NURSES SAFE STAFFING RATIO 17
NursesSafe Staffing Ratio
The Reason behind The Public Policy Issue
Ideveloped the interest in nurse staffing ratios after reading awebsite article about a patient who developed a large pressure ulcerat the ARH Regional Medical Centre. A nursing assistant discoveredthe patient after she noticed an enormous pressure sore on thepatient’s back. The patient required intensive care because of thecondition that had developed 10 hours after his admission (Rice,2015).
Afollow up by the Federal Bureau of Investigation revealed that thepatient remained in one position for a long period. Consequently, thevictim’s sore was blamed on the hospital’s policy that requiredone nurse to attend to six patients in the intensive care unit. Eachnurse attended to several patients at a time since the facility wasunderstaffed. During the day of the incidence, one nurse was incharge of 14 patients (Rice, 2015).
Theabove incident best demonstrates that a shortage of nurses in healthcare centers has a dangerous outcome on the patients in a hospital.Besides, a scarcity causes nurse burnout due to overworking. Theproposed policy of establishing nurse-staffing ratio is the firststep to improve the patient outcomes, reduce patient mortality ratesand improve nurses’ working conditions (Rice, 2015).
b.The relevance of the public policy
Accordingto Nicely (2012), a well-staffed nursing unit in the aortic abdominalaneurysms department (AAA) improves the patient outcomes. It is alsoassociated with a decreased patient mortality, as well as, fewerrescue failures. On the contrary, an increase in AAA patients withina poorly staffed nursing unit increases the rate of patient mortalityand poor patient outcomes. Hospitals with lower patient to nurseratios have a lower than 20% patient mortality rates.
Simonet al. (2014) conclude that the identification of the mostappropriate nurse to patient ratios has the ability to increase thequality of health care by improving the patients’ outcome andreducing mortality rates. Besides, the application of appropriatenurse to patient rates reduces the liability suites of nursing homesdue to poor service. In addition, it reduces the operational costs ofhiring extra temporary nurses. The identification of appropriatenursing ratios decreases the workers’ burnout rate, increasesperformance and trims down nurse absenteeism.
Dufin(2014) observes that the contribution of nurses to health care isunderestimated.  They conduct complex tasks such asengaging with patients as well as collecting and assessinginformation concerning the sick persons. These responsibilities areoften mistaken as simple. Besides, nurses conduct rescue work andprevent readmission of patients.  The effect of their rolein the hospital setting is never felt until it is gone.  Thecurrent trends of understaffed nurses emanate from the massivereductions in the nursing budgets, which have led to a shortage inthe number of nursing professionals. Consequently, fewer nurses areforced to work for long hours. The situation has created a conditionthat drives nurses from the bedside.
c.The financial impact of the public policy
Theeconomic implications associated with the lack of appropriatenurse-to-patient ratio are significant. First, the low staffingratios are associated with management costs due to the increased riskof nurse injury in caregiving homes. Besides, the high mortalityrates are subject to implicate liability insurance for nursingcenters. The average cost of nursing home recovery is estimated atUSD 400,000. The amount is double the average national recovery sumrelated to malpractice suits. Nursing homes with a lowerpatient-to-nurse ratio have less litigation compared to those thatfail to meet the required standards (Johnson et al., 2004).
Second,hospitals with a high patient to nurse ratio are associated with anincreased nurse turnover frequency. The turnover affects the qualityof care and increases the cost of labor. A met analysis of CAN, RN,and LPN turnover rates revealed that CAN varies from 14% to 35%. Therates are associated with additional direct costs ranging from USD4,500 to USD 6,000 (Hornet al., 2005).
Highnurse turnoverrates are associated with costs linked to the use of psychotropicdrugs. Decreasing the number of nurses lowers the treatment ofresidents, which, in turn, induces their use of psychotropic drugs. Lessening the use of psychotropic drugs lowers the cost spent ondrugs by patients. Besides, it minimizes the rate of injurious fallsthat may result into hospitalization. Patients hospitalized due tofalls had greater odds of developing the need for antipsychoticmedication and Zolpidemis, which is regarded as a safe sedative forantipsychotic medication. The falls are associated with 95% increasein the risk of hip failure (Horn, Buerhaus, Bergstrom & Smout,2005).
