Running head: NURSING STAFF RATIOS: QUALITY VERSUS COST 

Nursing Staff Ratios: Quality versus Cost

Joseph Mills

University of Central Florida

Abstract

The objective of this paper is to present and correlate the available research on the impact of nursing ratios to the quality of patient care and hospital cost avoidance.  The conclusion reached by this author is that, lower nurse to patient ratios have been measurably shown to improve patient outcomes by decreasing medical errors, length of stay and mortality.  It has also been found that lower nurse to patient ratios decrease nursing injuries, nursing burnout and nursing turnover rates.  The cost avoidance has not been calculated, only estimated as the variables are too numerous for the scope of this paper and can not be applied to every institution because of variations in skill mix, and working relationships between physicians and administration. 

Nursing Staff Ratios: Quality versus Cost

Every successful system of business, utilizes expense to profit ratios.  Appropriately investing in the right areas will reap the best outcomes.  System analysis is critical in determining the areas most essential in the operation of any given business.  The business of health care in many ways, is no different.  However, hospital based care delivery is unique, due to the high degree of variability.  Although, quality patient outcome is the highest altruistic level of success, financial solvency is crucial to providing that care.  At the primary level, in the delivery of care within the hospital system, is the nurse.  Many hospitals view nurses, as their largest single business expense, at up to 54% (Curtin, 2003) of general outlay.  This expense has been under scrutiny since the early 1990’s.  Many consulting firms attempted to ‘restructure’ care modalities to minimize the use of registered nurses in direct patient care.  Statistical data collected since that time has shown just the opposite to be true (Aiken, Clarke, Sloan, Sochalski, & Silber, 2002).

As stated earlier, the wide degree of variability within the acute care hospital settings, had  limited the initial studies, to weak correlations.  As analytical processes are better defined and  larger populations are utilized to ‘flatten’ the variables, strong and consistent relationships between nurse-patient ratios are beginning to emerge (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002).  

Some of the findings to date, although of limited example here, is that “adjusting for patient and hospital characteristics, each additional patient per nurse was associated with a 7% increase in the likelihood of patients dying within 30 days of admission and a 7% increase in failure to rescue” (Aiken, L., et al., 2002).  An ICU nurse to patient ratio of greater than 1:2 during the evenings was associated with increased length of stay in the hospital.  An ICU nurse to patient ratio greater than 1:2 during the day was associated with an increased number of days in the ICU (Pronovost, Dang, Dorman, Lipsett, Garrett, Jenckes, & Bass, 2001).  “The higher the skill mix (up to 87.5% RNs) the lower the incidence of adverse occurrences (medical errors, patient falls, skin breakdown, patient and family complaints, respiratory and urinary tract infections, and deaths)”. (Seago, n.d.).  Nursing satisfaction and subsequent retention is directly related to staffing load and has been noted in numerous studies (Aiken et. al., 2002).  Organizations with high turnover rates had 36% higher costs per discharge than hospitals with turnover rates of 12% or less.  Low turnover hospitals averaged 23% return on assets compared to a 17% return for high turnover ones.  Low turnover organizations had lowered risk adjusted mortality scores as well as lower severity-adjusted length of stay compared to hospitals with 22% or higher turnover rates (Curtin, 2003).  It is evident in the few cited studies, that the investment in quality nursing care, and reduction in nurse to patient ratios will return a healthy dividend.  The ideal ratio is dependent on many factors.  These factors are not necessarily linear.  The skill mix, nursing shortages, nursing satisfaction in scheduling and use of supplemental/part-time staff are just part of the variables that need to be addressed (Wright, Bretthauer, & Murray, 2006). 

Quality of patient outcome in an  acute hospital setting, is directly correlated to increased nursing contact.  The expense of which is recouped in the cost avoidance of the very same “quality of care”.  In economic terms, it is smart business for hospitals to invest in the best nursing care they can find, and to keep the patient to nurse ratio as low as feasible.          

References

Aiken, L. H., Clarke, S. C., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. The Journal of the American Medical Association, 288(16), 1987-1993.

Curtin, L. L. (2003, September 30). Online Journal of Issues in Nursing. Retrieved October 28, 2006, from http://www.nursingworld.org/OJIN/KEYNOTES/speech_3.htm

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-Staffing Levels and the Quality of Care in Hospitals. The NEW ENGLAND JOURNAL of MEDICINE, 346(22), 1715-1722.

Pronovost, P. J., Dang, E., Dorman, T., Lipsett, P. A., Garrett, E., Jenckes, M., et al. (2001, September 1). Effective Clinical Practice. Retrieved October 28, 2006, from AMERICAN COLLEGE of PHYSICIANS web site: http://wwws.acponline.org/journals/ecp/sepoct01/pronovost.htm

Seago, J. A. (n.d.). Nurse Staffing, Models of Care Delivery, and Interventions. Retrieved October 28, 2006, from http://www.ahrq.gov/clinic/ptsafety/chap39.htm

Wis. Fed. Of Nurses And Health Profesionals (n.d.). Set Limits Save Lives. Retrieved October 28, 2006, from http://www.wfnhp.org/setlimits/researchsummary.html

Wright, P. D., Bretthauer, K. M., & Cote, M. J. (2006). Reexamining the Nurse Scheduling Problem: Staffing Ratios and Nursing Shortages. Decision Sciences, 37(1), 40-70.