Appendix 1: Summary of study characteristics table

Appendix 1: Summary of study characteristics table

Author, Year published, Country, Title Study Design Study Aim/Purpose

Sample and setting Data collection/data analysis Results/Key findings Limitations Recommendations

McHugh et al. (2021)

Australia

Title: Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals Prospective panel study To evaluate the impact of nurse-to-patient ratio legislation on nurse staffing and patient outcomes such as mortality, readmissions and length of stay. 27 hospitals with the ratio policy and 28 comparison hospitals in Queensland, Australia Patient outcomes data (30-day mortality, 7-day readmissions, length of stay), nurse surveys, and hospital records before and after policy implementation. Hospitals with mandated nurse-to-patient ratios showed significantly lower patient mortality, readmissions, and shorter hospital stays compared to those without ratios. Improved staffing levels were observed. Results may not generalize to all settings; Findings were limited to Queensland hospitals only Broader implementation of nurse-to-patient ratios legislation globally, given the significant improvements in patient outcomes, including reduced mortality, lower readmissions and shorter hospital stays.

Sujin Shin et al. (2019)

Korea

Title: Impact of nurse staffing on intent to leave, job satisfaction and occupational injuries in Korean hospitals: A cross sectional study Cross-sectional study To examine nurse staffing in comprehensive nursing care units in Korea and assess the effects on nurse outcomes such as intent to leave, job satisfaction and occupational injuries. 356 nurses from eight small-medium sized hospitals in Seoul and Gyeonggi Provinces, Korea. Data were collected using self-reported questionnaires and analysed using descriptive statistics, logistics regression and ordinary least square models. Nurse staffing levels were not significantly related to intent to leave, job satisfaction or occupational injuries. However, workload was strongly associated with intent to leave and job satisfaction, while voluntary overtime was related to increased occupational injuries The study was conducted only in small-medium-sized hospitals in Seoul and Gyeonggi Province with limits generalisability. Self-reported data and cross-sectional design restrict casual conclusions. The study recommends adjusting nurse workload to account for patient acuity and care needs. A labour policy should be developed to regulate nurses work hours, as voluntary overtime was linked to occupational injuries. Future studies should explore these issues in various regional setting using longitudinal data.

Hellin Gil et al. (2022)

Spain

Title: Relationship between job satisfaction and workload of nurses in adult inpatient units Observational, analytical, descriptive and concurrent quantitative study. Relationship between job satisfaction and workload of nurses in adult inpatient units, with an emphasis on intrinsic and extrinsic satisfaction. 104 nurses from eight adult inpatient units in four hospital centres in Spain (Internal medicine and surgery units) Data were collected through the overall job satisfaction scale and a newly validated nursing workload measurement scale (MIDENF). Descriptive and inferential statistical analyses were used to evaluate job satisfaction and workload relationships. There is a strong relationship between higher workloads and lower job satisfaction, particularly in organisational aspects and professional recognition. Nurses reported higher satisfaction with their relationships with immediate supervisors and fellow workers, but dissatisfaction with senior management and organisational structures. The study was limited to four hospitals and focussed only on internal medicine and surgery units, which may affect generalisability of the findings. The study suggests improvements in organisational management to enhance job satisfaction, particularly addressing workload distribution and professional recognition. Recommends policies aimed at improving both intrinsic and extrinsic job satisfaction factors like staff workload management.

Albishri et al. (2023)

Saudi Arabia

Title: The Relationship between Nurse Burnout, Job Satisfaction, and Patient Care Quality Mixed mode study combining both quantitative and qualitative approaches To explore the relationship between nurse burnout, job satisfaction, and the quality of patient care in healthcare settings. 500 nurses working in various healthcare settings, including hospitals, clinics, and long-term care facilities. 50 nurses participated in semi-structured interviews. Quantitative data were collected via surveys, and qualitative data were gathered through interviews. Statistical methods such as correlation and regression analyses, as well as structural equation modelling (SEM), were used for quantitative analysis. Qualitative data were analysed for thematic insights. There was a significant negative correlation between nurse burnout and job satisfaction. High levels of nurse burnout were associated with decreased patient care quality, including increased medical error and lower patient satisfaction. Self-reported data may introduce bias, and the study was limited to specific healthcare settings. Further research in different healthcare environments would enhance the validity of the research. The study emphasises the need for healthcare organisations to address nurse burnout and improve job satisfaction to enhance patient care quality. Organisations should focus on creating supportive work environments, improving staffing levels, and fostering leadership to reduce burnout.

