Running Head: EFFECTS OF NURSE-TO-PATIENT RATIO

Effects of Nurse-to-Patient Ratio on Quality Outcomes of Patient Care

Rachel Boano, Hailey Brown, Savannah Franks, Anthony Stiles, Cole Davis

04/15/2020

NURS 3749: Nursing Research

Dr. Valerie O’Dell

Abstract

The purpose of this research was to look at the relationship between nurse-to-patient

ratios and the effects it has on the quality outcomes of patient care along with how it affects the

nurse’s overall outlook of their profession. The relation of nurse-to-patient ratios to patient

outcomes, quality of care, medication errors, mandated staffing ratios, nurse burnout and staffing

laws are discussed. This research was collected from ten differing studies. It was found with

significant evidence that there is a strong correlation between high nurse-to-patient ratios to

medication errors, poor patient outcomes due to improper care, nurse burnout and even patient

mortality. Also discussed throughout are the mandated staffing laws that are in place in certain

states in the nation. There is no significant amount of research and evidence-based practice

recorded that defines an efficient way to mandate nurse-to-patient ratios in every state. There are

many different variables that reflect staffing issues that are pending to be reviewed. Overall, the

research conducted proved that nurses who receive a high, demanding patient assignment during

their shifts had a poorer overall outcome of their patients due to the lack of quality of care and

attention patients received.

Effects of Nurse-to-Patient Ratio on Quality Outcomes of Patient Care

As the shortage of registered nurses (RNs) continues to grow, the workload placed on

nurses has begun to increase. Currently there are numerous states in America who have

mandated laws regarding nurse-to-patient ratios that will be thoroughly discussed at a later

moment in this report. The term “nurse-to-patient ratio'' describes the number of patients

assigned to each nurse during their specific shift. These nurse assignments are based upon the

needs of each patient for nursing care. Many studies have been conducted to dispute the effects a

higher nurse-to-patient ratio can have on proper and quality care that patients receive by a nurse. 

It has been proven that a higher nurse workload has resulted in adverse outcomes of patient care.

When inadequate staffing is present, proper nursing care becomes affected. This increases the

risk of medication errors, patient mortality, increased length of stay in the hospital, along with

preventable events such as central line infections, healthcare-associated infections, patient falls

and other complications relating to patient hospitalization. This presents a huge issue to the

nursing profession as patients are receiving less quality of care, resulting in poorer outcomes due

to the nurse’s workload remaining rather demanding. Patients are not receiving the proper and

attentive care needed when nurses are given too many patients to care for. Safety of both the

patient and the nurse is of utmost importance in the nursing profession. Nurses with an increased

patient assignment and highly demanding workload increases the risk of nurse burnout and job

dissatisfaction when nurses feel that what they are doing is not sufficient enough because they

are often given such a rigorous workload. Therefore, the following research question is

addressed: In registered nurses, how does a high nurse-to-patient ratio compare to a low ratio

affecting patient outcomes during their length of stay in the hospital?

Literature Review

Introduction

To appropriately address this issue in the profession of nursing, information was acquired

from ten different nursing practice journals, healthcare forums and reviews, along with the

mandated laws regarding the nurse patient ratio in specific states. Ten sources were reviewed to

gain research data and information to be able to accurately and thoroughly discuss the ways that

patient outcomes are affected by a nurse’s specific workload. Among the issues discussed are the

nurse patient ratios, nurse workload, medication errors, effects of staffing on patient outcomes,

benefits of a lower patient load, mandated nurse staffing ratios, laws in place regarding the ratio

and nurse burnout resulting in poor quality of care.

Nurse-to-patient Ratios 

Optimal staffing is essential to providing the proper care and achieving the greatest

quality of patient outcomes during their length of stay in the hospital. According to Lee (2017),

exposing critically ill patients to high workload and staffing ratios decreases chance of patient

survival. Lee (2017) found that in the United States, the average patient ratio for a single nurse is

1.29 to 3.8.  When this ratio is increased, the amount of time and acuity a nurse has with a patient

to instill proper care is limited. Safety is of utmost importance when taking care of patients who

are in need of extensive care by a nurse. Nurses encounter different levels of care to give based

on the complexity of their patient’s condition. Patients in the ICU for example require more

intense care and skills therefore when the nurse ratio is “greater than 1:1, this would suggest a

substantial proportion of patients were exposed to the levels of staffing that are associated with

worse outcomes” (Lee, 2017). Adequate staffing plays a key role in improving patient
EFFECTS OF NURSE-TO-PATIENT RATIO

satisfaction and survival and should be of utmost priority to the hospital administration in the

satisfaction of their patients and nurses as a whole.

