title: Ratios and nurse staffing: the vexed case of emergency departments.
abstract: BACKGROUND
  Within Australia nursing unions are pursuing mandated nurse-patient ratios to safeguard patient outcomes and protect their members in healthcare systems where demand perpetually exceeds supply. Establishing ratios for an emergency department is more contentious than for hospital wards. The study's aim was to estimate average staffing levels, skill mix and patient presentations in all New South Wales (NSW) Emergency Departments (EDs).
  
  
  METHODS
  The design was a retrospective historical census audit. Nurse rosters and patient presentation data were collected for three randomly selected census days in May 2010. Twenty-six valid responses out of 44 were returned. A ratio of the number of beds per nurse was calculated as well as skill mix and bed occupancy.
  
  
  RESULTS
  The average beds per nurse ratios found were 3.8 (morning shift), 3.6 (evening), and 5.1 (night). However, ratios as high as 8.4 (morning), 7.3 (evening) and 16.0 (night) were identified on particular shifts. Overall a rich skill mix was found with an average of 90% of nursing hours being provided by Registered Nurses. The average daily bed occupancy of 4 patients per bed was similar across ED levels.
  
  
  CONCLUSIONS
  The study adds to the limited literature on ED staffing and demonstrates the utility in the simplicity of ratios in flagging potential staffing problems. The audit revealed wide variation in staffing levels which was not always linked to patient activity. Of particular concern were the regional EDs (Level 5) which have the capacity to deal with all types of emergencies but where ratios as high as 7 beds per nurse were found during the day. Ratios cannot be used to determine the optimal staffing levels in every clinical situation; their purpose is to force an increase in nursing supply and to prevent individual units from becoming understaffed.
authors.affiliation: Faculty of Health, University of Technology, Level 7, 235-253 Jones Street, PO Box 123, Broadway, NSW 2007, Australia. Electronic address: sarah.wise@student.uts.edu.au.
authors.forename: Sarah
authors.initials: S
authors.lastname: Wise
authors.affiliation: Northern Sydney Local Health District, NSW Health, Level 7 Kolling Building, Royal North Shore Hospital, St Leonards, NSW 2065, Australia. Electronic address: mfry@nsccahs.health.nsw.gov.au.
authors.forename: Margaret
authors.initials: M
authors.lastname: Fry
authors.affiliation: Faculty of Health, University of Technology, Level 7, 235-253 Jones Street, PO Box 123, Broadway, NSW 2007, Australia. Electronic address: christine.duffield@uts.edu.au.
authors.forename: Christine
authors.initials: C
authors.lastname: Duffield
authors.affiliation: Faculty of Health, University of Technology, Level 7, 235-253 Jones Street, PO Box 123, Broadway, NSW 2007, Australia. Electronic address: michael.roche@uts.edu.au.
authors.forename: Michael
authors.initials: M
authors.lastname: Roche
authors.affiliation: Workplace Research Centre, University of Sydney Business School, Burren Street Building A, University of Sydney, NSW 2006, Australia. Electronic address: john.buchanan@sydney.edu.au.
authors.forename: John
authors.initials: J
authors.lastname: Buchanan
mesh_terms: D001509:Bed Occupancy / Q000706:statistics & numerical data; D002983:Clinical Competence / Q000706:statistics & numerical data*; D016529:Emergency Nursing; D004636:Emergency Service, Hospital; D006801:Humans; D009517:New South Wales / Q000453:epidemiology; D009731:Nursing Audit; D009741:Nursing Staff, Hospital / Q000706:statistics & numerical data*; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D000078329:Workforce
keywords: Emergency departments; Nurse–patient ratios; Nursing supply; Staffing