Safe Staffing Ratios – the New Zealand context

Written by Bailey Henderson

  Executive Summary

In New Zealand safe staffing ratios are yet to be enforced and this is having a detrimental effect on nurse to patient ratio in our hospitals. Nurses are currently taking large patient loads, which are causing two main areas of concern. Many studies have identified that larger workloads for nurses correlates directly with patient outcomes; mortality rates, morbidities, adverse events and nursing errors.  As well as nurse outcomes such as job satisfaction, absence/sickness, burnouts and intentions to leave work. The following report raises the concerns around the current nurse to patient ratio within New Zealand hospitals, impending demands and recommendations to improve nursing and patient outcomes.

Current issues:

  • No limitations for nurse to patient ratio
  • High workload for nurses
  • Potential for nursing errors
  • Potential for adverse patient outcomes
  • Higher burnout rates for nurses and job dissatisfaction

Impending demands:

  • Aging population: increase in hospital admissions
  • Developing nurse role and increasing scope of practice
  • Potential impact of seasonal surges and chronic illness


  • Create a national survey for nurses regarding safe staffing
  • Gather adverse patient outcome statistics
  • Trial safe staffing ratios

The purpose of this submission is to increase awareness of the absence of regulations around nurse to patient ratios in New Zealand and the current issues that this has on nurse and patient outcomes. This submission also provides specific recommendations towards gathering comprehensive data which can be put forward as the leading foundation for implementing safe-staffing ratios in New Zealand. The author proposes that enforcing safe-staffing ratios throughout New Zealand hospitals will improve patient outcomes, minimise hospital stay times and improve job satisfaction and nursing retention. There has been a significant amount of research on nurse to patient ratios and the outcomes this has, for both nurses and the patients they care for. Collectively these studies have indicated a convincing connection between nurse staffing levels and patient outcomes. They have identified exact associations between nurse to patient ratios and patient mortality, and nurse retention (Knudson, 2013). According to research carried by the Journal of the American Medical Association every additional patient allocated to a nurse was directly associated with a 7% increase in the chance of dying within a month of hospital admission and a 7% increase in failure to rescue rates (Knudson, 2013). Nurse to patient ratios is also having detrimental effects on nurses with each additional patient linked to a 23% increase in burnout and 15% increase in work dissatisfaction (Knudson, 2013).

I have been on many placements in medical and surgical wards in different hospitals throughout the South Island I have noticed that every nurse I have worked alongside and the majority of their colleagues are taking patient loads far over the recommended 4-5. Nurses are stressed, rushed and leaving important nursing duties to the next shift because they cannot find the time to provide adequate care. Quality of care is a policy that is a main focus worldwide, with patient outcomes being a direct indicator of this care (Zhu et al., 2012). Quality of care embodies the values of safe, effective, patient-centered, equitable, and competent health services. This is measurable by but not limited to nurse reported adverse events, and patient satisfaction. However with understaffing in New Zealand and nurses taking on increasing workloads I believe that quality of patient care is jeopardized.

  Californian Assembly Bill 394

In 1999, California was the first state internationally to mandate nurse to patient ratios in hospitals, known as Assembly Bill 394. This Bill would compel the department to adopt regulations that establish clear minimum nurse to patient ratios, and would require these health services to adopt written policies and processes for teaching and orientation of nursing staff (Assembly Bill No. 394, 1999). The California Nurses Association (CNA) and National Nurses United (NNU) were the driving forces behind AB 394. The CNA brought over 2500 nurses and supporters to the steps of the California State Capitol in Sacramento and presented over 14,000 letters in support and a contracted an opinion poll showing that over 80% of the public were in support of the bill (Collective Patient Advocacy Trailblazers, 2012).

The California legislation was driven by an increasing nurse shortage in hospitals and the belief that reducing nurse retention in hospital settings was due to heavy workloads and great levels of job-related burnout and job dissatisfaction (Aiken, Clarke, Sloane, Sochalski & Silber, 2002). This legislation was implemented in hospitals across California in 2004. The bill specifies the minimum number of nurses that should be in every hospital unit, given the current figure of patients therein (DeVericourt & Jennings, 2008). For example, according to the Bill there should be at least one registered nurse for every two patients in an intensive/critical care unit, at anytime in California (DeVericourt & Jennings, 2008). Assembly Bill 394 ensures that the same ratios are applied at all times. This condition applies to all shifts, breaks, meals and clarified absences. The rationale for instigating these ratios stems from the direct relationship between nurse staffing level and patient safety. The purpose of the legislation in California was to guarantee a certain level of quality of care in all hospitals across the state (DeVericourt & Jennings, 2008). Victoria, Australia, followed California and mandated nurse to patient ratios in 2000 (Heslop, 2012). 96% of nurses in Victoria now regard ratios as vital (Moore & Walters, 2012).

