One2Four: Finding the ideal ratios…


We all know why One2Four are a good idea, but how did experts find the ideal ratios?

The NSW Nurses’ Association is committed to improving the safety of patient care and the quality of nurses’ working lives. One proven method for safeguarding patients and staff is mandated nurse to patient ratios, a system of workload management which stipulates the minimum number of nurses required for a particular number of patients.


The Association commissioned a large scale, systematic study of staffing levels in NSW public hospitals in:

• Medical and surgical wards
• Rehabilitation wards
• Palliative care wards
• Emergency departments

The Workplace Research Centre (WRC), School of Business at the University of Sydney and the Centre for Health Services Management, University of Technology, Sydney (UTS) to conducted the research. The team brought together a unique blend of research skills and specialist knowledge in the areas of industrial relations,
workload management, nurse staffing and its impact on patient outcomes.

As well as drawing on the wider literature, the project builds on the team’s previous research in analysing the impact of nurse staffing on patient outcomes, and evaluating the Victorian and Californian experiences in devising and implementing nurse‐patient ratios.

The objective of the research was to survey every ward in scope to determine current nursing workloads and skill mix and to express these in the form of nurse‐patient ratios.

Accurately capturing the data items required to complete an arithmetically simple formula (patients ÷ staff) is a challenging task given the complexity of nurses’ working hours, job roles and classifications in addition to patient movements in and out of the ward and the categorisation of ward activities.

Ratios are controversial, but Victoria and California have successfully implemented and sustained nurse ‐patient ratios since the early 2000s.

Critics of ratios say they undermine both managerial prerogative in determining patient access to services, and the professional judgement of nursing managers about the appropriate staffing of wards given patients’ clinical needs.

However, public hospital wards are under mounting pressure to meet rising demand and are experiencing increased patient acuity, co‐morbidity and high bed occupancy rates. These trends have led many in the nursing profession to conclude that minimum staffing standards set by mandated nurse‐patient ratios are needed to ensure patient safety.

What do you think about the claim that ratios are undermining managerial prerogative?

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  1. I have seen first hand in Nursing Homes how the ratio of resident to carer is far too dangerous. There are residents who are left sitting on toilets for long periods of times while the carer has to run from resident to resident – having to deal with 14 residents at a time!!! Would love to see this one2Four applied to aged care 🙂

    Great article, sure makes you realise how dangerous the hospital is for staff, and for patients.


  2. My mother is in a nursing home. She has Alzheimers. I think there are 16 patients in the dementia wing with only 2 duty nurses on at a time. The patients are often left unsupervised in the dining room as the nurses are required elsewhere in the ward. My mother was assaulted by another patient a week ago. There was no-one available to prevent the incident. Are nursing homes supposed to have one nurse for every four patients? If so, this one is breaking regulations. I look forward to hearing from you. Merril
    Merril, unfortunately there are no ratios in aged care.

  3. Some interesting points: nursing homes are only required to have one RN present on a shift. If they have an RN on call, then an EN will suffice. In one nursing home (in Tasmania, where my mother is resident in one), the nighttime ratio of RNs to residents is 1 to 120. In another, one RN covers over 22o residents across two facilities overnight, using a car to drive between them. The care is delivered by Cert IV carers.


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