Running head: NURSE TO PATIENT RATIO

Nurse to Patient ratio and the Impact

Michelle Carrillo
Western Washington University

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Introduction

Nurses are the forefront of healthcare, they spend the most time with patients than other
healthcare professionals do, but the amount of time allotted for care is limited because their
patient load is high. Nurses are expected to deliver high quality care regardless of how many
patients they are caring for. The healthcare system does not recognize the amount of time that
goes into patient care, nor does it give attention to the acuity of a patient and it fails to consider
the dire consequences of healthcare delivery when nurses are given too many to care for. The
healthcare system is not supportive of the nursing staff or the patient because there are no
regulations that require a set number of patients to nurses (ratio). Requiring regulations that
mandate a specified number of patients per nurse will improve healthcare delivery by increasing
patient survival rates, improving patient safety, and increasing nurse job satisfaction.
People heavily rely on healthcare professionals and seek out their expertise when they are
struck with illnesses and diseases. All people who utilize healthcare services share a common
goal which is to get better, be stabilized, and to be treated or cured of illness and disease when
possible. They expect to be provided with quality and safe care. Patients place their lives in the
hands of expert healthcare professionals and fully entrust them along the way. Currently, there
are several issues within the healthcare system that are far from helping patients achieve these
goals.
Research Process
This issue within the healthcare system of having too many patients to care for and not
enough time is well known to me because I am a nurse and have worked in healthcare for eleven
years. A question that came to me initially when I began examining this issue was, Why are

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there no laws that mandate a specific number (ratio) of patients to nurses across healthcare
settings? As I began my quest of finding articles to answer this question I didnt find much
information that could and so I decided to expanded my research process. I started reviewing
articles and literature in CINHAL a nursing database that were about patient safety, mortality,
and staffing guidelines in healthcare, as well as nurse burnout and job dissatisfaction. What I
discovered is that all of these directly relate to each other and are interesting to me, which was
how I arrived at my final thesis and claims for this paper.
The articles and literature review included in this paper has all been peer reviewed. The
selection for them was based on what topics they covered and that they also included studies
done internationally, covering a broader basis. They accurately present the purpose of this paper
and support the claims which include patient mortality, effect of patient safety, and nurses job
satisfaction, all of which are affected from not having mandated ratios across healthcare settings
and therefore has negatively impacted healthcare delivery.
Patient Mortality
The effects of not having specified nurse to patient ratios within healthcare settings has
caused an increase in patient mortality. Although the amount of patients that nurses care for is
varied across different healthcare settings, it falls short in meeting the demands of care due to
insufficiently staffing nurses. A study was done by Duffin (2014) that focused on Intensive Care
Units (ICU) specifically, A team of UK researchers concluded that seven extra lives would be
saved for every 100 patients at relatively high risk of death if nurse numbers increased from four
to six per bed. Among patients with mid-range relative severity of illness, about four extra lives
per 100 would be saved. The idea of having ratios across healthcare settings is not limited to

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suggesting that nurses care for a set number of patients, but to also provide enough staffing per
bed and to consider patient acuity-meaning the amount of time and care one needs. There is an
increase in patient mortality that results when nurses are given too many to care for and likewise
a decrease when the ratio is adequately portioned. These results are astounding not only because
it shows that the ratio does matter, but it also emphasizes how much nurses impact healthcare
delivery.
The importance of nurses in healthcare settings cannot be emphasized enough because
staffing them accordingly will in fact, provide patients with better outcomes and increase their
chances of survival. With the addition of one more full-time nurse per day, G. Martin (2012)
found that patient deaths decreased by 9% in the ICU, surgical deaths decreased by 6%, and
medical deaths decreased by 6%. What G. Martin (2012) also found is that when a nurse was
given an additional patient to care for, the death rate increases to 15%. These results reveal why
it is so important to address this issue and supports the need for mandating ratios in all healthcare
settings. It gives consideration to two issues by providing not only the positive effects that occur
with the addition of one full-time nurse, but also proves that negative outcomes happen when
they are given one more patient to care for. These results are profound and the healthcare system
has not considered implementing safer staffing guidelines to prevent such tragedies that can be
avoided.
International studies have been done that support the need for implementing specified
nurse to patient ratios across healthcare settings. These studies were done in 30 countries on 4
continents and considered differences which included financial resources, strategies used, and the
amount of staffing. The results by Aiken (2015) found that patient mortality is increased by 7%

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more when nurses are given an additional patient to care for, regardless of the healthcare setting.
It is clear in research findings that patient death rates rise when nurses have too many to care for.
Patient Acuity
It is vital that there is a guideline established to mandate safer nurse to patient ratios
across healthcare settings. Along with the implementation of mandating ratios there is additional
information to consider. A guideline needs to consider essential information about which
population the nurse is caring for, a patient in an ICU or that is in critical condition would require
more time for care, in contrast to patients on a medical floor. It really depends on the patients
level of acuity so its important to establish a safer staffing ratio for each setting that addresses
these differences. The current methods that are used for safer staffing in healthcare are based on
cost containment and customs strategies; G. Martin (2012) believes that this is a modifiable
change within the healthcare structure. As a starting point in applying safer nurse to patient
ratios a Safe Staffing Escalation Toolkit as G. Martin (2012) suggests is useful because it
acknowledges the amount of work that nurses do, and accounts for several factors including,
patient rate of admission to discharge, duration of stay, the age and type of acuity, as well as
considering the nurses level of expertise. Methods such as these are needed because it gives
attention to the many aspects that are important and will improve healthcare delivery. Applying
this Toolkit does address the current shortcomings patients and nurses are left with and it is a
good guide for healthcare professionals to use.
Furthermore, what Duffin (2014) found is that specialized nurses caring for the critically
ill have the necessary skills and experience to detect changes more rapidly in a declining patient.
This suggests that staffing safely will lessen the chances of negatively affecting patient

