Critical Review on Nurse to Patient Ratio

The paper concentrates on literature review of the articles related to nurse to patient ratio and the impact in the healthcare industry. Research articles relevant to the topic has been critically apprised and synopsis has been provided in a literature evaluation table. From the critical analysis of the articles it has been concluded that nurse to patient ratio has a significant effect on patient outcome. Higher quantity of available nurse eases the workload. This results in favourable patient outcome with reduced mortality rates and adverse incidents.

Running head: A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
Name of the Student:
Name of the University:
Author Note:

1A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
Executive Summary
The paper concentrates on literature review of the articles related to nurse to patient ratio and
the impact in the healthcare industry. Research articles relevant to the topic has been
critically apprised and synopsis has been provided in a literature evaluation table. From the
critical analysis of the articles it has been concluded that nurse to patient ratio has a
significant effect on patient outcome. Higher quantity of available nurse eases the workload.
This results in favourable patient outcome with reduced mortality rates and adverse incidents.

2A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
Table of Contents
1. Introduction............................................................................................................................3
2. Discussion..............................................................................................................................3
2.1. Literature Evaluation Table.............................................................................................3
3. Conclusion..............................................................................................................................9
References................................................................................................................................10

3A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
1. Introduction
Nurses are the primary providers of healthcare to the patients and nurse to patient
ratio is a crucial factor in the health industry. Number of patients allocated to a nurse has a
direct effect on the workload, decision making and performance of the nurse. The nurse to
patient ratio also effects the work environment in the hospital and the service provided to the
patients (Cho et al., 2016). So nurse to patient ratio is a critical factor effecting the mortality
rates in adults and neonatal (Watson et al., 2016). In this report articles on the relevant topic
will be critically appraised by using a literature evaluation table.
2. Discussion
2.1. Literature Evaluation Table
Criteria Article 1 Article 2 Article 3 Article 4
Author,
Journal
(Peer-
Reviewed),
and
Permalink
or Working
Link to
Access
Article
Eunhee Cho, Dal
Lae Chin, Sinhye
Kim and
OiSaeng Hong.
Journal of
Nursing
Scholarship
https://doi.org/
10.1111/
jnu.12183
Andrea Driscoll,
Maria J Grant,
Diane Carroll,
Sally Dalton,
Christi Deaton,
Ian Jones,
Daniela
Lehwaldt,
Gabrielle McKee
and Theresa
Munyombwe and
Felicity Astin.
European
Journal of
Cardiovascular
Nursing
DOI:
10.1177/1474515
117721561
Debra C. Hairr,
Helen
Salisbury, Mark
Johannsson and
Nancy Redfern-
Vance.
Nursing
Economics
https://
studydaddy.com
/attachment/
38269/
pmrpn0c7z3.pdf
Jeong-Hee Kang,
Chul- Woung
Kim and Sang-Yi
Lee.
Osong public
health and
research
perspectives
https://doi.org/
10.1016/
j.phrp.2015.10.0
15
Article
Title and
Year
Published
The
Relationships of
Nurse Staffing
Level and Work
The effect of
nurse-to-patient
ratios on nurse-
sensitive patient
Nurse staffing
and the
relationship to
job satisfaction
Nurse-perceived
patient adverse
events depend on
nursing

4A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
Environment
With Patient
Adverse Events.
2016.
outcomes in acute
specialist units: a
systematic review
and meta-
analysis.
2018.
and retention.
2014.
workload.
2016.
Research
Questions
(Qualitativ
e)/Hypothe
sis
(Quantitati
ve), and
Purposes/
Aim of
Study
To examine the
relationship of
work
environment and
nurse staffing
level with the
adverse events
related to
patients.
To review and
examine the
relation between
nurse staffing
level and patient
outcomes which
are nurse
sensitive.
To examine the
relationship
between nurse
staffing, job
satisfaction and
retention of the
nurses in an
intensive care
hospital unit.
To evaluate the
correlation
between nursing
workload and
adverse events
related to
patients.
Design
(Type of
Quantitativ
e, or Type
of
Qualitative
)
Quantitative
cross-sectional
study.
Combination of
nurse survey
data, patient
hospital dis-
charge data and
facility data.
Systematic
review based on
cross-sectional
study of relevant
articles. Meta-
analysis of
patients.
Quantitative,
correlational
research study
of nurses
working for six
months at least.
Quantitative
analysis
involving logistic
regression
analysis of data
collected from
nurses and the
hospitals.
Setting/
Sample
4864 nurses,
113426 patients
and 58 hospitals
of South Korea
35 articles,
175755 patients
from six studies
admitted to
intensive care
unit.
70 nurses who
were registered,
licensed and
practicing for at
least 6 months.
1816 nurses
working in
general inpatient
units, 23 general
hospitals in
South Korea.
Methods:
Interventio
n/Instrume
nts
Survey used for
nurses and
patients and
secondary data
collection for
hospitals.
Secondary data in
form of articles
were chosen from
nine electronic
databases based
on the inclusion
criteria. Articles
were published in
English between
2006 to 2017.
NWI-R
(Reversed
nursing work
index) was used
along with
survey
questions to
understand the
job experiences
and satisfaction
of the
participating
nurses.
Workload of
nurses and
variables
regarding that,
adverse event
related to
patients and
dependent
variables
regarding that
and hospital
regarding
variables were
evaluated by
HLM 7 for
multilevel

