“Nurse-to-Patient Ratios and the Future of Health Care” by Gordon

The major purpose of the book is to explore the role of nurses and care for inpatients. Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care is the first book to address matters about nurse-to-patient ratios. In the book, Gordon, Buchanan and Bretherton (2008) explored nurse-to-patient ratio historical events, decision-making processes, legal obstacles, nurse leadership and other factors that led to effective implementation of ratios in Victoria and California. Specifically, the authors tackle the complex historical accounts and justification that led to the legal mandate of nurse-to-patient ratios in many hospitals for inpatients, particularly in California, the US and Victoria, Australia.

Legally mandated nurse-to-patient ratios have remained the most complex healthcare issues. The book critically addresses the issue of registered nurse shortage in the US despite some improvements in certain locations. Generally, the authors show the need to understand the issue of nurse-to-patient ratios. The book highlights historical accounts of how stakeholders engaged in formulating policy details, politics and logic that resulted into addressing the nurse shortage in California and Victoria through ratios.

Suzanne Gordon is a Visiting Professor and a journalist who has several awards. In addition, she has authored, co-authored and co-edited some books from Cornell. John Buchanan is a Director at the University of Sydney, Workplace Research Centre, and he has co-authored some books. Tanya Bretherton is a senior research fellow and editor at the Workplace Research Centre, University of Sydney and Human Resource in Practice respectively. This book won the 2009 AJN Book of the Year Awards.

Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care is a creative work that reflects leadership, management and public interests supported with factual evidence from empirical studies. Therefore, it is a good read, well written and easy to grasp. In addition, the book addresses several topics such as Sociology of Work, Health Care Professions and Policy, and Human Resources. The book, therefore, can provide valuable insights to a wide-ranging audience from lay people, registered nurses, nurse leaders, politicians and other healthcare professionals. Aiken, Clarke, Sloane, Sochalski, and Silber noted that poor nurse-to-patient ratios were associated with increased patient mortality (as cited in Gordon et al., 2008, p. 183).

Later studies by Aiken, Clarke, Sloane, Lake, and Cheney (2008) have shown similar outcomes. Insufficient number of nurses in hospitals compromises quality of care and patient safety with risks associated with poor health outcomes, costs, morbidity and mortality (Rosenberg, 2011).

Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care has three major sections. The first two section cover historical events, politics and decision-making processes that led to the introduction of nurse-to-patient ratios in California and Victoria (Gordon et al., 2008). The final section highlights ideas of opponents and proponents of these policies, potential results and other options to the ratios to address nurse crisis (Gordon et al., 2008).

The authors pointed the origin of ratios in nurse staffing. The ratio debates have been necessitated by the global nurse shortage (Gordon et al., 2008, p. 5). Hence, nurse-to-patient ratios could be an effective approach of addressing a global nursing shortage.

The first section of the book provides a broad account of different reasons California had to adopt the ratio law. It also accounts for major stakeholders in the contentious debate, legal and political challenges that hindered enactment of the ratio law and the aftermaths after the enactment of the law. Apparently, the authors support the idea of nurse-to-patient ratios. Therefore, one may conclude that the authors’ opinions about the ratios in California could have clouded some of their claims.

However, they presented accurate data, events and therefore, the conclusion made can be supported by historical facts. Political influences were noted when Governor Arnold Schwarzenegger tried to stop the ratio debate and its implementation. The California Nurses Association provided strong leadership and advocacy platforms that forced the governor to back down on his stance.

The second section of the book provides a detailed account of the nurse work escalation in Victoria, Australia (Gordon et al., 2008). The anecdotal account of Rachael Duncan in the book showed nurse work intensification in Victoria public hospitals and its impacts on nurse work environment, health and patient outcomes. A study by Needleman et al. highlighted that effective RN-staffing levels led to positive outcomes for patients (as cited in Gordon et al., 2008, p. 184).

