Intensive & Critical Care Nursing xxx (xxxx) xxx

Contents lists available at ScienceDirect

Intensive & Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Review Article

Outcomes sensitive to critical care nurse staffing levels: A systematic

review
Pamela J.L. Rae a,⇑, Susie Pearce a, P. Jane Greaves b, Chiara Dall’Ora c, Peter Griffiths c, Ruth Endacott a,d,e
a
School of Nursing & Midwifery, University of Plymouth, Plymouth PL4 8AA, UK
b
School of Health and Life Sciences, University of Northumbria, Newcastle Upon Tyne, UK
c
School of Health Sciences, University of Southampton, UK
d
Royal Devon and Exeter Hospital, University of Plymouth Clinical School, Royal Devon and Exeter Hospital, Barrack Road Exeter EX2 5DW, UK
e
School of Nursing & Midwifery, Monash University, Melbourne, Vic 3199, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine associations between variations in registered nurse staffing levels in adult crit-
Received 25 January 2021 ical care units and outcomes such as patient, nurse, organisational and family outcomes.
Revised 29 April 2021 Methods: We published and adhered to a protocol, stored in an open access repository and searched for
Accepted 4 June 2021
quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO,
Available online xxxx
SCOPUS and NDLTD databases up to July 2020.
Three authors independently extracted data and critically appraised papers meeting the inclusion cri-
Keywords:
teria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed
Critical care
Cross infection
review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is
Health care also presented.
Health workforce Results: Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion cri-
Mortality teria. Studies with strong internal validity report significant associations between lower levels of critical
Outcome assessment care nurse staffing and increased odds of both patient mortality (1.24–3.50 times greater) and nosocomial
Registered nurse infection (3.28–3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and
lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staff-
ing and outcomes were measured.
Conclusions: A large number of studies including several with high internal validity provide evidence that
higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However,
inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to
translate findings into recommendation for safe staffing in critical care.
Ó 2021 Elsevier Ltd. All rights reserved.

Implications for clinical practice

 Reduced critical care nurse staffing is associated with increased rates of patient mortality and increased risks of nosocomial
infection.
 Reduced staffing may also be associated with increased hospital costs, lower nurse-perceived quality of care and lower family
satisfaction.
 Inconsistent approaches to measurement and aggregation of staffing levels reported in research makes it hard to translate findings
into recommendation for safe staffing in critical care.

⇑ Corresponding author at: South West Clinical Schools, School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Rm 104, 8 Kirkby Place, Drake Circus,
Plymouth, Devon PL4 8AA, UK.
E-mail address: [email protected] (P.J.L. Rae).
@@DrPamelaJLRae (P.J.L. Rae), @@susiempearce (S. Pearce), @@JaneGreaves4 (P.J. Greaves), @@ora_dall (C. Dall’Ora), @@workforcesoton (P. Griffiths), @@rdepu (R.
Endacott)

https://doi.org/10.1016/j.iccn.2021.103110
0964-3397/Ó 2021 Elsevier Ltd. All rights reserved.

Please cite this article as: Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al., Outcomes sensitive to critical care nurse staffing levels: A systematic review,
Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2021.103110
Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al. Intensive & Critical Care Nursing xxx (xxxx) xxx

