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Q: Nursing Staffing ( Answered,   0 Comments )
Subject: Nursing Staffing
Category: Health
Asked by: pill-ga
List Price: $10.00
Posted: 05 Sep 2002 20:21 PDT
Expires: 05 Oct 2002 20:21 PDT
Question ID: 62161
What is the natiional standard set by the Oncology Nursing Society
(ONS) for nurse/patient ratio in an outpatient radiation oncology
clinic which also includes a brachytherapy program?
Subject: Re: Nursing Staffing
Answered By: silviares-ga on 09 Sep 2002 21:40 PDT
Hello pill-ga

I tought that the best thing to do to find out the answer to your
question was ask directly to the Oncology Nursing Society
( They have been so kind to promptly answer me. I am
posting their answer. For any clarification you can contact Laurl
Matey, RN, MSN directly at
I am of course available for any further help


Thank you for your inquiry. 
You are correct in that finding data that is as specific as you are
looking for will be difficult. ONS does not have a specific
"recommended staffing ratio". However:
In 1989, ONS conducted and published a staffing survey. It was divided
into separate settings:
The 1989 National Survey of Salary, Staffing & Professional Practice
Patterns in Oncology Nursing: Radiation Therapy-Based Oncology
Nursing, Office Based Oncology Nursing, Oncology Related Infusion
Units, Ambulatory Oncology Clinics, Oncology Related Home care &
Hospice Agencies.

It was accompanied by the following Oncology Nursing Forum  piece: 

 Oncology Nursing Forum 1991 Sep-Oct;18(7):1241-3 
 Staffing standards: why not? A report from the ONS Administration 
 Lamkin LR, Sleven M. 
 Queen's Medical Center Cancer Institute, Honolulu, HI. 
 This report from the Administration Committee of the Oncology Nursing
 Society (ONS) follows the publication of the Committee's monograph, 
 The 1989 National Survey of Salary, Staffing, and Professional 
 Practice Patterns in Oncology Nursing. Based on the experience of 
 other professional organizations, the committee explains why it 
 recommends that staffing standards not be developed at this time. An
 example of how to use the survey data to develop ideal staffing is 
 included. Issues to consider in developing a staffing plan are also 

Another staffing survey is now published in the Vol 28/Number 10
Nov/Dec, 2001 issue of the Oncology Nursing Forum. The article is:
"Oncology Nursing Society Workforce Survey Part 1: Perceptions of the
Nursing Workforce Environment and Adequacy of Nurse Staffing in
Outpatient and Inpatient Oncology Settings",by Luana Lamkin, RN, MPH,
Jean Rosiak, RN, BSN, OCNŽ, Peter Buerhaus, RN, PhD, FAAN, Gail
Mallory, RN, PhD, CNAA, and Mamie Williams, BA, MPH.
If you are an ONS member, you can access the online version of ONF at
this link:

The most recent (Jan/Feb 2002) Oncology Nursing Forum, as "Oncology
Nursing Society Workforce Survey Part II: Perceptions of the Nursing
Workforce Environment and Adequacy of Nurse Staffing in Outpatient and
Inpatient Oncology Settings" includes a section on HPPD (see below):
"Budgeted versus actual staffing: Many nurse executives and managers
budget the number of nurses needed by calculating the total direct
productive "hours of care per patient day" (HPPD) for the number of
patients expected to require nursing care over a given time period.
Calculating the HPPD takes into account the number of minutes and
hours nursing staff directly interact with patients (i.e., the time it
takes to administer treatments and medications, monitor patients, and
provide teaching). It also reflects the time staff takes to document
care, order supplies, prepare medication, and direct other caregivers.
HPPD equals the sum of all direct care time provided by all staff
members (RNs and ancillary staff) who care for one patient in a
24-hour period.
Actual HPPD may differ from the budgeted HPPD for several reasons. For
example, if staffing vacancies exist because they cannot be filled as
a result of staff illness or a shortage of staff to hire, then the
actual HPPD would be lower than budgeted. On the other hand, actual
HPPD would be higher than budgeted if patient acuity was so high that
extra nurses were called in to provide care or if an RN was not
available and had to be replaced by two nursing assistants.
Nurse executives were asked to report both budgeted and actual HPPD
for the settings they supervised. Executives reported a mean of 7.63
HPPD of direct productive care as budgeted on inpatient units, whereas
the actual HPPD was slightly higher at 7.77. Because outpatient areas
typically operate on a less than 24-hour per day basis and patients
usually are present in these settings far less than 24 hours, nurse
executives reported lower budgeted and actual HPPD staffing in
outpatient settings, with a mean budgeted amount of 3.61 HPPD and 3.52
actual staffing. The similarity between budgeted and actual HPPD in
both settings is an unexpected finding. The differences are considered
negligible because of measurement errors."
Please keep in mind, though, that as with the 1989 survey, the results
are not to be followed as standards/guidelines; rather, the data
represents averages, etc.
The full text of the most recent ONF article can be found at:
You will be able to access this directly if you are an ONS member. 
Please see below my signature  for a list of publications dealing with
staffing standards or staffing and patient outcomes "in general", i.e.
specific to ONS or the oncology setting. 

