아동병동 간호사-환자 비율 규제의 제도화 개념 분석: 캘리포니아 모델과 한국 사례 비교

Concept Analysis of the Institutionalization of Nurse‑to‑Patient Ratio Regulation in Pediatric Wards: A Comparison of the California Model and the Korean Case

(Background) Pediatric patients differ physiologically and developmentally, are prone to abrupt deterioration, and require caregiver education and multidisciplinary coordination. Accordingly, in pediatric units (general wards, PICUs, NICUs), the nurse‑to‑patient ratio (NPR) is a core determinant of safety and outcomes. (Objective) Using Walker and Avant’s (2019) concept‑analysis method, we define institutionalization of NPR regulation in pediatric wards and, comparing California with Korea, propose design principles and an evaluation framework for Korea’s legal, sub‑regulatory, and enforcement systems. (Methods) We conducted a comprehensive review (January 2000-July 2025) in Pub Med, CINAHL, and RISS using the keywords institutionalization, nurse‑to‑patient ratio, nurse staffing, mandated ratios, patient classification system(PCS),enforcement, compliance, pediatric ward, PICU, NICU, California,Title 22, and “Health & Safety Code. After screening, 40 of 400 records were included. (Results) Institutionalization comprised five defining attributes: (1)coerciveness and enforceability; (2)clarity in application unit and counting rules(shift‑and ward‑level; direct‑care only); (3) adaptability and flexible operation (PCS‑linked augmentation and exception rules); (4) sustainability (financial and workforce linkages); and (5) equity and evaluation linkage (public reporting and risk adjustment). California’s Health & Safety Code 1276.4 and Title 22 70217 mandate shift‑level minima (1:4 pediatric wards; 1:2 RN in PICU/NICU), count only direct‑care staff, prohibit shift averaging, and operate oversight-corrective action-sanction mechanisms—an archetype of institutionalization. Korea lacks pediatric‑specific statutory minimums, relying on incentive‑based tools (nursing care fee differential grading, Integrated Nursing and Care Service). Despite 2023-2024 refinements (e.g., patient‑based calculations), shift‑level monitoring and sanction structures remain limited, perpetuating regional and institutional disparities. We propose an indicator set of eight core measures. (Conclusion) Institutionalizing NPR means embedding an operational public system—not merely codifying or recommending—ensuring shift‑level floor compliance, PCS‑triggered augmentation, a corrective/recurrence‑prevention cycle, and data transparency. For Korea, we propose an integrated design linking law, sub‑regulation, operational guidance, oversight/sanctions, and public reporting; a standardized PCS with explicit exception rules; a finance‑workforce package; and an equity‑weighted evaluation framework.