Literature Review

The optimal nurse-to-patient ratio has remained an issue of contention in most
healthcare settings; however, strong evidence suggests that nurse staffing levels in hospitals
and other care settings have a remarkable influence on patient outcomes. Numerous studies
have explored this association over the past three decades, highlighting the different factors
that affect nurse staffing levels and professional burnout.
PICOT Statement: Does implementing minimum 1:1 nurse-to-patient ratios compared to the
average 1:3 nurse-to-patient ratio lead to improved patient outcomes in acute care patients
over a period of 6 months?
Search strategy
The Grand Canyon University Library was used to identify scholarly articles published
between 2017 and 2022 using “nurse staffing,” “patient outcomes,” “acute care,” “acute
specialist units,” “nurse-patient ratio,” and “patient outcomes” as the keywords. The results
were further screened according to the following inclusion criteria:
 Patients admitted to acute care units such as ICU or HDU, and where nurse to patient
ratios (NPRs) was a variable studied
 The impact of NPRs was analyzed using a method such as the number of nurses
available divided by the number of acute care patients over 24 hours.
 Nurse-sensitive primary outcomes include failure-to-rescue, mortality, unplanned
extubation, surgical bleeding, heart failure, patient falls, hospital-acquired pneumonia,
nosocomial blood infection, unplanned readmission, and medication errors.
All the identified studies met the criteria, and most of them adjusted for age, hospital
characteristics, and comorbidities as confounders.
Literature Review

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Different approaches have been used to measure NPRs in clinical settings in the past
few decades. Driscoll et al. (2018 ) conducted a meta-analysis and systematic review to
investigate the relationship between nurse staffing levels patient outcomes in acute specialist
units. To accomplish this, the researchers searched nine electronic databases for articles
fitting the search strategy criteria, which includes nurse staffing levels and nurse-sensitive
patient outcomes. The authors selected 35 articles that met the inclusion criteria. After
analyzing the studies, the researchers found that higher nurse staffing levels in acute
specialist units were associated with reduced incidences of medication errors, mortality,
nosocomial infections, and a lesser degree of FTR cases. This study is crucial to my PICOT;
it includes an analysis of evidence from the literature about actual observational studies in
acute care units about the level of staffing and patient outcomes based on established
indicators.
McHugh et al. (2018) is a prospective study that explores the impact of the existing
NPRs on three patient outcomes: readmissions, mortality, and length of hospital stay. The
study included 55 hospitals in the prospective panel study and compared hospitals
implementing the Queensland NPR policy (n=27) with those that did not implement the
recommended NPR policy (n=28) over a 2-year period. Patient outcomes were obtained using
the standardized HIS–Queensland Hospital Admitted Patient Data, and nurses were recruited
in surveys to measure nurse staffing levels. Overall, post-implementation data suggested that
mortality rates were not significantly different from baseline in comparison hospitals but
were considerably lower than at baseline in hospitals implementing the Queensland NPR
policy. The researchers also found that readmissions increased significantly in the control
population but remained constant at intervention hospitals within the two-year period. The
intervention hospitals also reported a reduced length of stay over the two years, albeit
statistically insignificant. In the intervention cohort, implementation of a 1:1 NPR resulted in

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reduced mortality, readmissions, and length of stay. While adopting the NPR policy was
costly, the studied hospitals saved twice as much in the healthcare budget. This study
provides crucial insights into the benefits of implementing a 1:1 NPR in acute care units and
thus contributes immensely to the evidence needed for my EBP-project. With a clear
indication that such a policy is attainable, more healthcare providers can endeavor to enforce
such a mandate and increase their budget for nurse staffing.
Carthon et al. (2019) introduce an aspect of nurse staffing– level of engagement, which
plays a pivotal role in patient safety interventions. The researchers conducted a secondary
analysis of cross-sectional data involving 559 hospitals and 26 960 nurses across four states.
According to the findings, 32% of nurses thought their hospital registered a poor patient
safety grade; in 25% of hospitals included, nurses reported being “somewhat” or “least”
engaged. Only 19% of hospitals favored an environment where nurses felt highly engaged.
Furthermore, nurses in hospitals with poor staffed levels were six times more likely to miss
critical patient information during patient transfer. The authors propose the adoption of
adequate staffing and nurse engagement to foster positive patient outcomes. Undoubtedly,
staffing levels correlate with nurse engagement in hospitals. Evidence suggests that nurses in
poorly staffed hospitals were six times more likely to miss critical patient information during
transfers, leading to poor nurse-sensitive patient outcomes.
Owing to the need to increase the rate of translating research into practice, Aiken et al.
(2018) explore the impact of the European Commission-funded RN4CAST study in 30
countries and the implications of the program findings on a new program in Chile–
RN4CAST-Chile. The program seeks to establish the relationship between lower NPRs in
countries and how the findings can be implemented across various countries’ clinical and
governmental policies. For example, California has adopted safe nurse staffing mandates and
resulted in better nurse-sensitive patient outcomes. This study provides an evidence base that

