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Nurse to Patient Ratios


There are certain things that clinicians must have access to for them to provide the best possible health care to people, including work schedules, technological tools, and mentorship. These necessities also promote the health and well-being of healthcare providers, but there is one other critical factor that cannot be overlooked. The workforce is one of the major aspects of healthcare that has to be given utmost consideration for the promotion of health and well-being of the patients as well as healthcare providers. For instance, if the number of patients largely exceeds that of available nurses, then clinics and hospitals may face serious problems. It is of great significance to construct and maintain a suitable ratio that would ensure the provision of the best healthcare services to people who need it. The employment of nurses takes place in large quantities throughout the branch of healthcare. Additionally, nurses are, arguably, the group of employees that is most costly due to their salaries. However, since the healthcare industry has a form of business in America, unlike in the majority of other countries, insurance companies play a major role in treatments and patient care. Reducing their numbers to attain large financial savings is not an option since the issue of the nurse-to-patient ratios affects the well-being of patients, staff, and the organization itself. With modern healthcare increasingly becoming a considerable business in the country, the nursing department has suffered deeply, with nurses being affected most, which resulted in complaints of being overworked and underpaid. Thus, this issue directly and adversely affects patient care. Two distinct positions regarded in this paper concern the question of whether increasing or decreasing nurse-to-patient ratios could decrease hospital costs and overall hospital expenditures. It is highly possible that reducing nurse-to-patient ratios will enhance the quality and safety of care, dispel poor morale, and result in fewer lawsuits, as well as decrease the use of agency nurses.

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Background of the Issue

Nurses are the core professionals in the healthcare industry, and they have an assorted role that encompasses many duties, including spending a lot of time with the patients, which is the essence of the effective operation of healthcare facilities. The nurses comprise a large percentage of the healthcare workforce and are valuable for the effective operation of a hospital. However, the department cannot be streamlined under any circumstances since it would result in nurses being overworked. Furthermore, several pieces of research suggest that when nurses take care of a large number of patients, it adversely affects patient care (Sherenian et al., 2013). nurse-to-patient ratios affect the degree of nursing malpractice, nurse retention, and staff morale, which in the long run may result in increased hospital costs, inferior patient care, and widespread nursing and healthcare concerns.

1. Patient Outcomes

It is vital to note that nurses are the core professionals in the healthcare industry, the members of the healthcare team who are responsible for patient care and patient outcomes. Nevertheless, while the contribution of the entire healthcare team is indispensable, the nurses have the utmost involvement and contact with the patients. Hence, if the nurse-to-patient ratio is substandard, then there is the risk of unsatisfactory patient outcomes.

Sherinian and colleagues (2013) studied the admission of patients to Neonatal ICUs to determine how nurse-to-patient ratios affected patient outcomes in the Neonatal ICUs. The study found that there is a direct correlation between the nurse-to-patient ratios with neonatal mortality. The main outcome of the study was the rates of mortality before discharge from the hospital, which were directly connected to nurse-to-patient ratios. The other outcomes of the study concerned a nosocomial infection, intraventricular hemorrhage, and days on oxygen, as well as the days of assisted ventilation (Sherenian et al., 2013). Duffin (2012) argues that increasing the nurse-to-patient ratios will increase safety, which ultimately promotes patient satisfaction. According to the study, care will not be secure if one nurse oversees more than seven patients in the wards of older people. TS (2015) demonstrated the ability of the higher nurse-to-patient ratios to reduce injuries. The study found that when the nurse to patient ratio is set at 1 nurse to 5 patients (1:5), then there are fewer occupational illnesses and injuries, which is a lot slower than the expected rate without the set nurse to patient ratios (TS, 2015).

Tellez (2012) also carried out a longitudinal comparative analysis, evaluating the impact of nurse-to-patient ratios on job satisfaction levels among the nurses. He established that the nurse-to-patient ratio laws contributed to an improvement of nurse satisfaction since there has been a rise in the level of satisfaction of nurses after the introduction of the law. Knudson (2013) reported similar findings in a study examining the relationship between the nurse-patient ratios, nurse burnout, and patient outcomes. The research showed that every additional patient allocated to a nurse brought a 7 percent increase in the possibility of death within 30 days of admission, as well as a 7 percent increase rate in the inability to prevent the patient from dying (Knudson, 2013). Every additional patient assigned to a nurse brings an increase in burnout, which results in job dissatisfaction. The study also found that healthcare facilities with fewer patients per nurse have lower mortality rates. According to Knudson (2013), job dissatisfaction among the nurses that work in hospitals is at least four times higher than the usual rate of dissatisfaction for all other workers in the United States. Hence, the severity of the allusion related to the issue of the nurse-to-patient ratios calls for the implementation of safe staffing strategies for optimal patient outcomes and enhanced nurse retention.

