Safe nurse staffing levels in acute hospitals
Authors: Van Den Heede Koen , Bruyneel Luk , Beeckmans Dorien , Boon Niels , Bouckaert Nicolas , Cornelis Justien , Dossche Dorien , Van de Voorde Carine , Sermeus Walter 
Published: January 2025

SCIENTIFIC REPORT 17 -- 1 INTRODUCTION AND BACKGROUND 17 -- 1.1 BACKGROUND: A CHANGING HOSPITAL CONTEXT 17 -- 1.1.1 Hospital landscape and evolutions in type of hospital stays 17 -- 1.1.2 Nurse staffing levels: the hospital budget and bedside staffing levels 19 -- 1.2 THE IMPACT OF NURSE STAFFING LEVELS ON NURSE AND PATIENT OUTCOMES 20 -- 1.2.1 Nurse staffing and outcomes are associated but the relationship is complex 20 -- 1.2.2 International safe nurse staffing policies 21 -- 1.3 DEFINITIONS AND TERMINOLOGY 22 -- 1.4 RESEARCH QUESTIONS AND STUDY APPROACH 25 -- 2 NURSING EDUCATION AND PRACTICE IN BELGIUM 26 -- 2.1 ORIGIN AND EVOLUTION 26 -- 2.2 TWO (PRE-)REGISTRATION EDUCATIONAL PATHWAYS 27 -- 2.3 POST-REGISTRATION EDUCATION 28 -- 2.4 REGULATION OF NURSING PRACTICE 30 -- 2.5 CARE ASSISTANTS 31 -- 2.6 FACTS AND FIGURES ON THE BELGIAN NURSING WORKFORCE 32 -- 2.6.1 Nurse density in Belgium is higher than EU-average 32 -- 2.6.2 Most nurses work in hospitals  the working percentage is lower than in other countries 33 -- 2.6.3 Other macro-level indicators on the nursing workforce 34 -- 2.7 LICENSING STANDARDS: NURSE STAFFING 35 -- 2.7.1 Overall licensing standards 35 -- 2.8 ATTRACTION AND RETENTION 39 -- 2.8.1 Chronological overview of attraction and retention measures in Belgium 39 -- 2.8.2 Short description of the several attraction and retention measures 41 -- 3 NURSE STAFFING AND INTENTSITY OF NURSING CARE BASED ON THE BELGIAN NURSING MINIMUM DATA SET 47 -- 3.1 BACKGROUND 47 -- 3.1.1 The Belgian Nursing Minimum Data Set  version I 48 -- 3.1.2 The B-NMDS version II 50 -- 3.2 STUDY OBJECTIVE 52 -- 3.3 METHODS 53 -- 3.3.1 Data Selection 53 -- 3.3.2 Measures 54 -- 3.3.3 Statistical analysis and data presentation 58 -- 3.4 STUDY POPULATION 60 -- 3.4.1 Care Intensity per Patient Day 63 -- 3.4.2 Patient turnover 68 -- 3.4.3 Nursing Hours per Patient Day 69 -- 3.4.4 Care Intensity relative to staffed nursing hours 71 -- 3.4.5 Patient-to-nurse ratio 73 -- 3.4.6 Proportion of Bachelor-prepared nurses 76 -- 3.4.8 Supporting staff 78 -- 3.4.9 Regional differences 78 -- 3.5 RESULTS PER WARD TYPE 80 -- 3.6 INTENSIVE CARE WARDS 90 -- 3.7 CARE INTENSITY FOR A SELECTION OF PATHOLOGY GROUPS 92 -- 3.7.1 Background on evolution in intensity per patient day 92 -- 3.7.2 Evolution in intensity by relative day 97 -- 3.8 KEY POINTS 100 -- 4 NURSE STAFFING IN HOSPITALS: THE BELGIAN PAYMENT SYSTEM 101 -- 4.1 HOSPITAL REVENUE SOURCES 101 -- 4.1.1 Budget of Financial Means 101 -- 4.1.2 Deductions on physician fees 102 -- 4.2 A DRG-BASED BUDGET ALLOCATION, CORRECTED FOR NURSING CARE 102 -- 4.2.1 General principle 102 -- 4.2.2 Justified beds are weighted per department type 103 -- 4.2.3 Basic and supplementary budget for nursing staff in 2018 104 -- 4.3 ADDITIONAL BUDGETS FOR NURSING STAFF 105 -- 4.3.1 Additional budgets for extra nursing staff in general nursing wards 105 -- 4.3.2 Nursing staff for specific wards, patients or tasks 107 -- 4.3.3 Additional budgets for better working conditions or higher income of existing staff 108 -- 4.4 RELATIONSHIP BETWEEN NURSE STAFFING LEVELS AND THE HOSPITAL BUDGET 110 -- 4.4.1 The hospital budget and patient-to-nurse ratio 110 -- 4.4.2 A maze of rules makes it impossible to know the budget for nurse staffing 