Nurse to Patient Ratio in Emergency Rooms

Nurse to Patient Ratio in Emergency Rooms

It is worth noting that nursing plays a core role in the health sector due to their high rate of contact with patients. It is due to such critical role that Needleman and Hassmiller (2009) indicate that nursing is indispensable to the achievement of quality care and safety. Moreover, Ball et al. (2013) add to this factor by stating that number of nurses affects safety and quality of care administered. However, there has been growing concerns over continued decline in the number of nurses globally (Cheung, Aiken, Clarke & Sloane, 2008). Cheung and colleagues further observed that inadequate nursing to patient ratio is associated with adverse effects on both the nurse and the patient. This paper seeks to explore nurse to patient ratio with the aim of promoting the implementation of an action plan to curb inadequate nurse to patient ratio. The discussion is based on emergency room (ER) nurses. In proposing the action plan, the paper conducts a literature review on issues pertaining nurse to patient ratio. The aim of the action plan is to ensure that the health sector has at least the minimum but sufficient ER nurse staffing to ensure that quality and safety of care is not compromised.

Literature Review

The issue of nursing to patient ratio has been controversial that has seen various research trying to unfold the mystery of this issue. Nurse to patient ratio determines the workload for the nurses. Inadequate nurse to patient ratio causes high workload to the nurses. Hughes, Carayon, and Gurses (2008) observed various drawbacks associated with such high workload for the nurses. For instance, high workload on nurses is inversely related to the patient safety. Moreover, high workload may increase the turnover rate of the nurses due to increased job dissatisfaction consequently promoting a decline in the number of nurses.

Considering the factors mentioned above, most researchers have proposed that there ought to be a mandatory nurse to patient ratio. These researchers have evaluated the relationship between workload and patient mortality and safety. For instance, a study by Kane et al. (2007) found out that a high number of nurses resulted in low mortality within the hospital settings as well as low adverse effects to the patients. A study conducted by Aiken et al. (2010) also observed a decline in patient mortality with increased number of nurses in California. The establishment of the mandatory nurse to patient ratio in the state facilitated a decline in the number of adverse effects on patients and reduced mortality in hospitals. A study by Hughes, Carayon and Gurses (2008) associated high workload on nurses with high turnover rate and also poor health care quality.

In light of such issues associated with nursing to patient ratio, some researchers such as Tevington (2011) have proposed the establishment of a minimum threshold. Tevington explains that a minimum and guaranteed nurse staffing ought to be established. Rothberg, Abraham, Lindenauer and Rose (2005) went forth and proposed a nursing to patient ratio of one to four. However, such proposals of establishing a mandatory nursing to patient ratio have been faced with various opposing studies.

For instance, in an opposing study Cook, Gaynor, Stephens Jr and Taylor (2012) observed that the increase of nurse staffing did not result in improvement of patient safety. Moreover, Welton (2007) accounts for various issues that the opponents of the mandatory nurse to patient ratio stipulate. For instance, opponents of the mandatory nursing to patient state that it is costly. Moreover, most studies are based on hospital averages and rather not on the unit level causing generalization. Some units do not require a high number of nurses as compared to others such as the intensive care unit. Moreover, nursing to patient ratio does not address differences in levels of treatment complexity.

Action Plan: Active nurse involvement in unit-based staffing plan development

In consideration of issues regarding the nurse to patient ratio, it is essential to establish a comprehensive action plan. This plan will be personalized depending on the requirements of individual emergency rooms. The intentions of this action plan are to ensure that the minimum adequate nurse staffing is attained to promote health care quality and achieve safety. Moreover, the action plan intends to reduce nurse turnover rate through improved job satisfaction. Through the consideration of the nurse staffing requirements for each unit, the action plan will reduce opposition by opponents of the minimal nursing to patient ratio. The cost due to minimum nursing requirement will also be reduced since staff number will be dependent on the needs of an individual unit of emergency rooms.

Some of the crucial stakeholders in the implementation of this action plan involve the states, nurses associations, hospital associations and the hospital management. States need to support this intervention to establish nursing staff number depending on an individual emergency unit level which might be contradicting with the former response. Moreover, nursing association and the hospital associations need to support this intervention as it will promote nurse’s motivation through job satisfaction. The hospital management also plays a critical role in involving nurses in the implementation of this intervention.

Hospital management and the state government are the key stakeholders affected by the proposed change. As mentioned above, the state governments mostly promoted for the establishment of the nurse to patient ratio at the hospital level (Tevington, 2011). However, the proposed change requires nursing staffing to be based on unit level. Moreover, the hospital management determines its nurse staffing depending on financial objectives (Chan et al., 2010). Balancing of the financial goals and staffing based on proposals by nurses will be a key concern for the management.

It is also worth noting that the management will likely oppose this proposal due to its financial interests. Addressing of opposition will be by encouraging the management to formulate a cost evaluation plan. The proposed plan will cause a reduction in the number of nurses in some units while increasing the number of nurses in some other units. Moreover, the management will be encouraged to establish the maximum number of nurses at the hospital level to ensure that the overall number does not cause financial loss. The management will also be made aware that achieving minimum nurse to patient ratio is cost effective (Rothberg, Abraham, Lindenauer & Rose, 2005).

The implementation process will involve promoting legislation formulation by various states. Tevington (2011) accounts for different states formulating bills on mandatory nursing to patient ratio at the hospital level. States will be encouraged through nursing association and hospital association to stipulate legislations promoting staffing based on unit level rather than at the hospital level. The implementation will also comprise utilization of the nurses association, hospital associations and the hospital management. The nursing association will also be required to conduct awareness training regarding this process to encourage nurses to be involved constructively in establishing nurse staffing. On the other hand, hospital associations will be encouraged to promote unit-based nurse staffing and act as a compelling force to the hospital management.

Creation of awareness will also be a crucial step of implementation. This step will comprise informing stakeholders, especially the management and the various associations, on the importance of unit-based nurse staffing. The management will also be made aware that unit-based staffing does not incur additional costs as Rothberg, Abraham, Lindenauer and Rose established in 2005. Hospitals should also match nurse staffing and the patients during peak periods. Hospitals would be encouraged to tailor the number of nurses present depending on the time when the patient rate is high rather than following the 8-5am and night shifts. Such intervention will be critical in reducing the overall number of nurses in a hospital (Schofield & Callander, 2009).

The purpose of this intervention is to promote adequate nurse to patient ratio at the unit level. Therefore, the evaluation should also be performed at the unit level. One of the methods for evaluation is determining patient to nurse proportionality by conducting a patient census at a given unit. Moreover, evaluation can be performed by performing an assessment of nursing time relative to patient acuity. According to Ray et al. (2003), 86.1% of care given to a patient ought to be given by a registered nurse.


It is no doubt that nurse to patient ratio is critical in administration of care. Nurses have high contact rate with patients during care administration. Such care may be affected by an inadequate nurse to patient ratio resulting to poor care quality and safety as well as patient satisfaction. Therefore, it is pertinent to ensure that hospitals have sufficient nurse staffing. However, due to differences in intensity of care required in emergency departments, it would be prudent to establish nurse staffing based on unit requirements. The discussion above proposes determination of nurse staffing through active involvement of nurses at the unit level. Such process will be pertinent in ensuring moderate workload for nurses and will eliminate the issue of generalization as is the case with mandatory nursing to patient ratio.




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