Nurse-Patient Ratios: A Literature Assessment

Introduction

The issue of mandatory staffing ratios for hospitals — intended to ensure that adequate quality care is available to patients — has generated substantial debate in nursing and health policy. Fox and Abrahamson (2009) note that "nursing care arguably falls into the realm of protecting the common good, and therefore requires government oversight" (p. 235). The sources in this literature assessment relate to this issue and provide context for it.

Taken together, the sources show that there is much debate surrounding the ideal nurse-patient ratio. While some argue that the ratio should be based solely on patient need, others contend that a variety of factors must be considered. The literature does appear to show, however, that the proper ratio depends on the individual hospital and can only be determined through careful analysis. For example, units with a high admissions rate will require more staff than those with a lower admissions rate. Similarly, units with complex patients will require more experienced nurses than those with simpler cases. Regardless, if a hospital is short on staff or supplies, it will not be able to provide the same level of care as one with more resources. What follows is a literature assessment regarding common themes, assumptions, approaches, weaknesses, limitations, and implications for future research.

Common Themes, Assumptions, and Approaches

A review of the literature on nurse-patient ratios reveals several common themes, assumptions, and approaches. First, there is a general consensus that proper staffing is essential for providing quality patient care (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). The common assumption is that proper ratios would improve quality of care. However, this assumption is not shared by all; Reiter et al. (2012), for instance, argue that mandatory staffing ratios will increase labor costs, which will increase care costs, and which could potentially lead to worse quality care. Clarke and Aiken (2003), moreover, argue that quality staffing is what policy should address, not ratios.

Second, there is a significant amount of research indicating that nurse-patient ratios have a direct impact on patient outcomes. The same authors generally agree on this point (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). However, there is also some research that suggests the ratio does not have a direct impact on patient outcomes (Clarke & Aiken, 2003). It is the approach of the latter source that distinguishes it from the others: Clarke and Aiken (2003) examine entirely different variables and apply an entirely different theoretical lens when analyzing their data.

Third, there is a significant body of evidence suggesting that lower nurse-patient ratios are associated with better patient outcomes, and once more it is largely the same researchers who demonstrate this (ANA, 2019; Dousay et al., 2016; Fowler & Comeaux, 2017; Martin, 2015; Twigg et al., 2015). The assumption is that more nurses per patient means better care. Not all authors agree, but supporting literature by Laschinger and Fida (2015) and Rondeau and Wagar (2016) shows that nursing shortages due to turnover stem from nursing dissatisfaction, which in turn stems from high nurse-patient ratios.

Finally, there is some recognition that proper staffing levels are not always achievable in practice due to resource constraints (Fox & Abrahamson, 2009; Reiter et al., 2012). However, the majority of authors indicate that policy should nonetheless be changed to mandate staffing ratios. These themes, assumptions, and approaches provide a useful framework for understanding the current state of research on the topic of nurse-patient ratios.

Common Sources and Methodological Variety

There was no evidence of common sources being cited across the literature, as each article chose a different focus or approach to the topic. Some studies were qualitative, while others examined quantitative data. Some focused on nurse satisfaction levels, and others addressed quality care issues. Most data sources include surveys of nurses and patients, as well as anecdotal reports. However, these sources may be less reliable than data obtained through the National Database of Nursing Quality Indicators, which collects data from more than 3,600 hospitals across the United States.