A nurse to patient staffing ratio can be defined as a number which describes the total number of patients which have been assigned to each nurse. Inappropriate nurse to patient staffing ratios can compromise patient safety and the quality of care that is delivered to the patients (Kutney-Lee and et.al., 2009). Poor staffing results in patient safety issues which is a serious concern in healthcare. Patients are being subjected to various medication errors because the nurses struggle to cope with the workloads (Code red: Our hospitals struggle with workload, 2014). Public and private hospitals in Australia are experiencing a shortage of nurses. This leads to maldistribution and poor utilization of nurses. Overworked staff express concerns as they are failing to detect key injuries. Inappropriate patient ratios can lead to nurses not being able to provide the level of care that they have been trained and educated to do so. This can effect nursing morale as well as health of the patient (Wood, 2009). In Australia, there have been difficulties in recruiting and retaining skilled nurses in both public and private sector because of unreasonable workloads (Lake and et.al., 2010). Research undertaken by Shekelle, 2013, indicated that approximately 75 per cent of Health projectnurses in hospital wards are considering leaving the profession. The problem is even more severe in specialised areas such as mental health, aged care, critical care and midwifery due to acute nursing shortages.
It is against the background of nurse shortages and, on occasion, poor nurse to patient ratios that the question of standards has arisen. These situations indicate the need for right number and mix of staff for provision of quality care in Australia. Considering the critical situation prevailing in health care in Australia, it is important to review the current policies which are in place in both public and private hospitals. Further, there is a need to draw comparison with legislation from other OECD countries.
It is important to investigate the topic of nurse to patient ratios and current policies in public and private hospitals in Australia regarding this. In Australia, nursing has been considered to be a highly fulfilling career (Needleman and et.al., 2011). It is rewarding feeling to be able to provide relief to the sick and injured. An essential role is played by nurses in delivering health, aged and general community care in Australia (Schwab and et.al., 2012). Moreover, it has been estimated that the demand for nurses is expected to increase due to the increase in population and ageing. It is important to note that minimum staffing ratios are a critical safety standard to deliver quality care to the service users. It has direct impact on the clinical outcomes. However, nursing ratios have been a long standing debate in Australia. Inappropriate nurse to patient ratios make the nurses overburdened (O'Keeffe, 2015). By considering the above mentioned aspects, the present research project has provided a series of recommendations for the development of a single national strategy on nurse to patient ratios.
The rationale behind carrying out the present research project is to understand the crisis in nursing in Australia and generate awareness about the need to implement standard legislation on nurse to patient ratios. Nurses in Australia frequently proclaim that they are overworked and express concern about patient safety. Moreover, they have become so stressed with the current working conditions that they feel forced to leave the profession (Cook and et.al., 2012). As the demand for nurses is expected to grow in Australia, there is a need to review current policies in public and private hospitals regarding nurse to patient ratios and compare them with other OECD countries. The problem of inappropriate nurse to patient ratios highlights the need to research the issue and provide recommendations so that a single national strategy can be developed on this issue.
The objectives of the research project are the following:
- To review current policies on nurse to patient ratios
- To compare policies in Australia with legislation of other OECD countries
- To recommend the development of single national strategy on nurse to patient ratios
The issue that is being addressed is that of inappropriate nurse to patient staffing ratios in Australia. These have made the nurses overburdened and overworked which has indirectly compromised on patient safety and quality of care being delivered to the service users in private, public and aged care in Australia (Penoyer, 2010).
The issue of nurse to patient ratios has come to attention through the availability of much evidence which indicates that the nurses in Australia are over worked. They have continually expressed serious concerns for patient safety. The staff has feared over patient ratios (Duffield and et.al., 2011). Moreover, health care officials in Australia realized that with greater flexibility and redistribution of resources, they could make a great health care system. For the past few days, there has been confusion about ratios and introduction of split shifts. Increase in the patient demand needs to be matched with the nurse workforce. Demand for health care care suffers from peaks and troughs. This necessitated the need to manage the nursing workload relative to the demand (Cook and et.al., 2012).
The issue of nurses being overworked has come to attention because there have been incidents where patient safety had to be compromised and quality care could not be delivered to the patients. The nurses have been overworked while attempting to assess, medicate and settle for the patients under their care (Furukawa, Raghu and Shao, 2010). Meanwhile, the rising demand of health care puts additional work pressure over them. As a result of this the nurses work without any breaks for long hours. At the end, they are worried that they might have forgotten something. Due to overcrowding, there is compromised care, high rates of hospital acquired infections and unnecessary hospital re-admissions.
