Yearbook on Journal of the Japan Society of Nursing Research 2013

Effects of a 7:1 Patient-to-Nurse Staffing Ratio on Nurses’ Stressors, Accumulated
Fatigue, and Intention to Continue Working
Hiroko Namba 1), Atsushi Koike 1), Takeko Wakabayashi 1)
Key Words :nurse-patient ratio
job stressfatigueretention
hospital nursing services

ABSTRACTThis study aimed at verifying the effects of differences in patient-to-nurse staffing ratios on nurses. In total,
868 nurses were investigated in terms of peripheral tasks implemented, the Nursing Job Stressor Scale(NJSS), the self-Diagnosis Checklist for Workers’ Accumulated Fatigue, and intention to continue working.
Data was compared between the 7:1 and 10:1 groups and multiple regression analysis was conducted using
each scale as the criterion variable and the patient-to-nurse staffing ratios as the explanatory variable. The
results showed that compared to the 10:1 group, the 7:1 group had fewer transfer tasks among peripheral
tasks, as well as significantly lower scores for “human environment at work” and “quantitative workload” on
the NJSS as well as “assessment of subjective symptoms” on the accumulated fatigue scale. As for intention
to continue working, the proportion of nurses who viewed their hospital as a good place to work wassignificantly higher in the 7:1 group. Multiple regression analysis showed that patient-to-nurse staffing ratios
had a slight effect on intention to continue working. These results indicate that the characteristics of hospitals
capable of implementing a 7:1 patient-to-nurse staffing ratio influence the nurses’ work environment andthe nurses themselves.

I. Introduction

Although nurse staffing has become a serious medical
policy-related issue in Japan, there have been few studies on
the deployment of nurses and its outcomes. Furthermore, few
analyses have been conducted to examine the relationshipbetween nurse staffing and its benefits for nurses: hownurses are affected by different assignments. Therefore, it issignificant, in terms of nursing management, to examine theeffects of the introduction of the patient-nurse ratio of 7:1
due to the 2006 reimbursement revision on nurses in Japan.
The present study, which examined the relationships
between differences in related tasks performed by nursing
staff due to varying assignments, job stressors faced by them,
the level of accumulated fatigue, and their intention to continue
working, will promote discussions on appropriate nurse
staffing to nurture a favorable work environment for nurses.

Since the adoption of a stricter standard for the deploymentof nurses due to the 2006 revision of the medical fee
reimbursement system, a shortage of nurses has become aserious problem nationwide, and it has become particularly
more difficult to secure nursing staff in rural areas. In thiscontext, the introduction of nurse staffing with a patient-nurse
ratio of 7:1 is expected to alleviate the shortage of nurses
and promote environments that allow them to concentrateon nursing practice. However, some studies suggest that
adoption of the 7:1 ratio does not necessarily improve theirwork environment (Ogushi and Kitaura, 2009a; Ozawa,
Arai, Nagai, and Yoshizawa, 2009). Kadota (2007) pointed
out that introduction of the 7:1 ratio based on the revised
reimbursement system would increase, rather than reduce,
their burden of related tasks. For nurses, being prevented
from conducting daily tasks and nursing practice constitutes afactor determining turnover (Yamaguchi, Misawa, and Tahara,2006). Therefore, it is significant to distinguish between nurse
staffing and assigning nurses related tasks in terms of nursing
management.
A large number of overseas studies suggest that, the higher
the nurse-to-patient ratio, the more benefits the patients andnurses receive (Aiken, Clarke, and Douglas, 2002; IOM, 2006;
Kramer and Schmalenberg, 1992; Rothberg, 2005). However,
the relationship between a high nurse-to-patient ratio and its
benefits has not been established; some studies suggested thepossible positive effects of a high nurse-to-patient ratio on
patient outcomes (Kanai, 2007; Yasukawa, 2008), but others
reported no significant correlations between the nurse-topatient ratio and numbers of medical accidents or adverse
events (Ota, Oku, Koba, Yasui, and Ibe, 2006; Uchinuno,2008). Most of these surveys were conducted prior to the2006 revision of the reimbursement system. Few studies havebeen conducted to examine the relationship between nurse
staffing and its outcomes following the revision, and mosthave only involved a single facility.

II. Purpose of the Study

The purpose of the study was to examine differences inthe status of nursing-related tasks performed in healthinstitutions with a patient-to-nurse ratio of 7:1 and 10:1,
and discuss the influences of the differences on job stressors
faced by nurses, the level of accumulated fatigue, and theirmotivation to continue working.
III. Operationally Defined Terms

1) Nurse staffing: The ratio of patients assigned to one nurse,which is determined according to the “basic hospitalization
fees” based on the medical fee reimbursement system andsubmitted to the ministry.
2) Job stressor: Causes of work-related stress attributed
to subjective requirements in the workplace, which can beassessed using the “scale for assessment of job stressors
in clinical nurses” (Higashiguchi, Morikawa, Miura, Saijou,
Tabata, and Nakagawa, 1998).
3) Level of accumulated fatigue: Level of physical andpsychological fatigue in the previous month, which can beassessed using the “checklist for self-diagnosis of the levelof accumulated fatigue in workers” developed by the healthpromotion division of the Japan Industrial Safety and Health
Association.

1) Mie Prefectural College of Nursing

Corresponding author. Tel.: +81 59 233 5622; Fax: +81 59 233 5622.
E-mail address: hiroko.namba@mcn.ac.jp (H. Namba)

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This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013

mean subscale score. Its reliability and validity have been
established by the developer (Higashiguchi et al., 1998).
4) Level of accumulated fatigue: The “checklist for selfdiagnosis of the level of accumulated fatigue in workers”(accumulated fatigue scale), including 20 items, developedby the health promotion division of the Japan Industrial
Safety and Health Association, was used to determine thelevel of fatigue. Using a seven-grade scale, the accumulated
fatigue scale aims to determine the [level of burden at work]in a comprehensive manner, based on a combination ofassessments of [subjective symptoms] in the previous month(13 items) and [working conditions] (7 items). Although theprevious study employed another scale to determine the levelof accumulated fatigue, the present study adopted the score
for [burden at work] as the score for [accumulated fatigue].
Its reliability and validity have been established by Sasaki
et al. (Sasaki, Iwasaki, Mouri, Hisanaga, and Shibata, 2005)
5) Intention to continue working: Based on the “analysisof the possibility to continue working”, developed by Hirai,
Ohara, Kinoshita, Oshima, and Kusakari (2003), four questions
regarding the intention to continue working: “Do you think ofthis hospital as an excellent workplace in general?”, “Do you
think of yourself as a member of this hospital?”, “Have you everthought of leaving this hospital?”, and “Do you hope to continue
to work at this hospital?”, as well as an additional question: “Areyou planning to leave this hospital (in two years)?”, were asked.
Response options included “Yes”, “I do not know”, and “No”.