Introduction Study selection

Studies show that nurse staffing levels in acute hospital wards We included primary quantitative and mixed methods studies
have serious implications for patient outcomes and staff wellbeing exploring the association between variations in staffing levels of
(Ausserhofer et al., 2014; Griffiths et al., 2016). For example, nurse registered nurses working in adult critical care units, and out-
staffing has been linked to patient mortality, failure to rescue, and comes. We use the term Registered Nurse (RN) to include all nurs-
staff satisfaction (Aiken et al., 2012, 2014). Getting the level of ing staff who were professionally registered or licensed (for
nurse staffing right was brought into sharp focus by the UK Francis example, Licensed Professional Nurses).
report into failings at an NHS hospital (Francis, 2013) and acknowl- We included studies measuring any outcome, for example,
edgement of the need to improve the safety of patients and quality patient, family, staff, care quality or organisational outcomes. The
of care (Berwick, 2013). term ‘family member’ is defined as per Rowan et al (2014) in their
Systematic reviews of research in this field show clear links study evaluating family satisfaction with adult critical care: ‘‘a per-
between nurse staffing and patient outcomes (Assaye et al., son with a close familial, social or emotional relationship with the
2020; Griffiths et al., 2014). However, these reviews are largely patient and is not restricted solely by next of kin” (pg 12) (Wright
concerned with staffing levels in general acute wards and not in et al., 2015).
intensive care settings. Nurse staffing levels in intensive care set- We did not include studies conducted in paediatric or neonatal
tings are modelled on different indices to those in acute settings intensive care units (PICUs, NICUs) because nursing in these envi-
and are generally much higher, reflecting that patients with higher ronments differs in terms of, for example, parental involvement
acuity need more nursing resource. For example, the UK classifies and care delivery (Aiken et al., 2014; Nipshagen et al., 2002). Stud-
higher acuity patients (Level 3 patients) as requiring a minimum ies conducted in a mixture of NICUs, PICUs and adult ICUs were
1:1 registered nurse:patient ratio, whereas high dependency only included if their analysis for adult ICU was reported
patients recovering from critical illness (Level 2 patients) require separately.
a minimum of 1:2 to deliver direct care (Bray et al., 2010). Thus Studies published in English, with no lower date limit up to July
in this example, unlike acute care settings, staffing levels in UK 2020, were included. In line with guidance from the Cochrane
intensive care tend to follow fixed ratios and are potentially Handbook (Lefebvre et al., 2019), we imposed no a-priori date lim-
impacted in a different way when nurse workloads increase due its. Citations were managed using Endnote X8 (Clarivate Analytics,
to changes in treatment policy or the clinical profile of patients PA, USA) and uploaded to RAYYAN systematic review software
admitted. Therefore, the link between variations in nurse staffing (Qatar Computing Research Institute). The results of the search
level and outcome, evident in the acute care setting, may not repli- are reported at Fig. 1 (Tricco et al., 2018).
cate in critical care settings.
Existing reviews on nurse staffing levels have excluded studies Data extraction and quality assessment
carried out exclusively in settings used for the delivery of critical
care (Griffiths et al., 2014) or have focussed on other care settings Data was extracted from quantitative and mixed methods
such as acute or paediatric care (Kim et al., 2018; Wilson et al., (quantitative component only) studies using a template developed
2011). Previous reviews examining critical care nurse staffing have by NICE (Griffiths et al., 2014) and presented in e-component file 1.
focussed on patient outcomes (Liang et al., 2010; Numata et al., Although we intended to carry out a meta-analysis of data on effect
2006; Aragon Penoyer, 2010; West et al., 2009) were carried out sizes, this was not possible because there was considerable hetero-
a decade or more ago and research in this area has since grown. geneity in how staffing levels and outcomes were measured in
Therefore, this review will synthesise data from studies examining included studies. As an example of the former, Table 1 presents a
associations between outcomes and variations in critical care nurse selection of nurse staffing level operational definitions. As an
staffing levels in Intensive Care Units (ICUs). example of the latter (see e-component file 2), the range of opera-
tional definitions of patient mortality included in-hospital mortal-
Review question ity, ICU mortality, 28- and 30-day mortality. As a quality
assessment, the internal and external validity of each study was
The objective of this review is to identify associations between evaluated independently by two reviewers against a framework
variations in registered nurse staffing in adult critical care and adapted from NICE for observational/cross-sectional studies
patient, nurse, organisational and family outcomes. (Griffiths et al., 2014). The framework (e-component file 1) assigns
each study one of three grades based on methodological rigour:
strong, moderate or weak. Whether included studies explored
Methods nurse-staffing and outcomes as primary or secondary aims, assess-
ment of methodical rigour remained focussed on how these data
This is a systematic review. We published and adhered to a pro- were collected and analysed. The main focus for the review was
tocol, stored in an open access repository, Plymouth Electronic on internal validity however, we also present our assessment of
Archive and Research Library (PEARL) (https://pearl.plymouth.ac. external validity. Internal validity was assessed primarily by rating
uk/handle/10026.1/16017). the design of the study on aspects such as when and how data were
collected, the reliability of measures used and level of risk adjust-
Search strategy ment incorporated into analysis. Strong internal validity therefore
suggests that the statistical conclusions of a study are likely to be
We searched CINAHL Plus, MEDLINE, PsycINFO and SCOPUS for an unbiased reflection of the association between staffing variation
published studies and the Networked Digital Library of Theses and and outcome in the setting and population studied. The quality
Dissertations (NDLTD) and conference proceedings listed in SCO- appraisal checklist is provided as e-component file 1.
PUS for unpublished studies and grey literature. We used two cat-
egories of search terms, one to identify staffing, for example, ‘nurse Data synthesis and integration
staffing’ and the other to identify specialism, for example, ‘inten-
sive care’. An example of our MEDLINE search strategy is included Data extraction was conducted for all studies, regardless of their
in supplementary material (e-component file 1). methodological quality however, our synthesis is focussed on the
2
Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al. Intensive & Critical Care Nursing xxx (xxxx) xxx

Fig. 1. Flowchart of study inclusion.

