Hospital: a place that employs one doctor to work a bazillion-hour week, one nurse to care for 4 very sick people, and three maintenance men to put up 1 small shelf.

There has been quite a bit of discussion (particularly in the US) lately surrounding nurse patient ratios. The question is often put to examine what would be a safe nurse to patient ratio.
Well, seems to me what we should be striving for is not a ratio that provides safe patient care, but rather a ratio that fosters quality nursing care.

In our own emergency department we usually run about one nurse to 4 or 5 patients in the acute care setting1.
I think (without trawling the literature), this is probably a minimum safe level of staffing. But it is far from a level that promotes quality care delivery in an emergency department setting.

Just ask most nurses following a typically busy shift and they will complain of feelings of frustration and dissatisfaction. They feel that they couldn’t deliver the care they wanted to.

This is not surprising really, as patients in most emergency departments are an unstoppable queue of complex, undifferentiated, acutely unwell people who require continuous and careful assessment, frequent interventions, and constant vigilance2.

Most nights we spin the plates and juggle the balls and get through the show.
But its a pretty crap show.
Which is a crying shame. We have some fantastic nurses working in our department the best of the best. And nobody wakes up in the morning thinking “gee, I think I’ll skip my observations today, and I’ll pass on any pressure area care.”
But as the workload increases and nurses try to cover an exponentially increasing list of tasks, orders, interventions, interactions, interruptions, prioritisation’s and documentations…..quality is often the first casualty of the shift.

So what do I think is a quality nurse-patient ratio? Well, and feel free to scoff at this point, I think it would be one nurse to 2 patients in the acute care setting, one to two nurses for a critically unwell/unstable patient and four to one for a trauma or similar emergency.

Now we could get down to delivering some seriously good standards of nursing care.

……….I know, I know3.

  1. that can increase to one on one for a critically unwell patient and up to four to one for a trauma or emergent situation []
  2. Constable’s first law of nursing: all patients will crash if you look away []
  3. I live in some sort of phantasmagorical nursing dream world []

7 Responses to “what is a quality nurse-patient ratio?”

  1. I know how this issue is an important ,not only for nurce but absolutely for patients to improve thier satisfaction & to increse thier compliance ,stick with treatment and to avoid any divertion behaviour especialy among addictive paptients. In my 26 years experience in addiction psychiatric, the ratio depend on the quality of nurce, severity of illness,time of duty shift ( night or day) and different times in week ( holiday)or year( cellbration time/ winter or summer..etc).However, I think the ideal ratio is 1:3 ( Nurce: patients) at night shift in sever illenss or those withdrawal symtomes and in holiday(weekend).the ratio changes to 1:4-5 at day shift in less critical illeness & other times of week or specfic time in year ( cellebration times according culture).

  2. Ideally in an emergency setting,a 1:4 nurse-patient ratio is just too much to handle if you want to deliver a high quality of patient care.So,a 1:3 ratio might just be acceptable to look after stable patients in the emegency department,whereas,a 1:2 ratio for an intensive care patient in emergency department is just an ideal one.

  3. I know exactly how you feel. I work in an acute medical ward (basically we take overflow from the ED) in and area with a very sick and poor population, many with addiction problems. Usually we have one nurse to 6-9 acutely ill patients, most of which need assistance of 2 for most ADLs. 1 nurse to 2 patients sounds like heaven. I could actually plan and deliver care effectively rather than just deliver the bare acceptable minimum. As a new RGN I find the reality of of nursing (basically being too busy to do anything but complete a list of tasks) versus quality nursing care hard to assimilate in practice and in my own head.

  4. I work in an Oncology/Hematology department. We recently opened a BMT unit for stem cell transplant patients and it is fantastic to work in there – the ratio is now 2 patients to 1 nurse – 3:1 on night shift. It is such a change from the usual 5-6:1 on the main part of the unit. It is very satisfying to have the time you want and need available to spend with each patient and not feel like you have to run from one person to the next in order to get all your “tasks” done.

  5. I had this exact thought last week, so you’re not the only one in a dream world. Think about how much fun nursing can be those times when you only have to think about one or two patients, even if they are complex cases, because your attention isn’t divided. The ED is the bastard child of the ICU and the walk-in clinic, two very different beasts, creating a even more complex system. With such complexity, a certain degree of inefficiency is required in order to keep the whole thing from collapsing. In the terms of engineering (my first study), you need to put more potential energy (fuel) into the machine than the kinetic energy you want to get out (motion), because no engine is 100% efficient (fyi: the gas engine in your car is about 25-30%). Emergency medicine is still a very young and dynamic department, and as a result, we are far from developing a model that is even 40% efficient, except for very select trauma cases that breeze through to the OR (or so I hear at large places, never at my community hospital). As a result, we need more fuel to keep the engine running, and the best way to do that isn’t hiring a greater ratio of docs (expensive and less practical), nor more techs (my current job in-hospital, which is essential, but more detail oriented), but nurses, who are really the workhorses of managing the patients and getting them out the door (easier), or upstairs (more luck of the draw). In summary, it’s sad that our hope for lower ratios is dreaming, because it really makes sense for the state of the department as a whole, but will likely never be seen unless some advantage is shown in the hospital’s accounting books, or if surveys really start to go down the tubes and inservices on “how to care” get too costly to constantly run.

  6. There’s been some serious research in the US on nurse to patient ratio’s (http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/MandatoryNursetoPatientRatios.aspx). And in Victoria it’s mandated as 5 nurses to 20 patients in a Med/Surg ward – things seem to be happening….but only at a rate similar to 3 maintenance men getting around to putting up a simple shelf…..

  7. It is very hard when the institution policy is in front of everything. Book says for example that you must put one needle on when you are drawing drug into the syringe, and than you must take another needle when you want to administrate the drug to patient. But than, your chief says you must economize with eqiupment. Where is here quality care?

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