The following questions have been formulated for the health project:
- What are the current policies on nurse to patient ratios as compared to legislation of other OECD countries?
- How nurse to patient ratios and dynamic staffing models can help in addressing the issue of inappropriate nurse to patient staffing ratios in Australia?
The health project on the issue of inappropriate nurse to patient staffing ratios in Australia comprised of various milestones. The first among them was identification and detailed analysis of the issue of nurses being overburdened and overworked in Australia. The problems which result from inappropriate nurse to patient staffing ratios were also discussed in detail. The project also attempted to cover various current policies that are in place in both private and public hospitals. It also successfully compared legislations from other OECD countries. It also provided recommendations for development of a single national strategy on nurse to patient ratios.
Hence, the health project was more focused upon policies and legislations for appropriate nurse to patient staffing ratios. However, it did not cover the reasons behind inappropriate ratios. Also, implementation of single national strategy to nurse patient ratios could not be addressed as the project focused upon development op this strategy.
Risks and how they were managed
Various risks were associated with carrying out the present health project on inappropriate nurse to patient staffing ratios. These were associated with fraud in collection of data, loss of data due to inadequate back – up procedures, serious breach of ethical considerations etc. These risks were managed by taking appropriate steps in the right direction. The researcher adopted reliable methods for collection of data. Also, authentic sources of data were used for collection. Required actions were taken for appropriate storage of data which not only involved back-up procedures but also checked unauthorized access to the data. Ethical norms and rules were followed by the researcher which ensured that the project is sound on ethical grounds.
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Costs for the project
The health project had various costs in the form of collection of data, salaries to the research assistants, analysis of data etc. Costs were also incurred on purchasing equipments such as computer, printers etc. Office supplies and materials was another area which contained costs for the project.
This section provides information on how the project was completed. The methods used for the project have been discussed along with the limitations of study procedures and methods. This section comprises of evidence review which describes the search strategies utilized, inclusion and inclusion criteria etc. project tools and methodologies used have been described. Explanation has been provided how the risks were identified and managed. Lastly, this section informs how the study was designed and the methods of data collection used.
In order to carry out the health project, appropriate search strategy was utilized. In order to explore the problem of inappropriate nurse to patient staffing ratios, there was a need to search for secondary data. For carrying out the search effectively, the researcher used a definite plan. For the present health project, search strategy comprised of deciding the key search terms, Boolean operators, use of electronic databases and setting the inclusion and exclusion criteria.
For collecting data, the researcher utilized computerized databases. E- database or electronic database refers to an organized collection of information on particular subjects in a search-able form. These contain book reviews, journal articles etc. on specific disciplines. These were referred because they provided the advantage of high searching speed (Levac, Colquhoun and O’Brien, 2010). A single search query provided millions of results in a few seconds. Various databases such as science direct, The Cochrane Library etc. were utilized.
The search strategy also comprised of using search terminologies which consisted of key search terms. Key words are significant words which act as main variables for the search (Andrade, 2009). Suitable key search words directly impact the number of relevant records retrieved. The following key search terminologies have been used for conducting electronic search for the health project.
|TERM 1||Ratio, proportion, balance|
|TERM 2||Overworked, overburdened, overloaded|
|TERM 4||Patient, service users|
Boolean operators are important aspect in research. In the health project, these were used because they helped in connecting the search terms and defining relationship between them. Use of appropriate Boolean operators yielded more focused, relevant and productive results. Boolean AND was used because it instructed the search engine to retrieve all those records which contained both the search terms. Therefore, through it, the search could be made narrow and more focused. Operator OR was used because with the help of it,
all those records could be retrieved that contained either of the search terms. Hence, it broadened the search for the health project.