Table 1
Examples of Operational Definitions of Nurse: Patient ratio.

N:P per eight-hour shift (Verburg et al., 2018; Vicca, 1999)

Total number of nurses working/patient census for that day (Hugonnet et al., 2007)
Collective N:P of ratios taken at two separate one hour time points on one day (Sakr et al., 2015)
Self-reported number of patients each nurse had cared for on their last shift, from which a mean critical care staffing measure for each participating hospital was
generated (Kelly et al., 2014)
Fixed ICU characteristic with no evidence that the intended staffing (e.g. 1:1N:P) was met at the time of outcome measurement (Dodek et al., 2015; Johannessen et al.,
2011; Pronovost et al., 1999)

findings of strong internal validity studies. Therefore, while moder- The number of centres per study ranged from a single ICU to
ate and weak studies are included in the review with regard to the 1265 ICUs. The number of patients per study varied between 30
description of, for example, number of studies investigating each and 159,400. Forty-one studies measured patient outcomes (see
outcome, their findings are presented in tables only. Table 2) which were predominantly mortality and nosocomial
We gave particular emphasis to studies where staffing and out- infection (see e-component file 2 for detailed evidence sum-
comes were measured simultaneously or longitudinally as opposed maries). Thirteen studies measured care process outcomes, includ-
to cross-sectional studies where average outcomes were associated ing costs (Table 3). Four studies measured family satisfaction
with average staffing over long intervals. Although the former type (Table 4), and one study measured nurse outcomes (Table 4).
of studies do not provide evidence of cause, they do allow an explo- Forty-four studies were designed with nurse staffing as a primary
ration of the temporal link between staffing variation and outcome. focus, twenty-three studies (42%) had strong internal validity (+
We refer to these studies as longitudinal. +). We classified 14 studies as longitudinal (25%), of which six
had strong internal validity (43%) and eight had moderate internal
validity (57%). Studies with high internal validity all had some
Results
form of risk-adjustment to account for potential confounders.

The electronic search yielded 10,882 citations; duplicate

removal left 7960 titles of which 55 met the inclusion criteria Measures of nurse staffing
(Fig. 1). The earliest date of publication was 1993. Study designs
comprised 41 cross-sectional (including retrospective and prospec- Although the precise definition of ‘nurse’ was not specified in all
tive aspects) and 14 longitudinal studies (8 retrospective and 6 studies, studies with nurses and nursing assistants included but
prospective). not delineated in nurse staffing calculations, were excluded. Stud-
3
 Table 2

Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al.

Association between nurse staffing level and patient outcomes.

First Author (Year) Design Nurse Number Number of Number Internal External Mortality Nosocomial Adverse LoS LoS Satisfaction Ventilator Length of Multiple
Country Staffing of nurses patients of ICUs validity validity events * ICU hospital days weaning organ
Measure failure
Amaravadi et al. CS NNPR NR 366 NR ++ ++
(2000) US
Baykara et al. (2018) CS N:P NR 1499 132 + ++
Turkey
Blegen et al. (2011) CS NHPPD NR NR 285 ++ +
US
Blot et al. (2011) PO N:P NR 1658 21 – –
Europe
Boev and Xia (2015) CS, RO NHPPD NR 3610 4 + –
US
Checkley et al. (2014) CS N:Bed NR NR 69 + +
US
Chittawatanarat et al. RO N:P NR NR 155 – +
(2014) Thailand
T
Cho et al. (2008) RO N:P NR 27,372 NR ++ ++
South Korea
N:PS

Dancer et al. (2006) RO, L N NR 174 1 + +

UK
Dang et al. (2002) US RO N:P NR 2606 38 ++ ++

Dimick et al. (2001) RO NNPR NR 536 33 ++ ++

US
Dodek et al. (2015) CS, RO N:P NR 56,546 371 ++ ++
Canada
4

202

Dorsey et al. (2000) RO, L Staffing NR 52 1 + +

US quotient
Faisy et al. (2016) PO, L N: Bed NR 498 1 + +
France
Fridkin et al. (1996) RO, L N:P NHPPD NR 1760 1 + ++
US

Graf et al. (2010) CS N:P NR 415 454 + ++

Germany
Halwani et al. (2006) PO, L N:P NR 430 1 ++ ++
UK
Hugonnet et al. PO, L N:P NR 2470 1 ++ ++