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Moreover, some authors have associated poor nurse-to-patient ratios with complications such as pneumonia, urinary tract infection, and some post-operative complications (Sherenian et al., 2013). These researchers acknowledge that fewer nurses during the evening shifts add to the risks of complications since it is during these hours that the numbers of the ancillary staff, such as the housekeepers, secretaries, and hospital porters, are the lowest, which leaves the nurses with extra duties. This extra sense of obligation further increases the nurse's responsibilities, which affects their productivity. However, there may be times when there is a decreased level of activity, meaning that nurse-to-patient ratios would not significantly affect patient care. Additionally, nurses' experience can help to alleviate the negative consequences associated with the reduced number of nurses, although nurse-to-patient ratios should still not exceed a certain level.

2. Staff Morale

Nurse-to-patient ratios also affect nursing morale. According to Sherinian and others (2013), nursing morale is at its lowest when there is a presence of negative attitudes and apathy in personal practice. Several other things may result in such reactions in nursing practice, yet undoubtedly, a reduced number of nurses and an increase in patient load contribute significantly to such behaviors. Furthermore, low morale results in stress decreased attention to important details and a decrease in general nursing performance. According to a study published several years ago, various nurses interviewed felt that nursing was not a good profession and they would not recommend it to others (Knudson, 2013). Also, American researchers found that the majority of nurses changed professions because of the escalating workloads and the deteriorating morale in nursing. Arguably, the lack of nurses' morale at work is, and continues to be the driving force behind the decision of nurses to leave the profession, which adds to the issues of nurse staffing and the increasing nurse shortages.

Additionally, there is an increasing number of vacant nursing positions which is likely to go higher due to the low staff morale evoked by the nurse to patient ratios. It is also difficult to recruit new nurses, especially since the current nurses do not promote the profession. The recruitment of nurses is expensive and it is better to retain the practicing nurses, which is more cost-effective than recruiting new ones (Knudson, 2013). Still, recruiting new nurses is also essential despite its costliness since it is needed to lessen the effects of the aging nursing workforce. It is important for practicing nurses to be motivated to continue working as nurses, which is currently a problem. The reason for this is the lack of desire of many nurses to continue working in an environment where there are high patient loads since it makes them feel undervalued.

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3. Legal Ramifications

Nurse-to-patient ratios also affect legal ramifications in nursing. Nurses suffer from a heightened risk of facing more legal consequences if they are required to work with increased workloads due to unbalanced nurse-to-patient ratios. In the United States alone, nurses make high malpractice payments that are the result of poor documentation, failure to follow the required standards, and lack of proper communication. All these reasons are nursing requisites that demand time, which is something that is encountered rarely in this area, considering high nurse-to-patient ratios.

The employment of nurses might be very costly to healthcare facilities, but lawsuits are even costlier. In 1999, according to the court's decision, $2.7 million was paid for damages to Shirley Keck, a 61-year-old patient who suffered from a respiratory arrest resulting in a brain injury due to the lack of frequent assessments by the nurse, who was evidently overworked (Curtin, 2011). At the time of the incident, the unit had 41 other patients, and despite the hospital's staffing standards necessitating the presence of 2 licensed practical nurses and 5 registered nurses, only a total of 5 nurses were on duty. Keck did not sue any of the nurses, but instead took action against the hospital due to the lack of a sufficient number of nurses, which adversely affected patient care. It means that additional four or five nurses would have saved the hospital a lot of money.

Maintaining poor nurse-to-patient ratios with the intent of saving money gives hospitals the notion of a false economy. Despite the evidence that high nurse-to-patient ratios result in increased mortality, it is a question whether consumers will be willing to increase their health insurance premiums and if hospitals will be willing to pay higher salaries to fund the diminishing nurse-to-patient ratios. One nurse who has worked in healthcare systems all over the world believes that until people find overwhelming evidence that shows the dangers of increasing the nurse-to-patient ratios in almost all healthcare facilities in America, the hospitals will still not spend their precious resources on the increment of staffing levels. Another dire consequence of high nurse-to-patient ratios is medication errors that can result in severe complications and even death (Duffin, 2012). With such consequences, negligence and malpractice suits are expected, and most nurses blame the occurring errors on the lack of staff.

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The Proposed Plan

According to the literature reviewed, it is evident that something has to be done to enhance the nurse-to-patient ratios. The central issue for many healthcare managers is to reduce costs, but the implications of reducing the nurse's number to reduce the costs are severe and disconcerting. These issues have been made known to political leaders and healthcare administrators, especially with more and more American states taking into consideration the mandating of nurse-to-patient ratios. California was the first American state to do so, followed by Hawaii, Tennessee, and Nevada (Mchugh et al., 2012). The state of Victoria has also made set nurse-to-patient ratios official, which proved to be successful despite little empirical data to support the claim. It might be costly to put this initiative into action in the short-term perspective, but decreasing the patient's length of stay in hospitals could save quite a large sum of money for the hospitals.

