Nurse-to-Patient Ratio in a Medical-Surgical Unit

Introduction

Introduction

Apart from their role as care givers of acutely sick patients, nurses also provide round-

the-clock care for inpatients (Lasater et al., 2021). In the medical-surgical unit, nurses are

responsible for providing patients with medical care before, during, and after surgery. In these

stages, they administer various medications, provide the patients with information about their

procedures as well as act as coordinators of healthcare plans with other medical professionals

(Choi & Miller, 2018). The number of roles and their overall importance in supporting the

patient’s life in the medical-surgical unit makes the nurse-to-patient ratio a very critical issue in

the field of health care (Winter et al., 2020).

The nurse-to-patient ratio not only influences the quality of life of the nurses but also

influences the quality of life of the patients. A low nurse-to-patient ratio translates to an increase

in the probability of the nurses making medical errors. According to Twigg et al. (2021), medical

errors are three times more likely to be committed in cases where nurses work in an environment

where there is understaffing which results to a low nurse-to-patient ratio. In such an

environment, nurses are likely to experience high levels of fatigue as a result of longer working

shifts. Constant fatigue puts the nurses at risk of experiencing burnout. A study by Bakhamis et

al. (2019) indicated that the nurse-to-patient ratio is equal to 1:8. Increasing the ratio to around

1:3 is likely to be advantageous as it is likely to minimize cases of medical errors, increase

patient satisfaction, improve overall patient outcomes and reduce nurse fatigue as well as

burnout. The medical-surgical unit should seek to increase the nurse-to-patient ratio from 1:8 to

1:3 so that patients who have been hospitalized for conditions such as pneumonia, stroke, and
fractures can experience minimal cases of medical errors, increased patient satisfaction, and

improved overall patient outcomes, reduced nurse fatigue, and burnout.

PICO

P = Adult patients in the medical-surgical unit who have been hospitalized for conditions such as

pneumonia, stroke, and fractures

I = Increase in the nurse-to-patient ratio from the current 1:8 to a recommended 1:3

C = Patients will be exposed to reduced cases of medical errors, increased patient satisfaction,

improved overall patient outcomes, reduced nurse fatigue, and burnout

O = Reduced cases of medical errors, increased patient satisfaction, improved overall patient

outcomes, reduced nurse fatigue, and burnout

Amongst adult patients in the medical-surgical unit who have been hospitalized for

conditions such as pneumonia, stroke, and fractures, can an increase in the nurse-to-patient ratio,

from the current 1:8 to a recommended 1:3 such that more nurses are attending to patients in the

department, reduce cases of medical errors, increase patient satisfaction, improve overall patient

outcomes, reduce nurse fatigue and burnout? This discussion aims to explore whether increasing

the nurse-to-patient ratio from the current 1:8 to a recommended 1:3 in the medical unit serving

adult patients who have been hospitalized for conditions such as pneumonia, stroke, and

fractures is likely to reduce cases of medical errors, increase patient satisfaction, improve overall

patient outcomes, reduce nurse fatigue and burnout. Overall, this study aims to answer the

question: What is the impact of increasing the nurse-to-patient ratio from 1:8 to 1:3 on both

patients and nurses?

John Hopkins Nursing EBP tool

2
 In the assessment of the literature in this study, the tool adopted was the John Hopkins

Nursing EBP tool shown in the attachments below.

Matrix Review

The heterogeneous nature of designs adopted in the studies assessed and the outcomes

measured in those studies limits the current study to conduct a narrative synthesis of their

findings. The articles assessed in this study were adopted based on the relevance of the measured

outcome. Overall, past studies continue to highlight the importance of a high nurse-to-patient

ratio. On medical errors, the studies link them to fatigue, as a result of a low nurse-to-patient

ratio, which in turn translates to errors in the decision-making process (Jun et al., 2021). Medical

errors increase when nurses are understaffed as a result of increased fatigue which may in turn

affect the outcome of the patient. The study by Lasater et al. (2021) identified the existence of a
3
relationship between the nurse workload and an increase in the patient’s probability of dying

within the first 60 days after admission. The study also pointed to increased workload among the

nurses translating to an increase in the patient's stay in hospital. This study linked the nurse-to-

patient ratio to the overall patient outcome. However, despite the study providing Level III good

quality evidence, the study's design limits it from concluding that there exists a significant cause-

effect relationship between patient outcomes and the nurse’s workload. A study carried out

among patients in mental wards also failed to establish the existence of a cause-effect

relationship between patient relapse and the patient-to-nurse ratio (Moyo et al., 2020). However,

the study by Aiken et al. (2021), with good evidence, pointed to an increase in the nurse

workload by one patient increasing a patient’s risk of hospital death by 4%. Overall, these

studies support the possible influence of the nurse-to-patient ratio on the patients’ outcomes.

