He Tipua Conference FAQ

Skill mix levels refer to the availability of the right proportions of different types of nursing staff such as registered nurse, registered midwife, enrolled nurse and health care assistant/kaiāwhina to safely meet patient care needs at the time in a way that is also culturally safe.

Top

How do nurse/midwife-to-patient ratios and cultural/skills mix levels work?

Ratios and cultural/skills mix levels provide a safety net for patients, staff and organisations by stipulating the minimum staffing and skills required to adequately manage patient demand. Higher levels of staffing and/or changes in skill mix may be necessary depending on internal/external changes impacting on overall patient needs.

Established minimum safe staffing levels should be adhered to at all times for patient and staff safety. Ratios and cultural/skills mix levels are supported by operational guidelines that determine how they are applied in relation to actual patient numbers.

Ratios can be applied across a range of health services in the public, private and Aged Care sectors and are based on the type of facility, types of nursing staff required and time of day.

Top

Why should nurse-to-patient ratios and skill mix levels be mandated in Aotearoa New Zealand?

All people in Aotearoa New Zealand have a right to receive safe and high-quality health and aged care based on the best evidence available.

Ratios and mandated skills mix levels are an economically sound method to save lives and improve patient outcomes. National and international studies have irrefutably proven the number, skill mix and practice environment of nurses/midwives directly affects the safety and quality performance of health services.

Health services with a higher percentage of nurses and increased nursing hours per patient will have:

lower patient mortality
reduced length of stay
fewer adverse events such as failure to rescue, pressure injuries and infections.

Additionally, ratios will contribute to organisational productivity, hospital efficiency and continuity of patient care by increasing staff satisfaction, decreasing attrition rates, reducing service variation and improving health care equality across the sectors.

Top

What patient benefits do ratios provide?

Increased nursing numbers, a higher proportion of registered nurses and better practice environments improve patient satisfaction, lower mortality, decrease readmission rates and reduce adverse events such as infections, pressure injuries and postoperative complications. For the people of Aotearoa New Zealand, this means they are likely to spend less time in hospital and receive more personal nursing/midwifery care than they would now.

Every one patient added to a nurse’s workload is associated with a 7 percent increase in deaths after common surgery.[1]
Every 10 person increase in the presence of registered nurses is associated with 7 percent lower mortality. [1]
Hospitals with higher nurse staffing had 25 percent lower odds of problems with excessive readmissions compared to otherwise similar hospitals with lower staffing. [2]
Every one medically admitted paediatric patient added to a nurse’s workload increased a child’s odds of readmission within 15-30 days by 11 percent and a surgically admitted child’s likelihood of readmission by 48 percent.[3]

Top

How will ratios benefit Māori, Pacific peoples and other communities?

Māori and Pacific peoples experience significantly fewer positive outcomes when they interact with the health system in Aotearoa New Zealand. Reasons for this include a cultural alienation from a health system based on western models and methodology and relatively lower numbers of health professionals that are Māori or Pacific.

It is a matter of ratio justice that Māori and Pacific peoples receive care that is culturally safe so their interactions with the health system are more appropriate and beneficial. This will lead to Māori and Pacific people spending less time in care, participating more in their own care – in turn lowering costs for the health system overall.

Top

What staff benefits do ratios provide?

Improving staffing numbers and skill mix through ratios results in increased staff satisfaction and decreased attrition rates.

Nursing turnover is costly and negatively influences organisational productivity and efficiency due to poor continuity of care. Ratios provide a better working environment, improved rosters and less overtime for nurses and midwives.

Every one patient added to a nurse’s workload is associated with a 23 percent increase in nurse burnout and a 15 percent increase in job dissatisfaction.[4]
A Queensland study showed 50 percent of nurses in the Aged Care sector, 32 percent of nurses in the public sector and 30 percent of nurses in the private sector experience the inability to meet patient demand due to insufficient staffing. Many of these nurses indicated they were planning to leave the nursing profession.[5]

Research suggests the following benefits are also associated with nurse-to-patient ratios:

recruitment and retention planning, implementation and monitoring
reduction and prevention of burnout/moral distress
suicide prevention
reduced fatigue and preventable harm to patients which can put nurse registration at risk
transparency of unsafe staff reporting
reduced violence and abuse toward staff
strong health and safety procedures that are backed by legislation.