4) Intention to continue working: Intention to continue
working as a nurse in a health institution.
5) Nursing-related tasks: Ten tasks listed by the JapaneseNursing Association (2001) as “related work” that they wantto commission to professionals other than nurses (servingof meals, checking of leftover food, single-dose packaging ofdrugs, mixing of injectable drugs, drug inventory management,
transfer of drugs, hygiene products, and specimen, bedmaking, and ME maintenance and management).
IV. Research Methods
A. Subjects

Subjects of the study were full-time nurses (excluding
those with experience of less than one year) working on
general wards of 15 acute care hospitals with 200 or more
beds for general patients in Prefecture A (excluding advanced
treatment hospitals) that agreed to participate in the study.
B. Research methods
1. Survey methods

A self-completed anonymous questionnaire survey was
conducted. The researcher asked the Department of Nursingof each hospital to distribute survey sheets and addressedenvelopes to the subjects. Completed survey forms weresent back by the respondents by mail within three weeks. To
collect data on the attributes of the hospitals, a “list of hospitals
and clinics” (Life and Culture Division of Prefecture A) was
referred to and the managers of the nursing departments wereinterviewed.

4. Analysis methods

An unpaired t-test was conducted to compare theattributes (number of beds, mean bed occupancy rate, andmean hospitalization period) of 7:1 and 10:1 hospitals. A
comparison was also conducted of the basic attributes ofgroups of nurses working at 7:1 and 10:1 hospitals and thestatus of implementing nursing-related tasks. To examine theattributes, χ² tests were conducted to compare category data,
and unpaired t-tests were used to compare quantitative data,such as the number of years of experience. Using unpaired
t-tests, job stressor and accumulated fatigue subscale scores
were compared between the 7:1 and 10:1 groups. Nurses’
intentions to continue working were examined using a χ² test.
Pearson’s correlation coefficients were used to examine
the relationships between nurse staffing and variables. To
examine the influences of differences in nurse staffing on
job stressors in nurses, the level of accumulated fatigue, andintention to continue working, a multi-regression analysis(stepwise procedure) was conducted between the 7:1 and10:1 groups: job stressor scale and accumulated fatigue
scores and the intention to continue working were criterion
variables; explanatory variables included the attributes offacilities and individual nurses, including the deployment ofnurses and status of implementing nursing-related tasks.
Prior to calculating the correlation coefficients andconducting a multi-regression analysis, the intention tocontinue working and status of implementing nursing-related
tasks were converted into quantitative data, according to
the following procedures: To determine the intention tocontinue working, a positive response was counted as one
point and other responses were counted as zero points. The
higher the score (between 0 and 5 points), the more strongly
determined to continue working the nurse was. Regarding
the implementation of nursing-related tasks, the response

2. Survey period

Between April 22 and May 28, 2009

3. Data collection tools

1) Basic attributes: The survey items included the age, gender,
type of job, experience as a nurse, job title, marital status, andwhether or not the nurse had children.
2) Implementation of nursing-related tasks: The nurses
were asked if they performed specific nursing-related
tasks. Response options were: “I always perform the task”,“I only perform the task on holidays/at night/in emergency
situations”, and “I do not perform the task / Other answers”.
3) Job stressors: The “scale for assessment of job stressors
in clinical nurses” developed by Higashiguchi et al. (1998)
was used. The job stressor scale consists of seven factors as
subscales and 33 items: Factor 1 (stressors related to personal
relationships in the workplace) including seven items, Factor
2 (stressors related to roles as nurses) including five items,
Factor 3 (stressors related to relationships with physicians
and autonomy as nurses) including five items, Factor 4(stressors related to the attitude toward death) including four
items, Factor 5 (stressors related to the qualitative burden ofwork) including five items, Factor 6 (stressors related to thequantitative burden of work) including five items, Factor 7(stressors related to relationships with patients) including two
items. Five-grade subscales were used, and the total subscalescore was divided by the number of items to calculate the2This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013

“I always conduct the task” was counted as one point andother responses were counted as zero points. The higher
the score (between 0 and 10 points), the larger the numberof nursing-related tasks implemented. Dummy variables
were used to assess the following items: nurse staffing (7:1
nurse staffing=1, 10:1 nurse staffing=0), managerial position(managerial position=1, non-managerial position=0), marital
status (married=1, unmarried/divorced/bereaved=0),
and with or without children (with children=1, withoutchildren=0). In all tests, the significance level was “p<0.05”.
For statistical analysis of data, SPSS16.0 for Windows,
statistical software, was used.

were selected as valid responses (valid response rate: 68.5%),
completely excluding overlapping and defective data, andresponses from 868 nurses were analyzed in the present survey.

The present study was conducted with the approval of
the research ethics committee of Mie Prefectural College ofNursing (Notification No. 083501).
The researcher visited hospitals at which the nurses work,and provided the managers of the nursing departments withoral and written explanations of the purpose of the survey,
its methods, distribution of survey forms to the nurses, andethical considerations to obtain their consent. For all subjects,
a document stating the anonymity of the survey, its purpose
and significance, that participation in the survey must be
based on the nurse’s own free will, that nurses would never
be disadvantaged because of their refusal to participate, thatsurvey data and results would be processed in a manner toprevent individual nurses from being identified prior to their
publication, and that returning a completed form would be
regarded as consent to the study was attached to the survey
form. The subjects were asked to complete the form, put it in
an envelope, and send it back by mail.
Although the survey forms used in the study had code
numbers indicating the hospitals and wards where therespondents worked, the code numbers were only used to
identify the hospitals at the time of data analysis. Information
to identify the hospitals was handled only by the researcher
and promptly discarded following the completion of the study.