I hope that this is useful information to you. If not, please feel
free to email me directly.

To complete our records, I would appreciate knowing if you are indeed
an ONS member, and would greatly appreciate a quick email back to me
with that information; or, if you are not, to allow us to send you
some information about ONS. In that case, if you would provide an
address to which we may send you an informational guide to ONS, I
would also be appreciative
Best regards, 
Laurl Matey, RN, MSN 

The following ANA publications are relevant to your inquiry: 

Nurse Staffing and Patient Outcomes in the Inpatient Hospital Setting
This ANA study qualifies relationships between nurse staffing and 
patient outcomes for a large scale cross section of the nation's 
hospitals and their inpatients. Today's pressures for hospital cost 
control make it imperative to determine whether differences across
acute care hospitals in nurse staffing can be statistically shown to
relate to measurable differences in important patient outcomes. 
Pub# NSP-20. 
List $24.95/ SNA Member $19.95 

Implementing Nursing's Report Card: A Study of RN Staffing, Length of
Stay and Patient Outcomes

This pilot study-an extension of ANA's Nursing Quality Indicators: 
Definitions and Implications-explores the relationships between 
specific patient outcome indicators and nurse staffing, and assesses 
the feasibility of capturing the information necessary to develop 
specific nurse staffing and outcome measures. Among the conclusions: 
shorter lengths of stay were found to be strongly related to higher 
nurse staffing per acuity-adjusted day. Such findings are critical as
nursing is at a crossroads between the increase in demand for health 
care services and the push to economize the provision of care. 
Quantifying the practice of nursing and its impact on patient care 
outcomes and cost may be a prerequisite for the health of the nursing

1997/32 pp. Pub# Q-1. 
List $15.95/ SNA Member $12.75 

The following articles: 

Journal of Nursing Scholarship 2001;33(2):179-84 
A response to California's mandated nursing ratios. 
Bolton LB, Jones D, Aydin CE, Donaldson N, Brown DS, Lowe M, McFarland
PL, Harms D. 
Cedars-Sinai Health System/Burns & Allen Research Institute, Los 
Angeles, CA, USA. 

PURPOSE: To explore the need for evidence-based health policy, as 
illustrated by the mandatory staffing bill passed by the California 
state legislature in 1999. DESIGN: Prospective data were collected 
from a voluntary sample of California acute care hospital 
representatives to describe selected patient safety and clinical 
outcomes and nurse staffing variables at the patient-care unit level.
METHODS: Data for descriptive analysis were collected on hospital 
nurse staffing, patient falls, and pressure ulcers from 257 medical, 
surgical, medical-surgical combined, step-down, 24-hour observation 
units, and critical care patient care units in 38 California acute 
care hospitals from June 1998 to June 1999. FINDINGS: Nursing staffing
ratios varied among the 257 units. RNs provided 91% of the nursing 
care in critical care units. Patients in medical-surgical units 
received 59% of their care from RNs, 11% from licensed vocational 
nurses, and 30% from other caregivers. Preliminary data showed no 
relationships between reported staffing ratios in these hospitals and
the incidence of patient falls or hospital-acquired pressure ulcers. 
CONCLUSIONS: California Nursing Outcomes Coalition (CalNOC) data 
showed wide variations in staffing ratios, patient falls, and 
hospital-acquired pressure ulcers among nursing units and hospitals. 
These early findings indicate the need for additional research before
determining minimal RN staffing requirements. Analysis of multiple 
sources of data may be necessary to determine safe staffing ratios and
to provide evidence-based data for public policy. 
PMID: 11419315 

Nursing Outlook 1998 Sep-Oct;46(5):199-200 
Nurse staffing and patient outcomes. 
McCloskey JM 
University of Iowa College of Nursing, Iowa City, USA. 

