Imagine that you are a nurse who has recently graduated from nursing school, and after a month of studying for your boards, you have just passed your NCLEX exam. After a few interviews you find a job and once the training process is over you are ready to officially start your nursing career. On your first day you are assigned to a patient who was diagnosed with congestive heart failure and has decreased cardiac output as a result.
The patient is also experiencing shortness of breath on exertion and when he lies down, along with pulmonary edema. The patient has also been diagnosed with sleep apnea in addition to +2 edema in the ankles and feet. The patient’s abdomen is swollen, and he has been experiencing severe weakness and fatigue. His kidneys have begun to shut down (due to the heart’s inability to pump) and has low muscle mass. About an hour ago (before your shift started) the patient started to experience sudden and severe shortness of breath and began to cough up pink, foamy mucous and the electrocardiogram is displaying an abnormal heart rhythm.
The physician has been notified and he wants you to take vital signs every five minutes until the he arrives and attempt to stabilize the patient. This is an example of a complex patient who requires quite a bit of consistent care and will need to be monitored frequently throughout the day. Now, add six to eight other patients onto the nurse’s list of responsibilities to get a more realistic picture of a typical day on the floor. Unsafe nurse-to-patient ratios pose many different hazards for both the patient and nursing populations, which has created a public health problem worldwide.
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As this issue is becoming more and more prevalent, there are many different organizations that are working towards a resolution, one of the most well-known being QSEN. Founded in 2005, QSEN (Quality and Safety Education for Nurses) is a national movement that works hard to address the challenge of “preparing future nurses with the knowledge, skills, and attitudes,” that are required to improve the quality and safety of patient care delivery. Their vision is to inspire and encourage health care personnel to emphasize the importance of improved quality and safety to enhance patient centered care and satisfaction. The six competencies developed by QSEN include: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (QSEN, n.d.).
While the competencies of QSEN may seem generalized, they encompass a variety of healthcare issues. When focused on individually, the health care outcomes will not be as successful. However, when all of the elements are used together, the goals of QSEN can be accomplished. One issue that has been the focus of groups such as these, is the improvement in nurse-to-patient ratios in hospitals and long-term care facilities nationwide.
This issue has gained much attention over the past several years due to the growing concern regarding the safety of both patients and health care workers. According to an article published on the National Center for Biotechnology Information, some risks of low nurse-to patient ratios include: higher patient mortality rates, an increased number of complications during recovery, and an overall decrease in patient safety and satisfaction (McHugh, M. D., 2011).
In a New York State Nurses Association article, it states that the odds of patient death increase by seven percent for each additional patient that the nurse takes on during the care process (Safe Staffing, n.d.). Unfortunately, many facilities do not consider statistics when making nursing assignments each day. In fact, California is the only state that has passed a legislative law mandating facilities to implement these safe staffing ratios.
In 1999, Governor Gray Davis signed the Assembly Bill 394 into law, which requires health services to enforce the safe patient ratios intended to improve quality of care and ensure safe patient care. Of the mandatory ratios outlined in this law, some examples include: Medical/Surgical 1:5; Psychiatric 1:6; Intensive/Critical Care 1:2; Emergency Room: 1:4 (ICU 1:2; Trauma 1:1); Labor and Delivery 1:2; and Pediatrics 1:4 (Nursing Education). These ratios not only impact the safety of patients, but nurses as well. Higher patient workloads are typically associated with negative nursing outcomes such as job dissatisfaction, burnout, can result in staff retention problems, and can even take a toll on their overall health and well-being (McHugh, M. D., 2011). As we continue to investigate this growing problem, a high priority has been placed on resolving the negative outcomes that can occur with unsafe nurse-to-patient ratios. One issue that has been created because of these ratios is an increased level of patient mortality.
According to the New York State Nurses Association hospitals or long-term care facilities that staff 1:8 patient ratios experience five additional deaths per each one thousand admitted patients than facilities that have a 1:4 nurse to patient ratio (Safe Staffing, n.d.). Having a maximum work load to nurse ratio consistently increases the risk of patient death before they are discharged from the hospital.
This substantial reduction in the odds of patient survival makes early intervention, in order prevent theses adverse outcomes from occurring, vital. A PubMed article titled, “Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients?” described an analysis performed by a cohort group that found there was a more ninety five percent chance that death was more likely to occur with an increased nurse-to-patient ratio (Lee, A., 2017). When patients are exposed to these problematic conditions during their hospitalization it is almost guaranteed there will poor patient outcomes. Maintaining a safe patient environment is another potential problem that has presented and can affect the quality of patient care and the overall distribution of it. Some of the issues that can result include: high risks of patient falls, higher risks of medication administration errors, higher risks for inconsistency of care between providers, neglect or omission of care, and an overall increase in sentinel events.
As a nurse’s workload increases, she or he is not able to provide a patient with the proper care and supervision that is required for optimal health outcomes. While few studies have been performed regarding the association between an increased nursing to patient ratio and falls, we do know that with an increased nursing patient workload a nurse will have less time for each patient.
This may lead to patients attempting to self-transfer due to a delayed nurse response to an activated call light. Patients may attempt to climb over bedrails, exit a bed that is not lowered all the way to the floor, transfer without mobility devices, or fail to use non-skid footwear which all lead to an increased risk for patient falls. Now consider the number of patients who are on IV therapy; according to the Morse Fall Scale just having a heparin or saline lock in place raises the risk by 20 points (Tool 3H, 2013).
Medication administration errors are also a potential problem because the attention to details required for this task is difficult to implement when a nurse has many different patients and a time limit on medication administration. These medication errors can lead to increased mortality for patients, a longer hospital stay, and a major increase in medical expenses. A study performed by the Iranian Journal of Nursing and Midwifery Research group suggest that issues with medication administration prolong a patient’s stay by at least two days and can increase a patient’s hospital bill by $2,000 to $2,500 during one hospital admission (Cheragi, M. A., 2013).
