Assessing the Effectiveness of 1:1 Nurse-Patient Ratio in Achieving Positive Patient Care and Nurse Job Satisfaction

This study aims to assess the effectiveness of the 1:1 nurse-patient ratio in achieving positive patient care and nurse job satisfaction. It explores the impact of nurse staffing on patient outcomes and job satisfaction among nurses. The study also discusses the significance of proper nurse-patient ratio in improving patient health outcomes and reducing medication errors. The review includes systematic reviews that examine the relationship between nurse-patient ratio and patient outcomes. The search strategy involves using databases like CINAHL and PubMed to find relevant studies published between 2009 and 2019.

Running head: NURSING ASSIGNMENT
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Name of the Student
Name of the university
Author’s note

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Title: A summary of assessing the effectiveness of 1:1 nurse-patient ratio in achieving positive
patient care as well as nurse’s job satisfaction: a rapid review
Objectives
The objective of the study is to assess the effectiveness of the 1:1 nurse patient ratio, in order to
achieve a standardised and positive patient’s outcome.
Research question: What is the effectiveness of 1:1 nurse-patient ratio in achieving patient’s
health outcome and job satisfaction?
PICO element:
P: Number of nurse and patient in the health care setting
I: Strategy of maintaining the1:1 nurse-patient ratio
C: Comparing between the patient health outcome of adequate nurse-patient ratio and inadequate
nurse patient ratio.
O: Patient health outcome and job satisfaction
Keywords used: Nurse –patient ratio, nurse staffing, standardised care, systematic reviews
Significance of the study:
Nurses provides holistic care to the patient and their families 24 hour a day. Inadequate
nurse staffing in the health setting significantly effects on the quality of patient care and may

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results in negative nurse’s outcomes such as job dissatisfaction and emotional exhaustion
(Nantsupawat et al., 2015). In one hand, the nurse-to-patient ratio shows nurses outcomes, as,
one-fourth (approximately) of nurses have job dissatisfaction, about half of the nurses outcome
includes needle injury and three-fifth of nurses reported having misses in the past year
( Nantsupawat et al., 2015). On the other hand, the research study shows that proper nurse patient
ratio, as well as increase in their working hours per patient has a significant impact on patient’s
health outcomes such as lower rates of pressure ulcers, pneumonia, falls and sepsis, reduces
medication error and decrease in the mortality rate. Additionally, the research conducted in
England shows health settings with less number of patients per registered nurse had lower
mortality rate (20%) comparing to those hospitals which has higher number of patient per
registered nurses (Watson et al., 2016.). Inadequate staffing of the nurses has been found to be
dangerous for the patients and they increases the rates of infections, illness, errors and mortality.
When the nurses are assigned with too many patients, they are at a higher risk of the medical
errors that can be easily prevented, the avoidable medical errors, the falls and the injuries, the
pressure sores, increased length of the stay and readmissions.
Globally, there had been an increasing concern about the job satisfaction of the nurses, as
it plays an important role in the retention of the nurses and the care quality of the patient (Lu,
Zhao, & While, 2019). Inadequate staffing has been found to have been long working hours, lack
of personal time and lack of organisational commitment.
Other studies by Kleinpell et al., (2015), have found that understaffing in the intensive
care unit increases the risks of medical infection. Specific ratio of the nurse and patient are
maintained in an intensive care. In paediatric intensive care unit the ratio was found to be 1 to 4.