5A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
logistic
regression
analysis.
Analysis Descriptive
statistics analysis
of Nurse Staffing
Level, Work
Environment,
and Adverse
Events and
characteristics of
nurses, patients
and hospitals.
Systematic
review on
adjusted measures
as primary effect
measures, Odd
ratios, Hazard or
risk ratios. Meta-
analysis involving
nurse staffing
level (NPR) and
inhospital
mortality.
Descriptive
statistics using
SPSS FOR
NWI-R
subscale
variables and
demography.
Rank
Correlation
Coefficient
Analysis of
Spearman was
performed for
each research
question.
Frequencies and
percentages
were also
evaluated.
Logistic
regression
analysis was
performed to
determine the
relation of
nursing workload
and patient
related adverse
events at the
nurse and the
hospital level.
Dependent
variable was
medication error
for nurses and
null hypothesis at
the hospital level
was verified
before
performing the
analysis.
Key
Findings
Adverse events
with patients had
an inversely
proportional
relation with
ideal working
environment.
Small number of
patients per
nurse lowered
the frequency of
adverse events
with patients.
Higher nursing
staff decreased
inhospital
mortality by 14%.
Patient care
increased with
higher nursing
staffs in the
hospital.
Nurses were
unhappy with
higher number
of patients
assigned to
them and had
low level of job
satisfaction as
they were more
burdened with
workload.
Non nursing
tasks increased
the nursing
workload and
that increased the
adverse events
related to
patients. High
proportion of
nurses reduced
the workload and
medication error
also decreased
with that.
Recommen
dations
South Korean
Hospitals should
create an ideal
work
environment and
better nurse
staffing to
reduce the
adverse incidents
with patients.
Higher level of
nurse staffing in
the critical care
unit is highly
recommended
along with having
a skill mix
working in a
intensive care
unit. This will
reduce the
Nurse staffing
should be
higher so that
each nurse is
allocated to a
lower number
of patients. This
will reduce the
workload so the
patient care and
patient outcome
More nurses
should be
recruited to ease
the workload of
the nurses that
can reduce
medication errors
and adverse
patient outcomes
as a whole.

6A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
inhospital
mortality risks
significantly.
will improve.
Explanatio
n of How
the Article
Supports
EBP/Capst
one Project
Allocation of
more nurses to
reduce their
burden and
creating a better
working
environment has
been
recommended as
it reduces the
adverse events
related to
patients.
Higher staffing
level of nurses in
the intensive care
unit will reduce
the inhospital
mortality of
patients and this
has been critically
appraised and
proposed in this
article.
This article
analyses nurse
staffing and
relates with job
satisfaction and
retention.
Higher nurse
staffing
decreases the
workload for
the nurses
which results in
greater job
satisfaction and
retention.
Nursing
workload and
adverse events
related to
patients have
been correlated
and the outcome
suggests that
with higher nurse
staffing
workload
reduces along
with the number
of adverse
patient outcomes.
Criteria Article 5 Article 6 Article 7 Article 8
Author,
Journal (Peer-
Reviewed), and
Permalink or
Working Link
to Access
Article
J. Paul Leigh,
Carrie A.
Markis,
Ana-Maria Iosif
and Patrick S.
Romano.
International
archives of
occupational
and
environmental
health
DOI
10.1007/s00420
-014-0977-y
Dewi Stalpers,
Brigitte J.M. de
Brouwer,
Marian J.
Kaljouw and
Marieke J.
Schuurmans.
International
Journal of
Nursing Studies
https://doi.org/
10.1016/
j.ijnurstu.2015.0
1.005
S I Watson, W
Arulampalam, S
Petrou, N
Marlow, A S
Morgan, ES
Draper and N
Modi.
Archives of
Disease in
Childhood-
Fetal and
Neonatal
Edition
http://
dx.doi.org/
10.1136/
archdischild-
2015-309435
Elizabeth West,
David N.
Barron, David
Harrison, Anne
Marie Rafferty,
Kathy Rowan
and Colin
Sanderson.
International
journal of
nursing studies
https://doi.org/
10.1016/
j.ijnurstu.2014.0
2.007
Article Title
and Year
Published
California’s
nurse-to-patient
ratio law and
occupational
injury.
Associations
between
characteristics
of the nurse
work
The effects of a
one-to-one
nurse-to-patient
ratio on the
mortality rate in
Nurse staffing,
medical staffing
and mortality in
intensive care:
an observational

