Nurse-to-Patient Ratios and Neonatal Outcomes: A Brief Systematic Review

Abstract

Background: Higher patient-to-nurse ratios and nursing workload are associated with increased mortality in the adult intensive care unit (ICU). Most neonatal ICUs (NICUs) in the United Kingdom do not meet national staffing recommendations. The impact of staffing on outcomes in the NICU is unknown. Objective: To determine how nurse-to-patient ratios or nursing workload affects outcomes in the NICU. Methods: Two authors (M.S., S.S.) searched PubMed, Medline, and EMBASE for eligible studies. Included studies reported on both the outcomes of infants admitted to a NICU and nurse-to-patient ratios or workload, and were published between 1/1990 and 4/2010 in any language. The primary outcome was mortality before discharge, relative to nurse-to-patient ratios. Secondary outcomes were intraventricular hemorrhage, daily weight gain, days on assisted ventilation, days on oxygen and nosocomial infection. Study quality was assessed with the STROBE checklist. Results: Seven studies met the inclusion criteria. Three reported on the same group of patients. Only four studies reported death before discharge from the NICU relative to nurse-to-patient ratios. Three reported an association between lower nurse-to-patient ratios and higher mortality, and one reported just the opposite. Because each study used a different definition of nurse staffing, a meta-analysis could not be performed. Conclusions: Nurse-to-patient ratios appear to affect outcomes of neonatal intensive care, but limitations of the existing literature prevent clear conclusions about optimal staffing strategies. Evidence-based standards for staffing could impact public policy and lead to improvements in patient safety and decreased rates of adverse outcomes. More research on this subject, including a standard and valid measure of nursing workload, is urgently needed.

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Educating Neonatal Nurses in Brazil: A Before-and-After Study with Interrupted Time Series Analysis

“…Interviews with nurses, neonatologists and senior managers at the end of the study revealed that a government policy to redistribute staff to underserved areas had been implemented during the study. This led to loss of the following staff in study NICUs, where staffing levels were already below norms for intensive neonatal care [27]: 9 qualified nurses (almost 9% of total), 15 nurse assistants and 16 part-time and 5 full-time neonatologists (1 head of department). The majority had not been replaced.…”

The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study

“…Of the identified studies, two were from the UK;18 19 results from these two studies, however, are based on the same data from 1998 to 1999, prior to wide, systematic changes in the structure of neonatal care in the UK from 2003 onwards. The authors of the systematic review concluded that the included studies were too heterogeneous to support any particular nurse-to-patient ratio 4. Moreover, these studies have not been able to observe specific nurse-to-patient ratios at the individual patient level nor adequately account for unobserved confounding that may occur due to higher-risk patients being more likely to receive more intensive nursing support.…”

“…A recent systematic review4 of studies that examined nurse-to-patient ratios in neonatal clinical care settings identified six studies published between 1990 and 2010 14–19. As far as we are aware, only two further studies on this topic have been published since that time 12 20.…”