Nurse Workload

According to Bogaert (2017), an acceptable workload is to give quality care while

working hard and meeting all of the patient’s needs. The amount of work to be done by a nurse

can affect many things. For instance, it can affect the nurse’s attitude, patient care that they

perform and patient outcomes. A nurse who was a part of a research interview, stated,

“Respondents reported various impacts of high and prolonged workload such as decreased

adequacy and efficacy complaints of fatigue, headache and vulnerability for diseases” (Bogaert,

2017).  Nurses who were interviewed explained that staff numbers were not adequate with the

work conditions that were being experienced. Such work conditions include, “increased patient

turnover, chronic conditions and acuity and in turn higher and complex care demands” (Bogaert,

2017). Increased patient turnovers cause much stress on the nurses due to the increased number

of tasks that must be done in a shorter period of time. Along with the increased number of tasks

that the nurse must already complete with her patients, there are unexpected admissions and

conditions evolving as the day goes on. 

According to a nurse in this case study, “To deal with such situations, staff nurses have to

set priorities when they deliver care. Staff nurses’ level of experience and competencies helped

to manage their workload” (Bogaert, 2017). A situation as simple as a positive work environment

and recognition for quality care can help to decrease the feelings of stress and workload on a

nurse. Communication is rather important to maintain a positive work environment as well.

Collaborating with one another is beneficial to not only the nurses but the patients.

Communication between nurses and management is also deemed beneficial for the nurses so that
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they could express their feelings about how situations were going and how management could

help to improve the work environment. A nurse who was interviewed during this study felt as

though management did not support the nurses by stating that, “Communication with the nursing

department management level was seen as difficult and with certain barriers. The nurse

administration did not always listen and respond to staff nurses’ concerns and caused certain

tensions” (Bogaert, 2017). These studies correlated the importance of communication in solving

the many problems nurses face such as workload. This communication should be followed by

not only nurses but by management as well to improve the overall difficulties relating to the

amount of stress and workload the nurses are dealt. 

Nurse Burnout Resulting in Poorer Quality of Care 

Nursing is one of the most complicated professions that one can reside in. The individual

must be aware of every detail regarding a patient including their medications, diagnoses, courses

of treatment, lab value patterns, preferred treatments, and even the patient’s families. While there

are countless benefits of being a nurse, obstacles and stressors coexist with them. Burnout can be

defined in many different ways. It is collectively thought as an impairment of one’s ability to do

their job at the optimal level due to excessive workload, sensory overload, an abundance of

stressors, physical and mental exhaustion, and inadequate resources or staffing. Burnout can first

become evident and detectable through its effects on a nurse’s clinical skills. According to

Kuwata (2017), “the United States spends more on healthcare than any other nation, [however],

it continues to perform poorly in health care quality when compared with other industrialized

nations.” The nation has the equipment and tools to provide excellent patient care, but in some

cases, staffing of medical personnel is a large contributor to the issue. Exhaustion experienced in

the medical field can lead to disasters such as errors in medication administration, overlooking
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patients, and malpractice. Many of these mistakes can lead to lawsuits or even the revocation of a

nurse’s license. Bogaert (2017) states that a “balanced, healthy and supportive psychosocial work

environment is linked to aspects such as patient satisfaction, mortality, co-morbidity and adverse

events.” This means that the nursing staff must be mentally present and capable of handling

situations to mend them before they may begin to decline. Teamwork and cooperation are an

absolute must to maintain a positive and healthy mindset. 

Precision of care and compassion are two of the most important traits an individual

displays as a practicing nurse. Numerous interactions occur between the nurse and the patients,

patients’ families, and doctors. As a result of this overload in interactions, many nurses report

that they experience “increased [nurse] burnout and act in a manner that lacks compassion

because of emotional detachment” (Russell, 2016). With high patient counts, nurses are finding

great difficulty with tasks as simple as comforting the patients. According to a meta-analysis

done by Sujin Shin (2017), “An increase of one patient per RN ratio was associated with an 8%

increase in odds of job dissatisfaction.” As previously mentioned, the best proven way to begin

to decrease this abundance of stimuli is to assign less patients to one nurse. According to Russell

(2016) and her survey of sixty-one nurses, “burnout could be prevented when adequate

resources, collaboration, teamwork, and support of family and friends all exist.” There is a direct

correlation between patient stress levels and their road to recovery. Stress increases the risk of

conditions ranging from heart disease to depression. If the nurse is struggling to keep

organization or feels exhausted from their workload, it is found that it will directly affect the

patient’s quality of care and increases their stress as well. 

