How Does the Nurse-to-Patient Ratio Impact Nurses?

An overnight nurse sat at my bedside a few years ago when I was on the patient side of the healthcare system. 

“I won’t be able to check in with you that often tonight – are you OK?” 

She looked stressed, staring at her computer screen, and clicking around frantically as she confirmed my information and documented her medication administration. 

“I am sorry, we are just so short staffed, and I have four other patients I’m taking care of.” 

As she left my room, I was grateful that my hospitalization was a very low acuity admission. Despite the fact that I didn’t require too much attention, I’m not sure that the nurse was happy with the amount of time she had to spend with me. 

What is the ideal nurse-to-patient ratio? 

It is still unclear whether perfect nurse patient ratios exists, though some states have implemented or are exploring the idea of mandating nurse-to-patient ratios. Nurse patient ratios are typically based on acuity considering the level of care the patient requires.  

In 2004, California was the first state to pass a nurse patient ratio law. The California legislation specifies that the ratio fluctuates based on the acuity of the patient care setting. Nursing unions in other states including Florida, Iowa, Minnesota, New Jersey, New York, Texas and District of Columbia are crafting legislation that could help these states follow suit. 

What are the benefits of nurse patient ratios? 

Understandably, limiting the number of patients that one nurse could care for at any given time would allow more time for nurses to spend with individual patients. However, this benefit may be complicated by higher acuity patients needing more nursing care.

Having nurse-to-patient ratios may lead to improved patient safety, lower levels of burnout, and higher levels of job satisfaction. Also, the logistics of preserving the ratio force teams to take breaks in a way that ensures the nurse-to-patient ratio is maintained. 

What are the challenges with implementing nurse patient ratios?

Hospital administrators are often against implementation of ratios due to budget implications of hiring more nursing staff. However, a study from the California Health Care Foundation (CHCF) found that financial implications of the patient ratio legislation were minimal. There are concerns that the higher costs of hiring more nursing staff could ultimately be passed to third parties or patients. Additionally, as hospital environments tend to be very dynamic, implementing a patient ratio may not allow for staffing flexibility. In light of the impending nursing shortage, recruiting more nurses to meet nurse-to-patient ratios will likely put hospitals in a difficult position. 

This systematic review evaluated observational studies which have demonstrated that increasing nurse-to-patient ratios results in decreased patient mortality. So, while the up-front cost of hiring more nurses would mean increasing budget for salaries, the projected cost avoidance could balance it out. In the CHF study, the impact of patient ratios on other outcomes such as length of stay, pressure ulcers, failure to rescue, deep vein thrombosis, were not impacted significantly by improved nurse-to-patient ratios. 

Where does this leave us in the nurse-to-patient ratio discussion? 

Many states have drafted legislation that is moving through the legislative process, but the jury is still out regarding the evidence-based implications of nurse-to-patient ratio on patient care outcomes. Health-systems should consider how implementing nurse-to-patient ratios would impact their clinical, humanistic, and financial factors in their institutions.