Inappropriate Nurse to Patient Staffing Ratios in Australia: A Review of Current Policies and Recommendations for a Single National Strategy

This health project reviews the current policies on nurse to patient ratios in Australia and compares them with legislation of other OECD countries. It provides recommendations for the development of a single national strategy on nurse to patient ratios. The project covers various milestones, risks and costs associated with the project. The systematic literature review method was used to collect data from various sources such as journals, books, online articles, blogs, government reports, and reports of various healthcare bodies. The project also discusses the methods used for the project and the limitations of study procedures and methods.

Health Project

TABLE OF CONTENTS
Table of Contents.............................................................................................................................2
BACKGROUND.............................................................................................................................3
RATIONALE...................................................................................................................................4
OBJECTIVES..................................................................................................................................4
QUESTION......................................................................................................................................4
SCOPE.............................................................................................................................................5
Milestones....................................................................................................................................5
Risks and how they were managed..............................................................................................6
Costs for the project.....................................................................................................................7
METHODS......................................................................................................................................7
Type of Study...............................................................................................................................7
Literature Search..........................................................................................................................8
LITERATURE REVIEW..............................................................................................................12
Current policies on nurse to patient ratios.................................................................................12
Comparison of policies in Australia with legislation of other OECD countries.......................13
Results............................................................................................................................................16
Results of search........................................................................................................................16
Findings of the study..................................................................................................................16
Discussion......................................................................................................................................19
CONCLUSION..............................................................................................................................22
REFERENCES..............................................................................................................................25

BACKGROUND
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 utilisation 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 nurses 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. (Aiken and et.al., 2012).
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.
RATIONALE
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.
OBJECTIVES
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
QUESTION
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 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?
SCOPE
Milestones
The health project on the issue of inappropriate nurse to patient staffing ratios in
Australia comprised of various milestones. Throughout the beginning of the project, emphasis
was laid on 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 of this strategy.
The health project will be undertaken over a period of 11 weeks. This will be from 30
November to 15 February. The following are the milestones for the project. Background,
rationale and objectives were achieved by 24 December. Following this were question, scope
definition, design and methodology which were completed by 31 December. Literature review
was undertaken on 8 January. Results section will be done by 25 January. This will be followed
by discussion section on 2 February. Conclusion will be finished by the date 10 February. Lastly,
completion of final report will take place by the date 15 February.
In the first week of December, the original search for the project was carried out. This
involved electronic search through various e-databases such as the Cochrane Library, Science
direct, Medline etc. All the study material was restricted to a period of 2005 – 2015 years. After
evaluating the journal articles from the various databases, 7 articles were selected to be include
in the project. Inclusion and exclusion criteria guided the evaluation of articles. Only those
journal articles were included which were published in English language. Articles in any other
language were excluded from the project a,long with those studies that were published prior to
the year 2005.
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.

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 equipment such
as computer, printers etc. Office supplies and materials was another area which contained costs
for the project.
METHODS
Systematic literature review comprises of identification, appraisal, selection and synthesis
of research evidence. It provides a coherent and updated synthesis of studies in a logical manner.
Systematic review also includes critical consideration of studies which helps in the generation of
new levels of understanding (Andrade, 2009).
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.
Type of Study
After selecting relevant articles and evaluating them, review was carried out regarding
appropriate nurse to patient staffing ratios in Australia. Numerous articles were searched and
their quality was assessed. After quality assessment, 7 articles were selected for the review.
Systematic review is carried out to provide a summary of the best available literature regarding a
research question (Herrett and et.al., 2010). It answers the research question by collecting and
analysing all the evidence which has been selected according to a pre-established eligibility
criteria.
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.

Literature Search
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 appropriate peer review journal articles and papers. 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.
Electronic search
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, Medline, Cinahl etc. were utilized. 146
articles were retrieved from The Cochrane Library, 200 articles from Medline and 100 from
Science direct.
Search terminologies
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 3 Nurse
Term 4 Patient, service users
Boolean operators

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 are 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.
Research limitations
Various limitations were raced by the researcher while carrying out the present systematic
review. First, limited time was available to carry out the research. However, the process of
carrying out the systematic review is a lengthy one and requires time. Hence, limited availability
of time was the first limitation faced. The second limitation was availability of secondary
literature pertaining to t5he topic. Some of the sites containing relevant literature did not provide
access to full text. This limitation was overcome by taking permission for accessing those sites.