However, the severity of the issue of the nurse-to-patient ratio varies from one region to the other

(Schlak et al., 2021).

Overall, various patient and nurse outcomes are associated with the nurse-to-patient ratio.

The concept of patient satisfaction and the patient’s outcome is closely related to the studies

assessed. The studies agree that patient satisfaction and patient outcome are linked to the

workload. Further, the studies associate burnout and nurse fatigue. In nurses, burnout results

from fatigue which originates from prolonged periods of being overworked (Azmoon et al.,

2018). Being overworked affects the mental and physical health of the nurses (McHugh et al.,

2021). These studies agree on the overall need to increase the number of nurses and increase the

nurse-to-patient ratio. However, these studies suffer from some similar limitations despite many

of them having overall good levels of evidence. The quantitative study mainly employs cross-

sectional designs which in turn affects their ability to draw cause-effect relationships. Overall,

4
the cross-sectional design produces results that are limited in terms of describing the causal

relationships between constructs (Salvarani et al., 2019). Quantitative studies also suffer from

both publication bias and article selection bias as well as researcher bias. Further, the studies

suffer from low levels of generalizability in findings.

Conclusion

Research on the issues surrounding the nurse-to-patient ratio are still ongoing. The issue

of nurse shortages which affects the nurse-to-patient ratio is not limited to a single area. The

literature analyzed in this study was carried out in various regions indicating its importance in

the health care sectors. Overall, the studies evaluated in this analysis, despite some having some

poor-quality evidence levels point to increasing the nurse-to-patient ratio from 1:8 to 1:3 for

adult patients in the medical-surgical unit who have been hospitalized for conditions such as

pneumonia, stroke, and fractures is likely to translate to minimal cases of medical errors,

increased patient satisfaction, improved overall patient outcomes, reduced nurse fatigue, and

burnout.

5
 References

Aiken, L. H., Simonetti, M., Sloane, D. M., Cerón, C., Soto, P., Bravo, D., & Lake, E. T. (2021).

Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional

study. The Lancet Global Health, 9(8), e1145-e1153. [Link]

109X(21)00209-6

Azmoon, H., Nodooshan, H. S., Jalilian, H., Choobineh, A., & Shouroki, F. K. (2018). The

relationship between fatigue and job burnout dimensions in hospital nurses. Health

Scope, 7(2), 22-41. [Link]

Bakhamis, L., Paul III, D. P., Smith, H., & Coustasse, A. (2019). Still an epidemic: the burnout

syndrome in hospital registered nurses. The health care manager, 38(1), 3-10.

[Link]

Choi, J., & Miller, P. (2018). Registered nurse perception of patient assignment linking to

working conditions and outcomes. Journal of Nursing Scholarship, 50(5), 530-539.

[Link]

Jun, J., Ojemeni, M. M., Kalamani, R., Tong, J., & Crecelius, M. L. (2021). Relationship

between nurse burnout, patient and organizational outcomes: Systematic

review. International Journal of Nursing Studies, 119, 103-133.

[Link]

Lasater, K. B., Sloane, D. M., McHugh, M. D., Cimiotti, J. P., Riman, K. A., Martin, B., &

Aiken, L. H. (2021). Evaluation of hospital nurse-to-patient staffing ratios and sepsis

bundles on patient outcomes. American Journal of Infection Control, 49(7), 868-873.

[Link]

6
McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021).

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality,

readmissions, and length of stay: a prospective study in a panel of hospitals. The

Lancet, 397(10288), 1905-1913. [Link]

Moyo, N., Jones, M., Kushemererwa, D., Pantha, S., Gilbert, S., Romero, L., & Gray, R. (2020).

The Association between the mental health nurse-to-registered nurse ratio and patient

outcomes in psychiatric inpatient wards: A systematic review. International Journal of

Environmental Research and Public Health, 17(18), 68-90.