2. Basic attributes of subjects

1. Attributes of surveyed facilities

Table 1 shows the attributes of surveyed facilities. Ten 7:1
and five 10:1 hospitals cooperated in the present survey. The
mean numbers of beds for general patients in 7:1 and 10:1
hospitals were 356.8 ± 157.6 and 322.2 ± 87.8, respectively.
The mean bed occupancy rates for 7:1 and 10:1 hospitals
were 78.4 ± 10.8 and 82.6 ± 7.2%, respectively. The mean
hospitalization periods for 7:1 and 10:1 hospitals were 14.1
± 1.7 and 16.3 ± 3.4 days, respectively.

5. Ethical considerations

Table 2 shows the basic attributes of the subjects. The 7:1
and 10:1 groups included 625 and 243 nurses, respectively(a total of 868). The mean age was 33.7 ± 9.0 years old (33.6± 9.2 for the 7:1 group and 33.9 ± 8.3 for the 10:1 group).
The mean period of experience as nurses was 11.4 ± 8.5
years (11.3 ± 8.7 for the 7:1 group and 11.6 ± 8.1 for the 10:1
group). There were no significant differences in the basic
attributes of subjects between the two groups.
3. Status of implementing nursing-related tasks

Table 3 shows the status of implementing nursing-related
tasks according to the pattern of nurse staffing. A significantly
larger number of nurses in the 7:1 group conducted the tasksof single-dose-packaging (χ²(2)=11.6, p<0.01) and bed-making(χ²(2)=12.62, p<0.01) on a regular basis, compared to nurses
in the 10:1 group. On the other hand, a significantly larger
number of 7:1 hospital nurses conducted the following
three tasks: serving meals (χ²(2)=9.86, p<0.01), transfer ofdrugs (χ²(2)=14.42, p<0.001), transfer of hygiene materials(χ²(2)=21.39, p<0.001)
4. Differences in nurse staffing and their relationships withthe levels of job stressors, accumulated fatigue, and intention
to continue working

V. Results

A total of 1,342 responses were collected from 2,213
subjects (response rate: 60.6%). Of the 1,342 responses, 919

Table 4 shows mean job stressor and accumulated fatigue

Table 1. Attributes of surveyed facilities
Number of hospitals(number of wards)

Mean number of beds for generalpatients*1 ± SD (beds)

Mean bed occupancy rate ± SD (%)

Mean hospitalization period ± SD (days)
Organizations that established healthcare facilities*2 (number of facilities)

Population of the area (city) ± SD
(number of people)

7:1 hospitals
10 (67)

10:1 hospitals
5 (30)

78.4±10.882.6±7.2

356.8±157.6

14.8±1.7
Public health careinstitutions (8)Social insurance-relatedorganizations (1)Health care corporations (1)165,407.5±87,199.3

Total
15 (97)322.2±87.8345.3±135.8

16.3±3.4
Public health careinstitutions (3)Social insurance-relatedorganizations (1)Health care corporations (1)15.3±2.4
Public health careinstitutions (11)Social insurance-relatedorganizations (2)Health care corporations (2)154,016.6±17,545.9

79.8±9.7

161,610.5±94,163.3[Note] All are hospitals that have adopted the DPC (diagnostic procedure combination)-based calculation system*1: Number of beds as reported to the ministry*2: Organizations that established health care facilities were classified according to a large classification by the Ministry of Health, Labour,and Welfare as part of its survey of medical facilities.

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This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013

Table 2. Basic attributes of subjects
Attribute

1. Mean age*1 ± SD

Classification

20s
30s
*2
2. Age categories
40s
50s or older
Male
3. Gender*2
Female4. Mean number of years of experience as*1nurses ± SD
None
Chief/Vice head nurse
5. Managerial position*2
Head nurse
Unmarried
Married6. Marital status*2
Divorced/Bereaved
With children*2
7. With or without children
No children[Note] *1: t test *2: χ² test

Total
N=868

N

7:1 hospitals
N=625

N

10:1 hospitals
N=243
N

%
33.7± 9.0
351
40.4
293
33.8
165
19
59
6.8
17
2
851
98

%
33.6±9.2
264
42.2
198
31.7
115
18.4
48
7.7
12
1.9
613
98.1

%
33.9±8.3
87
35.8
95
39.1
50
20.6
11
4.5
5
2.1
238
98

733
98
37
445
394
29
326
542

532
70
23
326
280
19
223
402

201
28
114
119
114
10
103
140

11.4±8.5

11.3±8.7

84.5
11.3
4.3
51.3
45.4
3.3
37.6
62.4

85.1
11.2
3.7
52.2
44.8
3
35.7
64.3

t or χ² value
t =-0.52 n.s.

11.6±8.1

82.7
11.5
5.8
49
46.9
4.1
42.4
57.6

χ²=7.68n.s.

χ²=0.17n.s.

t =-0.49n.s.

χ²=1.93n.s.
χ²=1.13n.s.
χ²=3.36n.s.

