The Impact Of Nurse-To-Patient Ratios On Patient Outcomes: A

Migration Letters

Volume: 19, No: S5 (2022), pp. 130-138

ISSN: 1741-8984 (Print) ISSN: 1741-8992 (Online)

www.migrationletters.com

The Impact Of Nurse-To-Patient Ratios On Patient

Outcomes: A Comprehensive Review

Abdulrahman Omar aljlime

, Blkher Mohammed Alkery

, Badrah Ibrahim Alzubaidi

Abdullah Ali Alkhiri

, Bader Abdulrahman Alsalamah

, Waad Hamad Alnawshan

, Abeer

Ayad Almotairi

, Obaid Ali Alkhairi

, Ali Hassan Mohammed Alrashdi

, Omar Naseer

Alzahrani

Abstract

This study reviews the existing literature on the impact of nurse-to-patient ratios on patient

outcomes. The study utilizes secondary data from various sources, including research articles,

systematic reviews, and meta-analyses, to explore the association between nurse staffing levels

and key patient outcomes. The review finds that nurse-to-patient ratios substantially influence

patient outcomes in various healthcare settings. Higher nurse-to-patient ratios are linked with

better patient outcomes, including reduced mortality rates, decreased rates of hospital-

acquired infections and reduced lengths of hospital stay. Conversely, inadequate nurse staffing

levels have been linked to contrary results such as medication errors, patient dissatisfaction

and falls. The review highlights the significance of sufficient nurse staffing in safeguarding

excellent patient care and emphasizes the necessity for healthcare organizations to prioritize

nurse-to-patient ratios as a key factor in achieving positive patient outcomes. The conclusions

of this review add to the growing body of evidence supporting the employment of adequate

nurse-to-patient ratios as a critical component of safe and effective patient care.

Keywords: Patient outcomes, Nurse-to-Patient Ratios, Mortality rates, Medication errors,

Patient care.

1. Introduction

Healthcare professionals have long debated nurse-to-patient ratios, with growing concern over

staffing levels and how they affect patient outcomes. Several patient outcomes, such as death

rates, infection rates, and patient satisfaction, have been related to the “nurse-to-patient ratio”,

which is vital in determining the value of care patients receive (Gordo

n, 2017). Therefore, it

is crucial to comprehend how “nurse-to-patient ratios” influence patient results to enhance care

quality and guarantee patient safety.

Nursing, Health Affairs in Al-Qunfudhah, Saudi Arabia.

Nursing, Second Dogah PHC, Saudi Arabia.

Nursing tech, Riadh Alkhabra General Hospital, Saudi Arabia.

Nursing specialist, Riadh Alkhabra General Hospital, Saudi Arabia.

Nursing, Althagar general hospital, Saudi Arabia.

Nursing, Al Qunfudhah Hospital, Saudi Arabia.

Nursing, MUDILEF PHC, Saudi Arabia.

Nursing technician, Al Noor Specialist Hospital, Saudi Arabia.

Abdulrahman Omar aljlime

et al. 131

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This study aims to present a thorough analysis of the research on nurse-to-patient ratios and

how they affect patient outcomes. This review aims to provide a greater knowledge of how

nurse staffing levels affect patient care by looking at various studies and integrating the results.

Based on several studies, higher “nurse-to-patient ratios” have previously been linked to

improved patient results. According to research that was published by Lasater et al. (2021), the

probability of in-hospital death increased by 7% for every extra patient per nurse. Similarly, a

review of the research conducted by Shin (2018) determined that shorter hospital stays and

lower incidence of hospital-acquired infections were linked to greater “nurse-to-patient ratios”

(Shin, 2018).

However, several variables affect the quality of care, making the association between nurse

staffing and patient results complicated. Patient outcomes are influenced by numerous factors,

including “nurse-to-patient ratios”, skill levels, experience, and the general work environment

(Twigg, 2021).

There is limited knowledge of this relationship despite the mounting body of research

connecting nurse staffing levels to patient outcomes (Watson, 2016). More research is required

to understand how “nurse-to-patient ratios” affect patient care and find ways to optimize nurse

staffing levels for better patient outcomes. This study aims to augment the current knowledge

regarding nurse-to-patient ratios and patient outcomes using a thorough literature evaluation.

Ultimately, this study's conclusions might contribute to formulating nurse staffing rules and

procedures to improve patient safety and care quality.