LITERATURE REVIEW
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. The 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, there 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).
In the year 2015, Upper House of Victorian parliament passed Safe Patient Care Bill
2015. Queensland’s Palaszczuk Government is supposed to be implementing similar ratios
legislation bill in the year 2016. Safe Patient Care Bill 2015 protect safe nurse and midwife
patient ratios by mandating these ratios across all public hospitals as well as aged care facilities
(Historic ratios win for nurses and midwives, 2015). As per the bill, nurse to patient ratio in
emergency department of large metropolitan hospitals would be one nurse to every three patients
in the morning and afternoon shifts.
Comparison of policies in Australia with legislation of other OECD countries
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).
Conway and et.al. (2008) studied trends and policy implications related to nurse staffing
ratios in California. The authors found that there were relative changes in the nurse staffing ratios
from 1993 to 1999. the ratios then increased significantly from 1999 to 2004. it was concluded
that nurse staffing legislation is capable of increasing nurse staffing. However, these ratios did
not bring positive outcomes for the patients in the absence of mechanisms which could help
achieve the ratios. Law AB394 was passed by California legislature in the year 1999 which
mandated minimum nurse staffing ratios (Conway and et.al., 2008). In the year 2006, California
implemented the legislation of staffing ratio of 1 nurse to 6 patients. In the year 2005, the
supreme court of California made it mandatory to have a ratio of 1 licensed nurse for every 5
patients (Simoens, Villeneuve and Hurst, 2005).
According to Twigg and et.al., (2011), National Nursing Shortage Reform and Patient
Advocacy Act were presented before the US house of representatives. This is considered to be
the first legislative step towards minimum nurse to patient staffing ratios in all the hospitals of
America. As compared to this, in the year 2001, Victoria became the first state in Australia that
implemented a mandatory nurse to patient staffing ratio. However, it can be noted that within the
Australian mandate regarding nurse to patient ratios, there was a greater degree of flexibility
(Twigg and et.al., 2011). This is because, as per the Australian mandate the employers are
allowed to keep a baseline of 1 nurse to five patients (West and et.al., 2009). In the situation
when an emergency arises, there can be movement of staff within the wards to deal with it. This
degree of flexibility is called as 5: 20 rule. As compared to this, according to the policy briefing
by Royal College of Nursing (2012), in South Korea, the government aimed at a ratio of one
nurse per 2.5 patients within general hospitals. In tertiary units, this ratio is one nurse per two

beds. On comparing it to Australia, it can be said that concerns regarding adequate nurse to
patient ratios are considered in South Korea (Royal College of Nursing, 2012).
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. This ratio was 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.

RESULTS
Results of search
In the present review, 456 combined articles were obtained after using the pre-established
search term and literature search strategy. Of them, 345 articles were excluded based on the first
and the second exclusion criteria. The articles were excluded as they were conducted in
languages other than English. Hence, it would have been difficult for the research to interpret the
research. Also, it would be time consuming to translate the language to English. The second
exclusion criteria on the basis of which articles were excluded was that the research was done
prior to the year 2005. By including the research conducted before 2005, up- to- date information
about nurse to patient staffing ratios would not have been obtained. This would have affected the
results. Therefore, 110 articles were selected and their full text was reviewed. Following this, the
articles were further scrutinised for their eligibility to be included in the review. 36 articles met
the third inclusion criteria. 74 articles were included because they were not specifically on
inappropriate nurse to patient staffing ratios. Of the 36 articles selected, 29 were further excluded
due to lack of data regarding other OECD countries. Finally, 7 studies were selected for the
review. All the selected studies were written in English and published between 2005 and 2016.
Findings of the study
From the review, it was found that there is a shortage of nurses in public and private
hospitals in Australia. This resulted into inappropriate nurse to patient staffing ratios thus making
the nurses overworked and stressed. The nurses have raised concerns regarding inappropriate
ratios which have led to patient safety errors. In response to the nurses' concerns, Safe Patient
Care Bill is supposed to be implemented in the year 2016. This would mandate safe nurse and
midwife patient ratios of one nurse to every three patients in morning and afternoon shifts in
various departments of large hospitals in Australia. As compared to other OECD countries,
Australia was attentive towards the concerns of nurses and has proposed and implemented
various nurse staffing models. The other OECD countries such as Japan, South Korea, United
Kingdom, implemented legislation regarding mandating nurse to patient ratios. However, these
were not implemented with dedication as compared to Australia.
Currently, there are various policies which are followed in Australia with respect to nurse
to patient staffing ratios. Victorian model is implemented which mandates a staffing ratio of five
nurses to 20 patients in acute surgical and medical wards (Gerdtz and Nelson, 2007). As a result