Table 3. Nurse staffing and the status of implementing nursing-related tasks
Items

Status of implementation

N
570
221
77
614
144
110
612
132
124
740
68
60
257
306
305
152
498
218
61
408
399
158
620
90
359
406
103
246
193
429

Task conducted on a regular basis
Serving of meals On holidays/at night/in emergency situations
Task not conducted/Others
Task conducted on a regular basis
Checking of leftovers On holidays/at night/in emergency situations
Task not conducted/Others
Task conducted on a regular basis
Single-dose
On holidays/at night/in emergency situations
packaging of drugs
Task not conducted/Others
Task conducted on a regular basis
On holidays/at night/in emergency situations
MixingTask not conducted/Others
Task conducted on a regular basis
Drug inventory
On holidays/at night/in emergency situations
management
Task not conducted/Others
Task conducted on a regular basis
Transfer of drugs On holidays/at night/in emergency situations
Task not conducted/Others
Task conducted on a regular basis
Transfer of hygiene On holidays/at night/in emergency situations
materials
Task not conducted/Others
Task conducted on a regular basis
Transfer
On holidays/at night/in emergency situationsof specimens
Task not conducted/Others
Task conducted on a regular basis
On holidays/at night/in emergency situations
Bed-making
Task not conducted/Others
Task conducted on a regular basis
ME maintenance and On holidays/at night/in emergency situations
inspections
Task not conducted/Others[Note] χ² test ***:p< 0.001 **:p< 0.01

Total

%
65.7
25.5
8.9
70.7
16.6
12.7
70.5
15.2
14.3
85.3
7.8
6.9
29.6
35.3
35.1
17.5
57.4
25.1
7
47
46
18.2
71.4
10.4
41.4
46.8
11.9
28.3
22.2
49.4

7:1 hospitals
N
%
392
62.7
392
62.7
169
27
64
10.2
429
68.6
111
17.8
85
13.6
456
73
79
12.6
90
14.4
531
85
56
9
38
6.1
174
27.8
231
37
91
14.6
366
58.6
168
26.9
34
5.4
276
44.2
315
50.4
103
16.5
457
73.1
65
10.4
278
44.5
269
43
78
12.5
181
29
136
21.8
308
49.3

10:1 hospitals
N
%
178
73.3
52
21.4
13
5.4
185
76.1
33
13.6
25
10.3
156
64.2
53
21.8
34
14
209
86
12
4.9
22
9.1
83
34.2
86
35.4
74
30.5
61
25.1
132
54.3
50
20.6
27
11.1
132
54.3
84
34.6
55
22.6
163
67.1
25
10.3
81
33.3
137
56.4
25
10.3
65
26.8
57
23.5
121
49.8

χ² value
9.86**

4.75n.s.
11.6**
5.87n.s.
4.47n.s.
14.42***
21.39***
4.54n.s.
12.62**
0.54n.s.

significant difference between the two groups. Mean scoreson job stressor-related subscales were compared between thetwo groups. Mean scores for <stressors related to personal
relationships in the workplace> (t (866)=-2.38, p<0.05) and<stressors related to the workload> (t (866)=-2.00, p<0.05)
received by the 7:1 group were significantly lower. Therescores and SDs, as well as Cronbach’s alpha coefficients.
a. Nurse staffing and job stressors (Figure 1)

The job stressor score was 2.86 ± 0.52 points for the 7:1
group and 2.84 ± 0.51 points for the 10:1 group; there was no4

This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013

were no significant differences in other job stressor-related
subscale scores between the two groups. In both groups, thescore for <stressors related to the attitude toward death>
was the lowest and the score for <stressors related to theworkload> was the highest. Cronbach’s α in the job stressor
scale was between 0.62 and 0.83.

5. The influence of nurse staffing on dependent variables

a. Relationship between nurse staffing and dependent
variables

Table 6 shows Pearson’s correlation coefficients. Although
there was a significant correlation between nurse staffing andthe intention to continue working (r=0.072, p<0.05), it was
not significantly correlated with the levels of job stressors,
accumulated fatigue, and nursing-related tasks. Nurse staffing
was significantly correlated with the number of beds forgeneral patients (r=0.286, p<0.001), mean bed occupancy
rate (r=-0.158, p<0.001), and mean hospitalization period(number of days) (r=-0.133, p<0.001).
Although nursing-related tasks were not significantly
correlated with nurse staffing, they were significantly
correlated with the level of job stressors (r=0.120, p<0.01),
accumulated fatigue (r=0.135, p<0.01), and intention
to continue working (r=-0.94, p<0.01). There were alsosignificant correlations between the levels of job stressors,
accumulated fatigue, and intention to continue working.
Figure 3 shows the relationships between the attributesof health institutions, including nurse staffing and nursingrelated tasks, the levels of job stressors, accumulated fatigue,
and intention to continue working. The variables wereplotted assuming that nurse staffing and other attributes of
institutions were associated with the levels of job stressors

b. Nurse staffing and the level of accumulated fatigue(Figure 2)

Mean scores for [subjective symptom assessment], [workcondition assessment], and [the workload] were compared
between the two groups. The 7:1 group received a significantly
higher score for [subjective symptom assessment] (t (866)=2.43, p<0.05). No significant differences were noted inother items between the two groups. Cronbach’s α in theaccumulated fatigue scale was between 0.74 and 0.88.
c. Nurse staffing and the intention to continue working

Table 5 shows the intention to continue working according
to the pattern of nurse staffing. To the question: “Do you thinkof this hospital as an excellent workplace in general?”, a larger
number of nurses in the 7:1 group answered “Yes” than thosein the 10:1 group (χ²(2)=15.27, p<0.001). There were no
significant differences in other items between the two groups.

Table 4. Job stressor and accumulated fatigue subscale scores, SD, and reliability analysis
Survey scale and subscale items(number of items)

Scales for assessment of job stressors in clinical nurses (33)
Personal relationships in the workplace (7)Roles of nurses (5)Relationships with physicians and autonomy as nurses (5)Determination to face death (4)Qualitative burden of work (5)Quantitative burden of work (5)Relationships with patients (2)Checklist for self-analysis of the level of accumulated
fatigue in employees (20)Assessment of the workload (level of accumulated fatigue)
Assessment of subjective symptoms (13)Assessment of working conditions (7)
3.5
3.0