  Patient Outcomes

There is now an abundance of international evidence of adverse patient outcomes due to understaffing in hospitals. A recent study conducted in 181 Chinese hospitals, surveyed 7,802 nurses, 5,430 patients and 600 surgical and medical wards. The findings showed that extra nursing staff per patient had statistically substantial positive effects on all obligatory nursing care, patient outcomes, patient satisfaction and nurse’s confidence on patients’ self-care ability on discharge off the ward (Zhu et al., 2012).  Since the 1960’s research from the United States and Britain has also shown that nurse to patient ratios directly correlate with an array of patient outcomes including patient satisfaction, mortality rates and complication rates (Sheward, Hunt, Hagen, Macleod & Ball, 2005). Other outcomes such as morbidities are just as important. A study conducted by Kovner and Gergen  (as cited in Sheward et al., 2005) through 589 hospitals throughout the US found a significant relationship between nurse staffing and adverse patient events such as urinary tract infections, pneumonia, pressure sores and wound infections. In 2002 The New England Journal of Medicine published results of an analysis of nurse staffing and outcomes. They too showed strong associations between nurse staffing and patient outcomes (as cited in Sheward et al., 2005). The most significant relationships were found in length of stay, upper gastrointestinal bleeding, UTI’S and pneumonia. Adverse patient outcomes have been prevalent in Thailand with mistakes in patient identity, falls, medication errors, pressure ulcers and UTI’s reported in Thai hospitals, due to nursing shortages (Nantsupawat, Srisuphan, Kunaviktikul, Wichaikhum, Aungsuroch & Aiken, 2011).  

A study conducted in Australia showed that staff recognized that staffing levels were due to government funding, but still felt that annoyed and incapable because they believed that these staffing levels did not provide satisfactory resources for the increasing elderly population. In particular concern was surrounding reduced staffing levels, which created circumstances where there was a higher potential for errors to occur (Moyle, Skinner, Rowe & Gork, 2003). It can be argued that strategies by organisations to save money may in fact end up costing more in the long run due to adverse patient events such as UTI’s, hospital acquired pneumonia, pressure sores, sepsis and gastro-intenstinal bleeding which result in longer hospital stay (Patterson, 2013). Professor Jack Needleman from the University of California states that a reduction of approximately one patient per nurse decreases the possibility of adverse patient outcomes such as infection and shock and minimises hospital stay by between 3% and 12% (New England Public Policy Center. [NEPPC] (2005).

  Nurse Outcomes

Patients are not the only ones affected negatively by high patient loads. There is rapidly accumulating evidence of strong associations between staffing and nurse outcomes internationally. A leading study in Pennsylvania lead by Linda Aiken explored patients and nurses in 168 hospitals and showed that with every additional patient assigned to a nurse there was not only an increase in burnout by 23% but also increased nurse job dissatisfaction by 15% (Cheung, Aiken, Clarke & Sloane, 2008). This finding was not limited to the United States but was present on a global scale, and as a result the International Hospital Outcomes Research Consortium was formed and now consists of teams from 14 countries including the US, United Kingdom, Canada, Russia, Australia and New Zealand. More than 43,000 nurses in 7000 hospitals in the US, Canada, Germany, Scotland and England were surveyed in their first research venture. Extensive problems were found in Europe and North America, with nurses reporting stress, burnout and job dissatisfaction, confirming that these issues were not unique to hospitals in the US (Cheung et al., 2008). More than half of the nurses surveyed reported that there were not sufficient numbers of nurses to deliver a high quality of care. In every country surveyed with the exclusion of Germany, 1 in 3 nurses had high levels of burnout, 25% of nurses under age 30 planned to quit their job and in England over 50% intended to resign. Furthermore 1 in 3 nurses were regularly performing non-nursing tasks such as receiving and delivering food trays and transporting patients. Consequently nursing duties such as oral care, skin care and patient and family education was neglected (Cheung et al., 2008). In England more evidence adds to the strong links between staffing, patient outcomes and nurse outcomes. A study conducted of close to 4000 nurses in 30 hospitals discovered that nurses and patients in hospitals with the most favourable staffing levels had superior outcomes in comparison to those with lower nurse to patient ratios. As the number of patients assigned to a nurse load increased so did the mortality rate. Due to these less then favourable nurse staffing levels these nurses were twice as likely to show high levels of job dissatisfaction, burnout and report low/deteriorating care in their units (Cheung et al., 2008).

Implications for Nursing Practice:

  • Improved outcomes for patients: decreased hospital stay
  • Better outcomes for nurses: lower nurse burnout and job satisfaction
  • Retention of nurses in the New Zealand health system
  • Create a national survey for nurses regarding safe staffing. This will gather specific data around nurse’s perception of nurse to patient ratios and their level job satisfaction.
  • Gather adverse patient outcome statistics. What occurred, why these occurred and the staffing ratio at the time of the outcome. By gaining data before implementing safe staffing strategies this can be used as a baseline document to show potential improvements.
  • Trial safe staffing ratios and request nurse and patient feedback on efficacy, satisfaction and adverse patient outcomes.

New Zealand nurses are dedicated to reducing disparities in health, improving health outcomes and continuously enhancing the quality of nursing care they provide. However countless studies having identified that large nurse to patient workloads directly correlate with poor patient and nurse outcomes with significant data and statistics to support this claim. California and Victoria in Australia are two places that have mandated nurse to patient ratios and are continuing to show substantial improvements in nursing care and patient outcomes. With the impending demands on New Zealand hospitals I believe following California and Victoria and implementing safe-staffing ratios will improve not only adverse patient outcomes and minimise hospital stay times but improve job satisfaction, nurse retention and quality of care for all New Zealanders.


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