sample of 52 California hospitals voluntarily contributing staffing data to the initiative, the data are useful because they are collected at the level of the nursing unit (as opposed to the aggregate hospital level), use common data definitions and reporting, and have ongoing verification to ensure accuracy. Data reported on the 330 critical care, medical–surgical, and step-down units across nine calendar quarters in these hospitals revealed averages and ranges of RN-to-patient staffing ratios across these facilities:

  • ICUs—a range of one RN for every 0.5–5.3 patients (average = one RN for every 1.6 patients)

  • Step-down units—a range of one RN for every 1.5–11.6 patients (average = one RN for every 4.2 patients)

  • Medical–surgical units—a range of one RN for every 2.7–13.8 patients (average = one RN for every 5.9 patients)

These findings did not vary over the nine quarters or by the size of the hospital (Donaldson et al., 2001).

As discussed in Chapter 3, data from a fiscal year 2002 national convenience sample survey of hospitals on staffing, scheduling, and workforce management of nursing department employees show similar variation. The 135 hospitals responding varied in nurse staffing levels even with the shift and type of patient care unit being held constant. Although the average RN-to-patient ratio in medical–surgical units on the day shift was 1:6, the range was from 1:3 to 1:12. Twenty-three percent of hospitals reported that nurses in their medical–surgical units on the day shift were each responsible for caring for between 7 and 12 patients. On the night shift, 7 patients on average were assigned to each nurse, but 34 percent of hospitals reported between 8 and 12 patients assigned to each nurse. For critical care units, the average number of patients assigned to each nurse was 2 for both the day and the night shifts, but 7.4 percent of hospitals reported having nurses care for 3 or 4 ICU patients during the day shift, and 11 percent reported nurses caring for 3 or 4 ICU patients during the night shift (Cavouras and Suby, 2003).

A 1999 survey (Aiken et al., 2002) of a 50 percent random sample of Pennsylvania hospital RNs working in all hospital units who held staff positions involving direct patient care similarly reported variable nurse-to-patient ratios (see Table 5-1).

Unfortunately, studies that distinguish type of nursing unit or separate direct-care nurses from nurses in administrative positions are rare. Most studies measuring nurse staffing levels collect staffing data aggregated across all hospital units, such as ICUs, general medical–surgical units, emergency rooms, and labor and delivery units (Aiken et al., 1999, 2002; Bolton et al., 2001; Bond et al., 1999; Cho et al., 2003; Flood and Diers, 1988; Kovner



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