Inclusion and exclusion criteria
Inclusion and exclusion criteria are important to be considered for evaluating the materials that arm a study. Inclusion criteria were used for evaluating the materials because it is important for the subjects to possess certain attributes to be capable of accomplishing the purpose of research (Zulman and et.al, 2011). Use of these criteria resulted in production of reliable and reproducible results. While conducting the health project on inappropriate nurse to patient staffing ratios in Australia, the following inclusion and exclusion criteria were used:e used in the study. Inclusion criteria refer to those characteristics which are desirable to be present in the prospective subjects to make them eligible to be included in a study (Herrett and et.al., 2010). As compared to this, exclusion criteria are those characteristics on the basis of which prospective subjects are excluded from a study. Inclusion criteria were used for evaluating the materials because it is important for the subjects to possess certain attributes to be capable of accomplishing the purpose of research (Zulman and et.al, 2011). Use of these criteria resulted in production of reliable and reproducible results. While conducting the health project on inappropriate nurse to patient staffing ratios in Australia, the following inclusion and exclusion criteria were used:
|Inclusion criteria||Exclusion criteria|
|Research studies conducted in English||Research studies carried out in any other language|
|Research conducted between the time period 2005- 2015||Research which was conducted before the year 2005|
|Research on inappropriate nurse to patient ratios in Australia||Research carried out on any other issue in any other country|
The above mentioned inclusion and exclusion criteria were used for various reasons. Only researches carried out in English were included while those carried out in other languages were excluded from the health project. This is because studies published in English language were easy to be interpreted and analysed and helped the researcher to get familiar with the area of study. However, studies published in other languages were excluded because translation of text required time. The researcher included only those studies which were published between the time period 2005 – 2015 years so that up- to- date information on the issue is obtained. These were also used for obtaining reliable results. It is for this reasons studies done prior to the year 2005 were excluded so as to avoid using obsolete information. Researches which were specifically done on the issues of nurse to patient staffing ratios in Australia were included so that the purpose of the health project could be achieved.
Risks and their management
While carrying out the health project, there were a number of risks that researcher faced. They are following:
- Fraud in data collection- The first was the risk of fraud in data collection. This could have seriously impacted the quality of research and research output. Also, it could have led to negation of data resulting in unreportable and unpublishable results (Bryman, 2012). This risk was managed by using relevant data collection methods as well as authentic sources for collection of information. The research focused on data accuracy.
- Loss of data- There was risk of loss of data owing to inadequate back- up procedures. This could have resulted in irretrievable loss of important data. The risk associated with loss of data was managed by using detailed standard procedures for management and storage of data. This not only helped in appropriate storage but also check unauthorized access to the data.
- Breach of ethical requirements- There was risk of serious breach of ethical requirements. This could have made the research progress without ethical considerations and approval from ethic committee (Mackey and Gass, 2013). In order to manage this risk, appropriate ethical considerations were taken into account by the researcher.
For the present research, descriptive design was used because it helped in describing the phenomenon which is being studied. It also helped in collecting the information without changing the environment (Silverman, 2010). The present research on nurse to patient staffing ratios in Australia required analysis of existing policies and practices pertaining to this issue in the country. It also required the researcher to compare the legislation with those of other OECD countries. For this, descriptive design was most suitable.
There are two methods data collection, primary and secondary. Primary methods involve observation, interviews, survey questionnaires, focus groups etc. In contrast to this, secondary data collection methods involve gathering data from various sources such as journals, books, online blogs, articles, government reports etc. (Bryman and Bell, 2015). For the present research on nurse to patient ratios in Australia, secondary data collection was done. Data was collected from various sources such as journals, books, online articles, blogs, government reports, reports of various health care bodies etc. This method was used because with it the researcher could appropriately compare the legislations with those of other OECD countries. Moreover, it also assisted in reviewing the current policies and practices in Australia with respect to nurse to patient staffing ratio.
Current policies on nurse to patient ratios
Gerdtz and Nelson, (2007) carried out study to critique a new model of minimum nurse to patient ratio. According to the authors there has been enactment of the legislation in Australia which mandated minimum nurse to patient ratios throughout all the large public hospitals in the state of Victoria. The Victorian model made it mandatory to observe a staffing ratio of five nurses to 20 patients in acute medical and surgical wards. The study found various issues associated with the legislation. The legislation was successful in attracting nurses to join public sector workforce. However, the authors found that there is lesser evidence which supports that the mandated ratios were observed in the hospitals. Another issue which was identified is that the ratio which was mandated by the legislation was not sufficient to take into account critical influence of skill mix on patient outcomes, hospitals and employees (Gerdtz and Nelson, 2007).
Twigg and Duffield (2009) critically reviewed various approaches for measurement of nursing workload. Through this, the study aimed to provide a context so that different approach to staffing can be introduced. Th authors studied the application of Nurse hours per patient day (NHPPD) in all public hospitals in Western Australia. It was found that the method significantly improved ward staffing without employing restrictive nurse-to-patient ratios. It also successfully attracted nurses back to the hospitals (Twigg and Duffield, 2009). However, the is no evidence of its impact on patient outcomes.
