Safety in numbers – ratios around the world


This article by Gerard Brogan RN on the international history of campaigns for nurse-to-patient ratios was first printed in the November 2012 issue of National Nurse magazine, which is published by National Nurses United, the largest union and professional association of registered nurses in the USA.

Nurses everywhere understand that minimum staffing ratios are a critical safety standard.

The 10-year legislative and regulatory struggle to enact ratios in California was actually not the first instance of nurse-to-patient staffing developed and won by nurses.


After intense lobbying and political pressure from the Australian Nursing Federation (ANF) Victorian Branch, the Victorian Ministry for Health, which is reponsible for acute-care hospitals in that state, adopted union-backed nurse-to-patient ratios effective December 1, 2000.

For medical/surgical units, those ratios varied from 1:4 to 1:6, with more patients permitted on the night shift. For emergency departments, the ratio was 1:3 at all times and triage and charge nurses were not counted in the ratios.

The Victorian government also committed to and funded re-entry and refresher programs for nurses who wished to return to the workforce. The results were impressive. In 1999, Victoria’s hospitals had approximately 20,000 fulltime-equivalent nursing positions, with 1300 of those positions vacant. By October 2001, there were an additional 2650 fulltime-equivalent nurses employed in Victoria’s hospitals — with half that number filling the vacancies and the other half as additional staff to meet the ratio requirements.

The results of the mandated, fixed nurse-to-patient ratios in Victoria have been similar to the results in California: improved recruitment and retention of nurses, reduced reliance on expensive agency staff, improved patient care, increased job satisfaction for nurses, more workplace stability and reduced stress (ANF Victoria Work/Time/Life Survey, 2003).


Bolstered by the success of the ANF in Victoria, the New South Wales Nurses’ Association (NSWNA) began its own campaign to establish ratios. In 2002, the group issued a report titled ‘Stop Telling Us to Cope’. NSWNA waged a long and comprehensive campaign involving the commissioning of reports and studies, lobbying politicians and using print, TV and radio ads to inform the public. Despite this and the public pressure that followed, the government remained intransigent. NSWNA then stepped up its campaign and took a vote in 2010 among members on whether to strike over the ratios issue. The members said yes and the vote further galvanized the campaign. In an innovative move that attracted a lot of public and media attention, the nurses rented a train and quickly renamed it the ‘strike train’.

This pressure by NSWNA improved its bargaining position with the government and in 2010, RNs won ratios in surgical medical wards, palliative care and in patient acute mental health units in 2010.

As with the California ratios, there is aggressive opposition from conservative political groups, the hospital industry and even the [state] government against ratios in Australia.

In March 2012, after a well-crafted nine-month campaign, Victorian nurses and midwives stopped the Victorian government from replacing nurses with health assistants as part of the ratios, saved the state’s unique nurse/midwife patient ratios and achieved some improvements to the ratios. Australian Nursing Federation (ANF) Victorian Branch Secretary Lisa Fitzpatrick proudly announced that patients admitted to rehabilitation wards would now benefit from an improved nurse-to-patient ratio of 1:7 on the evening shift to 1:5 in recognition of the enormity of nurses’ workloads in this specialty. ANF also secured annual funding to work towards a 1:3 ratio in day oncology units.



In the United Kingdom, nurse-to-patient ratios have been discussed for a number of years, mainly on an academic level. Prior to 2012, there had been no real push from organizations representing the nursing profession to pursue mandated nurse-to-patient ratios. 2012 was the year that all changed.

The Royal College of Nurses (RCN), with 400,000 members, is the largest organization of registered nurses in the world. At its 2011 general membership meeting, delegates voted to pursue mandated nurse-to-patient ratios.

Meanwhile, a damning report on unnecessary patient deaths at one large hospital facility had brought the UK public’s attention to the issue of declining nursing care standards. The study highlighted the deleterious effects of poor staffing ratios on patient care. As in many US states without nurse-to-patient ratios, UK RNs consistently report not being able to provide care up to the standard they would wish, with poor staffing being cited as the top reason.

In March 2012, the RCN issued a policy briefing on mandatory nurse staffing levels, citing the growing body of evidence that ratios are effective in providing better patient care and improving recruitment and retention of RNs. The RCN made its first public proclamations that it would be pursuing mandated nurse-to-patient ratios through legislation. The RCN began a campaign to publicize the situation to the UK public, knowing as nurses do everywhere that they enjoy the public’s trust in healthcare matters.

The House of Lords discussed the issue as part of a larger debate on a major new health and social care bill. It was proposed by the House of Lords that a maximum number of patients per nurse should be mandated across the UK.

UNISON is Britain’s largest public-sector union with more than 1.3 million members. At its 2011 conference, a representative from the New South Wales Nurses Association  in Australia described the impact of their successful campaign to introduce legally enforceable, nurse-to-patient ratios. UK nurses were energized after hearing how RNs had led the fight and how successful ratios were in Australia.

UNISON decided to hold a one-day survey to take a snapshot of what the ratios actually were in the UK. On March 6, 2012, RNs across the country documented their workloads. The results of this survey were not a surprise. UNISON members reported that they were unable to care for patients in the way they felt they should have and many felt unable to give safe, dignified compassionate care. This was the case even though the majority of members reported working more than their contractual hours on that day, a practice they said was normal. Ninety percent of the respondents to the survey were in favour of legislation to set minimum nurse-to-patient ratios.

Following the tabulation and publication of the results of the survey, UNISON made the following statements:

• UNISON will work with other organizations, including patient bodies, to identify a UK model of nurse-to-patient ratios for different specialties. We will aim to use international evidence as a benchmark.

• UNISON will campaign for national legislation to enshrine minimum nurse-to-patient ratios in all healthcare settings. We will be discussing this with [members of Parliament] to encourage them to support our position and to make sure that they are helping their local NHS staff achieve staffing levels that enable them to deliver safe, compassionate, and dignified care.

In late October 2012, UNISON invited an NNU representative and representative from the Australian Nursing Federation to address its nursing conference and help strategize for its own campaign to establish nurse-to-patient ratios through legislation in the UK.

South Korea

South Korean nurses from the Korean Health and Medical Workers Union have been in contact with the California Nurses Association and National Nurses United for several years and showed interest in many of our initiatives and methods, particularly the establishment of nurse-to-patient ratios. CNA/NNU staff have visited Korea to educate KHMU members on their ratios fight and Korean nurses have also attended NNU conventions to talk about their own fight to establish ratios.

In 2012, Korean nurses successfully pushed for a ratios bill that was introduced into the Korean Legislature by 20 lawmakers, mostly members of the United Progressive Party (which was formerly the Labor Party). It will be reviewed by various committees this year but is not likely to pass due to the government’s focus on South Korea’s November presidential election. The ratios bill will be reintroduced next spring and if a liberal presidential candidate wins, it is likely to pass and be signed into law.

The Korean ratios would not only be for registered nurses but would also ensure
that the following healthcare professions have mandated ratios:  certified nursing assistants, radiology technicians, laboratory technicians, physical and occupational therapists, pharmacists, nutritionists, and dietary workers.


  1. Low staffing is not the main reason for poor care, though appreciate it is a huge problem. References and historical analysis support this in many countries.
    Low staff level is no excuse for bad attitude to patients etc, often used as an excuse by major bodies. Still no minimum staff level in UK – and private/care home sector are ignored. RCN fights for set level of RGNs – it is overall staff level that is important.
    Free updates by somebody unconnected to any organisation:

  2. Wales (which since 1999 has devolved powers for health and education): A bill is currently going through the Welsh parliament to introduce mandatory nurse:patient ratios. Final decision is due early 2015.


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