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outcomes. What Duffin (2014) also acknowledges is that healthcare settings who rely on nurses
from an agency or bank staff (travel nurses, outside agencies) are not adept to their
environment, arent specialized in caring for those who are more severe or critically ill, and may
not be well in tune with recognizing rapid or subtle changes. It is essential that nurses have the
ability to provide the best care for patients and be educationally prepared to handle situations as
they arise to prevent negative outcomes.
Higher Education
Along the same lines, Aiken (2015) found that nurses who are university-educated
provide patients with better outcomes. Specifically, for every 10% increase in universityeducated nurses that work in healthcare there is a 7% lower mortality rate. Furthermore, Aiken
(2015) suggests that if European hospitals including, England, Spain, Poland, Germany, Greece,
and Switzerland, were to staff hospitals with 60% of the nurses being university-educated, then
3,500 patient deaths could likely be avoided.
Nurses that are university-educated have at least a Bachelors of Science degree (BSN) in
nursing or a higher degree, such as a Masters of Science (MSN) in nursing. Having education
that is beyond the Associates of Applied Science degree (AAS) in nursing, better prepares nurses
to serve and care for more diverse and complex populations. Several countries consider the entry
level of nursing being at the BSN level, while in the USA the AAS degree is entry level.
Currently the USA is encouraging nurses to pursue higher education that is beyond the AAS
degree level. Today, many employers in the USA that are looking to hire, highly prefer nurses
that hold a BSN degree, more so than ones with an AAS degree. This has prompted many nurses

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in the USA to pursue higher education and also provides them with more opportunities for
employment.
What is more assuring than ever as G. Martin (2012) points out is that California, the
USA, and Australia, have been implementing changes through government legislatures to
address the level of staff in proportion to patients including attention to the nurses level of
expertise, effect of care, and safety. These changes are becoming more evident as the USA is
giving attention to the nurse to patient ratios and are encouraging nurses to pursue higher
education, which is being expected more and more.
Patient Safety
Addressing the nurse to patient ratio will increase patient safety. It will provide
nurses with the time that is needed to deliver care and more opportunities for contact because the
amount of patients they have are less. Nurses are so busy while not at the bedside, they are
preparing medications, performing timely treatments, maintaining intravenous lines, and
performing procedures that the physicians order. The more time that is spent away from the
bedside compromises patient safety. According to G. Martin (2012) other duties that a nurse
fulfills during their shift such as paperwork, places time constraints on their availability in
providing care and as a result, negatively impacts patient outcomes. Every opportunity that a
nurse has for patient contact is used to assess their condition, the environment for safety and to
ensure that the monitors (medical equipment) are properly functioning.
Nurses are not always able to respond promptly when a situation arises because they are
busy completing job tasks or are caring for others. They are constantly working against the clock,
prioritizing and reprioritizing work throughout their shift to accommodate patient needs. What G.

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Martin (2012) has found is that staffing nurses inadequately increases failure to rescue rate to
7%. Failure to rescue is referring to a patient death after being treated for a complication, such as
surgery. Likewise, C. Martin (2012) has found that patients, their families and friends are
affected due to insufficient staffing.
Nurses Job Satisfaction
Nurses work in a demanding environment and are constantly shifting gears to meet
patient needs. With the amount of patients they are given and the workload, they struggle to keep
up with it. Over time, nurses become tired and stressed because they are so overworked. The
result of these effects takes a toll on nurses. Research by C. Martin (2015) found that nurses have
become less satisfied in their career with reports that 1 in 5 nurses in the USA resign within a
year. Employment retention becomes a problem as well as increased errors as longer hours of
nurses are demanded, causing burnout. If agencies expend on their staff C. Martin (2015)
suggests that it will increase staff retention and job satisfaction and will provide patients with
better outcomes. When there are negative effects felt by both the patient and the nurse it is
necessary to implement safer staffing ratios to achieve optimal outcomes. Today in the USA,
there is a shortage of nurses and many that are employed are close to retirement age. The deficit
of nurses in the USA is expected to rise and the healthcare system cannot afford to lose any of
them due to unfavorable working conditions.
How This Ties Together
Patients lives depend on nurses and delivering healthcare that is optimal for the best
outcome is needed. Mandating ratios that are safer will improve healthcare delivery by
increasing patient survival rates, increasing safety, and increase nurse job satisfaction. Guidelines

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are needed that consider patient acuity, nurse expertise and education, and the amount of time
that goes into care, all of which will improve the quality of healthcare and its delivery.
Conclusion
Addressing the shortcomings that are evident in the healthcare system will provide
patients and nurses alike, with better outcomes. It may or not be as simple as fixed nurse to
patient ratios to create better outcomes, but it is looking at different matters that all work together
to obtain them. There is proven research that strongly demonstrates a need for change in the
healthcare system. What this research has shown me is that there is a rippling affect by not
having safer staffing ratios in healthcare and it affects not only the patient, but the healthcare
team as well. This research has validated my opinion and has given me a broader understanding
of what is lacking in the healthcare system.

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References

Aiken, L. (2015). Ratios save lives.

Lamp, 72(1), 16-17 2
Duffin, C. (2014). Increase in nurse numbers linked to better patient survival rates in ICU.
Nursing Standard, 28(33), 10-10 1p. doi:10.7748/ns2014.04.28.33.10.s8
Martin, C. (2015). The effects of nurse staffing on quality of care.
MEDSURG Nursing, 24(2), 4-6 3
Martin, G. (2012). Perspectives on safe staffing.
Dissector, 40(2), 18-20