of this model, nurses have been attracted to join public sector workforce. However, this model
does not take into account the factor of skill mix and its influence on patient outcomes. Another
policy regarding nurse to patient staffing ratios in Australia is known as Nurse Hours Per Patient
Day (NHPPD) which was implemented in Western Australia (Twigg and Duffield, 2009). This
policy did not implement restrictive nurse to patient ratios, yet it brought improvements in ward
staffing. Further to this, Australian Nursing and Midwifery Federation mandated safe ratios of
one nurse to four patients during the day shifts (ANMF (Vic Branch), 2014). During the night
shift, ratios would be one nurse to eight patients. This is a policy of differential ratios which was
formulated in emergency department, aged care, regional hospitals etc. in Australia.
Apart from that it has been found that Australia has been cautiously concerned about the
importance of nurse to patient ratios. Key staffing models have been implemented in response to
the issues and concerns expressed by nurses and midwives. These are Victorian model, Western
Australian Model and Hybrid Model. Western Australian model takes into account other
associated factors such as presence of high dependency beds, patient complexity, patient
turnover, patient mix etc. Hybrid model implemented in 2010 proposed general nursing weight
of 1= 4.8 nursing hours per patient per day (Australian Nursing and Midwifery Federation,
2012).
Comparison of policies in Australia with legislation of other OECD countries shows that
various laws have been formulated in other countries as well. These include America, Japan,
United Kingdom and South Korea. While policies in Australia made nurse to patient staffing
ratios mandatory, the condition was not same in other OECD countries. Some countries had
legislation which avoided staffing ratios. Bill passed by Massachusetts Hospital Association
advocated to prevent the implementation of staffing ratios (Welton, 2007). It focused upon other
aspects such as funding and monitoring staffing trends. But, in California, law passed by
California legislators required hospitals to observe minimum staffing ratios. California also
focused on the importance of licensed nurses which Australian government did not consider. In
2006, a legislation was implemented in the state for nurse staffing ratio of 1: 6 (Conway and
et.al., 2008). California has experienced regular changes in the nurse staffing ratios. Bill
proposed in the state of Washington required health care organisations to adopt safe staffing
plans. While various bills have been proposed, these have not been implemented effectively in
other OECD countries as compared to Australia.

American Hospital Association considers nurse to patient ratios responsible for reducing
staff flexibility and scheduling. American Organisation of Nurse Executives has also opposed
mandatory staffing ratios. National Nursing Shortage Reform and Patient Advocacy Act was the
first legislative step towards minimum nurse to patient ratios in America (Twigg and et.al.,
2011). In Massachusetts Nursing Association made it mandatory to have a nurse to patient
staffing ratio of 1:4. In US, Registered Nurse Safe Staffing Act of 2013 was passed which stated
that nurse to patient ratio in rehabilitation should be one registered nurse to five patients
(McHugh, Berez and Small, 2013). The staffing ratios in South Korea were relaxed. The
government in the country aimed at a ratio of one nurse per 2.5 patients. In tertiary units, the
ratio was one nurse per two beds. As compared to this, Australia observed a greater degree of
flexibility in the staffing ratios which is known as 5: 20 rule. Hence, both the countries were
found to be cautious regarding the issues and concerns of nurses. Japan implemented formal
nurse to patient ratios in 2006. On comparing this to Australia, it was found that Australia was
quite late in implementing nurse to patient ratios with respect to other ECD countries. But, these
countries did not design any staffing models. As compared to this, Australia implemented
various staffing models such as Victorian, Western and Hybrid model.