While events that took place in California and Victoria were not necessarily the same, the strategies used to achieve nurse-to-patient ratios were similar. Specific characteristics of the political situation, healthcare funding, activities of unions and the healthcare system in Victoria created a stage for a wider definition of the nurse-to-patient ratio problems. Specifically, it clarified important issues related to nurse overwork, laws that ensured extra funding for more staff, understanding that healthcare facilities were different and therefore required different ratios and acknowledgement that ratios were not permanent and required constant revisions to reflect hospital dynamics.

Critics have noted that the book highlights contentious issues, legal and political challenges that nurse leadership faces in attempts to address nurse-to-patient ratios (O’Dwyer, 2008; Donaldson & Shapiro, 2010).

Generally, nurses and employers resisted change initially in both California and Victoria, but offered no viable solutions. While nurses were not satisfied with their working environments, they did not understand the role of ratios in nurse staffing.

The third section of the book covers both known and unknown issues about nurse-to-patient ratios and their impacts on patients, nurses and healthcare facilities. The authors establish credibility in their book by reviewing several other studies that have assessed the relationship between nurse staffing and patient ratios, outcomes on both nurses and patients and diverse views about ratios and possible alternatives.

In arguments for ratios, many studies have established that nurse-to-patient ratios are methods of enhancing patient safety strategy (Needleman et al., 2011). For instance, Cho et al. showed that increased RNs led to positive outcomes in patients (as cited in Gordon et al., 2008, p. 185). Shekelle (2013) noted that there was strongest evidence, which supported “a causal relationship between higher nurse staffing levels and decreased inpatient mortality came from a longitudinal study in a single hospital that carefully accounted for nurse staffing and patient comorbid conditions” (p. 404). It is critical to note that no single studies established any harms related to increased nurse staffing in healthcare facilities.

Gordon et al. (2008) acknowledged that California nurses and administrators did not have any empirical data to support their nurse-patient ratio claims. This challenge has persisted in the present time as Shekelle (2013) observed. There is “a lack of an evaluation of an intervention to increase nurse staffing ratios” (Shekelle, 2013) that could result into a stronger conclusion. In addition, it is difficult to establish the formal costs of increasing the nurse-to-patient ratios due to “a lack of evaluation of intentional changes in nurse staffing to improve patient outcomes” (Shekelle, 2013, p. 404).

Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care supports the use of nurse staffing ratios to enhance the quality of healthcare. Later studies have also supported effective ratios in hospitals (Frith, Anderson, Tseng, & Fong, 2012).

Gordon et al. (2008) showed that ratios have their costs. Studies by Anne Marie Rafferty et al. showed that there were relationship between job satisfaction, staffing and burnout (Gordon et al., 2008, p. 191). Overall, Gordon et al. (2008) identified positive outcomes associated with the increased nurse staffing to “improved outcome for patients as well as better health, less burnout, and greater job satisfaction for nurses” (p. 193). Needleman, Buerhaus, Stewart, Zelevinsky and Mattke argued that ‘unequivocal business case’ for hospitals to increase staffing, the skill mix, or the ratio of registered nurses to licensed nursing personnel (as cited in Gordon et al., 2008, p. 194).

Twigg, Geelhoed, Bremner, and Duffield (2013) assessed the economic outcomes of increased nursing hours and health outcomes in patients in Australia and found that “the implementation of the Nurse Hours per Patient Day staffing method was cost-effective when compared with thresholds of interventions commonly accepted in Australia” (p. 2253). Rothberg, Abraham, Lindenauer, and Rose showed that hospitals could enhance health outcomes through ratios by at increased costs, but they concluded that ratios were cost-effective safety interventions (as cited in Gordon et al., 2008, p. 195).

These conclusions show how ratios are effective in enhancing patients’ health and improving quality of care.

Some studies established harms associated with nurse-to-patient ratios in both California and Victoria. For instance, Aiken et al. (2010) found that that some “California nurses perceived that they had less support from the use of licensed vocational nurses, unlicensed personnel, and non-nursing support services (such as housekeeping and unit clerks) after implementation of the mandate” (p. 904). Only a small percentage reported increased support from other nurses while a significant percentage claimed that the situation remained the same (Aiken et al., 2010; Harless & Mark, 2010).

