Nurse-Patient Ratio on Care Quality Research Paper

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[. . .] Staff Safety

While incident reports may be susceptible to underreporting, the same is probably less true for needle stick injuries since the risk of blood borne disease is on the minds of everyone today. Patrician and colleagues (2011b) examined the same military hospital data and looked at the interaction between NPR and nurse skills mix (RNs vs. LPNs vs. NAs) and the incidence of needle stick injuries. The rate of needle stick injuries was equivalent between the three types of units examined, which were medical-surgical, step-down, and critical care; however, higher NPR (except for step-down units), percentage of RNs, civilian RNs, and night shift was significantly associated with a lower risk of needle stick injury. These findings suggest that NPR is important for staff safety too.

An important caveat to the findings of Patrician and colleagues (2011) is that needle stick injuries can still be underreported to some extent, but less likely if the offending needle has been contaminated with a patient's blood. Accordingly, 79% of the needle stick incident reports in the study involved contaminated needles. While needle sticks with uncontaminated needles may be underreported, this statistic was still sufficient to reveal the protective effect of a low NPR and better trained and more experienced nurses.

Quality of Care

Some of the most vulnerable patients are located in neonatal ICUs. For this reason, researchers interested in the impact of nursing care quality on health outcomes have studied these patients and their caregivers. Mefford and Alligood (2011) examined the impact of NPR and skills mix, among other variables, on the health outcomes of NICU and intermediate care nursery (IMCN) patients. The outcome measures were bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, nosocomial infection, length of stay, and duration of mechanical ventilation, supplemental oxygen, and parenteral nutrition. NPR was found to be significantly (p ? 0.01) and inversely associated with morbidity in the NICU, but not in the IMCN, although there were several non-significant results that were trending towards significance. The only NICU outcome not reaching significance or trending towards significance was periventricular leukomalacia. A similar result was obtained when RNs were the primary caregivers in both the NICU and IMCN, such that the presence of RNs improved patient outcomes. These findings support the importance of NPR and skills mix for the quality of care provided to the youngest patients. The major limitations for these findings are the retrospective design and the limited sample size (single university teaching hospital).

The limitations of the above study can be moderated somewhat as additional independent studies are published. Sink and colleagues (2011) also examined patient outcomes for NICU patients in a university hospital setting as a function of NPR and found that the amount of time patients spent in the SpO2 target range (85-92%) declined significantly (p < 0.001) from 38% to 22% to 15% as NPR increased from 1:1 to 1:2 to 1:3/1:4, respectively. It should be noted that only 6% of the time was the NPR at 1:1 during the study period and the patient sample size was small at just 14. Additional findings were presented, but the small sample size precludes drawing any general conclusions about statistical interactions between ventilation method, NPR, and time spent in the SpO2 target range. However, these results tend to support the findings of Mefford and Alligood (2011) that NPR has a significant impact on patient outcomes assuming that all other variables are equal. An important aspect of the NICU studies is that the patient population could not have had a significant influence on the study's findings.

Extending this approach to adults, Schwab and colleagues (2012) examined the patient outcome of nosocomial infections for almost 160,000 patients being cared for in 182 ICU across Germany. The independent variables were NPR, bed to patient ratio, and nurse to ventilated patient ratio. Both bed to patient ratio and nurse to ventilated patient ratio, but not NPR, significantly (p < 0.05) predicted the prevalence of nosocomial infections. Another potentially relevant finding is that ICUs with the highest bed occupancy had significantly (p < 0.05) lower infection rates, which would be consistent with the theory that nurse contact time with patients increases quality of care (Despins, Scott-Cawiezell, and Rouder, 2009). In other words, higher bed occupancy may create more opportunities for nurses to glance in the direction of other patients to ensure that they are stable. However, such a finding contradicts the notion that more patients per unit increases nurse workload, thereby decreasing patient safety and quality of care (Needleman et al., 2011; Duffield et al., 2011). The main limitation of this study was nurse staffing levels were based on annual reports, which tend to obscure reduced staffing levels due to holidays, vacation time, and sick days.

The reasons that a low NPR would contribute to poor quality of care may be more systemic than a few indicators, like NPR, can represent. To capture a more holistic view of the work climate that contributes to a low NPR, Paquet and colleagues (2013) looked at a number of psychosocial factors and their interactions with NPR, length of stay, and nosocomial infection rates. What they found was a low NPR was significantly (p < 0.01) associated with poor patient outcomes as a component of a poorly functioning workplace climate. Accordingly, higher rates of absenteeism, turnover, and overtime were also significantly (p < 0.01) associated with low NPR. It should be noted that the data used for this analysis represents an intermediate time point in a longer, 4-year study and therefore should be considered preliminary.


Earlier studies investigating the impact of NPR on patient safety helped awaken the medical field to the importance of having enough nurses staffing wards, but in the years since, investigators have begun to ask more nuanced questions about what factors influence the impact of NPR on patient safety, staff safety, and quality of care. For example, simply crowding wards with caregivers regardless of the level of nursing training and experience cannot replace the protective effect of RNs. Another aspect is discriminating the needs of patients in terms of contact time with RNs, which tends to increase the chances that an impending adverse event can be averted. In summary, a high NPR is an important quality of care indicator that must be qualified in terms of skill mix and patient need.


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Despins, Laurel A., Scott-Cawiezell, Jill, and Rouder, Jeffrey N. (2009). Detectiion of patient risk by nurses: A theoretical framework. Journal of Advanced Nursing, 66(2), 465-474.

Duffield, Christine, Diers, Donna, O'Brien-Pallas, Linda, Aisbett, Chris, Roche, Michael, King, Madeleine et al. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24, 244-255.

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Mefford, Linda C. And Alligood, Martha R. (2011). Evaluating nurse staffing patterns and neonatal intensive care unit outcomes using Levine's conservation model of nursing. Journal of Nursing Management, 19, 998-1011.

Needleman, Jack, Buerhaus, Peter, Prankratz, Shane, Leibson, Cynthia L., Stevens, Susanna R., and Harris, Marcelline. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364, 1037-1045.

Paquet, Maxime, Courcy, Francois, Lavoie-Tremblay, Melanie, Gagnon, Serge, and Maillet, Stephanie. (2013). Psychosocial work environment and prediction of quality of care indicators in one Canadian health center. Worldviews on Evidence-Based Nursing, published online April 30, 2012, 1-13.

Patrician, Patricia A., Donaldson, Nancy, Loan, Lori, Bingham, Mona, McCarthy, Mary, Brosch, Laura R. et al. (2011a). The association of shift-level nurse staffing with adverse patient events. Journal of Nursing Administration, 41(2), 64-70.

Patrician, Patricia A., Pryor, Erica, Fridman, Moshe, and Loan, Lori. (2011b). Needlestick injuries among nursing staff: Association with shift-levels staffing. American Journal of Infection Control, 39(6), 477-482.

Schwab, F., Meyers, E., Geffers, C., and… [END OF PREVIEW]

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Nurse-Patient Ratio on Care Quality.  (2013, April 19).  Retrieved February 23, 2019, from

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"Nurse-Patient Ratio on Care Quality."  April 19, 2013.  Accessed February 23, 2019.