Health Project: Nurse to Patient Ratios, Policies, and Legislation

This health project report investigates the critical issue of inappropriate nurse to patient staffing ratios in Australia, highlighting their impact on patient safety and the quality of care. The report provides a comprehensive review of current policies in both public and private hospitals, comparing them with legislation from other OECD countries. The rationale behind the project is to address the crisis in nursing and generate awareness about the need for standard legislation on nurse to patient ratios. The project's objectives include reviewing current policies, comparing them internationally, and recommending the development of a national strategy. The methodology involves a systematic literature review, examining various databases and articles from 2005 to 2015. The report also addresses potential risks, such as data loss and ethical considerations, and outlines the project's milestones. The findings underscore the need for appropriate nurse-to-patient ratios to alleviate nurses' workloads, ensure patient safety, and maintain the quality of healthcare delivery. The report concludes with a call for a national strategy to address this critical issue in Australian healthcare.

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/