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The factors affecting the nurse practitioners and physician assistant involved severity of the
illness, the number of patients in the intensive care unit.
It is the routine of the clinical settings to respond to the nurse-patient ratio and the
legislator calls for a minimum safe nurse staffing laws with threats of staffing cuts. A study in
Twigg, Cramer & Pugh, (2016) has found that the nurse staffing for the rural health care settings
needs to be increased for managing the workload staff utilisation and greater patient outcomes. It
has been found that the nurse staffing models of care with a diversity in the workload factors
driving the nursing activity pose a major challenge for providing a safe and quality patient care.
According to the Falk and Wallin, (2016), the nurse-patient ratio affects the intensive
care unit, the most. As per the results of the study, patient care and complications in relation to
the patient/ nurse ratio had shown that unplanned extubations occurred in 3-5 % of the cases. A
difference has also been found in the length of the patient’s stay.
Hockenberry and Becker, (2016), have stated that nurse face higher level of stress and
burnout in comparison to the other health care professionals. It has been found that hospitals
with higher levels of nurse’s per bed increases patient satisfaction. According to the study, less
traned staffs are never desired for the organisation. However, if properly trained, different
staffing mixes can affect the different domains of patient satisfaction. This can be supported by a
paper by Cho et al., (2015), which studied that nurses often have to work for long hours/
overtime due to shortage of staffing. A considerable link between patient outcomes and nurse
staffing, work environment has been found. The findings of the review has suggested that nurses
working for longer hours have experienced fatigue and have poor quality of sleep that has
affected their vigilance , reaction time , alertness and the decision making ability and thus

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decreases the overall patient care. According to Backhaus et al., (2016), poor quality of nursing
home care has been found to be associated with insufficient staffing level as nurse patient ratio
affects the quality of care. And the life of residents of the clinical care settings. The author has
associated events like falls, pressure ulcers, infections, resident weight loss with less staffing of
the nurses. Number of nurses are often considered to the quality indicators. Less number of
nurses has been associated with a decrease in the likelihood of the activities in a nursing care
setting. The rationale for choosing this topic is to investigate the relation between nurse- patient
ratio and patient outcomes, as inadequate staffing has been found to be associated to medications
errors and increased risk of infections and avoidable near misses, slips and falls (Kleinpell et al.,
2015). There had been an increased emphasis on restricting the turnover of the competent nurses.
According to the researches alternative and innovative approaches should be taken to prevent the
turnover of the nurses. This rapid review is important because, this would also help us to identify
the interventions that could be taken to maintain a proper nurse patient turnover in a clinical
settings.
Criteria for choosing studies for this review
This study will include those systematic review that would assess how the nurse patient
ratio is related to better patient outcomes and job satisfaction among the nurses. Proper nurse
patient ratio has been found to be associated to clinical and economic improvement in the patient
care including the enhancement of satisfaction in the patient, reduction of the medication errors,
patient mortality, hospital readmissions and the lengthy of the stay.

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Types of participants
The review will include the target population “nurses”, both registered nurses and the
enrolled nurses. Whose ratio in a clinical setting is important for providing a standardized care
to the patients and to maintain job satisfaction among the nurses.
Types of interventions
All the studies relevant to proper nurse patient ratio in a clinical care setting and their
impact on the patient outcome and job satisfaction among the nurses will be considered. Studies
related to excessive working hours due to inadequate staffs and their psychological impact on the
development of resilience among the nurses will also be considered. Studies mentioning about
the different interventions like involving a single staffing system, recruiting competent health
care workers, identifying the reasons behind high turnover, will also be considered (Hockenberry
& Becker, 2016) Other interventions like the introduction of a performance based reward system,
personal recruitment, socialisation ad long term career prospects should also be included
(Tourangeau et al., 2016). The rapid review will also focus on toolkits used for assessing safe
nursing staff establishment, for example the implementation of the safer nurse toolkit.
Type of outcomes
The outcome measures that will be measured are the incidences of medical errors in the
acute care settings due to nurse patient ratio and how the ratio affects the job satisfaction and the
level of resilience among the nurses.