2. Literature Review

This portion looks at the body of knowledge regarding the effects of “nurse-to-patient ratios”

on patient outcomes. Numerous research have looked into this link, and the majority have found

that better patient outcomes are significantly correlated with lower “nurse-to-patient ratios”.

Higher nurse staffing levels were linked to decreased rates of hospitalized patient mortality and

adverse events, according to a study by Tenorio (2021). Furthermore, Shin's (2018)

comprehensive research discovered a connection between increased rates of patient mortality

and complications and insufficient nurse staffing.

In a comprehensive study carried out in the US, Liang (2012) discovered that hospitals with

higher nurse staffing levels saw fewer adverse events and reduced patient mortality rates.

Similarly, Lang's (2004) meta-analysis found a correlation between lower rates of hospital-

acquired infections and patient mortality and increased nurse staffing levels.

Furthermore, research by Gutsan (2018) and Chau (2015) showed a correlation between lower

patient mortality rates, shorter hospital stays, better treatment quality and higher “nurse-to-

patient ratios”. Higher nurse staffing levels were also associated with improved patient results

regarding mortality, falls, and infections, according to a meta-analysis by Anders (2021).

On the other hand, no meaningful correlation between nurse staffing levels and patient results

has been found in other investigations. For example, Driscoll's (2018) UK study could not

discover a consistent correlation between patient mortality or readmission rates and nurse

staffing levels. Similarly, Jarrar's (2015) study discovered that although improved nurse

staffing levels were occasionally linked to better patient results, this association did not hold

for all hospitals.

132 The Impact Of Nurse-To-Patient Ratios On Patient Outcomes: A Comprehensive Review

These results emphasize how crucial it is to maintain proper “nurse-to-patient ratios” to

safeguard excellent patient care and good health results. More studies are necessary to

determine the ideal “nurse-to-patient ratio” that optimizes patient safety and outcomes and

further establish the causal relationship between nurse staffing levels and patient results.

3. Methodology

The study's approach comprised a thorough analysis of the research on the effect of “nurse-to-

patient ratios” on patient outcomes. A systematic search of relevant databases, including

PubMed, GOOGLE SCHOLAR and Cochrane Library, was conducted to identify studies

examining the relationship between nurse staffing levels and various patient results. The search

strategy used key terms related to “nurse-to-patient ratios”, staffing levels, patient outcomes,

and nursing care quality.

Studies included in this review meet the following criteria: (a) conducted in acute care settings,

(b) focused on the association of “nurse-to-patient ratios” and patient results, (c) published in

English, and (d) used quantitative methods to analyze the data.

Following the first search, the papers found were filtered according to their titles and abstracts

to assess how pertinent they were to the study question. After that, full-text publications from

possibly qualifying research were carefully examined to evaluate their methodological

soundness and applicability to the goals of the investigation. Key information from the chosen

studies, such as the study design, sample size, patient outcomes evaluated, and primary

findings, were gathered by data extraction.

The results of the studies included were analyzed and summarized using a narrative synthesis

approach. Finding recurring themes and patterns in the links between “nurse-to-patient ratios”

and patient results throughout the trials was part of this. The findings were then synthesized to

offer insights into the overall influence of nurse staffing levels on the results and quality of

patient care.

Limitations of the investigation included the variability in study designs and outcome measures

used across the included studies, which limited the ability to conduct a meta-analysis.

Additionally, the potential for publication bias in the literature could have influenced the

overall findings of the review.

4. Results and Discussion

4.1 Nurse-to-Patient Ratios: Definition and Importance

4.1.1 Definition of nurse-to-patient ratios

The total number of patients allocated to one nurse in a medical context is known as the “nurse-

to-patient ratio” (Lasater, 2021). This ratio is essential in assessing the caliber of treatment

given to patients. Appropriate nurse-to-patient ratios enable nurses to efficiently oversee their

workload, deliver prompt interventions, and guarantee patient safety. However, low staffing

numbers might make nurses more stressed out and burn out, which lowers the standard of care.

According to research, achieving the ideal nurse-to-patient ratio is vital for enhancing patient

results and nurturing the quality of care in general (Martin, 2015).

4.1.2 Significance of Appropriate Nurse Staffing Levels

To guarantee patient safety, lower medical errors, and enhance patient results, it is imperative

to maintain proper nurse-to-patient ratios. Research has indicated that healthcare institutions

with low staffing levels are susceptible to unfavorable incidents, including prescription

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mistakes, falls, and hospital-acquired infections (Sherenian, 2013). On the other hand, reduced

patient complications, lower death rates, and improved patient satisfaction ratings have all been

associated with appropriate staffing numbers. Appropriate nurse-to-patient ratios promote a

safer and more effective healthcare environment by giving nurses manageable workloads

(Twigg, 2021).