Introducing mandates will allow limiting the nurse to patient ratios despite the concerns that it would result in a maximum nurses number per patient. The policymakers in California dispute this and claim that ratios are there to enhance patient care as well as alleviate nurse stress, and not to reduce costs (Mchugh et al., 2012). The bill indicates that hospitals can be fined and disciplined if they fail to follow the ratios, and it encourages the nurses to report the cases when their patient numbers exceed those established by mandates.

Dependency scores is another way that can be used to regulate staffing since it considers patient numbers and acuity levels, although the scores may be inaccurate. It is evident in the fact that nurses are adaptable human beings who despite an increase in the number of patients and their staffing levels still perform their duties consistently, completing their work (Duffin, 2012). It can mislead the administrators, making them think that their staffing levels are adequate whereas they are far from being so, thus upholding a forged sense of security.

There is a plan related to Healthy People 2020 goals and professional nursing to associate the nurse to patient ratios with the patient outcomes. This plan, just as the Healthy People 2020 goals and professional nursing, aims to promote positive patient outcomes in acute care hospitals. It strives to influence and enhance the nurse staffing policies as well as the nurse staffing strategies that would ultimately improve patient outcomes. Furthermore, they both show the correlation between patient outcomes and nurse staffing ratios, which is attributed to reduced hospital-related rates of mortality.

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Policy Implications

Possible staffing decisions that strive to enhance the quality of care would lack practicality since they involve the comparison between the existing staffing and the changes in staffing that are necessary for attaining desirable patient outcomes. Most hospitals lack the viability to depend on rich staffing ratios. Defining the best nurse staffing levels is also difficult since it requires the addressing of cost-effective analysis, which is not regarded in this report. When a nurse looks after additional patients during each shift, the risk of negative patient outcomes also increases. Furthermore, the increased nurse-to-patient ratios are the main contributor to low nursing morale, and leveling out this balance can be the solution to promoting better recruitment as well as retention methods. Several U.S. states are putting into consideration the issue of mandating precise nurse-to-patient ratios that will be based on the minimum ratios and not the maximum ones. Some employers might reduce the supportive staff positions to cut the costs since being bound by a mandatory nurse-to-patient ratio means they cannot reduce the number of nurses. It is worth noting that reducing the number of nurses can save hospitals money for a while, but the benefits would not last long since in the long run, reducing nurse-to-patient ratios may increase hospital expenditures. As a final point, the amount of work done by a nurse is not measured by the number of patients he or she cares for. The patient flow, which includes transfers to and from other units, return from surgeries, admissions, and discharges, can show that the nurse is providing care for more patients than reflected in the nurse-to-patient ratio. It should be viewed as a significant factor of the issue of nurse-to-patient ratio and should be considered in future studies as a measure of nurse staffing.


The situation in healthcare facilities is similar all over the world. Nurse-to-patient ratios are related to patient outcomes, such as inpatient mortality, nosocomial infection, and intraventricular hemorrhage, among other medical issues. The healthcare systems may differ from country to country with varying levels of care and practices, but the issue of the nurse-to-patient ratios affects all of them. The paramount concern of the nurses is not salary, but poor levels of staffing that endanger their lives and those of the patients. Furthermore, most nurses prefer to be able to provide their patients with quality care, which is made possible by increasing the nurse-to-patient ratios rather than by being given a pay increase. Nevertheless, most healthcare managers do not wish to increase the number of nurses, but would rather reduce it because of cost reduction, especially since nurses make up the largest number of employees in healthcare with high salaries, making them a significant investment. It is therefore understandable that managers would wish to cut hospital costs by raising the nurse-to-patient ratios. However, the approach comes with a high price, and thus staffing ratios should be founded on patient needs and not on budgets. It is evident that when the number of patients is a lot higher than the number of nurses, then there are poor patient outcomes as well as longer hospital stays. Reducing nurse staffing levels can also result in poor staff morale, issues related to nursing retention and recruitment, as well as malpractice suits, which can substantially raise costs to a level above the expected expenses of recruiting more nurses.

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It is vital for healthcare managers not to solely focus on short-term budgetary restraints, but to look at the global picture. If they try to reduce hospital costs by increasing the nurse-to-patient ratios, it may increase the overall hospital expenditures. On the other hand, it is highly possible that reducing the nurse-to-patient ratios will enhance the quality and safety of care, dispel poor morale, and end in fewer lawsuits, decreasing the use of agency nurses. All of these factors could make a long-term contribution to the reduction of hospital costs. Additionally, with these measures put in place, nurses will be empowered to do their best by taking care of their patients in a safe and caring manner.

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