{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T21:36:08Z","timestamp":1788903368035,"version":"build-2803163510"},"reference-count":46,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2025,6,9]],"date-time":"2025-06-09T00:00:00Z","timestamp":1749427200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2025,6,9]],"date-time":"2025-06-09T00:00:00Z","timestamp":1749427200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Advanced Nursing"],"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>To evaluate the maximum number of patients per nurse before quality and safety outcomes deteriorate in medical\u2010surgical settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A secondary analysis of cross\u2010sectional survey data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We analysed data from 609 direct care nurses working in British Columbia's medical\u2010surgical areas. The relationship between nurse\u2010to\u2010patient ratios and quality and safety outcomes was analysed using both two\u2010level and one\u2010level regression models, including visualisations such as boxplots and scatterplots with LOESS curves. The analysis controlled for nurse demographics and hospital clustering effects.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Ratios ranged from 1:1 to 1:9, with outliers above 1:9 excluded. For desirable outcomes, last shift quality of care, unit safety grade, and recommending units to friends\/family and to colleagues, the means were generally positive for ratios ranging from 1:2 or 1:3 to 1:4 but negative for ratios ranging from 1:5 to 1:8 or 1:9. This pattern was reversed for adverse outcomes, undone tasks and emotional exhaustion; the means were generally negative for ratios between 1:1 and 1:3 to 1:4 but became positive for ratios between 1:5 and 1:6 to 1:8. A turning point (crossing zero) was found between the ratios of 1:4 and 1:5 for all outcomes except patient adverse events, where the turning point was between the ratio of 1:3\u20131:4.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The findings provide preliminary evidence in support of minimum nurse\u2010to\u2010patient ratios of 1:4 in British Columbia's medical\u2010surgical areas. Policy\u2010makers and decision\u2010makers should augment minimum nurse\u2010to\u2010patient ratios with other nurse\u2010driven tools and nurse\u2010management staffing methods that provide more flexibility to better meet fluctuating environmental, patient and staffing needs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>No Patient or Public Involvement<\/jats:title>\n                    <jats:p>This study did not include patient or public involvement in its design, conduct, or reporting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Implications for the Profession and\/or Patient Care<\/jats:title>\n                    <jats:p>Minimum ratios should be complemented by nurse\u2010driven tools and flexible staffing strategies to account for contextual and resource variability.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Impact<\/jats:title>\n                    <jats:p>\n                      <jats:list list-type=\"bullet\">\n                        <jats:list-item>\n                          <jats:p>This secondary analysis of 2015 survey data from 609 medical\u2010surgical nurses in British Columbia, Canada supported a minimum nurse\u2010to\u2010patient ratio of 1:4 using a series of quality and safety outcomes for patients and nurses.<\/jats:p>\n                        <\/jats:list-item>\n                        <jats:list-item>\n                          <jats:p>This finding provides important preliminary evidence in support of the specific minimum nurse\u2010to\u2010patient ratios of 1:4 as the province prepares to implement this ratio in medical\u2010surgical settings.<\/jats:p>\n                        <\/jats:list-item>\n                        <jats:list-item>\n                          <jats:p>Existing staffing models using minimum nurse\u2010to\u2010patient ratios may be augmented by employing additional staffing tools and methodologies that provide more flexible resource allocation.<\/jats:p>\n                        <\/jats:list-item>\n                      <\/jats:list>\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Reporting Method<\/jats:title>\n                    <jats:p>This study adheres to STROBE guidelines.