DISCUSSION
While conducting the study it was found that there exists a nursing shortage in private as well as
public healthcare sector of Australia. The lack of nurses has put a major impact on the nurse to
patient staffing ratios. It has further made them overworked and stressed. Concerns have further
been made by them on the Impacts go inappropriate ratios as it is hindering with patient safety
errors.
It has further been found that there has been an application of many models in Australia with
respect to maintain proper nurse staff ratio. These included Victors’ model that has made it
mandatory to observe the staffing ratios with respect to acute medical and surgical wards. In the
same way, there was further an application of Nurse Hours per patient day in the public hospitals
in Western Australia. The technique proved to be fairly successful in attracting nurses to
hospitals. A law was further made in Australia so as to maintain the ratio of one nurse to four
patients. The law has thus made it mandatory to apply the ratio in labour wards, special care
nurseries, high dependency unit’s etc. thereby bringing overall improvement in the services.
Other than that the Australian healthcare has further applied Hybrid nursing model that has aided
in assessing the overall workload. Other than that UK government further passed Safe Patient
Care Bill 2015 which was there to protect safe nurse and midwife patient ratios in public
hospitals and aged care facilities. The bill helped to maintain a ratio of one nurse to every three
patients in morning as well as evening shifts.
With comparison to other nations, several laws have been passed by California legislators so as
to maintain the minimum nurse to patient ratios. Some laws also emphasized on monitoring
nurse staffing trends and funding for primary nursing education. Overall the American healthcare
has sought to achieve a balanced approach that entails for monitoring of nurse staffing rather
than maintaining a specific ratio. In contrast to American healthcare, the South Korean
government has favoured maintaining adequate nurse to patient ratios in there hospitals. In the
similar manner, the Japanese Nursing Association also has a presence of formal nurse patient
ratios. Talking about Australia, its healthcare sector has understood the importance of
maintaining the ratios or taking other steps for the same. However, it came out to be too late in
realizing its significance. However, it is further true that the nations have not focused on
designing any staffing models. Australia on the other hand has made a well as implemented a
variety of them. These include Victorian, Western and Hybrid model.

Strengths and weaknesses of the study
The study had presence of strengths in form of adhering with a presentable study pattern. All the
chapters as well as sections were presented properly. This included by adding headings as well as
subheadings for the same.
However, there was a dearth of studies on the topic that made it difficult to gather adequate
information on the subject. Some of the studies just had a presence of abstract section that made
it difficult to review entire study. A few studies were also limited in terms of sampling and
generalizability... There was a presence of small surveys followed by usage of non-random
samples that were confined to a specific group. Moree the studies could not be generalized on the
entire nurse patient ration of Australia. This was as the results were specific to a given hospital
setting.
Issues were further found in accessing the reliable data. Other than the research studies
were also found to be written in different language other than English. THz limitation was aided
by using the translator option. In the same way, there was also a dearth of literature studies on
time period 2005- 2015. It was managed by taking maximum possible information from the
available studies. The research studies were poorly indexed in the electronic databases. Moreover
the studies were spread in many disciplines. This led to overlooking the search of relevant
studies. In this regard, advance search option was used in databases so as to avoid the issue.
Reference list of the available studies was also searched so as to yield additional reports.
There was also a presence of varied researcher specific reasons that created issues in
completing the study. This included lack of awareness about the topic, non-familiarity with
Australian healthcare system. This led to increase in time for searching the appreciate content for
the study. This issue was later avoided by making use of skimming technique so as to search for
apt content. The presentation of given study was also improved upon so as to attain more clarity.
What aspects might remain unanswered or new questions that have arisen?
There is a presence of many areas that have not been covered up in the entire study. Hence
further research is required to be carried out as to what issues are being faced by Australian
government. This is likely to aid in generating working over them for maintaining a better nurse
to patient ratio. In the same manner, the future research can also be conducted on other nations

who are making an attempt to manage the patient staff ratio. Then a comparative study can also
be carried out between two such nations. Other topic areas that can be used for future research
are as follows;
 A systematic review on the effects of nurse staffing on patient, nurse employee, and
hospital outcomes.
 Nurse–patient ratios as a patient safety strategy