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In order to measure that the nurse-patient turnover rate, studies describing the rate if
adverse events such as medication errors , slips and falls due to inadequate nurse staffing will
also be measured (Watson et al., 2016).
Search strategy
Both published and unpublished systematic reviews will be used for writing the summary.
The following data bases would be used for conducting the search:
1. CINAHL
2. PubMed
The search strategy that will be conducted in CINAHL data base has been provided in
appendix. In order to extract the additional studies the reference list of the studies will also be
included. The inclusion criteria for the search would be the systematic review papers obtained
between the years 2009- 2019. This time period has been chosen in order to get the most recent
evidences regarding the nurse patient ratio in a clinical care setting and how it impacts patient
care and satisfaction level among the nurses.
Methods of the Review
Assessment of the methodological quality
The validity and the reliability of the papers will be assessed by critically appraising the
papers by using the Assessment of the multiple systematic review (AMSTAR). The assessment
tool consists of 11 criterions for measuring the quality of the systematic reviews. The score for
AMSTAR is mainly calculated by the summation of the all the “yes“ and allocating zero points
for “no” criterion. The sum of the scores ranges from 0-11 (Shea, et al., 2017). The score levels

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determines the quality of the systematic reviews- 8-11-high quality studies, 5-7- medium quality,
0-4- poor quality of systematic reviews. The critical appraisal form for the appendix has been
provided below.
Data extraction
The data that has to be extracted from the papers included the objectives, findings, the
research design, the study methods and the discussions. A data extraction form will be used in
this step and has been provided in the appendix.

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References
Backhaus, R., Verbeek, H., van Rossum, E., Capezuti, E., & Hamers, J. P. (2014). Nurse staffing
impact on quality of care in nursing homes: a systematic review of longitudinal
studies. Journal of the American Medical Directors Association, 15(6), 383-393.
Cho, E., Sloane, D. M., Kim, E. Y., Kim, S., Choi, M., Yoo, I. Y., ... & Aiken, L. H. (2015).
Effects of nurse staffing, work environments, and education on patient mortality: an
observational study. International journal of nursing studies, 52(2), 535-542.
Falk, A. C., & Wallin, E. M. (2016). Quality of patient care in the critical care unit in relation to
nurse patient ratio: A descriptive study. Intensive and Critical Care Nursing, 35, 74-79.
Hockenberry, J. M., & Becker, E. R. (2016). How do hospital nurse staffing strategies affect
patient satisfaction?. ILR Review, 69(4), 890-910.
Kleinpell, R., Ward, N. S., Kelso, L. A., Mollenkopf, F. P., & Houghton, D. (2015). Provider to
patient ratios for nurse practitioners and physician assistants in critical care units.
American Journal of Critical Care, 24(3), e16-e21.
Lu, H., Zhao, Y., & While, A. (2019). Job satisfaction among hospital nurses: a literature review.
International journal of nursing studies. https://doi.org/10.1016/j.ijnurstu.2019.01.011
Nantsupawat, A., Nantsupawat, R., Kulnaviktikul, W., & McHugh, M. D. (2015). Relationship
between nurse staffing levels and nurse outcomes in community hospitals,

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Thailand. Nursing & Health Sciences, 17(1), 112–118. https://doi-
org.ezproxy.uow.edu.au/10.1111/nhs.12140
Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., ... & Henry, D. A.
(2017). AMSTAR 2: a critical appraisal tool for systematic reviews that include
randomised or non-randomised studies of healthcare interventions, or both. Bmj, 358,
j4008.
Tourangeau, A. E., Wong, M., Saari, M., & Patterson, E. (2015). Generation‐specific incentives
and disincentives for nurse faculty to remain employed. Journal of Advanced Nursing,
71(5), 1019-1031.
Twigg, D. E., Cramer, J. H., & Pugh, J. D. (2016). Nurse staffing and workload drivers in small
rural hospitals: An imperative for evidence.
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.
Appendix A: Proposed Timeframe
Dates 20/03/201
9-
28/03/201
9
29/03/201
9-
08/04/201
9
9/4/201
9-
19/4/20
19
20/4/19-
30/5/19
5/5/19-
10/5/19
11/5/19-
22/5/19
25/05/20
19

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Task Formulate
Project
question
(PICO)
Develop
eligibility
criteria
Literatu
re
search
Screeni
ng the
literatur
e,
assessin
g the
quality
of
studies
Data
Extracti
on
Synthesi
ze and
interpret
the
results
Submit
Project
Report
Comments