4.1.3 Factors influencing nurse-to-patient ratios

Several variables can affect “nurse-to-patient ratios”, such as patient acuity, nurse experience,

unit complexity, and resources available in the healthcare facility (Watson, 2016). The degree

of care that each patient needs is referred to as their "patient acuity," and it might vary

depending on their diagnosis, comorbidities, and treatment requirements. Higher patient acuity

levels require more nursing time and attention, resulting in lower nurse-to-patient ratios. Nurse

experience is another important factor, as novice nurses may require more supervision and

support, impacting staffing levels. Unit complexity, such as the presence of specialty services

or technology, can also affect nurse-to-patient ratios. Additionally, healthcare facility

resources, such as budget constraints and staffing shortages, play a significant role in

determining staffing levels (Twigg, 2021).

The importance of suitable “nurse-to-patient ratios” in enhancing patient outcomes and

lowering healthcare expenditures has been emphasized in earlier research. For instance, a study

by Scruth (2020) discovered a correlation between shorter hospital stays and lower mortality

rates and nurse-to-patient ratios. Similarly, Shin's (2018) meta-analysis showed that reduced

patient problems and readmission rates were linked to higher nurse staffing levels. These

studies show the importance of sufficient nurse staffing levels in fostering superior patient care

and improving healthcare outcomes.

In general, “nurse-to-patient ratios” are a major factor in assessing the standard of care in

hospital environments. Healthcare facilities can improve patient outcomes, lower medical

errors, and increase patient safety by ensuring the right number of employees is employed.

Nursing facility resources, unit complexity, nurse experience, and patient understanding are

just a few variables that affect nurse-to-patient ratios and should be considered when

calculating staffing numbers.

4.2 The Connection between “Nurse-to-Patient Ratios” and Patient Outcomes

4.2.1Impact on patient safety

The study's main finding is that nurse-to-patient ratios greatly influence patient wellbeing.

According to the paper's research, hospitals with lower “nurse-to-patient ratios” were linked to

greater patient safety incidents, including medication errors, falls, and pressure ulcers.

According to Martin's (2015) study, for instance, there was a 7% rise in the probability of a

patient safety event for every additional patient per nurse. This emphasizes the importance of

having enough staff members to guarantee patient safety and lower the possibility of

unfavorable outcomes.

Additionally, the findings demonstrated an association between higher “nurse-to-patient ratios”

and an increased risk of hospital-acquired illnesses. Research by Lee (2017) clarifies this by

showing a correlation between a higher risk of healthcare-associated infections and lower nurse

staffing levels. These results highlight nurse staffing is important to avert unfavorable

outcomes and preserve patient safety in medical environments.

4.2.2 Influence on patient satisfaction

134 The Impact Of Nurse-To-Patient Ratios On Patient Outcomes: A Comprehensive Review

The association between “nurse-to-patient ratios” and patient satisfaction was another

significant research finding. According to the review study, hospitals with more nurses were

linked to poorer patient satisfaction ratings (Lang, 2004). Patients in these environments were

more likely to voice discontent with the caliber of treatment they received and less likely to

report having had pleasant experiences with their care. According to Jarrar's (2015) research,

patients at hospitals with insufficient nurse staffing levels expressed lower satisfaction with

their overall care experience and poorer ratings of the quality of attention.

Furthermore, the study demonstrated a correlation between lower “nurse-to-patient ratios” and

patient wait times, a higher risk of medication errors, and a decline in patient-provider

communication. These elements may influence the general patient experience and lead to

patient discontent (Gordon, 2017). As a result, maintaining the proper number of nurses on

staff is crucial for patient safety, patient satisfaction, and the standard of treatment.

4.2.3 Effects on quality of care

The review's conclusions draw attention to how important “nurse-to-patient ratios” are for the

standard of patient care. Patient death, length of hospital stay, and readmission rates are among

the quality of care metrics negatively correlated with hospitals with lower nurse staffing levels.

According to a study by Chau (2015), shorter hospital stays and lower rates of avoidable patient

mortality were linked to higher nurse staffing levels.