Medication Errors

Administering medication is a vital part of patient care as a nurse. When administering

medication to patients, nurses must remember the five rights of medication administration such

as the correct dose, drug, patient, time and route. Medication errors are directly associated with

patient safety. According to Hammoudi (2017), mortality and morbidity rates are associated with

medication errors. When a nurse encounters an increased workload, they may not be taking the

proper steps to administer medications safely. Due to the increased number of tasks that they

must accomplish, they may not be using the five rights of medication administration due to the

amount of time and concentration it takes to thoroughly check each medication for each patient.

During a cross-sectional study, researchers found that “The main factors associated with

medication errors by nurses were related to medication packaging, nurse-physician

communication, pharmacy processes, nurse staffing and transcribing issues” (Hammoudi, 2017).

After distributing a questionnaire to nurses in a health care system, researchers found that

there were essentially two main reasons why nurses did not report medication errors. Many

nurses had a fear of what the response would be by administration, along with the arguments on

the definition of error. After receiving the results from the cross-sectional study, researchers

found that there are certain ways to decrease the amount of medication errors. All healthcare

settings should emphasize awareness of the culture of safety, provide support and guidance to

nurses and improve communication skills (Hammoudi, 2017). The use of computerized drug

administration systems are evolving and being used to help decrease the amount of drug errors.

Overall, teamwork needs to be improved to tackle the nurse’s difficulties with an increased

workload.
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Effects of Staffing on Patient Outcomes

According to Driscoll (2018), “Nurses are pivotal in the provision of high-quality care in

acute hospitals.” Many patient outcomes have been adversely affected by becoming sensitive to

changes in nurse staffing levels. Driscoll (2018) reviewed such outcomes including sepsis and

shock, hospital acquired pneumonia, respiratory failure, catheter associated urinary tract

infection, fluid overload, pressure sores, nosocomial bloodstream infection, medication error,

deep vein thrombosis, wound and central line infection, patient falls and even patient mortality.

All of these patient outcomes are easily avoidable outcomes with proper nursing care and

attention. When nurses are staffed to care for an abundance of patients, it takes away the focus

and accuracy of providing the utmost quality of care possible for patients. Proper nurse staffing

levels are associated with reduced mortality, medication errors, ulcers, restraint use, infections,

pneumonia, higher aspirin use and a greater number of patients receiving percutaneous coronary

intervention within 90 minutes (Driscoll, 2018). It is found evident that a proper nurse-to-patient

ratio contributes to the patients receiving the highest quality of care possible. 

Benefits of a Lower Patient Ratio 

According to Cho (2019), “Adequate staffing is required to reduce missed care and to

improve quality of care and nurse outcomes. A higher number of missed activities and poorer

staffing were associated with poorer patient safety, quality of nursing care and job satisfaction,

and a higher intent to leave.” This adequately displays that the lower the ratio between patients

and nurses will result in fewer missed activities and better overall patient outcomes. Nurses are

required to care for their patients in many ways, some patients need more critical care than

others. With these critically ill patients there are many roles that the nurse must take on such as

assessing the patient, giving medications on time, turning the patient, teaching, feeding,
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answering questions and educating the patient, monitoring vitals, and calling the physician for

any questions that they might have as the nurse. If a nurse were to have two to three critically ill

patients that require their constant attention and monitoring, there is a rather copious amount of

information to ask oneself and to be executing at the same time. Lowering the nurse-to-patient

ratio will allow the nurse to spend more time in the patient’s rooms, resulting in greater patient

satisfaction and outcomes. Not only are the patients going to be more satisfied with the care they

receive but the nursing staff will also benefit. The nurses are able to focus on priority care such

as on time medications and turning to prevent any complications from occurring within the

hospital. A lower nurse-to-patient ratio will also reduce both the physical and psychological

exhaustion of nursing. It was found that lowering the number of patients a nurse has to care for

will almost always result in fewer errors, better patient outcomes, quality of care, and overall

nurse satisfaction. 