2.Values impacted on the public policy issue
Theneed to increase the number of nurses-to-patient ratio affects theprinciple of beneficence. By increasing the number of nurses, thehospital management creates a favorable environment for the nurses topromote and extend the right actions in form of advanced care to thesick. Nurses avoid exhaustion, and they can maintain professionalismand efficiency while on duty. The policy affects the principle ofnon-maleficence since the nurses can avoid harming the patients atany cost. The provision of the right operational environment enablesnurses to work from a conscious mind. They are, consequently, able toavoid circumstances that may lead to the harm of patients (Shekelle,2013).
Thepolicy also affects the principle of justice. Patients can obtainquality care as promised by the hospital. On the other hand, thenurses achieve a stable and fulfilling working environment thatstimulates them to give their best while at work (Shekelle, 2013).
B. Policy Brief
1.Decision maker.
Thefollowing policy is targeted to the managing director of the Agencyfor Healthcare Research and Quality(AHRQ) Mr. Andrew B.Bindman. The policy brief serves as a guide andcontributes to the agency’s mission of providing evidence to saferand higher quality health care. Besides, it aims at providing moreaccessible healthcare and work within the United States of America,the Department of Health and Human Services and with other partnersto make sure that the evidence is understood and used efficiently(Welton, 2007).
Explanation
Thenurse shortage in the USA health care system is a threat to theachievement of the agency’s mission of providing safer and higherquality health care. The shortage creates a chain of reactions. Itcontributes to overworking the nurses, which in turn poses risk totheir health. The nurse shortage contributes to the high nurseturnover rate that is costly to hospitals. The overall result is poorhealth delivery and greater risk to patient’s health. The agencyshould address the problem by establishing nurse safety ratios forhospitals to ensure a safer nurse-working environment and improve thequality of health care delivery (Horn et al., 2005).
2.Key challenges of the policy
Althoughthe United States has experienced periods of high vacancy rates forthe Registered Nurses, the current shortage of the professionals inthe country is unique. There are fundamental changes in demographics,work attitudes, career expectations and worker dissatisfaction. It ispossible for the current situation to continue for the next decade.The national growth of nurses is estimated at 6%, while the demandfor the professionals is projected to increase by 40% by the year2020 (Douglas, 2010).
Thenumber of nurses reduced in the years 2001 and 2002 due to theweakened economy. The population of nurses increased by 100,000 only,and some of the additional professionals were old nurses aged above50 years who returned to work. The rest were foreign born. Thereduced recruitment rate of nurses locally is the key challenge toaddressing the shortage. The increase in number did not affect thestructure of the shortage in the long term, which entails aged nursesand the unwillingness of young women and men to join the profession.Consequently, the scarcity has led to higher patient to nurse ratiosthat deteriorates both the patient outcomes and the nurses’ workingenvironment (Nurse staffing ratios, 2013).
Shekelle(2013) conducted a study of 232,342 surgical patients inPennsylvania. The study revealed that 2% of the patients, died afterthe first 30 days of discharge. The study observes that thedifferences in the nurse to patient ratios of 4:1 and 8:1 are acontributing factor to the mortality rate. Besides, the studyobserved that a lower nurse to patient ratio is associated with thecontraction of cardiovascular diseases among the nurses. There is alinear trend between the occurrence of frequent overtime and theincidents of heart disease. Workers who reported three to four hoursof work shift per day had a higher prevalence of contracting thecardiovascular disease.
Inthe year 2002, the shortage of nurses was estimated at 125,000, whichis the same as 6% of Full-Time Equivalent nurses – (FTE). Althoughthe government could increase the wages of nurses to solve theproblem, the current projections indicate an increasing challenge. Itis expected that the deficiency of nurses will worsen over time dueto the small supply of nurses compared to the increased demand forcare of the senior citizens (Deathand mortality,n.d).
Thepresent estimates on the shortage of nurses in the United Statesstand at 400,000 to 808,000 by the year 2020. The shortage is due tothe limited increase in new entrants in the profession. Due to thelow rate of participants, the average age of new entrants in the year2020 is estimated to increase by 2.5 years. That is, from 42.4 to45.1 years. The total number of graduate nurses has seen a decliningtrend of 26% from the year 1995 to 2020 (Death and mortality, n.d).