*

*

2.82
Mean
2.74 2.77 2.70 2.71
2.69
subscale
2.58
score
2.50
2.5

2.0

①

②

③

④

3.04 3.06

⑤

3.26

3.36

⑥

3.10 3.08

Total

7:1
hospitals

10:1
hospitals

Cronbach’s alphacoefficient

4.36±2.15

4.29±2.2

4.56±2.1-

2.86±.52
2.73±.77
2.75±.65
2.70±.80
2.52±.76
3.05±.66
3.29±.61
3.09±.79

2.84±.52
2.69±.78
2.74±.6
2.70±.79
2.50±.76
3.04±.68
3.26±.61
3.10±.78

15.21±8.73
5.81±3.70

14.76±8.62
5.72±3.67
18

7：１
n=625

15

10：1
n=243

12
Mean
score 9630⑦

① Personal relationships in the workplace② Roles of nurses③ Relationships with physicians and autonomy as nurses④ Determination to face death⑤ Qualitative burden of workt test t＝-2.736～.281 *p<.05⑥ Quantitative burden of work

*

14.76

2.90±.51
2.82±.73
2.77±.65
2.71±.84
2.58±.76
3.06±.62
3.36±.60
3.08±.83

16.36±8.94
6.04±3.78

0.88
0.74

16.36

7：１
n=625
5.72 6.04①②

4.29 4.56① Workload② Assessment of subjective symptoms③ Assessment of working conditions

t test t = -2.43~1.137 *: p <0.05

Figure 1. Job stressor scale scores

0.82
0.82
0.82
0.62
0.8
0.83
0.74

③

Figure 2. Accumulated fatigue scale scores

5This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

10：1
n=243

Yearbook on Journal of the Japan Society of Nursing Research 2013

Table 5. Differences in the intention to continue working depending on the nurse staffing ratio
Items

7:1 hospitals
N
%
272
43.5
274
43.8
79
12.6
498
79.7
118
18.9
9
1.4
469
75
88
14.1
68
10.9
254
40.6
295
47.2
76
12.2
81
13
352
56.3
192
30.7

AnswerYes
I do not knowNoYes
I do not knowNoYes
I do not knowNoYes
I do not knowNoYes
I do not knowNo

Do you think of this hospital as an excellent
workplace in general?

Do you think of yourself as a member of this
hospital?

Have you ever thought of leaving this hospital?

Do you hope to continue working at this hospital?

Are you planning to leave this hospital (in two
years)?

***: p< 0.001

10:1 hospitals
N
%
71
29.2
130
53.5
42
17.3
194
79.8
45
18.5
4
1.6
207
85.2
21
8.6
15
6.2
84
34.6
119
49
40
16.5
39
16
122
50.2
82
33.7

χ² value
15.27
***

0.062
n.s.

4.747
n.s.

4.521
n.s.

2.913
n.s.

Table 6. Pearson’s correlation coefficients between the attributes of facilities and individual nurses and dependent variables (Total N=868)(1) Nurse staffing 1)(2) Number of beds forgeneral patients(3) Mean bed occupancy rate(4) Mean hospitalization
period(5) Implementation of nursingrelated tasks 2)(6) Age(7) Number of years ofexperience as nurses(8) Managerial post 3)(9) Marital status(10) With or without children 5)(11) Job stressors(12) Level of accumulated
fatigue(13) Intention to continue
working 6)

-1

-2

-3

-.158***

0.05

1-0.053-.189***

1.286***-.133***

1

-4

-5

-6

-.652***

0.054-0.0170.005-.108**

0.026-.107**-0.03-0.019-0.062-0.051-0.018-0.064-0.0510.008

0.019-0.019-0.038-.069*-0.01.078*.091**-0.006-.245***-.092**-.069*.120***

.072*

.080*

.094**-0.002-.094**-0.016-0.56

0-.083*

0.023

0.013

0.04

1

.234***

0.017-0.0491-.109**.135***-7

1.938***.478***.444***.574***.088**-0.008.188***

1.501***.443***.545***.080*-0.001.175***

-8

-9

-10

1
.222***.278***
0.053

1.693***
0.041

1
0.057

-0.017.217***-0.04.120***-0.048.181***-111.429**-.144***-12

1-.291***-131[Note] 1)The 7:1 nurse staffing: 1, the10: 1 nurse staffing: 0 2) The total was calculated by counting the answer “I always perform the task”
as one point and other answers as zero points and summing up the scores for ten task-related questions. 3) managerial position: 1,
non-managerial position: 0 4) married: 1, unmarried/divorced/bereaved: 0 5) With children: 1, without children: 0 6) The total
was calculated by counting an answer that expressed an intention to continue working as one point and other answers as zero points.
***: p< 0.001 **: p< 0.01 *: p< 0.05
Mean hospitalization
period.234.094

Level of accumulated-.291
fatigue (workload)-.135

Nursingrelated
tasks

.652
-.133

.429

.120

.144

.189

Job stressors

Beds for generalpatients
-.286

.080

Nurse staffing(7:1 or 10:1)

.072

-.158

Intentiontocontinueworking.094*Solid lines represent correlations.
*Each number of the lines represents Pearson’s
correlation coefficient “r”.

Mean bed
occupancy rate

Work environment (attributes of the organization)Nurses

A decrease in turnover/securement of personnel

Figure 3. Relationships between the attributes of health institutions, including nurse staffing and scale items

6
This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013

and accumulated fatigue in nurses and their intention
to continue working, and that they contributed to therecruitment of nurses and a decrease in the turnover rate.