[Link]

Salvarani, V., Rampoldi, G., Ardenghi, S., Bani, M., Blasi, P., Ausili, D., & Strepparava, M. G.

(2019). Protecting emergency room nurses from burnout: The role of dispositional

mindfulness, emotion regulation and empathy. Journal of Nursing Management, 27(4),

765-774. [Link]

Schlak, A. E., Aiken, L. H., Chittams, J., Poghosyan, L., & McHugh, M. (2021). Leveraging the

work environment to minimize the negative impact of nurse burnout on patient

outcomes. International Journal of Environmental Research and Public Health, 18(2),

61-70. [Link]

Twigg, D. E., Whitehead, L., Doleman, G., & El‐Zaemey, S. (2021). The impact of nurse

staffing methodologies on nurse and patient outcomes: A systematic review. Journal of

Advanced Nursing, 77(12), 4599-4611. [Link]

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Winter, V., Schreyögg, J., & Thiel, A. (2020). Hospital staff shortages: environmental and

organizational determinants and implications for patient satisfaction. Health

Policy, 124(4), 380-388. [Link]

8
 Appendix

Appendix A: EVIDENCE-BASED TOOLS: REVIEW MATRIX

Autho Purpose, Methodolo Sample Data Findings & Level and

r(s), Aim or gy (probabili Collectio Limitations to Quality of
Year PICO (Quantitati ty or non- n study Evidence (tool
Question ve, probabilit Methods used)
Qualitative, y)
Mixed # and
methods) descripti
Design on
(RCT, SR,
MA,
Cohort,
Focus
groups etc.)
The study Qualitative Judgment Secondar Findings -The V/ Good
Bakha aimed to al y data – study findings quality
mis et assess the Literature sampling Articles pointed to
al. sources and review published burnout among
(2019) effects of Nurses between nurses promotes
burnouts selected 2000 and the development
among for the 2017 in of physical and
registered interview English. mental
nurses s were difficulties. As a
working in expected Primary solution, the
US hospitals to have data – study suggested
to identify over 32 Semi- the increase in the
the years of structure number of
identificatio experienc d patients serving
n of e. interview patients.
possible s
solutions to Limits – The
this issue. strategies used to
select articles and
the overall quality
of databases the
data was sourced
from affects the
quality of
evidence present
in this study. This
study also suffers
from both
publication biases

9
 and a researcher’s
bias.
Twigg The study Qualitative No Secondar Findings – V/ High
et al. aimed to participa y data Minimal evidence quality
(2021) review past Systematic nts exists in the field
research to review and Articles of nurse staffing
facilitate the Narrative published and its impact on
assessment synthesis between nurses and
of the 2000 and patients.
association 2020 However, the
between were evidence points to
nurse obtained the overall
staffing from importance of
methodologi MEDLIN having a
es on nurses E(EBSC moderate
and patient O), workload.
outcomes. CINAHL
(EBSCO)
and Web Limits – Selection
off bias in identifying
Science. articles.
Lasate The study Quantitativ Non- Secondar Finding – II/ High quality
r et al. aimed to e probabilit y data – Increased nurse
(2021) assess y Hospital workload
whether Cross- sampling survey translates to a
patient-to- section data. significant
nurse design Hospitals increase in the
staffing selected probability of the
ratios were were patient dying
associated those within the first 60
with clinical classified days of admission
outcomes as acute as well as
for patients care increased days of
admitted hospitals stay in the
with sepsis and had hospital.
in some to have at
New York least 5 Limits – Varying
hospitals. registered measures of
nurses hospital staffing.
working The cross-
in sectional design
medical limits the ability
surgical of the study to
units. establish a cause
effect relationship
between

10
Moyo Is there an Qualitative No Secondar Finding – No III/ Good
et al. association participa y data – findings were
(2020) between the Systematic nts Data identified which
nurse-to- review from met the criteria
patient ratio scientific for the study. The
and the medical study failed to
relapse of databases establish the
adult mental association
health between nurse-to-
inpatients? patient ratio and
the outcome of
patients in mental
hospitals.

