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Is it time to stop researching nurse to patient ratios?

Determining nurse to patient ratios in haemodialysis units has been debated in many forums. Ratios to ensure safe and quality care vary globally, nationally, statewide, service-wide, clinic-wide and from nurse to nurse. Given the research complexities, this editorial asks, "How do we go about exploring ratios?", "What is the optimal ratio?" and "Is nurse to patient ratio research a worthy pursuit?"

The recent haemodialysis staff to patient ratio summary of evidence, developed and registered on the Joanna Briggs Institute Renal Node, posed the question, "What is the best available evidence regarding staff to patient ratios for haemodialysis (HD), including in-centre HD, satellite HD and home HD?" (Stephenson, 2015). As with many evidence forays the main finding was that there was scarce evidence informing the question. As expected, only Level 4 (observational/ descriptive studies) and Level 5 (expert opinion) evidence was the best that was found. No randomised controlled trials (RCTs), no pre-test/post-test studies, no cohort or case-controlled studies, and, therefore, no systematic reviews or meta-analyses had been reported.

So how do we go about scientifically exploring ratios? What outcomes do we use that best measure the effect of different ratios? Should the outcomes be nurse outcomes or patient outcomes, or both? What about the design of the research? Is it ethical to set up a traditional RCT comparing, for example, one nurse to three patients compared with one nurse to four patients? Can we measure current units who run on different ratios? How do we account or weight for variables such as patient acuity, size of the dialysis unit, skill mix, administrative resources, external human resources, regional context, leadership quality, organisational support, educational qualifications, allied health support and patient care assistant contribution? What are the outcome measures for success?

Given the lack of evidence, and the difficulty in researching this question, is it time to stop asking questions like, "Is there an optimal nurse to patient ratio?" The reality is that we will always be asking these questions because we all care about patient safety and the quality of nursing care. In particular, dialysis managers need to know they are providing appropriate nursing resources and unions and health service administrators need guidance in an area that they are not always familiar with.

Nurse to patient ratios are commonly political and not always a patient care issue (every nurse to patient ratio study or report has an author and power bias). Resources and research should be committed to useful areas in improving renal nursing and patient care.

This editorial's main aim is to ignite a conversation around how we are able to use our collective resources to provide and make recommendations regarding how a safe, effective and efficient nursing workforce looks in our dialysis units. Yes, we need skilled and appropriately resourced nurses in our dialysis units ... but let's focus on issues of improvement and actual direct patient care rather than the ideal nurse to patient ratio.


Stephenson, M. (2015). Evidence Summaries. Hemodialysis: Staff to Patient Ratios. Joanna Briggs Institute, Adelaide. Accessed 30th September, 2015.

Paul Bennett is Professor and Chair at the Centre for Nursing Research, Deakin University & Western Health Partnership, VIC, Australia.

Tiffany Whittington is a Nursing Director--Dialysis Services for the Central and Northern Adelaide Renal and Transplantation Service, Central Adelaide Local Health Network, Adelaide, South Australia

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Article Details
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Author:Bennett, Paul N.; Whittington, Tiffany
Publication:Renal Society of Australasia Journal
Article Type:Editorial
Geographic Code:8AUST
Date:Nov 1, 2015
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