Rogowski(2013) observed that hospitals have the tendency to understaff theirneonatal intensive care units by at least 32%. The hospital staffinglevels call for an additional 0.39% of nurses to meet the minimalstaffing standards for each high acuity infant. A high rate ofneonatal understaffing is associated with increases in the risk ofhospital-acquired diseases, as well as, an increase in the rate ofneonatal mortality. Difficulties in the nursing profession areemphasized by other changes in hospital care such as the new medicaltechnologies as well as the reducing average length of stay. Thefactors have contributed to an increase for care required by thepatients while admitted to the hospital. The advancement intechnology has led to allowing a majority of patients to receiveoutpatient care. Besides, most of the patients who required hospitalcare in the past are now discharged to skilled nursing homes fortheir recovery.
3. Primary Options/ Interventions
Theforegoing literature provides evidence that the Agency for HealthcareResearch and Quality (AHRQ) should develop sustainable and viableformula for safe staffing of nurses.
Intervention1
Theonly short-term intervention available to the AHRQ entails thecreation of safe nurse staffing since it takes five years to train aqualified nurse. By creating safe nurse to patient ratios, the agencycan balance the ever-increasing demand and declining supply ofnurses. The plans should address patient quality through staffcompetency and skills mix to maximize both patient and nursesatisfaction. The creation of plans requires a monitoring andimplementation structure as well as changing the management andadministration of hospitals to accommodate the associated changes. The use of ratios ensures a win-win situation through the optimalutilization of the available nurses. The current paper provides acourse of action to the creation of infrastructure required infacilitating safe nurse staffing ratios (Simpson, Barkby &Lockhart, 2010).
Intervention2
Thesecond option entails a long-term approach of gradually increasingthe supply of nurses through training. The option entails improvingthe nursing environment to attract more young people into theprofession. In the long term, the AHRQ should work towards enhancingthe salary package and the working environment of modern nurses toraise interest of young people in the future (Stevenson &Studdent, 2003).
4.Course of Action- Bottom up Approach
Firststep-designing staffing plans
Indesigning the staffing plans, it is appropriate to consider pertinentregulations and standards. It is also imperative to observe thetrends in the establishment of fixed staff ratios. California, forinstance, became the first state to establish a fixed nurse topatient ratio for comparable hospital institutions (Horn et al.,2005).
Challengesin designing staffing plans
Althoughgeneral staffing ratios such as one nurse for every four patientshave improved nurses working environment, they have proven expensiveto implement due to the variability of patients populations. Besides,as the number of patients that require serious help increases, thereare possibilities for compliance problems during emergencies such assurgeries that can place the patients at risk (Horn et al., 2005).
Solutions
Ratiosshould consider the variations of patient’s acuity and limited tospecialty areas. For example, a ratio of one to one should serve inoperating rooms and trauma emergency units. A ratio of one nurse fortwo patients should serve in critical areas such as emergencies andcritical care, intensive care, labor, delivery, and post anesthesiaunits. Whereas a ratio of one nurse to two patients should serve inthe emergency rooms, antepartum step down, and telemetry units(Simpson, Barkby, & Lockhart, 2010)
Secondstep-nurse staffing strategies
Hospitalsnurse staffing strategy should reconcile staffing needs with theexternal staffing mandates and principles. Specifically, eachhospital should have a customized safe nurse staffing strategy basedon the available human resources and patient volumes (Horn et al.,2005).
Challengein creating nurse-staffing strategies.
Dueto the variances in the volume of patients, hospitals face achallenge in reconciling hospital staffing needs and resources withthe external staffing mandates, and principles (Welton, 2007).
Solution
Hospitalsshould create nurse staffing management committee responsible forcreating safe practical and patient centered staffing policies. Thegroup should report directly to the governing board. Afterconvention, the committee should commence the process of policydesigns that capitalize on nurse’s contribution and lessen theassociated risks of burn out and acquiring work related injuries(Lang et al., 2004).
Thirdstep- create qualitative staffing plans for nurses
Qualitativeplans aim at increasing employees and patients satisfaction levels byaddressing staff competency, skills mix, training and education ofnurses. They also address the patients’ access to medical personneland support staff. Specifically, they provide flexible options to thefixed supply of nurses (Welton, 2007).
Skillmix challenges
Staffingcoordinators experience challenges in hiring competent nurses inspecialties such as pediatrics, obstetrics, emergency care, andcritical care for hospitals. Inexperienced nurses are more likely tocause errors or fail to observe potential hazards (Welton, 2007).