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jan.17104","type":"journal-article","created":{"date-parts":[[2025,6,9]],"date-time":"2025-06-09T10:19:03Z","timestamp":1749464343000},"page":"2976-2987","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Beyond the Ratios: Evidence for Optimal Minimum Nurse\u2010Patient\u2010Ratios in Medical\u2010Surgical Settings"],"prefix":"10.1111","volume":"82","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7769-7796","authenticated-orcid":false,"given":"Farinaz","family":"Havaei","sequence":"first","affiliation":[{"name":"School of Nursing University of British Columbia  Vancouver British Columbia Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3810-3120","authenticated-orcid":false,"given":"Claire","family":"Song","sequence":"additional","affiliation":[{"name":"School of Nursing University of British Columbia  Vancouver British Columbia Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2280-0335","authenticated-orcid":false,"given":"Danjie","family":"Zou","sequence":"additional","affiliation":[{"name":"Department of Educational and Counselling Psychology, and Special Education University of British Columbia  Vancouver British Columbia Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0340-197X","authenticated-orcid":false,"given":"Amery D.","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Educational and Counselling Psychology, and Special Education University of British Columbia  Vancouver British Columbia Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3603-8735","authenticated-orcid":false,"given":"Maura","family":"MacPhee","sequence":"additional","affiliation":[{"name":"School of Nursing University of British Columbia  Vancouver British Columbia Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1625-9506","authenticated-orcid":false,"given":"Elizabeth","family":"Saewyc","sequence":"additional","affiliation":[{"name":"School of Nursing University of British Columbia  Vancouver British Columbia Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2025,6,9]]},"reference":[{"key":"e_1_2_17_2_1","doi-asserted-by":"publisher","DOI":"10.7748\/ns.24.44.62.s55"},{"key":"e_1_2_17_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140\u20106736(13)62631\u20108"},{"key":"e_1_2_17_4_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.288.16.1987"},{"key":"e_1_2_17_5_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.ccm.0000999604.51606.6c"},{"key":"e_1_2_17_6_1","doi-asserted-by":"publisher","DOI":"10.18637\/jss.v067.i01"},{"key":"e_1_2_17_7_1","unstructured":"California Department of Health.2003.\u201cAssembly Bill 394: Safe Staffing for Quality Care Act. California Department of Health.\u201dhttps:\/\/leginfo.legislature.ca.gov\/faces\/billNavClient.xhtml?bill_id=199920000AB394."},{"key":"e_1_2_17_8_1","unstructured":"Canadian Federation of Nursing.2024.\u201cOpening the Blackbox: Unpacking the use of nursing agencies in Canada.\u201dhttps:\/\/nursesunions.ca\/research\/opening\u2010the\u2010black\u2010box\/."},{"key":"e_1_2_17_9_1","doi-asserted-by":"publisher","DOI":"10.1080\/01621459.1979.10481038"},{"key":"e_1_2_17_10_1","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-642-48425-4_2"},{"key":"e_1_2_17_11_1","doi-asserted-by":"publisher","DOI":"10.1080\/01621459.1988.10478639"},{"key":"e_1_2_17_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jsr.2017.06.009"},{"key":"e_1_2_17_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.outlook.2021.09.007"},{"key":"e_1_2_17_14_1","volume-title":"Multilevel Modeling: Applications in STATA, IBM SPSS, SAS, R, & HLM","author":"Garson G. D.","year":"2020"},{"key":"e_1_2_17_15_1","unstructured":"Government of British Columbia.2024 November 25.\u201cMinimum Nurse to Patient Ratios (mNPR).\u201dhttps:\/\/www2.gov.bc.ca\/gov\/content\/health\/practitioner\u2010professional\u2010resources\/mnpr."},{"key":"e_1_2_17_16_1","unstructured":"Government of Ireland.2018.\u201cFramework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Wards.\u201d Government of Ireland.https:\/\/www.gov.ie\/en\/publication\/2d1198\u2010framework\u2010for\u2010safe\u2010nurse\u2010staffing\u2010and\u2010skill\u2010mix\u2010in\u2010general\u2010and\u2010speci\/."},{"key":"e_1_2_17_17_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen\u20102019\u2010035828"},{"key":"e_1_2_17_18_1","doi-asserted-by":"publisher","DOI":"10.3390\/healthcare11152187"},{"key":"e_1_2_17_19_1","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph20010489"},{"key":"e_1_2_17_20_1","doi-asserted-by":"publisher","DOI":"10.4324\/9780429060274"},{"key":"e_1_2_17_21_1","doi-asserted-by":"publisher","DOI":"10.14288\/1.0379546"},{"key":"e_1_2_17_22_1","volume-title":"Crossing the Quality Chasm: A New Health System for the 21st Century","author":"Institute of Medicine","year":"2001"},{"key":"e_1_2_17_23_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcjq.2025.01.007"},{"key":"e_1_2_17_24_1","doi-asserted-by":"publisher","DOI":"10.12927\/cjnl.2020.26240"},{"key":"e_1_2_17_25_1","unstructured":"MacPhee M. F.Havaei P.Rodney et\u00a0al.2015.\u201cBC Nurses' Workload Impact Study: Final Report.