CONCLUSION
Conclusion section of systematic review discusses the issues so that a final judgment
could be reached. It is an important part of the systematic review as it takes the reader to a
new level of perception about the study. From the present systematic review, it can be
concluded that Australia is in need of a legislation which will be implemented next year for
mandating staffing ratios. The research questions for the present systematic review were
“What are the current policies on nurse to patient ratios as compared to legislation of other
OECD countries?” and “How nurse to patient ratios and dynamic staffing models can help in
addressing the issue of inappropriate nurse to patient staffing ratios in Australia?”
Australia experiences a shortage of nurses in public and private hospitals. Concerns
raised by nurses has compelled the government in the country to legislate nurse to patient
ratio of 1:4. The federal government is considering implementation of legislation for
mandating safe nurse to patient staffing rations all over Australia. The review found out that
Australia has been implementing various staffing models that addressed the concerns of
nurses. These were Victorian Model, Nurse Hours Per Patient Per Day and Hybrid model
(Australian Nursing and Midwifery Federation, 2012). The models have been implemented
effectively within the health care organizations in the country. However, issues were still
faced by nurses who were overloaded due to inappropriate staffing ratios. This indicates that
the models were not effective in managing the unreasonable workloads of nurses. Moreover,
the situation reached to the extent that there arose the need of implementing a legislation that
could mandate safe nurse to patient ratios.
As compared to the other OECD countries, Australia was quite late in implementing
legislation regarding safe nurse to patient staffing ratios (Van den Heede and et.al., 2009).
While the other OECD countries like Japan, South Korea, UK, US passed the legislations for
mandatory staffing ratios quite early, these were not implemented effectively. This means
that the planning for implementation of legislation has not been effective in other OECD
countries. Furthermore, OECD countries other than Australia emphasize that patients should
be looked after only by registered nurses (McHugh, Berez and Small, 2013). They do not
support implementation of mandatory nurse to patient ratios. However, it can be critically
analysed that safe nurse to patient ratios are equally important. From the review, it can be

concluded that Australia is aware of the importance of mandatory staffing ratios so that safer
care can be provided to the patients.
Moreover, considering the various staffing models which were implemented in Australia
to address nurses’ concern, it was found that Australia was constantly vigilant and aware
about the problems faced by nurses. On comparing this to other countries, it was found that
they did not implement any such model. From this it can be concluded that while Australia
has been making efforts to reduce the nurses’ workload, other countries were only confined
to legislating the ratio without effectively implementing it. From this it can be concluded that
the main issue in Australia was that the government focused on model but did not legislate
the ratio. Due to this, the nurses continued to be overloaded as the models could not provide
them with restrictive ratios. This suggests that not only do the models require to be reformed
but also they need to be linked with the legislation so that safe ratios can be mandated.
However, it can be critically analysed that nurses’ workload can be reduced in Australia
when the employers or health care provides observe the safe nurse to patient ratios. Despite
development of effective staffing models, the ratios are not safe. This indicates the issue of a
gap which exists at the level of implementation of safe patient ratios. It can be concluded that
safe nurse to patient ratios could be observed in public and private hospitals if a strategy is
developed which could eliminate the existing gap.
From the present systematic review, various threats as well as opportunities were
identified for health care system in Australia. As Australia has already implemented various
staffing models based on different concepts, there is scope for mandating safe nurse to
patient ratios. Mandating the safe staffing ratios would improve the working conditions of
nurses. This will provide various opportunities for the health care system of the country to
attract nurses and increase the workforce. With it, the workload could be better managed.
However, along with the opportunities, the present review also identified certain threats for
the Australian health care system. Inappropriate staffing ratios are making the nurses
overburdened and overworked (Kutney-Lee and et.al., 2009). This may threaten patient
safety and eventually the accountability of health care system in Australia. It will also
threaten the quality of health care in Australia. The issue of inappropriate staffing ratios
poses a threat to the retention of nurses in public and private hospitals in the country.

The government needs to take action regarding filling this gap because it is required to
solve the issue of inappropriate nurse to patient ratios in Australia. From the review it can be
concluded that nurses are concerned about the issue of inappropriate nurse to patient ratios.
As there are no mandatory ratios followed in the private and public hospitals in Australia,
nurse suffer from the problem of unreasonable workloads. Overworked staff often complains
about failure to detect key injuries thus resulting in inefficient care and support to the
patients. This issue is aggravated by the shortage of nurses. Moreover, there have been
problems in attracting and recruiting nurses because of workloads. Nurses play an essential
role in delivering the required care and support to the service users in public and private
hospitals. From this, it can be inferred that it is important for the government in Australia to
implement a standard legislation regarding nurse to patient ratios. More specifically, there is
need to develop a single national strategy for nurse to patient ratios.

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