Top

How do ratios benefit health services?

Mandating ratios and skill mix levels in Aotearoa New Zealand will reduce health care variation and deliver economic benefits through reducing adverse patient outcomes and improving equality of health care across the sectors.

In Western Australia, increased nursing hours have resulted in 1088 life years gained based on prevention of ‘failure to rescue’ adverse events.[6]
A study of Victorian and Queensland public hospitals estimated hospital-acquired complications such as pneumonia and urinary tract infections added 17.1 percent cost to a hospital admission.[7] Improved nurse staffing and skill mix levels will reduce these types of adverse events and minimise unnecessary costs.
Increased nursing skill mix in Aged Care is associated with reductions in hospital admissions, readmission rates, presentation to emergency departments and improvement in management of end of life care.[8]

Top

Why is NZNO demanding ratios now?

Aotearoa New Zealand is in the middle of a nursing/safe staffing crisis. The principles of what constitutes safe staffing in relation to nursing staff numbers, adequate skill mix levels and quality performance indicators are not consistent across all of our health care services.

Various ineffective approaches to workload management have led to unsafe work environments, disparity in patient outcomes and high levels of staff dissatisfaction.

Top

How will ratios help guarantee care in Aotearoa New Zealand?

Ratios will provide a reliable and enforceable workload management methodology for nurse staffing in public, private and Aged Residential Care facilities. The methodology will be reinforced by the public reporting of nurse-to-patient numbers, skill mix levels and quality outcomes.

Mandating that a registered nurse is on duty at all times in Aged Residential Care facilities will demonstrate a commitment to safety and quality of care delivered to older persons within our communities.

Top

Where are nurse-to-patient ratios already being used?

Ratios have been implemented in many countries around the world including Japan, Canada, and some states in the United States. Queensland, Victoria and New South Wales have mandated ratios to ensure the provision of safe, high-quality care to patients.

What is unique about the approach to nurse-to-patient ratios in Aotearoa New Zealand?

Nurse-to-patient ratios are important to the future because they will ensure safe nurse staffing across our health system. But in Aotearoa New Zealand we have opportunity to be world leaders because we want ratios that will also ensure cultural safety and justice for those using and working in the health system. We’re sure you won’t want to miss being part of this.

Top

[1] L. Aiken, D. Sloane, L. Bruyneel, K. Van den Heede, P. Griffiths, R. Busse, M. Diomidous, J. Kinnunen, M. Kozka, E. Lesaffre, M. McHugh, M. Moreno-Casbas, A. Rafferty, R. Schwendimann, P. Scott, C. Tishelman, T. Achterberg and W. Sermeus. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet, vol. 383, no. 9931, pp. 1824-1830, 2014.

[2] M. McHugh, J. Berez and D. Small. Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Affairs, vol. 32, no. 10, pp. 1740-1747, 2013.

[3] H. Tubbs-Cooley, J. Cimiotti, J. Silber, D. Sloane and L. Aiken, “An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions,” BMJ Quality and Safety, vol. 0, pp. 1-8, 2013.

[4] Australian Nursing Federation. Ensuring quality, safety and positive patient outcomes. Melbourne, 2009.

[5] D. Hegney, A. Plank and V. Parker. Nursing workloads: the result of a study of Queensland Nurses. Journal of Nursing Management, vol. 11, pp. 307-314, 2003.

[6] D. Twigg, E. Geelhoed, A. Bremner and C. Duffield. The economic benefits of increased levels of nursing care in the hospital setting. Journal of Advanced Nursing, pp. 2253-5561, 2013.

[7] T. Jackson, H. Nghiem, D. Rowell, C. Jorm and J. Wakefield. Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research. Journal of Health Services Research and Policy, vol. 16, no. 3, pp. 141-146, 2011.

[8] ACT Department of Health, Implementing the Nurse Practitioner role in aged care. Canberra, 2007.