According to Australian Nursing and Midwifery Federation, safe patient ratios will be made as a law. The law will require major metropolitan hospitals in Australia to observe safe ratios of one nurse to four patients during the day shift (ANMF (Vic Branch), 2014). In the night shift, the ration would be one nurse to eight patients. These differential ratios have been formulated to aged care, regional hospital care nurseries, emergency departments and aged care. This legislation, proposed by Daniel Andrews will also aim at preventing substitution of nurses by unregistered health assistants. Currently, nurse to patient ratios are applied in various areas including coronary care units, acute wards, labour wards, special care nurseries, high dependency units etc.
There are currently three key nursing staffing models which are applied in the hospital inpatient settings in Australia. These are nurse/ midwife to patient ratio (Victorian model), nursing/ midwifery hours per patient day (Western Australian model) and Hybrid nursing/ Midwifery hours per patient day (NSW model) (Australian Nursing and Midwifery Federation, 2012). Victorian model mandates a nurse to patient ratio of 5 nurses per 20 patients. The western Australian Model is a different approach which was introduced when West Australian nurses and midwives argued that appropriate patient care could not be provided by them due to inadequate staffing levels. They also complained of high workloads. Hence, this model was introduced which also took into consideration other aspects such as patient complexity, presence of high dependency beds, intervention levels, patient turnover and patient mix. The third model, which is called the Hybrid model, replaced “Reasonable workload model” in the year 2010 in New South Wales in Australia. This model is capable of considering the workload assessment. One of its elements is the general nursing weight of 1= 4.8 Nursing hours per patient day. These are applicable to various settings in Australia (Australian Nursing and Midwifery Federation, 2012).
The journal article by Welton (2007) provides arguments for and against mandatory nurse to patient staffing ratios. The authors found that a law was passed by California legislators, on behalf of the California Nursing Association which required the hospitals to staff nurses so that the minimum nurse to patient ratios could be met in various hospital units. However, another bill, which was supported by Massachusetts Hospital Association advocated to avoid staffing ratios. It was focused upon monitoring nurse staffing trends and funding for primary nursing education. Another proposed bill in the state of Washington required the hospital settings to adopt safe staffing plans rather than nurse to patient ratios. As compared to this, the policies in Australia have addressed concerns of the nursing staff regarding inadequate staffing ratios. In response to this concerns, the policies have been successful in making minimum staffing ratios as a mandate for the hospital settings in Australia (Welton, 2007). Appropriate nurse to patient staffing ratios have been a priority of the various policies in Australia.
Welton (2007) studied that laws which make nurse to patient staffing ratios mandatory have been universally opposed by American Hospital Association (AHA) and its individual member state associations. The AHA has argued that scheduling and staffing flexibility are reduced as a result of mandatory nurse to patient staffing ratios. Mandatory staffing ratios have also been opposed by American Organization of Nurse Executives. It has proposed a more balanced approach which includes monitoring of nurse staffing. As per the views of the authors, nurse to patient staffing ratio of 1:4 has been made mandatory by Massachusetts Nursing Association (Welton, 2007).
In the year 2013, Registered Nurse Safe Staffing Act of 2013 was passed in US. It was a step towards regulating nurse staffing (McHugh, Berez and Small, 2013). In the year 2014, Florida Hospital Patient Protection Act was filed in the Senate. This bill stated that patient to nurse ratio should be five patients to one registered nurse in rehabilitation. In a trauma emergency unit, this ratio was one registered nurse to one patient. These ratio were more focused and stressed on the requirement that the nurse should be a registered nurse (Pande, 2014). In the year 2006, formal nurse patient ratios were implemented by Japanese Nursing Association. As compared to these, legislation for mandatory nurse to patient ratios was passed in Australia in the year 2011 (Mandated nurse-patient ratios, 2015). This indicates that Australia was quite late in realizing the significance of adequate nurse to patient staffing ratios. However, it can be critically analysed that Australia has implemented various staffing models which helped in supporting the aspect of mandatory nurse to patient staffing ratios. In other OECD countries, legislations were passed few years before to mandate nurse staffing ratios (Van den Heede and et.al., 2009). However, these countries did not effectively design any model which could help in implementation of staffing ratios.
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