OBJECTIVE: This study described the relationship between 6 adverse 
patient outcomes (medication errors, patient falls, urinary and 
respiratory tract infections, skin breakdown, patient complaints, and
mortality), total hours of nursing care, and the proportion of those 
hours of care delivered by registered nurses (RNs). METHODS: With use
of hospital records, data from every unit of a large university 
hospital for fiscal year 1993 were analyzed. Correlations among 
staffing variables and outcome measures were determined, and 
multivariate analyses were completed, controlling for patient acuity.
RESULTS: Units with patients who had higher acuity had lower rates of
medication errors and falls and higher rates of the other adverse 
outcomes. When patient acuity was controlled, an inverse relationship
between RN hours of care and rates of medication errors, decubiti, and
patient complaints was found. A direct relationship existed between 
total hours of care from all nursing personnel and rates of decubiti,
complaints, and mortality. Interestingly, as the RN proportion of care
rose to an 87.5% level, it related to a lower incidence of negative 
outcomes; however, when the RN proportion of care went beyond that 
level, the adverse outcome rates also increased. 
PMID: 9805336 

Nursing Research 1998 Jan-Feb;47(1):43-50 
Nurse staffing and patient outcomes. 
Blegen MA, Goode CJ, Reed L 
College of Nursing, University of Iowa, Iowa City, USA. 

BACKGROUND: Nursing studies have shown that nursing care delivery 
changes affect staff and organizational outcomes, but the effects on 
client outcomes have not been studied sufficiently. OBJECTIVE: To 
describe, at the level of the nursing care unit, the relationships 
among total hours of nursing care, registered nurse (RN) skill mix, 
and adverse patient outcomes. METHODS: The adverse outcomes included 
unit rates of medication errors, patient falls, skin breakdown, 
patient and family complaints, infections, and deaths. The 
correlations among staffing variables and outcome variables were 
determined, and multivariate analyses, controlling for patient acuity,
were completed. RESULTS: Units with higher average patient acuity had
lower rates of medication errors and patient falls but higher rates of
the other adverse outcomes. With average patient acuity on the unit 
controlled, the proportion of hours of care delivered by RNs was 
inversely related to the unit rates of medication errors, decubiti, 
and patient complaints. Total hours of care from all nursing personnel
were associated directly with the rates of decubiti, complaints, and 
mortality. An unexpected finding was that the relationship between RN
proportion of care was curvilinear; as the RN proportion increased, 
rates of adverse outcomes decreased up to 87.5%. Above that level, as
RN proportion increased, the adverse outcome rates also increased. 
CONCLUSIONS: The higher the RN skill mix, the lower the incidence of 
adverse occurrences on inpatient care units. 
PMID: 9478183 

Nursing Economics 1998 Jul-Aug;16(4):196-203 
A multisite study of nurse staffing and patient occurrences. 
Blegen MA, Vaughn T 
College of Nursing, University of Iowa, Iowa City, USA. 
Restructuring of nursing care models has led to more 
"non-professional" caregivers, sometimes called unlicensed assistive 
personnel (UAPs) who provide more of the basic delegable direct 
patient care activities in collaboration with RNs. The purpose of this
study, wherein data were collected from 39 units in 11 hospitals, was
to determine the relationship between different levels of nurse 
staffing and patient outcomes (adverse occurrences). Using and 
tracking the same indicators of patient quality outcomes over a 
significant time period in different institutions with similar patient
groups would greatly enhance the usefulness of such data. Among the 
more surprising findings in this study was the "non-linear" 
relationship between the proportion of RNs in the staff mix and MAEs.
As the proportion of RNs on a unit increased from 50% to 85% "the rate
of MAEs declined, but as the RN proportion increased from 85% to 100%
the rate of MAEs increased." Further investigations are needed to 
explain this finding. 
PMID: 9748985 

Journal of Nursing Administration 1999 Feb;29(2):25-33 
Some impacts of nursing on acute care hospital outcomes. 
Lichtig LK, Knauf RA, Milholland DK 
NETWORK, Inc., Latham, NY, USA. 
Measuring nursing-sensitive patient outcomes using publicly available
data provides exciting opportunities for the nursing profession to 
quantify the patient care impact of staffing changes at individual 
hospitals and to make comparisons among hospitals with differing 
staffing patterns. Using data from California and New York, this study
tested the feasibility of measuring such outcomes in acute care 
hospitals and examining relationships between these outcomes and nurse
staffing. Nursing intensity weights were used to acuity-adjust the 
patient data. Both higher nurse staffing and higher proportion of RNs
were significantly related to shorter lengths of stay. Lower adverse 
outcome rates were more consistently related to a higher proportion of
PMID: 10029799 