Chen et al. (2019) Taiwan

Topic: Patient-Nurse Ratio is Related to Nurses Intention to Leave Their Job through Mediating Factors of Burnout and Job Dissatisfaction Cross-sectional study To investigate how the patient-nurse ratio affects nurses intention to leave their job, considering burnout and job dissatisfaction as mediating factors. 1409 full-time registered nurses from medical and surgical wards in 24 secondary or tertiary hospitals in Taiwan. Data were collected through self-administered questionnaires focussing on patient-nurse ratio, burnout, job dissatisfaction, and intention to leave. Multiple regression models and mediation analysis were used. The nurse-patient ratio significantly influenced nurses intention to leave their job, with personal burnout, client-related burnout, and job dissatisfaction acting as mediators. The cross-sectional design limits casual inference and the study was conducted only in Taiwan, restricting widespread applicability Policy makers should consider adjusting patient-nurse ratios to improve nurse retention, focussing on reducing burnout and job dissatisfaction.

Grace Huang (2021) United States

Topic: How does patient-to-nurse ratios relate to the quality of patient care and nurse burnout in hospital? Literature Review and Theoretical Model To review the relationship between patient-to-nurse ratios and nurse burnout, as well as their effects on patient care outcomes, including mortality and failure to rescue. Literature review included studies from countries like the United States, Canada, the United Kingdom, Taiwan and Chile. Data were collected from various research articles and studies using surveys and hospital records on nurse workloads and patient outcomes. Higher patient-to-nurse ratios are associated with increased burnout, job dissatisfaction and decreased quality of patient care. Nurses with lower ratios reported fewer instances of burnout and better care quality. The study did not include primary data collection and relied on secondary data from multiple regions, which may limit the direct applicability of the findings to specific contexts. Implementing patient-to-nurse ratio mandates, like Californias staffing law, to improve both nurse well-being and patient care quality. Further studies should explore the influence of educational levels (e.g., baccalaureate degrees) on patient outcomes like mortality and failure to rescue.

Impact of Nurse-Patient Ratios on Nurses Job satisfaction and Retention

Student name [Kuenley Dorji]

Project Introduction

The adequate staffing levels of nurses are a critical determinant of healthcare quality, particularly in an acute care setting where patients require intensive and continuous care (Rizany et al., 2019). The nurse-patient ratio, which refers to the number of patients assigned to each nurse during a shift has revealed to influence not only patient outcomes but also the working conditions and overall well-being of nurses (Bae, 2024). Inadequate nurse staffing has been linked to increased workload, stress, and burnout among nurses which can negatively affect their job satisfaction and the quality of care provided (Albishri, 2023). Job satisfaction is a key factor in nurse retention, productivity and overall well-being (Lee et al., 2019). When nurses are satisfied with their jobs, they are more likely to stay in their positions, perform their duties effectively and contribute to positive work culture (Lee et al., 2019). On the contrary, high levels of job dissatisfaction among nurses can lead to burnout, increased turnover rates, and decline in patient care quality (Chen et al., 2019). The relationship between nurse-patient ratios and patient outcomes has been extensively studied, with the research consistently showing that better staffing levels of nurses contributes to improved patient care and higher patient satisfaction (Elabasy et al., 2024; Shin et al., 2018). However, there has been less focus on how these ratios affect nurses job satisfaction in acute care settings. Understanding the impact of nurse-patient ratios on job satisfaction in these environments is critical, as it not only affects nurse retention and well-being but also has broader implications for patient care and overall functioning of healthcare systems (Falk, 2022). This research aims to explore this crucial area by examining how nurse-patient ratios in acute care settings impact job satisfaction among nurses, providing insights that could inform staffing policies and practices to better support both nurses and patients.