Mandated Laws Regarding Ratio

Across the nation, laws have been introduced to regulate nurse-to-patient ratios. In 1999,

California became the first state to introduce a bill to establish minimum nurse-to-patient ratios

for hospitals. Before the legislation could be passed, the question was raised as to what the

minimum ratio should be. The responses varied greatly. Nurse unions advocated for 1:4, while

the hospitals asked for 1:10. In 2002, the California Department of Health announced that 1:5

was the official ratio for medical units. Since the passage of this law, studies have shown that the

quality of care in California hospitals has improved (Kuwata, 2017). A study comparing patient

outcomes in California to those in New Jersey and Pennsylvania was conducted. It was found

that “if the nurse-to-patient ratios in New Jersey and Pennsylvania matched the California

mandate, there would have been 13.9 percent fewer surgical deaths in New Jersey and 10.6
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percent fewer surgical deaths in Pennsylvania” (Kuwata, 2017). Another study done by

California Healthcare Foundation found that “California performed better than expected through

the entire period for rates of DVT and decubitus ulcer” (Spetz, 2017).

Although California is the only state with a broad-based minimum nurse-to-patient ratio,

other states have staffing laws in place regulating specific units or patients. For example,

Massachusetts put a law into effect requiring a 1:1 or 1:2 nurse-to-patient ratio for patients in

intensive care based on the stability of the patient (Kuwata, 2017). Most other states only require

hospitals to have a staffing committee that operates at the local level to ensure staffing plans that

are reflective to the differing units’ specific needs. There is a flaw in these committees, for they

are made up of primarily hospital administrators. The issue arises due to administrators also

being in charge of hospitals budgets. According to Kuwata (2017), “despite the data that links

nurse staffing to improved patient outcomes, many administrators believe that one of the most

effective way[s] to decrease a hospital’s operating budget [is] by cutting nursing staff.” This is,

in part, due to the fact that staffing expenses range from 50 to 70 percent of a facility’s operating

budget, and nursing salaries comprise more than half of the labor costs (Kuwata, 2017). This

causes a conflict of interest that demands to be brought into balance. In a study done by UCLA,

researchers examined this exact dilemma. They compared the cost of increasing workforce with

the savings that result from avoiding readmittance or patient death. The study found that

increasing the nurse workforce could save U.S. hospitals as much as 5.8 billion dollars (Kuwata,

2017). These studies correlated the importance of laws that mandate low nurse-to-patient ratios

not only to the satisfaction of the nurse, but the outcome of patients and the benefit to the

hospital as a whole.
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Mandating Nurse Staffing Ratios 

There are clear gaps in the health services and nursing management literature relating to

staffing factors and patient safety, and very few well-designed intervention studies have been

conducted (Olley, 2019). The issue with attempting to mandate specific nurse-to-patient ratios is

that every patient is completely different. Some of the patients that come into the hospital require

an extreme amount of hands on care and some patients require very little care. According to

Olley (2019), measures must take into account patient satisfaction, workload and staffing,

clinical risks and other measures of the quality and safety of care and nurses’ work satisfaction

when regarding nurse staffing ratio. The issue with mandating staffing levels is that it involves

many different variables, which are hard to all predict. It is clear that more evidence-based

practice and research are needed to resolve staffing ratios within healthcare settings. 

Conclusion

When addressing how higher nurse-to-patient ratios affect quality outcomes of patient

care, studies showed that the higher the patient ratio to a single nurse, the more risk for adverse

outcomes and poor quality of care occurred. Studies showed that there were increased amounts

of nurse burnout relating to stressful workloads due to the complex care, numerous amounts of

patients needed during their length of stay in the hospital. It was shown that patients experienced

many avoidable outcomes such as medication error, infection, falls, fluid overload, pressure

sores and even patient mortality. Research found that these outcomes are labeled avoidable as

they all could have been prevented if adequate staffing was available allowing nurses to be more

attentive and spend more time with each individual patient. Currently, there are mandated ratio

laws in place in specific states in the nation, however, there are certain issues with mandating

staffing levels due to the involvement of many different variables, all of which are unable to
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predict. Through these studies, it is clear that more evidence-based practice and research is

needed to resolve these staffing issues among nurses.

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 Cho, S.H., Lee, J.Y., You, S.J., Song, K.J., Hong, K.J. (2019). Nurse staffing, nurse’s prioritization,

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Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., Astin, F. (2017). The effect of

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