Solutions
Theyhiring committee should consider the nurses ability to solve complexproblems, and undertake complex functions to avoid adverse outcomes.Therefore, it is imperative to evaluate a nurse’s communication andbehavioral skills. Besides certification, the staffing coordinatorsshould evaluate clinical experience, years on the job, tenure on theunit, past clinical work in a similar setting or with a specificpopulation of patients (Rogowski et al., 2013).
Fourthstep-examining nurse sensitive outcomes
Itis necessary to analyze hospitals staffing levels upon the occurrenceof nursing sensitive outcomes. Such outcomes include urinary tractinfections, central line catheter associated blood stream infection,shock, pneumonia, restraint prevalence, upper gastrointestinalbleeding, longer hospital stays, and failure to rescue occurrences(Welton, 2007).
Fifthstep – structural governance
Hospitalsshould exercise transformational leadership and associated practicesincluding shared governance, professional autonomy, continuouslearning, and career advancement. Appropriate governance structuresensure nurse empowerment and motivate their performance at work.Effective empowerment necessitates an overhaul of the currentreimbursement system and perpetuates nursing as a fixed cost asopposed to a variable cost (Douglas, 2010).
Challenge-nurse turn over
Unfavorablenurse working conditions and low wages have led to high nurseturnover rates. The turnover affects the quality of care andincreases the hospitals cost of labor (Tucker & Spear, 2006).
Solution
Forhospitals to thrive in an era of rising competition and nurseshortages, they should focus on staff retention. Hospitals shouldminimize the paperwork burden for nurses that distract them frompatient care. There is a need to control the amount of mandatory timespent on emergencies. Besides, hospitals should diversify theirworkforce in terms of age, gender, and ethnicity to broaden theemployment base and reduce the impact of nurse shortages (Stevenson &Studdent, 2003).
5. Evaluation of thePolicies
Theprojects monitoring and evaluation process shall adopt the CBPRprinciples in gauging the effectiveness of the policy. There are keyperformance indicators for each of the recommended course of action.The effectiveness of staffing plans shall be evaluated by theirconsequent outcomes on patients. There is need to obtain feedbackfrom patients by conducting patient satisfaction surveys after theyare discharged. The surveys help in evaluating patients experienceswhile at the hospital. Besides, there is need to ask for suggestionson areas that they felt required improvements (Tucker & Spear,2006).
Abaseline-patient-satisfaction index should be created at thebeginning of the program and consequent surveys shall be used toindicate improvements or reduced satisfaction. Nurse turnover ratesfrom various hospitals are another key primary indicator. Nursesquitting their jobs shall be required to complete an exit survey toindicate their reasons for exit (Stevenson & Studdent, 2003).
C.Implementation Plana). Identification of an Organization Interested in theNurse-ratio Staffing Policy
TheAmerican Nursing Association has expressed interest in the nursingstaff policy. It is among the associations that called for thedevelopment of patient centered care and flexible nurse staffingpolicies. These are based on various patient needs, fluctuations inthe volume of patients, nursing education, and practice and otherhospital setting characteristics (Welton, 2007).
b. A Discussion on the Alignment of the Community’s Goal to thatof the Policy
Theassociation has identified the need for nursing staffing levels thatare based on the quantified patient’s requirements. Besides, it hascalled for the quantification of the amount of time associated withvarious patient needs to enable the provision of timely services(Welton, 2007).
c. Discussion on the Step Required to Achieve the Goals
ADiscussion of the Roles and Responsibilities of the Community andOrganization Members
Theimplementation team for the plan will be comprised of various keyplayers. They include the American Nursing Association (ANA) AcuteHospital Division, ANA Human Resource, ANA Finance, QualityImprovement, Hospital/Hospital Group level Director of Nursing, HR,CEO, Finance, academic partners and the staff associations. Besides,it will also involve the Department of Health (DoH) and Office of theNursing and Midwifery Services Director (ONMSD). The group willreport progress to the main Taskforce Steering group on a quarterlybasis (Douglas, 2010).
d.A Discussion on Key Elements of Developing a Collaborative EvaluationPlan using CBPR Principles
CBPRprinciple 1 – cyclical and iterative process
Toensure a cyclical and iterative process, the CBPR team shall meet ona monthly basis. During the meetings, the group shall adopt aniterative process of brainstorming and content development review andrefinement. Besides, the team members shall make informed decisionson the most appropriate approach to address the nurse-staffingproblem (Horn et al., 2005).