Statement of the Problem and Justification

The nurse-patient ratio is a critical factor in healthcare delivery, particularly in acute care settings where patients often require intensive and immediate care (Falk, 2022). Extensive research has demonstrated that lower nurse-patient ratios are associated with better better patient outcomes, such as decreased mortality rates, fewer medical errors, and shorter hospital stays (Stemmar et al., 2022). McHugh et al. (2021) examined the impact of nurse-to-patient ratio legislation on nurse staffing levels and various patient outcomes including mortality, readmissions and length of hospital stay. The study utilized a prospective approach, examining a data from a group of hospitals in Queensland to compare patient outcomes before and after the introduction of legislation mandating nurse-to-patient ratios. Results from the study suggest that nurse-to-patient ratio legislation has led to improvement in staffing level which was associated with significant reductions in patient mortality, readmissions rates and shorter lengths of hospital stays (McHugh et al., 2021). However, the study does not thoroughly explore the direct relationship between nurse-patient ratios and nurses job satisfaction and it does not explain about how improved staffing levels, due to the legislation, affect nurses job satisfaction and their retention.

As healthcare systems face increasing patient loads, budget constraints, and workforce shortages, nurses are frequently assigned more patients than recommended (Qureshi et al., 2019). This situation can lead to increased stress, burnout, and job dissatisfaction among nurses, which can affect quality of patient care and safety (Twigg et al., 2021). Shin et al. (2020) investigated the relationship between nurse staffing levels and nurses intention to leave, job satisfaction and occupational injuries in eight small-medium sized hospitals in Korea. The study utilized a cross-sectional design, gathering data through a survey administered to 356 nurses working in the selected eight hospitals in Korea. The study revealed that increases in nursing workload were significantly associated with higher intent to leave, lower job satisfaction and increased occurrence of occupational injuries but lacks exploration of the long-term effects of staffing levels on nurses job satisfaction and the intent to leave (Shin et al., 2020). Moreover, the study did not explore the potential impact of organizational factors, such as management practices or workplace culture on the relationship between nurse staffing levels and job satisfaction.

Helen Gil et al. (2022) examined how workloads of nurses affect job satisfaction in adult in-patient wards. The study utilized a cross-sectional survey method to collect data from 104 nurses working in eight in-patient wards among four hospitals in Spain. Results from the study suggest that higher workloads, often due to inadequate nurse-to-patient ratios, were significantly associated with lower job satisfaction among nurses (Helen Gil et al., 2022). However, the study does not explore how specific types of workloads (e.g., administrative task v/s direct patient care) impact job satisfaction and also it lacks a longitudinal perspective to understand the long-term effects of workload on nurse job satisfaction and retention.

Although the existing studies has established link between nurse staffing and patient outcome, there has been comparatively less focus on how these staffing levels affect nurses themselves, particularly in terms of job satisfaction and retention. This research seeks to fill the gap in the literature by investigating the impact of nurse-patient ratios on nurses job satisfaction and retention in acute care settings.

Formulation of the Research Question

The PEO framework, which stands for Population, Exposure and Outcome (Elsevier, n.d.), was used to guide the literature search for the research question, what is the impact of nurse-patient ratios on nurses on job satisfaction and retention?. The search strategy was shaped by the population (nurses/enrolled nurses), exposure (nurse-patient ratio) and outcome (job satisfaction & retention).

Search Strategy

A literature search was conducted using PEO framework (Elsevier, n.d.), to guide the process across various electronic databases, including CINAHL Ultimate, PubMed, ProQuest, Google scholar and Edith Cowan University (ECU) library. Specific search strategies were developed for each database, incorporating Boolean operators OR and AND to combine search terms along with the use of research title. Keywords such as nurse OR nurse-patient ratio OR nurses staffing level AND job satisfaction OR turn over OR retention are used. Truncations (*) were applied as needed, and the search was restricted to full-text papers in English, excluding those published more than 10 years ago. This research will adopt qualitative methodology.