\u201dhttps:\/\/doi.org\/10.14288\/1.0389883."},{"key":"e_1_2_17_26_1","doi-asserted-by":"publisher","DOI":"10.1002\/nur.21503"},{"key":"e_1_2_17_27_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen\u20102019\u2010036264"},{"key":"e_1_2_17_28_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140\u20106736(21)00768\u20106"},{"key":"e_1_2_17_29_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.2041\u2010210x.2012.00261.x"},{"key":"e_1_2_17_30_1","doi-asserted-by":"publisher","DOI":"10.1111\/inr.12629"},{"key":"e_1_2_17_31_1","unstructured":"National Institute for Health and Care Excellence (NICE).2014.\u201cSafer Nursing Care Tool (SNCT): Statement of Endorsement.\u201d NICE.http:\/\/www.nice.org.uk\/guidance\/sg1\/resources\/sg1safestaffingfornursinginadultinpatientwardsinacutehospitals4."},{"key":"e_1_2_17_32_1","doi-asserted-by":"publisher","DOI":"10.1071\/AH16252"},{"key":"e_1_2_17_33_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jsp.2009.09.002"},{"key":"e_1_2_17_34_1","unstructured":"Posit Team.2023.\u201cRStudio: Integrated Development for R (Version 2023).\u201d Posit Software PBC.https:\/\/posit.co\/."},{"key":"e_1_2_17_35_1","unstructured":"Queensland Nurses and Midwives' Union (QNMU).2023.\u201cNurse\u2010to\u2010Patient Ratios in Queensland.\u201d QNMU."},{"key":"e_1_2_17_36_1","unstructured":"R Core Team.2021.\u201cR: A Language and Environment for Statistical Computing (Version 4.1) [Computer Software].\u201d R Foundation for Statistical Computing.https:\/\/www.R\u2010project.org\/."},{"key":"e_1_2_17_37_1","doi-asserted-by":"publisher","DOI":"10.1111\/jocn.14058"},{"key":"e_1_2_17_38_1","unstructured":"Royal College of Nursing.2024.Safe Staffing Levels Across the UK: What Does the Law Say? Royal College of Nursing.https:\/\/www.rcn.org.uk\/get\u2010help\/rcn\u2010advice\/safe\u2010staffing."},{"key":"e_1_2_17_39_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejor.2019.10.047"},{"key":"e_1_2_17_40_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jen.2016.07.003"},{"key":"e_1_2_17_41_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.healthpol.2020.08.003"},{"key":"e_1_2_17_42_1","unstructured":"Victorian Government.2015.\u201cSafe Patient Care Act 2015.\u201d Victorian Government.https:\/\/www.health.vic.gov.au\/safe\u2010patient\u2010care\u2010act\u20102015."},{"key":"e_1_2_17_43_1","unstructured":"Welsh Government.2016.\u201cNurse Staffing Levels (Wales) Act 2016.\u201d Welsh Government.https:\/\/gov.wales\/nurse\u2010staffing\u2010levels\u2010wales\u2010act\u20102016."},{"key":"e_1_2_17_44_1","doi-asserted-by":"crossref","unstructured":"Wickham H.2016.ggplot2: Elegant Graphics for Data Analysis. Springer\u2010Verlag.https:\/\/ggplot2.tidyverse.org.","DOI":"10.1007\/978-3-319-24277-4_9"},{"key":"e_1_2_17_45_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.aenj.2014.08.001"},{"key":"e_1_2_17_46_1","doi-asserted-by":"publisher","DOI":"10.1002\/nop2.2218"},{"key":"e_1_2_17_47_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jemermed.2024.08.017"}],"container-title":["Journal of Advanced Nursing"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/jan.17104","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/jan.17104","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/jan.17104","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,17]],"date-time":"2026-03-17T16:15:02Z","timestamp":1773764102000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/jan.17104"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,9]]},"references-count":46,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1111\/jan.17104"],"URL":"https:\/\/doi.org\/10.1111\/jan.17104","archive":["Portico"],"relation":{"has-review":[{"id-type":"doi","id":"10.1111\/JAN.17104\/v2\/decision1","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v1\/review3","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v2\/response1","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v3\/decision1","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v1\/review1","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v1\/review2","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v2\/review1","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v3\/response1","asserted-by":"object"},{"id-type":"doi","id":"10.1111\/JAN.17104\/v1\/decision1","asserted-by":"object"}]},"ISSN":["0309-2402","1365-2648"],"issn-type":[{"value":"0309-2402","type":"print"},{"value":"1365-2648","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,9]]},"assertion":[{"value":"2025-01-17","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-05-20","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-06-09","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}