CBPRprinciple 2 –Facilitating collaborative, equitable involvement ofall partners in all phases of the research
Toensure a collaborative and equitable involvement of partners,Leadership will vary based on the stage of the research assignment.The American Nursing Association shall assume leadership during theresearch and design process. Meanwhile, the hospital group-leveldirectors shall take leadership of the literature review. Thedepartment of health shall also assume leadership during the datacollection process. Its main role will be to establish the mostappropriate method of data collection based on the ground situationof the hospitals (Douglas, 2010).
CBPRprinciple 3- Dissemination of findings and knowledge gained to allpartners
TheCBPR team members will select a project coordinator to overseecommunication over the entire phases of the project through emails.The coordinators roles will include analysis, reporting anddissemination of information to team members. Besides, he or she willconstantly brief the team on the pending subjects and anydifficulties experienced throughout the assignment. The team willproduce monthly reports on the progress towards the achievement ofthe overall goal for dissemination to various partners (Tucker &Spear, 2006).
f.A Discussion on Evaluation
Theevaluation of the success of the policy shall be conducted through acollaborative approach of the team members. A cyclical and iterativeprocess shall be adopted to adjust projections to the actualtimelines. Besides, the team shall ensure constant dissemination ofinformation to health partners as indicated below (Simon et al.,2014).
CBPRprinciple 1-Facilitating collaborative, equitable involvement of allpartners in all phases of the research
Theteam members shall conduct an evaluation and agree on the mostappropriate key performance indicators for the project. Besides, theyshall outline data collection approaches to ensure the measurement ofthe performance indicators. Some of the key performance indicatorsinclude nurse satisfaction, patient satisfaction and hospitalsprofitability. Besides, there is need to reckon the nurse sensitiveoutcomes such as patient’s urinary tract infections, shock,restraint, and longer hospital stays. Such indicators are useful inestablishing the effectiveness of the set policies (Simon et al.,2014).
CBPRprinciple 2- Cyclical and iterative process
TheCBPR team shall conduct an iterative process of brainstorming andcontent development to create the time-lines of the project. First,the team will propose a monitoring and evaluation process for theproject. Afterwards a cyclical process of document reviews andcontent development shall be conducted to identify the key milestonesof the project. The team shall repeat the process throughout theproject to adjust the gap between actual and projected timelines aswell as evaluate the time required to achieve the objectives (Horn etal., 2005).
CBPR3-Dissemination of findings and knowledge gained to all partners
TheCBPR team shall conduct quarterly meetings to evaluate the projectachievements and create a draft quarterly progress report. Thequarterly progress report shall be disseminated to the healthpartners for review and comments. The team shall incorporate thecomments to the draft reports and create a final report for records.Besides, they shall evaluate any pending issues and assign extraresources to fast track the achievement (Simpson, Barkby &Lockhart,2010).
D.Benefits and Shortcomings Posed by the Top-bottom and Bottom-topApproaches.
1.Strengthsand Weaknesses of the Top-down Approach
Scholarsrefer the top-down approach as The Nurses per Occupied Bed Approach(NPOB). The method is similar to the professional judgment approach.It has an advantage of simplicity when approaching the demand ofnurse workforce. The use of informed and experienced personnel in theprocess increases the effectiveness of the process. The team canprovide quality estimates of the required workforce after a longhistory in the nursing industry. Secondly, the methods used togenerate the skills mix and the formulas have an empiricalbackground. The methods are used frequently collected data on bedoccupancy and payroll information (Douglas, 2010).
Themethod can classify data to meet the requirements by variousdepartments since it is obtained from the specific departments in thehospital. Besides, the method simplifies the process of creatingdeterminants. It enables the generation of ward’s grade mix sincethe formulas are broken down in terms of grade. The primary weaknessof the method is the assumption that the base staffing data isrationally determined. A serious misstatement in the base data hasthe capacity of reducing the effectiveness of the outcomes.Literature also exhibits that there is a relationship between wardsize establishment and occupancy. Another key shortcoming is the lackof enough evidence to support the standard of care between averagesobtained from other sources and the averages of a new study group.There are also barriers from the insensitivity of formulas todependency changes. The formulas recommend the same number ofpatients for highly ill patients similar to less ill patients (Simonet al., 2014).