Intensive & Critical Care Nursing xxx (xxxx) xxx

(2007) Switzer-
land
Jansson et al. (2020) CS N:P NR 10,230 1 ++ ++
Finland
Jansson et al. (2019) PO, L N:P NR 85 1 + ++
Finland
Johannessen et al. CS N:P NR 150 3 – +
(2011) Norway
Kelly et al. (2014) US CS N:P NR 55,159 NR + +

Kim et al. (2020) CS N:Bed NR 46,779 203 ++ ++

South Korea
Kim et al. (2019) CS, RO N: Bed NR 1696 121 – +
South Korea
 Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al.
Table 2 (continued)

First Author (Year) Design Nurse Number Number of Number Internal External Mortality Nosocomial Adverse LoS LoS Satisfaction Ventilator Length of Multiple
Country Staffing of nurses patients of ICUs validity validity events * ICU hospital days weaning organ
Measure failure
Kim et al. (2012) PO N:P NR 251 28 + +
South Korea
Lee et al. (2017) Hong RO, L Workload: N NR 894 2 ++ +
Kong
Margadant et al. CS NNR NR 29,445 15 ++ ++
(2020) Holland
N:P

Neuraz et al. (2015) RO, L N:P NR 5718 8 ++ ++

France
Pronovost et al. RO, PO N:P NR 2606 NR + –
(1999) US
Sakr et al. (2015) CS N:P NR 13,796 1265 ++ ++
Multi
Schwab et al. (2012) RO, L N:VentP NR 159,400 182 + ++
Germany
N:P NR 159,400 182 + ++

Seynaeve et al. CS, RO N: Bed NR 79 1 + –

(2011) Holland
Stone et al. (2007) US CS, PO NHPPD NR 15,846 51 ++ ++

Strazzieri-Pulido RO NAS NR 1196 9 + ++

et al. (2019) Aus-
tralia
Tarnow-Mordi et al. RO, L Workload NR 1286 1 ++ +
(2000) UK
5

Thorens et al. (1995) PO, L N:P NR 87 1 ++ +

Switzerland
Van den Heede et al. CS, RO NHPPD NR 9054 58 ++ ++
(2009) Belgium
Verburg et al. (2018) CS, RO N:P NR 93,807 38 ++ ++
Holland
Vicca (1999) UK RO, L N:P NR 50 1 + +
West et al. (2014) UK CS, RO N:Bed NR 38,168 65 ++ ++

Yeh et al. (2004) Tai- CS N:P 265 1176 11 – +

wan

Design: CS cross-sectional, RO retrospective observational, PO prospective observational, L longitudinal. Nurse staffing measure [Ratio antecedents and consequents may have been calculated either way round, for e.g. as N:P or P:
N]: N:P Nurse to Patient ratio (Table 1 breaks this down further); N:PT in tertiary hospitals, N:PS in secondary hospitals (Cho et al., 2008); NNPR Night-time Nurse to Patient Ratio; N: VentP nurse to ventilated patient ratio; N: Bed
Nurse to bed ratio; NAS Nurses Activity Score; N number of nurses on shift; NHPPD nursing hours per patient day; NNR NAS score per nurse ratio; Workload composite measure based on average nursing requirement per occupied

Intensive & Critical Care Nursing xxx (xxxx) xxx

bed and peak occupancy in any shift during patient’s stay (Tarnow-Mordi et al., 2000); total TISS-76 divided by the average number of direct patient care nurses per 24 h day (Lee et al., 2017). Staffing quotient: number of nurses
(1:1 patients = 1) + (1:2 patients = 0.5), calculated twice a day at the start of each 12 h shift (Dorsey, 2000). NR – Not Reported. Number of ICUS: 1 37 ICUs in British Columbia; 2 20 ICUs in Ontario. Internal, External Validity: ++
Strong; + Moderate, - Weak. *Adverse events: Risk of reintubation (Amaravadi et al., 2000; Dimick et al., 2001); pressure injury (Stone et al., 2007; Strazzieri-Pulido et al., 2019); complications during surgery (Dang et al., 2002);
unexpected cardiac arrest, unplanned extubation (Faisy et al., 2016; Yeh et al., 2004), reintubation after planned extubation, readmission with 48 hrs (Faisy et al., 2016); adverse drug events (Seynaeve et al., 2011). LoS Length of
stay. Higher staffing is significantly (p < 0.05) beneficial, Higher staffing is numerically beneficial. Higher staffing is significantly (p < 0.05) detrimental, Higher staffing is numerically detrimental. No
evidence of a significant association (p  0.05) and no figures given.
 Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al.
Table 3
Association between nurse staffing level and care process outcomes, and costs.