110 -- 4.4.3 Lack of transparency undermines a safe staffing policy at the macro and micro level 111 -- 4.4.4 Insufficient hospital budget to cover basic financing standards 112 -- 5 EVOLUTION OF NURSE STAFFING AND WORK ENVIRONMENT IN BELGIAN ACUTE HOSPITALS 2009-2019 113 -- 5.1 BACKGROUND 113 -- 5.2 STUDY OBJECTIVE 113 -- 5.3 STUDY DESIGN 113 -- 5.3.1 Participants 113 -- 5.3.2 Survey methodology 113 -- 5.3.3 Measures 114 -- 5.3.4 Statistical analysis 115 -- 5.3.5 General Data Protection Regulation (GDPR) 116 -- 5.4 STUDY POPULATION 116 -- 5.4.1 Participating hospitals 116 -- 5.4.2 Participating nurses 117 -- 5.5 RESULTS 119 -- 5.5.1 Findings for the 2019 KCE study on nurse staffing 119 -- 5.5.2 Evolution of nurse staffing and quality of care between 2009 and 2019 176 -- 5.6 KEY POINTS 202 -- 6 INTRODUCTION AND APPROACH TO THE INTERNATIONAL SAFE STAFFING POLICIES 203 -- 6.1 AIM OF INTERNATIONAL COMPARISON 203 -- 6.2 STUDY APPROACH 203 -- 6.2.1 Selection countries / regions 203 -- 6.2.2 Approach international comparison 205 -- 7 ENGLAND 206 -- 7.1 CONTEXTUAL INFORMATION ENGLAND 206 -- 7.2 SAFE STAFFING POLICIES: LOCAL INITIATIVE SUPPORTED BY NATIONAL GUIDANCE 209 -- 7.2.1 Nurse staffing and patient safety: extensive public debate but no top-down imposed policy measures 209 -- 7.2.2 National guidance focuses on a triangulated approach and a Board-to-ward policy 210 -- 7.2.3 Caring Hours per Patient Day (CHPPD) as a central measure to compare staffing within and between hospitals 213 -- 7.2.4 Approaches used by other UK countries 214 -- 7.3 IMPACT OF THE POLICY 216 -- 7.4 KEY LEARNING POINTS 218 -- 8 AUSTRALIA WITH A FOCUS ON MANDATED RATIOS IN VICTORIA AND QUEENSLAND 219 -- 8.1 CONTEXTUAL INFORMATION AUSTRALIA 219 -- 8.2 VICTORIA ONE OF THE FIRST STATES IN THE WORLD TO INTRODUCE MANDATED PATIENT-TO-NURSE RATIOS 221 -- 8.2.1 Nursing profession in malaise after a series of budget cuts 221 -- 8.2.2 Introduction of mandated patient-to-nurse ratios: first obligatory part of the industrial bargaining agreements now imposed via the Safe Patient Care Act 222 -- 8.2.3 Mandated staffing ratios for various areas: nursing ward level ratios allow flexibility 223 -- 8.2.4 Impact of Victorian ratios: understudied 224 -- 8.3 QUEENSLAND: MANDATED PATIENT-TO-NURSE RATIOS RESEMBLING THE VICTORIAN MODEL 225 -- 8.4 KEY LEARNING POINTS 227 -- 9 IRELAND 229 -- 9.1 CONTEXTUAL INFORMATION IRELAND 229 -- 9.2 DEVELOPMENT OF AN IRISH FRAMEWORK FOR SAFE STAFFING 230 -- 9.3 KEY COMPONENTS OF THE IRISH SAFE STAFFING FRAMEWORK 231 -- 9.3.1 Acuity based NHPPD: an important measure to guide staffing decisions 231 -- 9.3.2 Safe staffing depends on the broader context 234 -- 9.3.3 Macro-level factors 235 -- 9.3.4 Nursing workforce governance 235 -- 9.3.5 Accountability measures 235 -- 9.3.6 Accompanying measures 236 -- 9.4 IMPACT OF THE POLICY 236 -- 9.5 KEY LEARNING POINTS 238 -- 10 UNITED STATES WITH A FOCUS ON CALIFORNIA 238 -- 10.1 CONTEXTUAL INFORMATION USA 238 -- 10.1.1 Number of nurses in the USA 238 -- 10.1.2 Professional levels and education in nursing in the USA 239 -- 10.2 DESCRIPTION OF SAFE STAFFING POLICY 240 -- 10.2.1 Background safe staffing policies in the USA 240 -- 10.2.2 Minimum patient-to-nurse staffing ratios 241 -- 10.2.3 Staffing committees and nurse staffing plans 251 -- 10.3 KEY LEARNING POINTS 253 -- 11 DISCUSSION INTERNATIONAL COMPARISON 255 -- 11.1 LESSONS LEARNED 255 -- 11.1 BUDGET IMPACT OF A SAFE STAFFING POLICY IN BELGIUM 259 -- REFERENCES 262 -- APPENDICES 284