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supports the redesign of nurse staffing mandates and provides healthcare practitioners greater
involvement in institutional and governmental policy decisions.
According to Shin et al. (2018) , a higher NPR was linked to a higher degree of
professional burnout among nurses, increased job frustration and dissatisfaction, and a higher
intent for quitting. The authors conducted a systematic review and meta-analysis of articles
published between 2000 and November 2016 in major scholarly databases such as PubMed,
Cochrane Library, and CINAHL. This study is helpful to my research because it collates
significant findings on NPRs impact on patient outcomes for an extended period (16 years).
Therefore, the authors provide critical insights on how hospitals can implement safe nurse
staffing policies to lower adverse nurse-related outcomes.
Addressing patient safety and assessing significant correlations between different
factors in the nursing environment is crucial for many healthcare providers. Specifically,
nurses are involved in everyday decision-making, which warrants evaluation of the complex
factors that come into play. Driven by such foundational knowledge, Nibbelink and Brewer
(2018) explore decision-making in nursing practice and the involved processes that affect the
quality of nursing care in medical-surgical environments. The authors’ approach is a practical
approach to understanding existing literature to support decision-making in acute care
settings, specifically about nursing.
Lasater et al. (2021) explore the reality of nurse understaffing in the middle of the
Covid-19 pandemic; failure to enact nurse staffing legislation directly impacts the public’s
health. The pandemic worsened the ineffectiveness and disparities in staffing across U.S.
hospitals, and this situation prompted Lasater and her colleagues to conduct a real-time
evaluation of health implications caused by understaffing. The authors include 254 hospitals
in a survey conducted in Illinois and New York between December 2019 and February 2020.

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Findings suggest that understaffing led to burnout, risking the public’s health. NPR ranged
from 1.15 to 1.52 in medical-surgical units and 1.32 to 3.63 in intensive care units.
Poor nurse staffing levels have also been linked with missed vital signs, resulting in
increased failure-to-rescue across numerous hospitals. Griffiths et al. (2018) investigate the
impact of missed vital signs on patient outcomes and its link to low nurse staffing levels. The
authors conduct a retrospective longitudinal observational study to explore the relationship
between RN and healthcare assistant staffing and patient outcomes. Therefore, this article is a
crucial resource for my EBP-project on nurse staffing levels in the U.S.
Suggestions for Future Research
Although the topic of nurse staffing levels and their impact on patient outcomes has
been studied widely in recent years, more evidence is still needed to standardize approaches
to set staffing levels in acute care settings. Other tenets of missed nursing care could also
contribute significantly to poor patient outcomes. Moreover, it would be helpful to establish
the incentives of investing more in staffing and nurse education to improve patient outcomes.
Conclusion
Based on the literature review, nurse staffing levels in acute care settings need to be
lowered to achieve the best patient outcomes. In this case, substantial evidence suggests that
hospitals can effectively reduce mortality, length of stay, hospital-acquired infections, FTR,
and other adverse patient outcomes directly related to poor quality of nursing care due to
burnout and increased workload. Therefore, these studies provide a much-needed perspective
on the reality of NPRs in most acute care settings and highlight a correlation between the
translation of research findings into institutional and government policies about safe nurse
staffing levels.

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References

Aiken, L. H., Cerón, C., Simonetti, M., Lake, E. T., Galiano, A., Garbarini, A., Soto, P.,
Bravo, D., & Smith, H. L. (2018). HOSPITAL NURSE STAFFING AND PATIENT
OUTCOMES. Revista Médica Clínica Las Condes, 29(3), 322–327.
https://doi.org/10.1016/j.rmclc.2018.04.011
Carthon, B., J. M., Davis, L., Dierkes, A., Hatfield, L., Hedgeland, T., Holland, S., Plover, C.,
Sanders, A. M., Visco, F., Ballinghoff, J., Del Guidice, M., & Aiken, L. H. (2019).
Association of Nurse Engagement and Nurse Staffing on Patient Safety. Journal of
Nursing Care Quality, 34(1), 40–46.
https://doi.org/10.1097/NCQ.0000000000000334
Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., Lehwaldt, D., McKee,
G., Munyombwe, T., & 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.
https://doi.org/10.1177/1474515117721561
Griffiths, P., Ball, J., Bloor, K., Böhning, D., Briggs, J., Dall’Ora, C., … & Smith, G. (2018).
Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective
longitudinal observational study.
Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Martin, B., Reneau, K., Alexander,
M., & McHugh, M. D. (2021). Chronic hospital nurse understaffing meets COVID-
19: An observational study. BMJ Quality & Safety, 30(8), 639–647.
https://doi.org/10.1136/bmjqs-2020-011512
Nibbelink, C. W., & Brewer, B. B. (2018). Decision-Making in Nursing Practice: An
Integrative Literature Review. Journal of Clinical Nursing, 27(5–6), 917–928.
https://doi.org/10.1111/jocn.14151

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Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic
review and meta-analysis. Nursing Outlook, 66(3), 273–282.
https://doi.org/10.1016/j.outlook.2017.12.002