The study analysis also showed that hospitals with greater “nurse-to-patient ratios” adhered to

clinical rules and protocols more closely, resulting in better patient results and decreased

incidence of problems. This implies that sustaining good standards of care and encouraging

favorable patient outcomes depend on having an appropriate number of nurses on staff. Our

results highlight the significance of managing nurse staffing ratios to guarantee the delivery of

good care and generate favorable healthcare outcomes, consistent with earlier research by

Anders (2021).

4.2.4 Association with adverse events and healthcare outcomes

The relationship between adverse occurrences or poor healthcare outcomes and nurse-to-

patient ratios was also investigated in this paper. It was clear that adverse events like falls,

pressure ulcers, and medication errors were more common in hospitals with reduced nurse

staffing levels (Carlisle, 2020). These incidents can result in negative healthcare outcomes for

patients, including longer hospital stays, increased healthcare costs, and higher readmission

rates.

Furthermore, the data showed a correlation between higher rates of patient death and morbidity

and insufficient nurse staffing levels. Patients' health outcomes are adversely affected by

complications, adverse drug responses, and other healthcare-related difficulties that are more

common in settings with lower nurse-to-patient ratios (Driscoll, 2018). This demonstrates how

important nurse staffing is to avert unfavorable incidents and enhance patient outcomes.

4.3 Factors Contributing to Nurse-to-Patient Ratios

4.3.1 Nurse workload

The nurse workload has been identified as a significant factor contributing to nurse-to-patient

ratios. It was observed that nurses who are required to care for numerous patients experience

higher levels of stress, fatigue, and burnout (Gutsan, 2018). A study conducted by Kouatly

(2018) found a significant association between high patient-to-nurse ratios and increased nurse

workload. Nurses overburdened with excessive patient assignments may be unable to offer

high-grade care to patients, leading to compromised patient outcomes.

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Additionally, the workload factor is influenced by the difficulty of patient requirements and

acuity levels. Patients with more complex care requirements, such as those in critical care or

oncology units, may demand more time and attention from nurses, thereby increasing the

workload per patient (Lasater, 2021). This highlights the importance of tailoring nurse staffing

levels based on patient acuity to ensure safe and effective care delivery.

4.3.2 Nurse burnout and turnover

Elevated nurse-to-patient ratios are directly proportional to higher burnout and turnover rates

among nurses. Burnout is a psychological reaction to ongoing stress at work and is typified by

depersonalization, diminished sense of personal accomplishment, and emotional tiredness.

Burnout among nurses increases their likelihood of quitting, raising healthcare facility turnover

rates (Liang, 2012).

The literature has provided ample evidence of the association between high “patient-to-nurse

ratios” and burnout among nurses. According to a McHugh (2021) study, burnout was more

common among nurses who worked in settings with high workloads and low staffing levels. In

addition to detrimental effects on nurses' well-being, burnout also compromises the standard

and security of patient care. According to Sherenian (2013), burnt-out nurses have higher

chances of making mistakes, giving subpar care, and experiencing compassion fatigue, all of

which can negatively impact patient outcomes.

4.3.3 Organizational policies and practices

Nurse staffing levels are mostly determined by organizational rules and procedures, which also

affect nurse-to-patient ratios. Caregiver staffing ratios and other staffing models are frequently

used by healthcare administrations that prioritise quality care to guarantee appropriate nurse

staffing levels (Tenorio, 2021). These organizations may also support initiatives to improve

nurse retention, job satisfaction, and work environment conditions to enhance patient care

delivery.

Conversely, organizations prioritising cost-cutting measures over patient safety may

compromise nurse staffing levels, increasing nurse-to-patient ratios. This can cause adverse

results for nurses and patients, as discussed earlier (Wang, 2020). Additionally, organizational

cultures that do not prioritize nurse well-being may contribute to a higher turnover rate and

staff shortages, further exacerbating the issue of nurse-to-patient ratios.

4.3.4 Regulatory factors

Regulatory factors, such as state-mandated nurse staffing ratios and accreditation requirements,

influence nurse-to-patient ratios in healthcare surroundings (Sherenian, 2013). Some nations

have applied legislation authorizing the smallest nurse-to-patient ratios in specific care

surroundings, such as intensive care units and surgical departments. These regulations aim to

ensure patient safety, improve nurse workloads, and reduce adverse events related to

understaffing.