7A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
2015.
environment
and five nurse-
sensitive patient
outcomes in
hospitals: a
systematic
review of
literature.
2015.
neonatal
intensive care: a
retrospective,
longitudinal,
population-
based study.
2016.
study.
2014.
Research
Questions
(Qualitative)/
Hypothesis
(Quantitative),
and
Purposes/Aim
of Study
To determine
the relation of
state-ordered
minimum
nurse-to-patient
ratios in
California
hospitals and
effect on
occupational
health related
hazards.
To review the
literatures on
relationship
between nurse
work
environment
and five nurse-
sensitive patient
outcomes in
hospitals in a
systematic
manner.
To investigate
the effect of
one-to-one ratio
between nurse
and the patient
on the mortality
rates of
neonatal
intensive care
units.
To examine the
relation between
the size of the
workforce in the
hospital and
survival chances
of severely sick
patients in the
ICU and
hospital.
Design (Type
of
Quantitative,
or Type of
Qualitative)
Quantitative
Difference-in-
differences
method to
evaluate the
frequency
changes in
nursing after
law
enforcement.
Systematic
review on
articles based
on quantitative
studies on the
relevant topic.
Quantitative
study based on
longitudinal
analysis and
population
based data by
variable
instrumental
method.
Quantitative
cross-sectional
and
observational
study.
Setting/Sample Injury rates of
nurses in
California were
compared to the
nurses of 49
other states
including DC.
29 articles
meeting the
inclusion
criteria were
reviewed to
understand the
work
environment of
the nurses and
patient
outcomes.
43 tertiary level
neonatal units
observed
between 2008
January and
2012 December
on a monthly
basis.
Secondary data
of 38,168
patients and 65
ICUs were
collected.
Methods:
Intervention/In
struments
Data from the
California
Employment
Development
Articles
published
between 2004
and 2012 on the
NNRD data was
collected for
tertiary neonatal
units
Risk
management
variables and
human resource

8A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
Department and
US Bureau of
Labor Statistics
were taken as
secondary data.
relevant topic
was searched in
Medline
(PubMed),
CINAHL,
Cochrane and
Embase. To
assess the
quality of the
articles included
in the study the
Dutch version
of Cochrane's
critical
appraisal
instrument was
used.
participating in
NESCOP
project.
Proportion of
neonatal care
admissions and
days were
calculated based
on only one-to-
one nursing.
variables were
evaluated by a
multilevel
logistic
regression
method.
Analysis Numerator
taken as number
of injuries and
denominator
taken as number
of registered
nurses and
licensed
practical nurses.
Means and
standard errors
were calculated
for Californian
nurses and for
rest of the
states.
The review
analyzed the
relation of
patient outcome
and nursing
environment.
Collaborative
relationships,
nurse education
and nursing
experience were
the factors that
were evaluated.
Linear
regression
model was used
to evaluate the
relation of one
to one nursing
in neonatal
units with
mortality rates
in the tertiary
hospitals.
Logistic
regression
model involving
different
variables were
performed to
evaluate the
relation of
number of
health
professionals
including nurse
and the
mortality rate of
the patients.
Key Findings Occupational
injury dropped
by 55.57 per
10000
registered
nurses after the
implementation
of law in
California.
A clear relation
is present
between work
environment of
nurses and the
nurse-sensitive
patient
outcomes.
One-to-one
nursing care to
neonatal is
inversely
proportional to
the mortality
rates. Mortality
rates decreased
with increased
one to one
nursing care.
Higher quantity
of medical and
nursing staff
reduces the
mortality rates
of the patients
admitted in the
ICU and the
hospital.
Recommendati
ons
Enforced law in
California has
controlled the
workload of the
nurses and
occupational
A better
working
environment for
the nurses that
involves
reduced
Neonatal
mortality rates
should be
controlled and
one-to-one
nursing care
Human resource
policy should be
looked at and
more medical
and nursing
staffs should be