groups of nurses from registered 7:1 and 10:1 hospitals inJapan, respectively.
No significant differences were noted in the attributesof 7:1 and 10:1 hospitals. All health care facilities thatconsented to cooperate in the survey had adopted the DPC(diagnostic procedure combination) system, and efforts toshorten the mean hospitalization period and differentiate
their functions were already in progress. On the other hand,as the 7:1 hospitals had to satisfy a criterion for 7:1 nurse
staffing, a mean hospitalization period of 19 days or shorter,
they had a greater incentive to shorten the duration of
hospitalization than the 10:1 hospitals, instead of increasing
the bed occupancy rate. Therefore, an extension of the mean
duration of hospitalization increased job stressors and thelevel of accumulated fatigue in the 7:1 group.
A significantly larger number of nursing-related tasks,transfer and other tasks not involving direct contact withpatients in particular, were performed by the 10:1 group.
When hospitals introduced 7:1 nurse staffing and newly
recruited nurses, most of them are reported to havereviewed nursing tasks, including their commission to otherprofessionals (Kurosawa, 2008; Takehisa, 2008) - the majorityof transfer and other tasks not directly related to patientswere commissioned to other professionals and commissioned
staff. A shortage of nurses attributed to the adoption of 7:1
nurse staffing may inappropriately increase salaries fornurses, their salaries as a percentage of the total personnel
expenditure, and eventually the budget for recruiting otherstaff. For this reason, it has been pointed out that the adoptionof 7:1 nurse staffing may increase the burden of nursingrelated tasks performed by nurses (Sumida, 2007). However,according to the results of the present study, the numbersof staff other than nurses and the burden of related tasks
performed by nurses were maintained.
Although bed-making was assigned to commissioned staff
and assistant nurses in most hospitals, regardless of the nurse
staffing ratio, most nurses in the 7:1 group performed thetask on a regular basis. Different from other nursing-related
tasks, bed-baking directly influences the lives of patients. The
7:1 hospitals presumably provided appropriate nursing careintervention, including the exchange of sheets on a regularand as-required basis.

b. Influences of nurse staffing

Table 7 and Figures 4 and 5 show the results of the multiregression analysis based on the patterns of nurse staffing.
In both 7:1 and 10:1 groups, an increase in the burden of
nursing-related tasks increased the levels of job stressors(β=0.090 and p<0.05 for the 7:1 group, β=0.233 and p<0.01
for the 10:1 group) and accumulated fatigue (β=0.126 and
p<0.01 for the 7:1 group, β=0.179 and p<0.01 for the 10:1
group). In both groups, nurses in a managerial post (β=0.197
and p<0.01 for the 7:1 group, β=0.146 and p<0.05 for the 10:1
group) and those with children (β=0.134 and p<0.01 for the
7:1 group, β=0.143 and p<0.05 for the 10:1 group) morestrongly hoped to continue working.
In the 7:1 group, the higher the mean bed occupancy rate,
the greater the intention to continue working (β=0.119 and
p<0.01) and accumulated fatigue (β=0.081 and p<0.05), andthe shorter the mean duration of hospitalization, the greater
the intention to continue working (β=-0.81, p<0.05) andaccumulated fatigue (β=-0.121 and p<0.01).
In the 10:1 group, the higher the age, the higher the levelof job stressors (β=-0.216, p<0.01), which is not in line withthe 7:1 group.
VI. Discussion

1. Differences in the characteristics of health care facilities
due to varying nurse staffing
The attributes of health care facilities selected for thepresent survey, including the number of beds per ward, mean
hospitalization period (number of days), and bed occupancyrate, were in line with those of 7:1 and 10:1 hospitals
selected as the subjects of the “survey regarding 7:1 basic
hospitalization fee hospitals” (Ministry of Health, Labour, andWelfare, 2009a) conducted by the Central Social Insurance
Medical Council. Therefore, 7:1 and 10:1 groups, selected as
the subjects of the present study, are considered to represent

Table 7. Effects of nurse staffing on the levels of job stressors, accumulated fatigue, and intention to continue working

Nurse staffing 2)
Mean bed occupancy rate
Mean hospitalization period
Nursing-related tasks 3)
Age
Managerial or non-managerial post 4)
With or without children 5)
Adjusted R2

Total.131***.102**

Job stressors
7:1-.081*.090*

Level of accumulated fatigue
Total
7:1
10:1
.081*
-.085*-.121**.155***.126**.179**

10:1.233***.216**

Intention to continue working 1)
Total
7:1
10:1
.104**.112**.119**.179***.142***
0.078
19.371***.197***.134**
0.081
19.432
***

.146*
.143*
0.043
6.374
**

0.023
0.016
0.084
0.023
0.024
0.028
11.011
4.335
12.14411.172
6.194
7.916
F value
***
***
***
***
***
***
[Note] 1. The values represent significant differences in the standardized regression coefficient “β”
2. The numbers of beds for general patients, years of experience as nurses, and marital status are not expressed in the table because they
were not adopted as criterion variables.
1) The total was calculated by counting an answer that expressed the intention to continue working as one point and other answers
as zero points. 2) The 7: 1 nurse staffing : 1, the 10:1 nurse staffing: 0 3) The total was calculated by counting the answer “Ialways perform the task” as one point and other answers as zero points and summing up the scores in ten task-related questions.
4) Managerial post: 1, non-managerial post: 0 5) With children: 1, without children: 0***: p< 0.001 **: p< 0.01 *: p< 0.05

7This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013
Explanatory
variables

Mean
hospitalization
periodCriterion
variables

Level of accumulated
fatigue (workload)

-.121
-.081
.126

Nursingrelated tasks

Job stressors

.090
.081

Mean bed occupancy rate

.119

Intentiontocontinueworking.197

Managerial or nonmanagerial post

.134

With or withoutchildren* The number in each arrow indicates thestandardized regression coefficient “β”

Figure 4. Effects of the attributes of facilities and individual nurses on scale items in the 7:1 group

Explanatory
variables

Criterion
variables

Level of accumulated
fatigue (workload).179

Nursingrelated tasks.233

Job stressors
Intentiontocontinueworking

.216

Age

.146

Managerial or nonmanagerial post
With or withoutchildren.143* The number in each arrow indicates thestandardized regression coefficient “ β”

Figure 5. Effects of the attributes of facilities and individual nurses on scale items in the 10:1 group

These results suggested that the 7:1 group could afford
to spend more time providing nursing care, compared to
the 10:1 group, because they were exempt from transfer
and other chores. Yamaguchi et al. (2006) stated that, whennurses are unable to fulfill their primary duties (or unable toprovide adequate care services), it has negative effects on thesense of satisfaction with the job and their commitment to it,leading to a high turnover rate. When performing nursingrelated tasks, the transfer of patients in particular, nurses
cannot take advantage of their expertise because they do notdirectly come into contact with patients. Therefore, nursingrelated tasks, which were performed by a significantly larger
number of nurses in the 10:1 group, may have increased
job stress in nurses and even reduced their motivation tocontinue working.