This may also be an inaccurate representation due to the number of nurses who do not report their medication errors because they fear the repercussions that may occur from their mistake. Often times these errors can be avoided due to new electronic medication administration programs and double checks that should occur at the patient’s bedside, but when nurses are rushed, mistakes are more prominent. Certain medications are easily confused due to sound alike, spelled alike, or look alike issues and administering an incorrect medication can have lethal effects for the patient.
One example of this issue occurs with the administration of a medication such as Klonopin (clonazepam), which is a sedative medication that is used to treat seizure disorders, panic disorder, and anxiety. However, if this medication is confused with a similar sounding medication, such as Catapres (clonidine) which is an antihypertensive drug.
Accidental administration in a person who does not need Catapres (clonidine) can have disastrous effects on the patient and rapidly lower their blood pressure. When nurses are responsible for many different patients it is easy to misread an order or confuse medications such as these. If interventions are not implemented quickly, the results could be deadly for the patient.
There are many other issues that a patient may experience as a result of poor nurse to patient ratios including: ineffective pain management, longer hospital stays, increased health care costs, and an overall decrease in patient satisfaction with care. Poor pain control can lead to unfavorable psychological outcomes (depression, anxiety, or even suicidal thoughts) and can cause further problems for the patients’ health status.
According to a study published in the American Journal of Managed Care (AJMC), patients whose pain levels were ineffectively controlled during hospitalization cost their health plan an estimated $12,877 dollars annually (Ineffective Pain, n.d.). As nurses, the ability to provide appropriate care that is patient focused, depends on the time we are able to spend with those patients. Nurse staffing levels can greatly affect the quality of care provided and influence the patient’s perception of their overall health care experience. When a nurse has too many patients assigned to his or her workload, they are not going to be able to provide effective care for each individual.
Regardless of the nurse’s effort, it is nearly impossible to spend an adequate amount of time with each patient and focus on their individual needs. While patients continue to suffer from the consequences of decreased nurse-to-patient ratios, many fail to recognize the profound impact this issue can have on the nurses who provide the care. A survey performed by the Health Affairs (Project Hope) group found that with higher staffing levels, 36% of nurses in hospitals and 47% in nursing homes report that their increased work load causes them to miss important changes in a patient’s condition and may cause them to fail to report important information during shift change (Nurses’ Widespread, 2011).
Burnout and injury are two major issues that nurses face as they struggle to care for the patients they are assigned. Fatigue due to lack of sleep, emotional exhaustion, and unconducive work environments can cause a high amount of stress for nurses and reduce overall job performance. These staffing problems also cause a decreased level of job satisfaction due to the overwhelming pressure that can result from being assigned so many additional patients.
Job dissatisfaction among nurses can contribute to costly labor disputes, increased employee turnover, and an increased risk of health disparities for patients and their overall level of safety (Nurses’ Widespread, 2011). While many nurses experience this dissatisfaction with their work environment, they may be reluctant to speak up or take action due to a fear of backlash or disciplinary action.
When a nurse is not satisfied with the policy at his or her given facility, the quality of patient care may be jeopardized. The Health Affairs (Project Hope) group found that patient satisfaction levels are lower in hospitals with an increased number of nurses who are “burned out,” a finding that suggests flaws in the care that patients receive. (Nurses’ Widespread, 2011).
There is currently a nursing shortage worldwide, and if these unsafe staffing levels remain unchanged throughout heath care facilities, we will continue to see a decrease in overall staff retention rates. To contribute to the improvement of health and wellbeing of another person, it is first important to ensure that nurses are able to manage their own health.
Unsafe nurse-to-patient ratios can cause prolonged strain on a nurse’s health which can emotionally, physically, and mentally drain him or her. Studies have shown that nurses who continue to work in these high stress conditions have displayed many signs and symptoms related to consistently increased workloads including: lack of focus, insomnia, increased risk for illness (due to a weakened immune system), anxiety disorders, depressive disorders, anger, detachment, lack of productivity, and poor performance (The Tell, n.d.).
Some physical symptoms that have been displayed by nurses include: chest pain, heart palpitations, shortness of breath, GI pain, dizziness, fainting, and/or headaches (The Tell, n.d.). It is important to recognize that these symptoms will not go away on their own, but if changes are made to improve working environments, we can more easily prevent the chronic effects of nursing burnout.
As future nursing graduates, this topic is one that we feel deserves the utmost attention because it has a direct impaction on our future practice. Unsafe nurse-to-patient ratios can quickly drain nurses and can impact the excellence of patient care that is being delivered. Throughout our educational program, we have been consistently taught the importance of not only providing high quality care for our patients, but also providing it in the safest manner possible.
With the current unsafe working conditions, aspiring to provide this type of informant is almost unattainable. As we enter into our new professional roles, we have the ability to make some changes but without legislative action there will be no definitive solution to this problem. We do not want this issue to just be overlooked, because it is detrimental to the health of both ourselves and the patient’s we will be caring for.
Now think back to the complex patient that was presented in the opening scenario, while some may think this representation was a bit exaggerated, after reviewing the information, it is not uncommon to witness this actual problem on a daily basis.
When making nursing assignments each day, consideration should be given to the complexity of care required for each patient in addition to ensuring the proper nurse-to-patient ratios are established. Resolving these hazardous conditions is vital to improve patient outcomes and prevent complications, as well as nursing fatigue and burnout. By taking small strides towards bettering the overall care process, there will be a positive impact on both patient and nursing levels of satisfaction.