Research has indicated that nurse staffing restrictions positively affect nurse satisfaction and

patient outcomes. In contrast to hospitals in states without required ratios, Liang's (2012) study

revealed that nurse staffing proportions in California hospitals resulted in lower death rates and

greater job satisfaction among nurses. The results underscore regulatory elements' significance

in managing nurse-to-patient ratios and advancing secure and efficient patient treatment.

4.4 Strategies for Improving Nurse-to-Patient Ratios

136 The Impact Of Nurse-To-Patient Ratios On Patient Outcomes: A Comprehensive Review

4.4.1 Staffing Models and Ratios

Using suitable staffing models and ratios is one of the most important ways to improve nurse-

to-patient ratios (Kouatly, 2018). Studies have indicated that greater patient results, such as

lower mortality rates, fewer prescription errors, and higher patient satisfaction, are linked to

lower “nurse-to-patient ratios”. To guarantee safe and efficient care delivery, the Nurses

Association suggests a nurse-to-patient ratio of 1:2 for acute care units and 1:4 for medical-

surgical units (Driscoll, 2018).

Nurse staffing ratios are beneficial, according to several studies. For instance, Carlisle's (2020)

study discovered a correlation between reduced hospital-acquired illnesses and patient death

rates and greater nurse-to-patient ratios. Similarly, Gutsan's (2018) research revealed a

correlation between lower levels of burnout and work discontent among nurses and higher

nurse-to-patient ratios.

However, implementing appropriate staffing models and ratios can be challenging due to

budget constraints and staffing shortages. To address these challenges, healthcare organizations

can consider implementing flexible staffing models, such as float pools and nurse-patient

matching algorithms, to optimize nurse allocation based on patient acuity and workload

(Lasater, 2021).

4.4.2 Technology and Innovations

Another strategy for improving nurse-to-patient ratios is leveraging technology and

innovations to enhance workflow efficiency and patient care delivery (McHugh, 2021). Several

technological solutions, such as electronic health records (EHRs), medication administration

systems, and telehealth platforms, have improved nurse productivity and communication,

reducing the burden of high patient ratios (Lee, 2017).

A study by Kouatly (2018) found that the implementation of EHRs in a hospital setting reduced

documentation time for nurses, allowing them to spend more time on direct patient care.

Additionally, telehealth platforms have been shown to facilitate virtual patient monitoring and

consultations, enabling nurses to remotely monitor multiple patients simultaneously and

intervene promptly when necessary.

4.4.3 Education and Training Programs

Effective education and training programs are vital for providing nurses with the knowledge

required to handle high patient ratios effectively. Continuous education and training can help

nurses develop critical thinking, time management, and communication skills, allowing them

to offer safe and excellent care to patients despite challenging work environments (Gordon,

2017).

For instance, simulation-based training programs have improved nurses' clinical decision-

making and problem-solving abilities in high-stress situations (Carlisle, 2020). Additionally,

ongoing educational opportunities, such as workshops and continuing education courses, can

assist nurses in being informed on best practices for patient care.

4.4.4 Policy Implications

Organizational, state and national policy alterations are vital in addressing nurse-to-patient ratio

disparities and ensuring safe staffing levels. Legislative mandates and regulations can help

enforce minimum nurse-to-patient ratios and hold healthcare organizations accountable for

maintaining safe staffing levels (Anders, 2021).

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As an illustration, California was the pioneer state in enacting laws requiring particular “nurse-

to-patient ratios” in acute care hospitals. According to studies, California's required ratios have

been linked to better patient results, such as fewer hospital-acquired contaminations and death

rates (Driscoll, 2018).

Moreover, policy initiatives that support nursing workforce development, such as funding for

nursing education programs and loan forgiveness programs, can help address nursing shortages

and improve nurse retention rates (Tenorio, 2021). By investing in the nursing workforce and

implementing evidence-based staffing guidelines, policymakers can promote a philosophy of

safety and quality in healthcare settings.

5. Conclusion

In conclusion, this comprehensive review has revealed the significant effect of “nurse-to-

patient ratios” on patient results across various settings and populations. The evidence suggests

that greater “nurse-to-patient ratios” are related to improved patient safety, decreased mortality

rates, and higher quality of care. Sufficient staffing levels enable nurses to offer essential care

and action to each patient, leading to better patient outcomes. However, implementing optimal

nurse-to-patient ratios requires careful consideration of various factors, including staffing

models, nurse skill mix, and resource availability. Future research and policy initiatives should

continue to address the staffing challenges to improve patient results and safeguard the delivery

of excellent care.

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