2. Differences in the characteristics of dependent variables
due to varying nurse staffing
a. Differences in the characteristics of job stressors due tovarying nurse staffing

The 7:1 group received significantly lower mean scoresfor <stressors related to personal relationships at work> and<stressors related to the workload> than the 10:1 group.
<Stressors related to personal relationships at work> is a
subscale item to determine scores for stressors related tointerpersonal relationships in the workplace, social support
provided by seniors and colleagues, and differences in theirattitudes toward work. The introduction of 7:1 nurse staffing is
considered to have alleviated the shortage of nurses and reduced
the “stressors related to personal relationships at work”.
8This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013

nurses in the 7:1 group answered “Yes” than those in the
10:1 group. Nurses had presumably received increasingly
higher recognition from other health professionals, directly
experienced by nurses themselves, since the hospital as awhole was determined to secure the required number ofnurses in response to the introduction of 7:1 nurse staffing.
A number of previous studies suggested the relationshipbetween psychological stress and burnout syndrome
experienced by nurses, as well as a correlation between
burnout and the intention to quit their job (Tsukamoto andNomura, 2007). The present study also revealed significant
correlations between the intention to continue working andvariables; their intention was influenced by job stressors andthe level of accumulated fatigue.

<Stressors related to the workload> is a subscale item
to determine scores for stressors related to the workload
placed on nurses. Nurses are in charge of different numbersof patients depending on the patient-nurse ratio. In addition
to this, the 10:1 group had to conduct a larger number ofnursing-related tasks than the 7:1 group, which is assumed
to have caused a larger number of stressors.
Shimazu (2004) stated that, in work settings in which alarge workload is placed on a nurse, stress responses are
more effectively reduced by achieving a sense of satisfaction
at work rather than reducing the workload. As nurses in the
10:1 group were involved in a number of nursing-related
tasks, transfer in particular, it is necessary to help promote
their sense of satisfaction with work. Prior to the survey,
other stressors in the 7:1 group had been expected to be fewer
compared to the 10:1 group because the former provided
quality care for fewer patients, although no significant
differences were noted between the two groups. The 2008
revision of reimbursement fees included new criteria for 7:1
nurse staffing: the mean hospitalization period of 19 days or
shorter; determination of the level at which a patient is inneed of nursing care, and a specified number of inpatients
who have satisfied the requirements. In other words, the 7:1
group was required to promote the earlier discharge of more
seriously ill patients, compared to the 10:1 group. Therefore,
nurses in the 7:1 group did not recognize the positive effectsof 7:1 nursing staff on relationships with patients and thequality of tasks conducted, although they were in charge offewer patients.
There were no significant differences in the following job
stressor-related subscale scores between the two groups:<stressors related to roles as nurses>, <stressors related
to relationships with physicians and autonomy as nurses>,<stressors related to the attitude toward death>, <stressors
related to the qualitative burden of work>, and <stressors
related to relationships with patients>; these subscale items
are presumably not affected by nurse staffing. Nurses may
consider that qualitative items, such as the roles of nurses andtheir relationships with physicians, are not associated withthe deployment of a sufficient number of nurses.

3. Relationships between differences in nurse staffing, job
stressors, and the levels of accumulated fatigue and intention
to continue working

The correlation coefficients were calculated and a multiregression analysis was conducted. The results suggested that
nurse staffing was associated with the intention to continue
working, and nursing-related tasks, which were influenced
by differences in the deployment of nurses, affected job
stressors, the levels of accumulated fatigue, and intention
to continue working. The mean hospitalization period andbed occupancy rate for 7:1 hospitals were associated withthe levels of job stressors and intention to continue working
in the 7:1 group in a characteristic manner. This means thatthe attributes of hospitals that could afford to deploy nurses
with a patient-to-nurse ratio of 7:1, rather than the numberof nurses itself, may have positively influenced job stressors,
the level of accumulated fatigue, and intention to continue
working. To become qualified for 7:1 nurse staffing, a hospitalis required to exert a collective effort. These attitudes of
hospitals are assumed to influence nurses.
Ashish, Orav, Zheng, and Epstein (2008) examined factors
related to the results of nurses’ assessments of hospitals
including items experienced by patients. Their study
suggested that a hospital’s characteristics that contribute toa high nurse-patient ratio may be associated with patients’favorable experiences, and presented evidence that a hospitalcan not only provide quality clinical care, but also help
patients have favorable experiences. The results - nurses’
intention to continue working is affected by nurse staffing
and the status of implementing nursing-related tasks, suggestthat these factors may also influence patients’ satisfaction
and management costs as well as nurses. Under the current
reimbursement system and policy of curbing medical
expenditure, “7:1 nurse staffing” is a life-or-death managerial
decision. It is important for nursing managers to consider
nurse staffing from the viewpoints of reducing the turnoverof nurses they are in charge of, patients’ assessments, andthe viability of the hospital, in addition to increasing thebasic hospitalization fee. They are also required to present
the positive effects of the adoption of 7:1 nurse staffing using
subjective data.
It should also be noted that factors including the age andjob title of a nurse and whether or not he/she had children
affected the intention to continue working, which is inline with the results of previous studies (Hirai et al., 2003;
Nakanishi, Tsuge, and Futatsumori, 2007; Ohara, Maruguchi,
Nishio, Tanaka, and Hirai, 2004). As most nurses are female,b. Differences in the characteristics of the level of accumulated
fatigue due to varying nurse staffing

The 7:1 group received a lower “subjective symptom
assessment” score than the 10:1 group; nurses in the 7:1
group did not have a strong feeling of fatigue as a physicalsymptom. No significant differences were noted in [working
conditions] and [burden at work] depending on the patternof nurse staffing, and even nurses at 7:1 hospitals, in which
the shortage of nurses was considered to be less serious,
felt burdened while working. This was presumably because
the 7:1 hospitals were required to facilitate the discharge ofseriously ill patients in the acute phase and nurses had a busy
schedule to fulfill the criteria for 7:1 nurse staffing, althougha larger number of nurses are deployed in 7:1 compared to
10:1 hospitals.
c. Differences in the characteristics of the intention tocontinue working due to varying nurse staffing

To the question: “Do you think of this hospital as an
excellent workplace in general?”, a larger number of

9This paper was published at “the Japan Society of Nursing Research” Vol.35 No.4 in 2012.

