Nurses are often described as the glue that holds hospital care together. They monitor patients for changes, administer medications and coordinate a wide range of services, keeping everything on track.
Author
- Andrew Jull
Professor of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Waipapa Taumata Rau
But what happens when that glue is spread too thin to hold? Nursing numbers are now an election issue and public attention is turning to the impact of understaffing on hospital wards.
With fewer nurses caring for more patients comes the risk of ” missed nursing care ” – essential work being delayed, only partly completed or not done at all. This can lead to poorer patient care, longer hospital stays, higher readmission rates and a greater risk of harm.
And the problem is widespread. In a 2022 independent review , 83% of 3,366 frontline nurses said patients did not receive complete care on understaffed shifts. More than half (53%) also rated their mental health as poor or very poor on understaffed shifts.
Recent research by my University of Auckland colleagues has meanwhile found lower nurse staffing on surgical wards was associated with higher rates of post-operative death and complications. Modelling in the study estimated correcting the observed staffing shortfall could result in around 182 fewer postoperative deaths each year.
This all raises pressing questions about whether current staffing settings are adequate – or whether New Zealand should consider legislated minimum nurse-to-patient ratios.
How short staffing affects patients
To measure how much nursing time patients need on each ward and shift, New Zealand uses a system called Care Capacity Demand Management .
Introduced nationally in 2021 after more than 15 years of work, it assesses patients according to the complexity of their needs and calculates the nursing hours required to look after them. That is then compared with the staff actually available.
In theory, this allows hospitals to identify where there is spare capacity and move staff to wards facing greater demand. But that depends on having enough nurses available across the hospital in the first place.
There have long been signs the system is under pressure. In 2021, 23% of shifts were understaffed. Between 2022 and 2024, that figure was 38% .
In the recent study , researchers analysed 223,415 surgical admissions and staffing data from 94 New Zealand surgical wards between 2022 and 2024. They found 43.5% of shifts had fewer nursing hours available than patients were assessed as needing.
Each one-nurse reduction in staffing per shift was associated with 13% higher odds of patients dying within 90 days after surgery, while the odds of complications and ” failure to rescue ” – dying after developing a complication – were each 7% higher.
The researchers then modelled what might happen if the observed staffing shortfall was eliminated. They estimated this would require another 166 nurses, or 141 full-time equivalent positions, and could result in around 182 fewer postoperative deaths each year.
Could minimum ratios help?
Care demand modelling relies on extra staff being available to support areas of high need.
That requires hospitals to have enough nurses on the roster, as well as new nurses being employed as others leave. When hospitals are not fully staffed, shifting nurses between wards can only go so far.
One alternative is to set minimum nurse-to-patient ratios in law.
Queensland legislated for such ratios on specified public hospital wards in 2016, with the rules updated in 2023 . On day and afternoon shifts, there must be an average of at least one nurse for every four patients, while at night the minimum is one nurse for every seven patients.
Using an average gives wards some flexibility to manage staffing across a shift, including meal breaks, rather than requiring the ratio to be maintained at every moment.
Research suggests the approach has benefited nurses as well as patients. Compared with hospitals not subject to the change, nurses in Queensland hospitals covered by the ratios had 24% lower odds of high burnout and 27% lower odds of job dissatisfaction.
After two years, having one fewer patient per nurse was associated with 7% lower odds of death within 30 days, 7% lower odds of readmission and a 3% shorter hospital stay.
The estimated savings from shorter stays and fewer readmissions were more than twice the cost of employing the additional staff.
Queensland is not alone. California legislated for minimum staffing ratios in 2004, with research finding improvements in job satisfaction and burnout, as well as patient mortality and failure-to-rescue rates. Patients there receive around two to three more hours of nursing care per day than patients in other US states.
Minimum ratios have also been introduced in Oregon, Victoria in Australia, Ireland and British Columbia in Canada .
Health New Zealand has acknowledged the need to consider new approaches to nursing numbers and is investigating whether nurse-to-patient ratios could be used alongside other staffing models.
With understaffing still widespread and growing evidence of its effects on patients and nurses, there would appear to be a clear case for New Zealand to go further and follow the lead of those overseas jurisdictions in making it law.
From the cost of living to how best to tackle climate change, the coming election involves some big choices.
This article is part of The Conversation’s Election 2026 series : expert analysis of the major policy debates and the big challenges New Zealand’s next government will face.
