¶ … Nurse-Patient Ratio on Care Quality
Nurse Patient Ratio
The Impact of Nurse to Patient Ratio on Healthcare Quality
The Impact of Nurse to Patient Ratio on Healthcare Quality
It would be hard to understate the importance of a high nurse to patient ratio (NPR) for patient and staff safety, as well as quality of care. While there are a number of different nursing factors that can influence these outcomes, including nursing education, experience, skills mix, contact time, frequency of interactions, and type of inpatient unit, the NPR has been the focus of considerable interest in part because it can be easily quantified (reviewed by Sidani, Manojlovich, and Covel, 2010). This review will examine the empirical evidence for the importance of NPR in determining patient and staff safety, as well as quality of care. Towards this goal, research articles obtained from the Library of Medicine will be reviewed in detail and compared to the findings of more recent research studies. This approach is intended to establish a historical foundation for this topic and then use it for elaborating on the different variables that influence the predictive value of the NPR.
Patient Safety
When the Institute of Medicine (2000) published their report on patient safety, To Err is Human, the American public woke up to the hidden reality that hospitals can be bad for patient health. The authors of this report estimated that between 44,000 and 98,000 people died each year as a result of medical errors. To put these numbers into perspective, this is more deaths than those caused by vehicle accidents, breast cancer, or AIDS.
In the aftermath of the Institute of Medicine report, Aiken and colleagues (2002) published a large study in the Journal of the American Medical Association revealing NPR to be a significant contributor to medical errors. Included in the study were 168 Pennsylvania general hospitals encompassing 232,342 patients and 10,184 nurses. The NPRs were broken down into less than or equal to 1:4 (11.9%), 1:5 (38.1%), 1:6 (24.4%), 1:7 (17.3%), and 1:8 or greater (8.3%). Based on the discharge abstracts for the patients included in the study, 23.2% experienced a major complication that emerged after being admitted to the hospital and another 2.0% died within a month. All patients were admitted for surgery: orthopedic (51.2%), gastrointenstinal (36.4%), and other (12.4%).
The main factors investigated in the study by Aiken and colleagues (2002) were the relationship between NPR and nurse burnout and patient adverse events. Their data reveal that for every patient increase in the NPR, nurses were 23% and 15% more likely to report feeling burned out and dissatisfied with their job experience, respectively. Every increase in NPR by one patient also increased the risk that a patient would die by 7%. To put this last estimate in perspective, increasing the NPR from 4:1 to 8:1 would result in 18.2 and 5.0 excess deaths per 1000 patients with and without complications, respectively. While there are some limitations to this study, including a hospital selection bias and the inclusion of only a few confounding factors, the large representative sample the authors were able to obtain created a high degree of confidence in their findings.
In support of Aiken and colleague's (2002) findings, a number of studies have investigated the same issue during the years since the Pennsylvania hospital study was published. However, none have conducted a controlled study of an intentional change in staffing levels. To get around these limitations, researchers have taken advantage of below target staffing levels to see if this tended to increase adverse outcomes for patients within the same hospital. By taking this approach, such variables as differences in organizational attitudes, the quality of nursing staff, and other variables would be minimized or eliminated.
This approach was taken by Needleman and colleagues (2011) at a major medical center when they examined almost 200,000 records for adult patient admissions to see whether there was an association between units operating with below target staffing levels and increased patient mortality. They also controlled for a number of other confounding factors, such as day vs. night shift and type of unit, and purposely selected a well-respected, high quality tertiary care hospital with a low NPR. Taking this approach allowed them to ascertain whether subtle changes in nurse staffing levels had a negative impact on patient safety. They also controlled for the impact that patient turnover would have on nursing load and patient mortality.
Staffing levels were generally found to be near target levels...
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