First Author (Year) Design Nurse Number Number of Number Internal External Adequate pain Professional DFLST Hospital Nurse perceived Physical Protocol Turning
Country Staffing of RNs patients of ICUs validity validity management Collaborationa costs quality of care restraint adherenceb
Measure
Aloush and CS N:P 171 171 15 – +
Alsaraireh (2018)
Jordan
Amaravadi et al. CS NNPR NR 366 NR ++ ++
(2000) US
Azoulay et al. (2009) RO N:P NR 14,488 282 ++ ++
Multiple
Bakhru et al. (2016) CS N:P 951 NR 951 – ++
Europe, US
Benbenbishty et al. CS N:P NR 669 34 – +
(2010) Europe
Cho et al. (2009) CS N:P 1365 NR 65 ++ ++
Korea
cpt
P
Dimick et al. (2001) RO NNPR NR 536 33 ++ ++
USA
Dodek et al. (2012) RO N:P NR 30 2 + –
6

i
Canada, France
ii
Goldhill et al. (2008) PO, L N:P NR 393 39 – +
UK
Kim et al. (2012) PO N:P NR 251 28 + +
Korea
Liu et al. (2016) CS N:P 1890 NR 134 + +
China
Roos-Blom et al. CS, RO N:P NR 8136 13 + ++
(2020) Nether-
lands
Rose et al. (2011) CS N:P NR NR 586 + +
Multiple

Intensive & Critical Care Nursing xxx (xxxx) xxx

Design: CS cross-sectional, RO retrospective observational, PO prospective observational, L longitudinal. Nurse staffing measure: N:P Nurse to Patient ratio; NNPR Night-time Nurse to Patient Ratio; Pcpt perception of adequate
staffing. NR – Not Reported. Internal, External Validity: ++ Strong; + Moderate, - Weak. a Professional collaboration: decisions not made by physicians independently of nurses, during titration of ventilator settings, weaning
method, determination of extubation readiness and weaning failure (Rose et al., 2011). DFLST: decisions to forgo life-sustaining therapies. bProtocol adherence: adherence to Central Line-Associated Bloodstream Infection
(CLABSI) prevention protocol (Aloush and Alsaraireh, 2018); i frequency Richmond Agitation-Sedation Scale measurement is taken, ii appropriateness of response to levels of sedation outside the target range (Dodek, 2011);
Adherence to sepsis protocol (Kim, 2012). Higher staffing is significantly (p < 0.05) beneficial, Higher staffing is numerically beneficial. Higher staffing is significantly (p < 0.05) detrimental, Higher staffing is
numerically detrimental. No evidence of a significant association (p  0.05) and no figures given.
Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al. Intensive & Critical Care Nursing xxx (xxxx) xxx

Table 4
Association between nurse staffing level and nurse outcomes and family satisfaction.

First Author (Year) Design Nurse Number Number of Number Internal External Burnout Job Intention Family
Country Staffing of RNs patients of ICUs validity validity dissatisfaction to leave satisfaction
Measure
Azoulay et al. (2001) PO N:P 920 637 43 + ++
France
Cho et al. (2009) Korea CS N:P 1365 NR 65 ++ ++
cpt
P

Gerasimou-Angelidi RO NAS 161 NR 1 + –

et al. (2014) Greece
Johnson et al. (1998) CS N:P 115 99 1 – +
Canada
Stricker et al. (2009) CS N:P 1321 NR 26 ++ +
Switzerland

CS cross-sectional, RO retrospective observational, PO prospective observational. Nurse Staffing Measures: Ratio antecedents and consequents may have been calculated
either way round (for e.g. as N:P or P:N). N:P Nurse to Patient ratio. NAS Nurses activity score. NR Not Reported. Higher staffing is significantly (p < 0.05) beneficial,

Higher staffing is numerically beneficial. Higher staffing is significantly (p < 0.05) detrimental, Higher staffing is numerically detrimental. No evidence of a
significant association (p  0.05) and no figures given.