Conclusion

Most of the studies have highlighted the relationship between nurse staffing levels and patient outcome but there exists a notable gap in understanding how these staffing ratios affect nurses job satisfaction and retention, particularly in acute care settings. This study seeks to address this gap by examining the relationship between nurse-patient ratios, job satisfaction, and retention among nurses working in the hospitals to provide evidence-based insights to the healthcare administrators for developing staffing strategies that support both nurses and patients.

References

Albishri, A. M. (2023). The relationship between Nurse Burnout, job satisfaction, and Patient Care Quality. Journal of Medical Science And Clinical Research, 11(11), 6569. https://doi.org/10.18535/jmscr/v11i11.08

Bae, S.-H. (2024). Nurse staffing, work hours, mandatory overtime, and turnover in acute care hospitals affect nurse job satisfaction, intent to leave, and Burnout: A cross-sectional study. International Journal of Public Health, 69. https://doi.org/10.3389/ijph.2024.1607068

Chen, Y.-C., Guo, Y.-L. L., Chin, W.-S., Cheng, N.-Y., Ho, J.-J., & Shiao, J. S.-C. (2019). Patientnurse ratio is related to nurses intention to leave their job through mediating factors of burnout and job dissatisfaction. International Journal of Environmental Research and Public Health, 16(23), 4801. https://doi.org/10.3390/ijerph16234801

Elabasy, H. A., Obied, H. K., & Mahmoud, S. A. (2024). Relation between nurses- patients ratio and nursing outcomes at Intensive Care Units. Tanta Scientific Nursing Journal, 33(2), 00. https://doi.org/10.21608/tsnj.2024.367922

Elsevier, n.d. Clinical Questions: PICO and PEO Research. https://scientific- publishing.webshop.elsevier.com/research-process/clinical-questions-pico-and-peo-research/Falk, A. (2022). Nurse staffing levels in critical care: The impact of patient characteristics. Nursing in Critical Care, 28(2), 281287. https://doi.org/10.1111/nicc.12826

Helln Gil, M. F., Ruiz Hernndez, J. A., Ibez-Lpez, F. J., Seva Llor, A. M., Roldn Valcrcel, M. D., Mikla, M., & Lpez Montesinos, M. J. (2022). Relationship between job satisfaction and workload of nurses in adult inpatient units. International Journal of Environmental Research and Public Health, 19(18), 11701. https://doi.org/10.3390/ijerph191811701

Lee, S. E., MacPhee, M., & Dahinten, V. S. (2019). Factors related to perioperative nurses job satisfaction and intention to leave. Japan Journal of Nursing Science, 17(1). https://doi.org/10.1111/jjns.12263

McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of Hospitals. The Lancet, 397(10288), 19051913. https://doi.org/10.1016/s0140-6736(21)00768-6

Qureshi, S. M., Purdy, N., Mohani, A., & Neumann, W. P. (2019). Predicting the effect of nursepatient ratio on nurse workload and care quality using discrete event simulation. Journal of Nursing Management, 27(5), 971980. https://doi.org/10.1111/jonm.12757

Rizany, I., Hariyati, Rr. T., Afifah, E., & Rusdiyansyah. (2019). The impact of nurse scheduling management on nurses job satisfaction in Army Hospital: A cross-sectional research. SAGE Open, 9(2), 215824401985618. https://doi.org/10.1177/2158244019856189

Shin, S., Oh, S. J., Kim, J., Lee, I., & Bae, S. (2020). Impact of nurse staffing on intent to leave, job satisfaction, and occupational injuries in Korean Hospitals: A crosssectional study. Nursing & Health Sciences, 22(3), 658666. https://doi.org/10.1111/nhs.12709

Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and Nurse Outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273282. https://doi.org/10.1016/j.outlook.2017.12.002

Twigg, D. E., Whitehead, L., Doleman, G., & ElZaemey, S. (2021). The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review. Journal of Advanced Nursing, 77(12), 45994611. https://doi.org/10.1111/jan.14909