Canadian Journal of Nursing Research 1999 Dec;31(3):69-88 
Nurse staffing and patient outcomes: evolution of an international 
Sochalski J, Estabrooks CA, Humphrey CK 
Center for Health Outcomes and Policy Research, University of 
Pennsylvania, Philadelphia, USA. julieas@pobox, 
Industry-wide health sector reforms in the United States, Canada, and
Europe have provided a unique opportunity to examine the effects of 
hospital restructuring on inpatient nursing care and patient outcomes
across an array of settings. Seven interdisciplinary research teams--1
each in Alberta, British Columbia, England, Germany, Ontario, 
Scotland, and the United States--have formed an international 
consortium whose aim is to study the effects of such restructuring. 
Each site has enrolled large numbers of hospitals and nurses to 
explicate the role that organization of nursing care, a target of 
hospital restructuring, plays in differential patient outcomes. The 
study seeks to understand more fully the influence of both nurse 
staffing and the nursing practice environment on patient outcomes. 
Discussion of the theoretical foundation, study design, and process of
developing the study instruments and measures illustrates the process
to date, as well as the feasibility of and opportunities inherent in 
such an international endeavour. 
PMID: 10696170 

Citation <1> 
Accession Number 
Ask AACN. Where can I find information on a national standard for 
nurse-patient ratios in ICU and step-down and telemetry units? 
RN, 64(6 Acute Care Decisions):24ac3, 2001 Jun. 

Citation <2> 
Accession Number 
Proposed nurse-to-patient staffing ratios from CNA. 
Hospital Home Health, 18(5):58, 50, 60, 2001 May. 

Citation <3> 
Accession Number 
Special Fields Contained 
Fields available in this record: cited references. 
AMSN position statement: staffing standards for patient care. 
Amsn News, 9(5):2, 2000 Sep-Oct. (3 ref) 

Citation <4> 
Accession Number 
Special Fields Contained 
Fields available in this record: cited references. 
Gallagher RM. Kany KA. Rowell PA. Peterson C. 
Workplace advocacy. ANA's nurse staffing principles. 
Kentucky Nurse, 48(4):16-8, 2000 Oct-Dec. (11 ref) 

Citation <5> 
Accession Number 
Special Fields Contained 
Fields available in this record: abstract, cited references. 
Kovner CT. 
Professor, Division of Nursing, School of Nursing, New York 
Policy perspectives. State regulation of RN-to-patient ratios. 
American Journal of Nursing, 100(11):61, 63, 65, 2000 Nov. (15 

Citation <6> 
Accession Number 
Special Fields Contained 
Fields available in this record: Cinahl full text. 
Bunch C. 
New hospital regulations require acuity-based nurse staffing levels. 
Nevada Rnformation, 9(1):1, 3, 2000 Feb. 

Citation <7> 
Accession Number 
2000010579 NLM Unique Identifier: 20003692. 
Special Fields Contained 
Fields available in this record: abstract. 
Mayo AM. Van Slyck A. 
Consultant, Nursing Consultant Services, San Diego, California, 
Developing staffing standards: statistical considerations for 
patient care administrators. 
Journal of Nursing Administration, 29(10):43-8, 1999 Oct. (4 ref) 
To demonstrate accountability and responsibility for patient care 
operations, patient care leaders are re-evaluating staffing standards.
Typically, activity studies are conducted and statistical methods 
correlate patient acuity levels to hours per patient day (HPPD). The 
authors discuss statistical considerations that allow patient care 
leaders to evaluate the appropriateness of HPPD generated by activity
study data. (4 ref) 

Citation <8> 
Accession Number 
1999031514 NLM Unique Identifier: 99250584. 
Special Fields Contained 
Fields available in this record: cited references. 
Gallagher RM. Kany KA. Rowell PA. Peterson C. 
Issues update. ANA's nurse staffing principles. 
American Journal of Nursing, 99(4):50, 52-3, 1999 Apr. (11 ref) 

Citation <9> 
Accession Number 
Special Fields Contained 
Fields available in this record: cited references. 
Mamaril M. 
ASPAN's position statement on minimum staffing. 
Breathline, 18(4):4, 1998 Jul-Aug. (2 ref) 

Citation <10> 
Accession Number 
1998042708 NLM Unique Identifier: 98362822. 
Curtin LL. 
One nurse, two nurse... red nurse, blue nurse. 
Nursing Management, 29(4):5-6, 1998 Apr. 


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