Yearbook on Journal of the Japan Society of Nursing Research 2013

the turnover rate is significantly influenced by marriage,
childbirth, and other major life events. To secure the required
number of quality nurses, it is necessary to not only improvenurse staffing and the assignment of nursing-related tasks,
but also implement nursing management while taking into
consideration the backgrounds of individual nurses.

Organization, and Quality of Care. Cross-National Findings,
NURSING OUTLOOK, Sep/Oct, 187-194.
Ashish, K.J., Orav, E.J., Zheng, J., Epstein, A.M. (2008). Patients’ Perceptionof Hospital Care in the United States, the NEW ENGLAND JOURNAL
of MEDICINE [Online]. http://www.nejm.org/doi/pdf/10.1056/
NEJMsa0804116
Higashiguchi, K., Morikawa, Y., Miura, K., Nishijo, M., Tabata, M.,
Nakagawa, M. (1998). The Job stressor Experienced by Hospital
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Hirai, S., Ohara, M., Kinoshita, M.,Oshima, S., Kusakari, J. (2003). A
case study of consultation support services to secure nurses
for small- and medium-scale private hospitals [2], Assessmentof nursing-related organizations using an analysis of the rateof nurses working long term. The Japanese Journal of Nursing
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for Nurses and Patient Safety. Edited by Ann Page. Supervised
and translated by Toshiko Ibe, Medical Journalists Associationof Japan (2006) Keeping Patients Safe – Transforming the Work
Environment of Nurses. Tokyo: Nippon Hyoron Sha.
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self-diagnosis of accumulated fatigue in employees. http.//www.
mhlw.go.jp/houdou/2003/05/h0520-3.html
Kanai- Pak, M. (2007). Clinical Issues Related to Nurse’ Work
Environment in Japan - Joint research with Linda Aiken-. The
Japanese Journal of Nursing Research, 40(7), 631-640.
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Nursing.
Kramer, M., and Schmalenberg, C./Translated by Toshiko Ibe (1992)
Job Satisfaction and Retention, Insights for the ‘90s Part 1.
Japanese Journal of Nursing Administration, 2(4), 256-261.
Kurosawa, I. (2008). Approaches to reduce the burden of nurses in
hospitals. Hospitals, 7(4), 327-331.
Masamura, K., Kakeda, T., Ichihara, K., Okuda, M., Tanida, N., Hobara,
T. (2006). Factors that Influence Nurses’ Perceptions of Workrelated Stress in Japan: Analysis According to Hospital Size.
Medicine and Biology, 150(5), 197-215.
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hospitals and clinics (as of September 1, 2008). Mie Prefecture
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Central Social Insurance Medical Council meeting(2009.11.10).
http.//www.wam.go.jp/wamappl/bb11GS20.nsf/0/46c771bc2
561af594925766b00036bda/$FILE/20091111_1shiryou2-2_1.
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Sectional Committee - An organization specializing in surveys on
the medical reimbursement system (2009. 5. 14). http.//www.
mhlw.go.jp/shingi/2009/05/s0514-6.Html
Nakanishi, M., Tsuge, Y., Futatsumori, E. (2007). Relationships between
the intention to continue working in mid-career nurses working
for five related hospitals, their satisfaction with the job, and senseof coherence (SOC). Japanese Nursing Association Collection ofPapers (Nursing Administration), 38, 139-141.
Ogushi, M., Kitaura, A. (2009a). What is the 7:1 basic nursing
fee system? - Importance of strategies as viewed from thestandpoint of the policy process. Japanese Journal of Nursing
Administration, 19(7), 562-563.
Ogushi, M., Kitaura, A. (2009b). Incentives to establish policies forVII. Conclusion

1. The levels of job stressors and accumulated fatigue innurses of the 7:1 group were lower compared to the 10:1
group, and the intention to continue working was greater.
2. In 7:1 hospitals, the longer the hospitalization period, orthe higher the mean bed occupancy rate, the lower the levelsof accumulated fatigue and intention to continue working.
3. The status of implementing nursing-related tasks, which
varied depending on the pattern of nurse staffing, affected
the levels of job stressors and accumulated fatigue and theirintention to continue working.
4. Characteristics of hospitals qualified for 7:1 nurse
staffing may have influenced the levels of job stressors andaccumulated fatigue in nurses and their intention to continue
work in a positive manner.
VIII. Future Challenges

The present study adopted the levels of job stressors,
accumulated fatigue, and intention to continue working
as indices of nurses’ task performance affected by nurse
staffing. These variables are considered to be significantly
influenced by the characteristics of an organization and its
individual employees (Inaoka, 1992; Masamura, Kakeda,
Ichihara, Okuda, Tanida, Yoshihara, 2006). Regarding theimplementation of nursing-related tasks, tasks assigned
to nurses vary depending on the scale of the hospital or
according to the criteria. Further examinations should be
conducted on the influences of factors other than nurse
staffing, such as the characteristics of an organization and its
individual employees.
Although the present study discussed nurse staffing basedon the criteria for basic hospitalization fees, questions havebeen raised about the fact that medical fees are determinedby the number of nurses, and not by the newly establishedstandard of 7:1 nurse staffing, as a result of a political initiativeor the skills of nurses and quality of care (Ogushi, Kitaura,
2009b; Yasukawa, 2005; Yasukawa, 2008). Further studies
should be conducted to help implement proper nurse staffing
while taking into account the skills of nurses, nurse-topractical nurse ratio, and rate of assistant nurse deployment.
Acknowledgment

I would like to express my heartfelt gratitude to the nurses
and managers of the nursing departments of the hospitals forcooperating in the survey. The present paper is a revisionof the thesis written by Hiroko Namba and published at amaster’s thesis presentation meeting organized by Mie
Prefectural College of Nursing Graduate School.
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