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Appendix B: Search strategy in CINAHL
1. Nurse patient ratio in clinical settings
2. Systematic review on the Nurse patient ratio and patient health outcomes
3. Nurse-patient ratio AND health outcomes AND job satisfaction
4. Nurse staffing AND job satisfaction
5. Nurse-patient ratio AND medical errors
6. Nurse staffing AND resilience
7. Limiters: 2009- 2019
8. Limiters: Data type: Journal articles
S10
nurse patient
ratio AND
patient
outcomes
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed
Search modes -
Boolean/Phrase
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
Complete
17
S9 nurse
staffing
AND patient
safety
Limiters - Full
Text; Abstract
Available;
Published Date:
Interface -
EBSCOhost
Research
Databases
30

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20130101-
20191231; English
Language; Peer
Reviewed
Search modes -
Boolean/Phrase
Search
Screen -
Advanced
Search
Database -
CINAHL
Complete
S8
nurse
staffing
AND work
overload
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed
Search modes -
SmartText
Searching
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
Complete
0
S7 nurse
staffing
AND work
overload
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed
Search modes -
Boolean/Phrase
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
0

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Complete
S6
nurse patient
ratio AND
medication
error OR
mortality
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed
Search modes -
Boolean/Phrase
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
Complete
12,672
S5
nurse patient
ratio AND
medication
error
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed
Search modes -
Boolean/Phrase
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
Complete
6
S4 nurse patient
ratio AND
job
satisfaction
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
Interface -
EBSCOhost
Research
Databases
Search
15

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20191231; English
Language; Peer
Reviewed
Search modes -
Boolean/Phrase
Screen -
Advanced
Search
Database -
CINAHL
Complete
S3
Nurse-
patient ratio
AND patient
safety
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed;
Randomized
Controlled Trials
Search modes -
SmartText
Searching
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
Complete
7
S2 nurse-patient
ratio AND
patient safety
AND patient
outcomes
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed;
Randomized
Controlled Trials
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
0

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Search modes -
SmartText
Searching
Complete
S1
nurse patient
ratio AND
( patient
safety or
patient
outcomes or
quality of
care )
Limiters - Full
Text; Abstract
Available;
Published Date:
20130101-
20191231; English
Language; Peer
Reviewed;
Randomized
Controlled Trials
Search modes -
Boolean/Phrase
Interface -
EBSCOhost
Research
Databases
Search
Screen -
Advanced
Search
Database -
CINAHL
Complete

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Appendix C: Critical Appraisal tool
S.N. ITEMS RESPONSES
1. Was true randomization used for assignment of participants to
treatment groups?
□ Yes
□ No
□ Can't answer
□ Not applicable
2. Was allocation to treatment groups concealed? □ Yes
□ No
□ Can't answer
□ Not applicable
3. Were treatment groups similar at the baseline? □ Yes
□ No
□ Can't answer
□ Not applicable
4. Were participants blind to treatment assignment? □ Yes
□ No
□ Can't answer
□ Not applicable
5. Were those delivering treatment blind to treatment assignment? □ Yes
□ No
□ Can't answer
□ Not applicable
6. Were outcomes assessors blind to treatment assignment? □ Yes
□ No
□ Can't answer
□ Not applicable
7. Were treatment groups treated identically other than the
intervention of interest?
□ Yes
□ No
□ Can't answer
□ Not applicable
8. Was follow up complete and if not, were differences between
groups in terms of their follow up adequately described and
analyzed?
□ Yes
□ No
□ Can't answer
□ Not applicable
9. Were participants analyzed in the groups to which they were
randomized?
□ Yes
□ No
□ Can't answer
□ Not applicable

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10. Were outcomes measured in the same way for treatment groups? □ Yes
□ No
□ Can't answer
□ Not applicable
11. Were outcomes measured in a reliable way? □ Yes
□ No
□ Can't answer
□ Not applicable

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Appendix D: Data extraction form
Author
Year
Countr
y
Focus
Search
details, range
(database
searched,
articles
included)
Quality
score
Number of
studies
Design of
included studies
Interventions/
Comparison
Main outcome
measures