Limits – The
study failed to
include a scoping
review.
Differences in the
definition of
various levels of
relapsing varied
from institution to
institution in the
studies assessed.
Aiken The study Quantitativ Probabilit Primary Finding – An III/ Poor
et al. aimed to e y data - increase in the
(2021) report on sampling Survey nurse’s workload
the Multilevel – Nurses by one patient
association cross- were increases the risk
of hospital sectional selected of the patient’s
nurse study from 40 death by 4%.
staffing with of 45
patient adult Limit – Cross
outcomes high sectional nature
and care complexi of the study.
costs in ty
Latin hospitals
America. participat
ing in
patient
diagnosis
related
groups.
Winte The Quantitativ Non- Secondar Finding – Staff II/ Good
r et al. objective of e probabilit y data – shortage varies

11
(2020) the study y– Hospital’ from areas to
was to Cross- Participa s Surveys area. Further,
further sectional nts were carried hospital staffing
highlight the design selected out in is directly
issue of from Germany associated with
staff those in 2015- the levels of
shortages. who had 16. patient
One of the completel satisfaction.
questions y filled
stated: How their Limits –
do hospital surveys. Incomplete data
staff entries. Inclusion
shortages bias by the
and nurse- researcher.
to-patient
ratios relate
to patient
satisfaction?
Choi To assess Quantitativ Non- Secondar Finding – Positive II/ Good
and the working e probabilit y data perceptions of
Miller conditions y patient
(2018) of nurses Previous assignments
and Descriptive Voluntee hospital translates to
outcomes design r patients survey. positive outcomes
(job were for the patient.
satisfaction, selected Patient
quality of from perceptions arise
care and those that from how the
desire to participat nurse is treated.
stay among ed in the
registered National Limits – Low
nurses with Database generalizability of
different of findings.
views on Nursing
patient Quality
assignments Indicator
. s Survey.
McHu The study Quantitativ Non Secondar Finding – II/ Good
gh et aimed to e probabilit y data – hospitals which
al. assess the y Medical had implemented
(2021) influence of Longitudin records the minimum
the al design Patients data ratio experienced
minimum were lower levels of
nurse to selected Primary patient mortality,
patient ratio from data - readmissions and
introduced hospitals Survey length of stay at

12
 in which data the end of the
Queensland had taken study.
on nurse up the
staffing and minimum
patient ratio Limits –
mortality, policy Inaccurate
readmission hospital records.
s, and length
of stay.

Azmo The study Quantitativ Probabilit Primary Finding – The II/ Good
on et generally e y data - study established
al aimed to Survey the existence of a
(2018) assess the Cross- Nurses positive
association sectional were relationship
between design randomly between fatigue
fatigue and selected and various
job burnout. from dimensions of job
teaching burnout.
hospitals
in Iran. Limits -Cross
sectional design.
Salvar The study Quantitativ Probabilit Primary – Finding – Nurses II/ Good
ani et aimed to e y Self who are more
al. verify the report mindful, have
(2019) role of Multi- Nurses questionn better skills in
dispositiona center were aires. emotion
l cross- randomly regulation an
mindfulness sectional selected empathy is able to
, difficulties design. among manage work
in emotion ER stress.
regulation nurses in
and a referral Limit – The
empathy in hospital. cross-sectional
explaining design.
burn out
levels of
Emergency
room
nurses.
Jun et The study Qualitative No Secondar Finding – Some III/ Good
al. aimed to participa y of the
(2021) review Systematic nts sources. organizational
critically review related outcomes
and The related with nurse
systematical articles burnout include

13
 ly the were patient
current sourced satisfaction, nurse
studies that from productivity,
assess the PubMed, quality of care,
relationship CINAHL safety of patients
between , as well as the
nurse PsychInf commitment of
burnout and o, Scopus nurses to the
patient and , institution.
hospital and Emb
institution ase were Limit - Selection
outcomes. the bias in identifying
search articles.
engines
used.
Schlak The study Quantitativ Non Secondar Finding – patients II/ High
et al. aimed to e probabilit y data - receiving care in
(2021) assess the y 2015– hospitals which
relationship Cross- sampling 2016 have nurses with
between sectional RN4CAS high levels of
nurse design Only T-US burnout have a
burnout and patients survey higher probability
clinical who met of patient
outcomes. certain mortality, failure
The clinical criteria to rescue as well
outcomes for the as a longer length
include study of stay.
mortality, were
failure to selected
rescue and from the Limit – The
length of data set. cross-sectional
stay. design. Further,
the measures of
burnout used in
the study are
relatively
ineffective.

14