ies conducted in countries where critical care nurse:patient ratio Six studies of strong internal validity used multiple categorises
has been previously defined in professional guidance, and such to describe staffing levels (for example, highest level of staffing,
definition clearly refers to Registered Nurse, were assumed to have second highest, lowest), however, categories were defined with
used the term in the same way. different thresholds (Kim2 et al., 2020; Margadant et al., 2020;
Staffing levels were measured and defined in a multitude of Neuraz et al., 2015; Sakr et al., 2015; Stone et al., 2007; Tarnow-
ways. Some form of Nurse:Patient ratio (N:P) was used in 39 Mordi et al., 2000). Two of the studies (Kim2 et al., 2020; Neuraz
(71%) studies. Other methods included: Bed to Nurse ratio et al., 2015) found a non-significant increase in magnitude of staff-
(Checkley et al., 2014; Faisy et al., 2016; Kim et al., 2019, 2020; ing benefit with each increase in staffing level (please see e-
Seynaeve et al., 2011; West et al., 2014); Nursing Hours Per Patient component file 2).
Day (Blegen et al., 2011; Boev & Xia, 2015; Fridkin et al., 1996; There were fifteen studies with high internal validity measuring
Stone et al., 2007; Van den Heede et al., 2009); number of nurses mortality outcomes. Ten of the fifteen, including three with a lon-
(Dancer et al., 2006). Six studies incorporated a measure of work- gitudinal design (Lee et al., 2017; Neuraz et al., 2015; Tarnow-
load using, for example, the Nursing Activities Score (Gerasimou- Mordi et al., 2000), report evidence of a statistically significant
Angelidi et al., 2014; Strazzieri-Pulido et al., 2019) or the Therapeu- association between higher staffing levels and lower mortality
tic Intervention Scoring System (Lee et al., 2017). One study mea- rates. However, one study with high internal validity showed a sig-
sured nurses’ perceptions of staffing adequacy alongside N:P nificant association between higher staffing and higher mortality
ratios (Cho et al., 2009). There was variation in the method of col- (Dodek et al., 2015).
lection and calculation of staffing level data. For example, some N:P Five studies rated with strong internal validity explored associ-
ratios were extracted from hospital databases, others were col- ations between nurse staffing and nosocomial infection (Amaravadi
lected through surveys of ICU ward managers. The calculation of et al., 2000; Blegen et al., 2011; Halwani et al., 2006; Hugonnet
N:P sometimes reflected a day shift but in other instances, et al., 2007; Stone et al., 2007). Two of these studies incorporated
reflected an average of three shifts/24 h. Staffing might be treated a longitudinal design (Halwani et al., 2006; Hugonnet et al., 2007)
as a fixed, static characteristic of the unit and compared to other and all five report statistically significant associations between
units with a different fixed ratio. Alternatively, staffing might be higher levels of staffing and lower rates of infection.
calculated during the unique study period and recorded per shift Four of eight patient outcomes studies investigating adverse
alongside the outcome measure. All studies measured natural vari- events had strong internal validity, all four report statistically sig-
ation in nurse staffing levels rather than an intended change in nificant associations between increased staffing and reduced rates
nurse staffing levels designed to improve outcomes. of adverse events (Amaravadi et al., 2000; Dang et al., 2002; Dimick
et al., 2001; Stone et al., 2007).
Three studies with strong internal validity measured hospital
Patient outcomes length of stay (Amaravadi et al., 2000; Dimick et al., 2001; Dodek
et al., 2015). One study reported a statistically significant associa-
Table 2 provides a summary of the 41 patient outcome studies tion between higher staffing and shorter length of stay (Amaravadi
(strong, moderate and weak) meeting eligibility criteria for the et al., 2000) and one reported a non-significant beneficial associa-
review. tion (Dimick et al., 2001). However, one reported a significant detri-
The patient outcomes measured across the 41 studies were mental association, with higher staffing associated with longer
mortality (n = 21 studies), nosocomial infection (n = 13), adverse stays (Dodek et al., 2015).
events (n = 8), length of hospital stay (n = 5), length of ICU stay Two of three studies measuring ICU length of stay were rated
(n = 3), number of ventilator days (n = 2), length of weaning with strong internal validity (Dodek et al., 2015; Verburg et al.,
(n = 1), multiple organ failure (n = 1) and patient satisfaction 2018). While the latter found a significant association between
(n = 1). The studies measuring mortality and nosocomial infection higher staffing and reduced length of stay, the former found an
are presented in detail in supplemental information tables (e- inconsistent relationship with length of stay both in magnitude
component file 2). Of the 21 studies measuring mortality, 17 mea- and direction across regions in the study.
sured hospital mortality, four measured 28- or 30-day mortality Other patient outcome studies with strong internal validity
and three measured ICU mortality. found a significant association between higher staffing levels, and

