler, Gavigan and Gannon (2000) have found this type of multidisciplinary interaction reduces ventilator-associated pneumonia rates and decreases readmissions to an intensive care unit.
Patient Outcomes: Studies Supporting the Influence of Nurse-to-Patient Ratios
Aiken and colleagues have been pioneers in studying nurse patient ratios and their relationship to patient outcomes.
Aiken, Sochalski, and Lake (1997) demonstrated that nursing presence, whether measured as RN ratios or as RN hours relative to other nursing personnel hours, is significantly correlated to mortality. When studying patient outcomes in specialized AIDS units,
Aiken, Sloan, Lake, Sochalski, and Weber (1999) found that at 30 days post admission, mortality rates were 60% lower in magnet hospitals, and 40% lower in dedicated AIDS units than in conventional scattered bed units. The researchers concluded that higher nurse patient ratios were a major factor in these lower