Evidence mounts for the value of ratios

Editorialmar2012December 2012

There is now a very strong body of research coming out of the United States and Europe, that gives a glowing assessment on health outcomes resulting from improving nurse-to-patient ratios.

When we won ratios in our last public health system pay and conditions campaign we were following in the pioneering footsteps of our nursing colleagues in California and Victoria.

Minimum staffing ratios have been operational in California since January 2004. Since their implementation there has been a growing body of academic research that has measured their effectiveness.

According to a report by an agency of the US Department of Health and Human Services, the news is spectacularly good for both nurses and patients.

“The (ratios) legislation has increased staffing levels and created more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in other states without mandated staffing ratios,” the report says. “Despite initial concerns from opponents, the skill mix of nurses used by California hospitals has not declined since implementation of the mandated ratios.”

The US Department of Health report cites impressive health outcomes that are a consequence of the implementation of ratios:

Nursing-hours-per-patient-day in California hospitals grew from 6.03 in 2003 (before the implementation of mandated ratios) to 7.11 in 2008. This is a half hour more than in comparable hospitals in Florida, New York, Pennsylvania and Texas.

A comparison of outcomes in California, Pennsylvania and New Jersey hospitals found that 30-day mortality rates were 10 to 13% lower in California than in the other two states.

After the implementation of mandated ratios, nurses in California had on average 4.1 patients per shift compared to 5.4 patients in states that didn’t have ratios.

A survey of 22,000 nurses in California, New Jersey and Pennsylvania showed Californian nurses reported they had significantly better workloads, adequate staff to ensure high quality care and the capacity ‘to get work done’.

In the same survey, California nurses reported much less burnout and higher levels of job satisfaction. More than two-thirds of nurses in California agreed they were more likely to remain in their jobs as a result of ratios.

Higher staffing levels, fewer patient deaths, better care, less burnout, higher retention of nurses – all the things we said ratios could deliver – have been delivered for the undoubted benefit of Californian patients.

This research has been backed up by numerous other studies that now extend to Europe and Asia. A 2007 US “meta analysis”, which analysed 94 separate pieces of research on patient outcomes and levels of nurse staffing, found that a decrease from five to four patients per RN on a shift was associated with:

  • 18% less deaths from in-hospital complications
  • 28% less cases of sepsis
  • 24% less cases of hospital-acquired pneumonia
  • 20% less cases of surgical wound infection.

The case for improving and extending ratios

As we prepare for our 2013 public health system pay and conditions campaign it is timely and appropriate to look at how ratios have improved patient care in places like California, where there has been sufficient time to analyse their impact.

While some in Australia may think that the jury is out on the benefits of ratios, the evidence from California is that they work very, very well for better and safer patient care.

It strengthens our case that not only should the current ratios be consolidated, they should be extended and improved in clinical and geographical areas where they are still to be fully implemented.

I would like to wish all members of the NSWNMA a safe and restful festive season as we all prepare for a busy year in 2013.