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ADVANCE Perspective: Nurses

Benefits of Low Nurse-to-Patient Ratios

Published December 12, 2012 1:25 PM by Guest Blogger

(Editor's note: This guest blog was written by Suzanne LeBeau, BSN, RN, CLNC.)

We all know the scenario. You're getting report on your sixth patient and the nurse who is giving report is spent, burnt out and just wants to go home to her cozy bed. As you may imagine, the conversation may go like this:

First nurse: "In room 320 is Mr. Jones, a 62-year-old patient of Dr. Smith who had a right total knee replacement yesterday. He has no allergies and his history consists of hypertension, hyperlipidemia and sleep apnea for which he wears his CPAP. Oh, and he also has AV malformations."

Second nurse: "Arterial venous malformations?" "Where?"

First nurse: "I don't know. I just got that in report from the previous nurse and I really haven't had a chance to read the chart (as she fumbles through the pages of the chart). Anyway, his vital signs have been WNL, he's afebrile, but he's been nauseous and complaining of stomach cramping for which I've given him Zofran as ordered, and Reglan as a one-time dose at 1430. His dressing is dry and intact, and he has good peripheral pulses. His hemoglobin dropped today to 7.5 from 9.2 yesterday, so he is on his second unit of packed cells now."

This scenario, if continued, might have devastating consequences on the patient. However, if the nurse had simply read the patient's chart, she would have known the patient's AVMs were in his GI tract and could have alerted the MD to suspected GI bleeding sooner. The sad reality, however, is that very few nurses have time to read through all their patients' medical records. Their knowledge of the patient's history, and course of treatment, is passed along from nurse to nurse. Kind of like that game we used to play as kids called, "Telephone." We all know how information can be misinterpreted and changed the further from the source it gets. But in the world of healthcare, this is no game. We are dealing with people's lives. 

In 2005, California made history as the first state to implement mandated nurse-to-patient ratios. In med/surg units, this ratio is 5:1. This means that any one nurse cannot have a caseload of more than five patients during her shift on a med/surg unit. The theory behind this legislation is to improve patient outcomes, decrease nursing job dissatisfaction and enhance staff retention in hospitals. There are conflicting studies regarding whether these objectives have been fulfilled, but one truth remains indisputable: Nurses, who are responsible for patients' lives, are too stressed and overworked to fully research their patients' histories and current situations to have a safe and comprehensive understanding of their patients' conditions. If this could be adopted as common practice by all patient care nurses, there would be less errors, better patient outcomes and a higher degree of job satisfaction among the nurses participating. 

My daughter just started college this fall and is majoring in nursing. Typically in nursing school, preparing for your clinical experience is a very in depth and meticulous process. A student has 1-2 patients, and spends the evening before her clinical experience carefully reading the medical record, researching meds, diseases and surgical procedures, and devising intricate care plans for each of their patients. It really is a sad commentary that possibly, these students are better prepared to care for these patients than the RN assigned to them who may already have years of experience under her belt. 

I want my daughter to have a wonderful and rewarding career. The nursing profession is truly an inspiring path. But it scares me to think of her cast into this world of high stress and less than adequate time to prepare for this position taht every nurse holds over her patients: a literal lifeline. Does the mandated nurse-to-patient ratios really improve the lives and satisfaction of both patient and nurse? That remains to be measured, but I, for one, believe without a doubt that it is a step in the right direction. Acuity is always the best judge of nurse-to-patient ratio, however; logistically speaking, it is always more favorable to have a lower ratio to maintain a high level of knowledge and understanding of the comprehensive care of the patient. 

I would certainly like to see this legislation implemented in more states, and I would hope that once my daughter enters the workforce as a full-fledged RN she will do so with a greater sense of self-assuredness and less trepidation regarding realistic workloads. The nursing profession is probably one of the most disrespected, abused and underpaid professions I can think of. I just hope that, in my lifetime, I will be able to experience the joy of seeing this profession rise to the level of respect that it truly deserves. 


The hospital that I work at just changed the patient nurse/cna ratio.  They have increased RN from 5:1 tof 6:1 (day shift), charge nurse now has 4:1 and they have increased our charting.  They are convinced that hourly rounding will makeup the difference.  We are suppose to smile, rehearse how we address pt. and that will make up all the difference.  If we do this our pt. satisfaction will be better because we are engaging with out pt. and anticipating their needs by hourly rounding.  This is completely ridiculous.  When a staff nurse questioned this, she was shot down immediately with this has been proven to work. Also as far as getting report, I get the worse possible reports from most of the nurses because no one has time to read the chart. Good luck new nurses. I've had it 11 years of this BS.

Robin, med/surg - RN, hospital April 11, 2013 10:21 AM
Detroit MI

Thank you for commenting, Natasha.  and I totally agree with you.  In nursing, so many times WE are the front lines to detecting subtle changes in a patients condition that may very well lead to a tragic end.  But how can we notice these things when we are constantly bombarded with an overload of patients with which we are concerned with the tasks we have to complete for all of them.  The stress of the sheer numbers are overwhelming and unfortunately causes nurses to focus on the wrong things when it comes to patient care.  I hope things change as well.

Suzanne LeBeau January 19, 2013 11:42 AM
Bethlehem PA

Very nice article. The nurse to patient ratio should also be revised in SNF. The last employer I worked for had a unit with a 38:1 ratio and I have always had concerns about quality of care and safety. That was my heaviest patient load that I have ever encountered and it concerns me greatly that this is allowed to happen. With the increase in acute care patients being released to facilities such as nursing/rehab homes the chances of scenarios such as Mr. Frank's isn't all too uncommon unfortunately. Patients entering these facilities require more care and more time and it's just not available and the quality of care becomes compromised even in those patients that are considered stable. There have been many nights I've tossed and turned over these issues and wonder when/if there will be a change. I am hopeful that there will be and am hoping it comes sooner rather than late for the sake of the patients.

Natasha Sinclair, SNF - LPN January 1, 2013 1:52 PM
New Haven CT

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