9A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
injuries
reduced. Other
administrations
should follow
the same.
workloads and
limited patients
assigned to
every nurse can
improve the
patient outcome
positively.
should be
implemented to
reduce the
mortality rates.
appointed that
will reduce the
mortality rates
in patients due
to better
provision of
care.
Explanation of
How the
Article
Supports
EBP/Capstone
Law
enforcement has
limited the
number of
patients per
nurse and
reduced their
workload. This
was beneficial
for their health
and better
healthcare to
the patients can
be provided as a
result.
Work
environment of
the nurses has
been assesses
and related with
patient
outcomes
related to
nursing care.
Better
environment
also improves
the patient
outcome.
Mortality rate
of the neonatal
in directly
related to the
one to one
nursing ratio
which has a
positive effect
on the neonatal
care by
reducing
mortality.
Survival rates
among the
patients has
been related to
the higher
number of
medical and
nursing staff
that can reduce
the mortality
rates of patients.
From the literature evaluation table it can be deduced that the available workforce in
the hospital effects the mortality rates of the patients (West et al., 2014). Through a
systematic review Driscoll et al., (2018) has supported the idea. According to Hairr et al.,
(2014) nurse staffing level effects job satisfaction as it directly effects the workload. Too
much workload affects the patient outcome and increases the mortality rate (Kang, Kim &
Lee, 2016). According to Stalpers et al., (2015) working environment of the nurses and the
nurse patient ratio effects the patient outcome and survival rates. Mandated law on nurse to
patient ratio can control the patient allocation to a nurse which helps to reduce workload of
the nurses and patient mortality (Leigh et al., 2015).
3. Conclusion
The purpose of the paper is to understand the factors regarding nurse to patient ratio
and the way it impacts the patient outcome. From the data extraction and the conclusion it is

10A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
clear that for better patient outcome and lower mortality rates of the patient higher allocation
of nurse is quintessential. This ensures a controlled nurse to patient ratio that eases the
workload of the nurse and improves patient outcome in the healthcare industry.

11A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
References
Cho, E., Chin, D. L., Kim, S., & Hong, O. (2016). The relationships of nurse staffing level
and work environment with patient adverse events. Journal of Nursing Scholarship,
48(1), 74-82.
Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., ... & Astin, F. (2018).
The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute
specialist units: a systematic review and meta-analysis. European Journal of
Cardiovascular Nursing, 17(1), 6-22.
Hairr, D. C., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and
the relationship to job satisfaction and retention. Nursing Economics, 32(3), 142-148.
Kang, J. H., Kim, C. W., & Lee, S. Y. (2016). Nurse-perceived patient adverse events depend
on nursing workload. Osong public health and research perspectives, 7(1), 56-62.
Leigh, J. P., Markis, C. A., Iosif, A. M., & Romano, P. S. (2015). California’s nurse-to-
patient ratio law and occupational injury. International archives of occupational and
environmental health, 88(4), 477-484.
Stalpers, D., de Brouwer, B. J., Kaljouw, M. J., & Schuurmans, M. J. (2015). Associations
between characteristics of the nurse work environment and five nurse-sensitive patient
outcomes in hospitals: a systematic review of literature. International Journal of
Nursing Studies, 52(4), 817-835.
Watson, S. I., Arulampalam, W., Petrou, S., Marlow, N., Morgan, A. S., Draper, E. S., &
Modi, N. (2016). The effects of a one-to-one nurse-to-patient ratio on the mortality
rate in neonatal intensive care: a retrospective, longitudinal, population-based study.
Archives of Disease in Childhood-Fetal and Neonatal Edition, 101(3), F195-F200.

12A CRITICAL REVIEW ON NURSE TO PATIENT RATIO
West, E., Barron, D. N., Harrison, D., Rafferty, A. M., Rowan, K., & Sanderson, C. (2014).
Nurse staffing, medical staffing and mortality in intensive care: an observational
study. International journal of nursing studies, 51(5), 781-794.