7
Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al. Intensive & Critical Care Nursing xxx (xxxx) xxx

reduced length of weaning (Thorens et al., 1995); reduced number poor outcome, hospital length of stay may mean better/prolonged
of ventilator days (Stone et al., 2007) and reduction in multiple access to rehabilitation (therapists and personnel). Hence, wide
organ failure (Jansson et al., 2020). variation in the impact of increased staffing on hospital length of
stay (from significantly detrimental to significantly beneficial)
Care process outcomes and costs should be interpreted with caution.
Thirty three of the 55 studies included in our review were pub-
Table 3 provides a summary of all care process outcomes and lished since the last systematic reviews on patient outcomes in this
costs studies (strong, moderate and weak) meeting the eligibility field (Numata et al., 2006; West et al., 2009), indicating the endur-
criteria for inclusion in the review. ing interest in this as a research focus. The patient outcome themes
Four studies were rated to have strong validity, two of which in our review are broadly similar to those in previous reviews how-
were large, multi-centre studies measuring hospital costs ever, our review presents a stronger body of evidence (more stud-
(Amaravadi et al., 2000; Dimick et al., 2001). Both found significant ies and stronger internal validity) and incorporates a broader range
associations between higher nurse staffing and reduced patient of outcomes.
hospital cost. Neither of the studies incorporated temporal Differences in ICU staffing levels across countries, and particu-
measures. larly between countries, persist across reviews and are reflected
The third study used both nurse to patient ratio and nurses’ per- in other multi-country studies. For example, researchers examin-
ception of adequate staffing, as measures of staffing levels (Cho ing early mobilisation practices contrasted levels of staffing across
et al., 2009). Both staffing measures showed a statistically signifi- both the UK and France; differences in levels were mostly inter
cant association between higher staffing and higher nurse- (rather than intra-) country with 97% of UK ICUs reporting a 1:1
perceived quality of care. nurse:patient ratio, and 90% of French ICUs reporting ratios of
The fourth study reported significant associations between 1:3 or higher (Bakhru et al., 2016). Aspects of ICU nursing practice
higher staffing levels and timely decisions on life saving treatment such as patient and family engagement (for example use of ICU
(Azoulay et al., 2009). diaries and open visiting for families) have been reported as consis-
tent within, but variable between, countries (Kleinpell et al., 2018).
A survey of 24 European countries revealed large variation in avail-
Nurse outcomes and family satisfaction
ability, duration and qualification awarded for critical care nursing
programmes (Endacott et al., 2015). These studies indicate that ICU
Table 4 provides a summary of nurse and family outcome stud-
nurses are perhaps undertaking different roles in different coun-
ies (strong, moderate and weak) meeting the eligibility criteria for
tries so any attempt to identify an optimal N:P ratio for interna-
inclusion in the review.
tional application would be doomed to failure.
Two studies were rated to have strong internal validity. One
study explored the association between nurse staffing and nurse
outcome (Cho et al., 2009) and found statistically significant bene-
Limitations
ficial associations between subjective measures of staffing and
burnout, job-satisfaction and intention to leave. An objective mea-
As with all reviews, there are limitations to our conclusions. The
sure of staffing also showed beneficial (but not statistically signif-
methodological quality of included studies, for example, determi-
icant) associations with job-satisfaction and intention to leave, but
nes the confidence with which we offer our final summary. We
showed a detrimental (non-significant) association with burnout.
assessed two fifths of studies to have strong methodical rigour
The second study (Stricker et al., 2009) showed a significant asso-
with respect to measuring and analysing nurse staffing and out-
ciation between higher staffing levels and greater family
come variables. We used a pre-established detailed framework
satisfaction.
replete with numerous examples of poor, moderate and strong
grades to guide us in our assessment (please see e-component file
Discussion 1). In addition, our decision to assign separate grades for internal
and external validity reduces the number of conflating issues.
We reviewed 55 papers and found evidence from studies Although this system worked well in so far as there was very little
assessed to have strong internal validity, that higher levels of crit- discord among assessors’ grade assigning, we acknowledge that
ical care nurse staffing are beneficial to a range of outcomes. In par- there remains an unavoidable degree of subjectivity in establishing
ticular, there is strong evidence that higher critical care nurse a cut-off for each of the three grades. Nevertheless, at the very
staffing levels are associated with reduced rates of mortality and least, this grading system enables a relative distinction of rigour.
nosocomial infection. There is also strong evidence of associations An additional limitation centres on the heterogeneity of risk
with reduced hospital costs, increased family satisfaction, reduced adjustment methods used across included studies. Studies
nurse burnout, increased nurse job satisfaction and less intention assessed with strong internal validity all reported key patient/
to leave the nursing profession. nurse and unit/hospital risk adjustments. This included measuring
Studies assessed to have moderate or weak internal validity and accounting for a plethora of variables such as nurse specialist
generally supported these findings (please refer to Tables 2–4 for training, length of critical care nursing experience, patient age, sex,
details). These studies also showed that higher staffing tended to type of admission, ICU specialism, type of hospital (public, private,
be associated with increased adherence to clinical protocols, large, small) and many more, too numerous to list here. Therefore,
reduced length of ventilator days and weaning, and impacted care while we are confident of the methodological rigour of studies we
processes such as facilitating time to make decisions on life- assessed as strong, we have not attempted to compare data based
forgoing treatment or using physical restraints. on the specific type of risk adjustments carried out, some of which
Evidence of an association between higher staffing and reduced were idiosyncratic to a particular study. In summary, strong stud-
length of hospital or ICU stay however, was mixed. Regardless of ies all carried out risk adjustments but not necessarily with the
risk adjustment, there may be organisational factors, such as diver- same combination of confounders. However, we would undermine
sity in the organisation of intermediate care, and hospital capacity our endeavour to synthesise these data should we attempt to
for recovering ICU patients, that may affect outcomes such as hos- group studies by both outcome measured and by type and combi-
pital length of stay. Whilst longer ICU stay is acknowledged as a nation of risk adjustment used.
8
Pamela J.L. Rae, S. Pearce, P. Jane Greaves et al. Intensive & Critical Care Nursing xxx (xxxx) xxx