This happened two years after the State mandated the minimum nurse staffing ratios for healthcare facilities. On the other hand, Twigg, Duffield, Bremner, Rapley, and Finn (2011) noted an increase in pressure ulcers related to increased nurse staffing in Western Australia (p. 540). Nevertheless, the authors pointed out that such observation could be noted because of enhanced detection of pressure ulcers in patients (Twigg et al., 2011). At the same time, other studies mentioned possible unexpected adverse outcomes from increased nurse-to-patient ratios (Cook, Gaynor, Stephens, & Taylor, 2012).

Ratios in hospitals limit individualised nursing care that many patients receive. In addition, it could affect the quality of healthcare because of unclear skill mix and nurse qualifications. For instance, Blegen, Goode and Reed noted that cases of pressure ulcers increased with higher nurse staffing (as cited in Gordon et al., 2008, p. 185) Nurse-to-patient ratios could affect the nursing profession because of legal mandates. Buchan has asserted that ratio is a blunt tool that could replace voluntary alternatives ((as cited in Gordon et al., 2008, p. 213). Gordon showed that nurse executives feel powerless to undertake any critical decisions ((as cited in Gordon et al., 2008, p. 205).

Such conflicts in decision-making processes could affect the use of ratios in hospitals (Chapman et al., 2009). The authors also expressed their concerns that ratios could lead to job loss and reduce services in other departments such as emergency, but the Donaldson study showed that there was a need to understand reasons for closure rather than ratios ((as cited in Gordon et al., 2008, p. 207). Inadequacy of nurses could also make the implementation of ratios impossible. Overall, the authors emphasised the need to address root causes of nurse shortage.

Alternatives to ratios have emerged from opponents of ratios. For instance, hospitals could sign voluntary pledges to ensure adequate nurse supply for patients throughout the year while patients should assess staffing plan in hospitals. However, these alternatives have serious drawbacks. Moreover, alternatives to ratios have not yielded any positive outcomes because the authors have noted that States without ratios have recorded poor quality of care in hospitals.

In conclusion, the book achieves its aim of advocating for nurse-to-patient ratios by showing that States without such ratios have poor healthcare services while alternatives to ratios are difficult to implement and monitor.

Information and sources used in the book are relevant and support nurse-to-patient ratio argument for and argument against. While there are anecdotal accounts, the authors use them to strengthen known facts about nurse work intensification and expected outcomes on patients, nurses and healthcare facilities.

The authors extend knowledge about ratios in hospitals. They show that it can help in managing the global nurse shortage. In addition, the book identifies critical issues for nurses and nurse leaders. First, collective nurse action and leadership are vital. Second, nurse-to-patient ratios require constant evaluation to reflect hospital dynamics. Finally, ratios, on their own, cannot adequately provide satisfactory work environments or enhance patient safety and quality care.

This is the first book that addresses the issue of nurse-to-patient ratios in two distinct locations and show similar outcomes irrespective of the prevailing circumstances. It provides historical events of ratios, legal challenges and implementation processes. The book is not only relevant to nurses, but also to other professionals and lay people.


Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 288(16), 1987-1993. Web.

Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration, 39(7-8 Suppl), S45-51. Web.

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Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. The New England Journal of Medicine, 364(11), 1037-45.

O’Dwyer, G. (2008). Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care. Nursing Standard, 23(5), 30-30. Web.

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Shekelle, P. G. (2013). Nurse–Patient Ratios as a Patient Safety Strategy: A Systematic Review. Annals of Internal Medicine, 158(5_Part_2), 404-409. Web.

Twigg, D., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2011). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: a retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48(5), 540- 8. Web.

Twigg, D. E., Geelhoed, E. A., Bremner, A. P., & Duffield, C. M. (2013). The economic benefits of increased levels of nursing care in the hospital setting. Journal of Advanced Nursing, 69(10), 2253-61. Web.

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