Nurse-Patient Assignments: Moving Beyond Nurse-Patient Ratios for Better Patient, Staff and Organizational Outcomes

Nurse-Patient Assignments? Moving Beyond Nurse-Patient Ratios for Better Patient, Staff & Organizational Outcomes

Adverse patient safety outcomes have been linked to higher nurse-patient staffing ratios (1).  But given the current shortage of nurses and financial constraints, reliance on lower nurse-patient staffing ratios is not a tenable solution for the delivery of high quality, safe patient care.  More educated nurses and better work practice environments have been suggested as solutions to improving patient safety (2).

A seminal study concluded that increasing the percentage of baccalaureate prepared nurses by 10% decreased the risk of mortality and failure to rescue by 5% after they controlled for patient and hospital characteristics (3).  Another study found that a one-year increase in the average tenure of the RN was associated with a 1.3 percent decrease in length of stay (4). Other researchers suggested that factors such as patient acuity and nurse competence affect patient safety outcomes (5, 6).  These authors suggested that instead of increasing nurse-patient ratios, clinicians’ efforts to improve patient safety should rely on more efficient and effective nurse-patient assignments.

This session will describe the results of a descriptive study about the nurse-patient assignment process.  Specifically, what were the purposes, factors and steps of the process.  Fourteen charge nurses from 11 different units were interviewed for this study and gave semi-structured interviews detailing how they approach the nurse-patient assignment process.

The results of the study indicated the purposes of the nurse-patient assignment process were interrelated among the patient, nurse and nursing environment.  “Best care” was the overarching purpose of the nurse-patient assignment.  Participants across units strove to make nurse-patient assignments where best care was a priority while ensuring that nurses were treated equitably and the work of the unit was completed.  The most common decision factors were related to patient and nurse demographics, acuity, proximity, competence, workload, nurse-patient ratio, collegiality and staffing.  Participants on each type of unit considered factors that were specific to their unit environments.  Participants described three pathways to making nurse-patient assignments which corresponded to the type of nursing unit on which they worked. 

Unit type and characteristics played a role in the differences seen amongst the three types of units related to purposes, decision factors and steps of the nurse-patient assignment.  Based on these findings nurse leaders can implement evidence-based, unit-specific solutions to improve outcomes for nursing staff, patients and the organization.  Process and quality improvement activities can track important outcomes for patients (ie, falls, infections, length of stay), nursing staff (ie, retention, sick time, morale) and organization (ie, costs, work environment).  Implementing policy & procedures and conducting policy & procedure reviews can standardize processes and improve assignment making transparency.

1.  Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA: Journal of the American Medical Association. 2002; 288 (16):1987-1993.

2.  Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. The Journal of Nursing Administration. 2009; 39(7-8 Suppl):S45-S51.

3.  Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA : The Journal of the American Medical Association. Sep 24 2003; 290(12):1617-1623.

4.  Bartel AP, Beaulieu ND, Phibbs CS, Stone PW. Human Capital and Productivity in a Team Environment: Evidence from the Healthcare Sector. American Economic Journal: Applied Economics. 2014; 6(2):231-259.

5.  West E, Mays N, Rafferty AM, Rowan K, Sanderson C. Nursing resources and patient outcomes in intensive care: A systematic review of the literature. International Journal of Nursing Studies. 2009; 46(7):993-1011.

6.  Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nurse-patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration. 2004; 34(7/8):326-337.