2. Strengths andWeaknesses of the Bottom-top Approach
Itis also referred to as acuity quality approach. The method iseffective in substituting the averages provided in database (Twigg etal., 2010). It also eliminates the need to conduct census in a highpatient throughput ward. The method converts short stay patient’speriods into patient whole time –equivalents (PWTE). It fulfillsthis by summing the daily patients hours for each dependency groupand dividing the figure by 24 instead of conducting a census (Tucker& Spear, 2006).
Themethod is criticized for using too complex staffing formulas comparedto the top-bottom method. However, the complexity creates variablesthat assist in determining the nurses’ workloads (Horn et al.,2005).
3.The Recommended Approach to Address the Policy Issue
Thebottom-up method is hailed for its accuracy. Besides, the methodtakes into account the sensitivity of patients and establishes adependency rate. The staffing method overcomes a majority of theweaknesses posed by the top bottom approach. The formulas in themethod are sensitive to the number and the mix of the patients. Inaddition, it provides a safety limit beyond which nursing carestandards should not fall. The approach is the most appropriate fordetermining the right nurse-to-patient ratio (Stevenson &Studdent, 2003).
References
Deathand Mortality NCHS Fast Stats, (n.d).Centersfor Disease Control and Prevention (CDC).Retrieved from http://www.cdc.gov/nchs/fastats/deaths.htm
Douglas,K. (2010). Ratios: If it were only that easy. NursingEconomics,28(2),119–125.
Duffin,C. (2014). Increase in nurse numbers linked to better patientsurvival rates nurse: Staffing ratios. NursingStandard, 28(33),10.
Horn,S., Buerhaus, P., Bergstrom, N., & Smout, R. (2005). RN staffingtime and outcomes of long-stay nursing home residents. AmericanJournal of Nursing, 105 (8),58-70.
Johnson,C., Dobalian, A., Burkhard, J., Hedgecock, D., & Harman, J.,(2004).Predictinglawsuits against nursing homes in the United States,1997-2001.HealthServices,39(6),1713-1732
Lang,T., Hodge, V., Olson, P., & Romano, R. (2004).Nurse-patientratios: A systematic review on the effects of nurse staffing onpatient, nurse employee, and hospital outcomes. Journalof Nursing Administration,34(7–8)326–337
Nicely,K., Sloane, D., & Aiden, L. (2012). Lower mortality for abdominalaortic aneurysm repair in high-volume hospitals is contingent uponnurse staffing. HealthServices Research,48(3),972–991. doi: 10.1111/1475-6773.12004
Rice,S. (2015, October 24). Got enough nurses? Nurse groups cite Kentuckycase to support push for staffing ratio laws. ModernHealthcare.Retrieved on 28 May 2016from http://www.modernhealthcare.com/article/20151024/MAGAZINE/310249979
Rogowski,J., Staiger, D., Patrick, T., Horbar, J., Kenny, M., & Lake, E.(2013).Nurse staffing and NICU infection rates. Journalof American Medical Association Pediatrics,167(5), 444–450. doi:10.1001/jamapediatrics.2013.18.
Shekelle,P. (2013). Nurse patient ratios as a patient safety strategy.Annals of Internal Medicine,158(5),404–410.
Simon,M., Ball, J., Drennan, J., Jones, J., Recio-Saucedo, A., &Griffiths, P. (2014) Effectiveness of management approaches andorganizational factors on nurse staffing sensitive outcomes.Centre for innovations and leadership in health sciences. Universityof Southampton.
Simpson,J., Barkby, I., & Lockhart, K. (2010). Workload and workforceplanning: Supplementary staffing. NursingManagement,179(2),24-28.
Stevenson,D., & Studdent, D., ( 2003). The rise of nursing home litigationfrom a national survey of attorneys. HealthAffairs,22(2),219-229
Tucker,A., & Spear, S. (2006). Operational failures and interruptions inhospital nursing. HealthResearch and Educational Trust,14(2),1-20.
Twiigg,D.,Dunffield, C., Bremner, A., Rapley, P., & Finn , J.(2010).The impact of the nursing hours per patient day (NHPPD)staffing method on patient outcomes: A retrospective analysis ofpatient and staffing data. Journalof Nursing Studies.Retrieved on 28 May 2016 from http://ro.ecu.edu.au/ecuworks/627
Welton,J., (2007, 30 Sept). Mandatory hospital nurse to patient staffingratios: Time to take a different approach: TheOnline Journal of Issues in Nursing,12(3)58-93