We acknowledge that in terms of time periods, older compared Dall’Ora: Methodology, Writing - review & editing, Funding acqui-
to newer studies may represent data collected against a different sition. Peter Griffiths: Methodology, Writing - review & editing,
backdrop of intensive care environment and staffing. However, this Funding acquisition. Ruth Endacott: Conceptualization, Methodol-
difference in backdrop also applies to studies conducted within the ogy, Formal analysis, Investigation, Writing - original draft, Writing
same time period: differences between two studies conducted in - review & editing, Supervision, Funding acquisition.
2019 may be just as likely as a 2000 study and a 2019 study. This
is largely because of variations in the use (rather than definition) of Declaration of Competing Interest
high intensity care wards. The stated function of the wards as, for
example, ICU, HDU, Cardiac, Burns, Neuro, represents variation in This paper presents independent research funded by the
use and throughput that is inconsistently available in studies. Fur- National Institute for Health Research (Programme Development
ther, the number of ICU beds per 100 hospital beds varies greatly. Grants, Safe staffing in ICU: development and testing of a staffing
The more abundant the supply of ICU beds the more low-acuity model, NIHR200100). The views expressed in this publication are
patients likely to be admitted, both by beds being available for those of the author(s) and not necessarily those of the National
more precautionary admissions and by patients being held in ICU Institute for Health Research or the Department of Health and Social
longer following serious illness. One way to address some of these Care, neither of whom have had involvement in any aspect of the
issues would be to directly compare only studies using the same design, data collection, synthesis, interpretation or writing of, this
risk adjustments. However, as already discussed, this was not fea- review.
sible. Therefore, we saw no justification in synthesising data by
time period, and in line with systematic review guidance
Acknowledgements
(Lefebvre et al., 2019), we did not impose a lower date limit on
included studies.
We would like to thank members of the SEISMIC (Study to Eval-
Overall, the heterogeneity of approaches to measurement in
uate the Introduction of nurse Staffing Models in Intensive Care)
these studies suggests there needs to be a more coherent frame-
study team for their feedback during the review process: Dr
work with which to examine the impact of nurse staffing. As a case
Suzanne Bench, Mrs Carole Boulanger, Miss Fiona Boyd, Mrs Jen-
in point, we were unable to identify staffing level thresholds
nifer Gordon, Dr Doug Gould, Prof David Harrison, Dr Jeremy Jones,
because there was no common framework and as such, the optimal
Dr Thomas Monks, Mr Paul Mouncey, Prof Natalie Pattison, Dr Ann-
‘dose’ of nursing remains unknown. A previous review of nurse
ette Richardson, Prof Kathryn Rowan.
staffing (Greaves et al., 2018) reported that formulae used to calcu-
late staffing were used inconsistently and that the clinical judg-
ment of a senior nurse performed as well as the best scoring Appendix A. Supplementary data
system. This was reflected in the large multi-centre study in which
N:P ratios and perceptions of adequate staffing were both signifi- Supplementary data to this article can be found online at
cantly associated with perceived quality of care (Cho et al., 2009). https://doi.org/10.1016/j.iccn.2021.103110.

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