Nurse Staffing Ratios

Nurses are expert professionals that provide direct patient care. There is no other business or healthcare professional that is taught or tasked with the critical thinking, the science, the legal responsibilities, or the multitasking workload of the clinically performing nurse. Clinically practicing nurse professionals have no less than (and some have more) education and experience than their nurse-colleagues that have chosen not to perform in a clinical environment and instead pursue careers in nursing leadership and nursing education.

Nurses are college-educated, board-tested, and licensed to practice nursing; physicians are also college-educated, board-tested but they are licensed to practice medicine. Nursing professionals are not responsible for medically diagnosing patients or performing surgical procedures, hence the additional four years of graduate medical education is not needed. Both professions enter into residency periods following graduation that provide supervised training for the independent and specialized practice of their careers. Nurses are not doctors, obviously, yet neither are they junior-doctors, wanna-be-doctors, doctor-servants or in any way connected to the practice of medicine …other than they share a patient population and a goal – the safe healing of patients.

The legalities of a patient’s nursing care are so immense that the education of them and their ramifications begins in the first nursing courses of nursing school. Nurses graduate and begin their careers completely cognizant of the fact that the hands-on care they provide (or fail to provide) and the medications they dispense could cause such harm to a patient as to cost the patient their life, their limb(s) or their ability to return to their previous levels of wellness. This type of assault or negligence could then cost the nurse their job, their career and ultimately their license to practice. …that the loss-of-license scenario rarely (if ever!) plays out is of no consequence to nurses at all. The threat is ingrained. Loss of license is a nurse’s most feared outcome.

The single nurse for each patient is legally responsible to provide or delegate (but remain completely responsible for the outcome) the nursing care for the shift. This includes: the administration of medications, the physical assessment with ongoing updates, the performance of wound care tasks and ambulation and comfort measures and infection control and pain management. The coordination of the day’s patient-appointments with other departments (i.e. Radiology, Laboratory) and other hospital professionals is an ongoing duty. The nurse is expected to begin/continue/finalize the patients’ education regarding their disease process, care regimen, home care needs, new/old/different medications and dosages and side effects (verbally and in writing). And finally the nurse is required to document in the patients’ charts all care, concerns, medications given/refused/missed, assessment-findings, calls to and from the patients’ physicians, education topics covered/needed, all the patients’ movements to/from other departments and visits with other healthcare professionals including their own physician, and all care tasks completed/refused/missed …for “If not documented, it did not occur.”

In the midst of these above-mentioned legal requirements of a clinical nurse professional, he/she is to establish a warm rapport with the patient and their family. Truth be told, this is the part nurses like best and is why most become and remain nurses. Quiet, gentle and clean environments of personalized and professional and calmly delivered care for any patient leads to relaxation and relaxation leads to rapid and safe healing. While doctors are responsible for the diagnosis and plan of medical stabilization of the patient’s healing, the nurse is responsible for the plan of nursing care that provides the environment of healing.

A senior nursing staff member – usually titled “Charge Nurse,” “Shift Manager,” “Clinical Leader” or some other title designated by the hospital – makes patient assignments to nurses at the beginning of each shift. This leader assumes a legal responsibility also. Assignments of patients to nurses must be done in such a way that ensures the nurse assigned to any one patient is clinically capable of independently providing the care that patient will need. In learning situations, the nurse leader will assign the patient to a student/trainee nurse with a capable nurse preceptor to oversee and ultimately be legally responsible for the patient’s care.

One licensed nurse is assigned to the individual care of each of the patients in a unit. If there are 30 patients and the Charge Nurse has 5 nurses that shift available for patient assignments, then the easiest way to make assignments is to give each nurse 6 patients. The Charge Nurse remains assignment-free to manage the incoming patients from other units, the out-going and discharged patients, assist physicians and be available to provide extra help with overflow needs from the other nurses.

Sometimes it is just that easy.

Sometimes the Charge Nurse will take a “light” assignment (the easiest patients) leaving only 5 patients to each nurse – which is always nice but then every nurse is busy and no one is immediately coordinating the admissions and discharges and physicians nor is anyone readily available for extra assistance and/or break coverage. (Everyone is always available to assist with emergencies. That is just the way nurses roll.)

Sometimes the patients themselves cannot be so equally divided. Some patients are more acute than others and require more assistance, medications, nursing management and nursing oversight. Some patients are just returning from surgery while others will be leaving for surgery and may be gone hours. To give one nurse a “heavy patient assignment with a fresh post-op” while another nurse has 6 stable patients “just to make all the numbers work out evenly” is totally immature patient management on the part of the Charge Nurse. Regardless, it happens.

If a co-worker calls in sick or leaves sick and there is not a nurse to replace him, the patient assignments are re-mixed and re-assigned. If the hospital management does not “think it necessary” for 5 nurses to be staffed on that unit per shift and only “allows for” 4 plus the Charge Nurse, each nurse will be assigned 7 and 8 patients per shift and/or the Charge Nurse will regularly take an assignment. While the Charge Nurse regularly “taking a fair share” may ease the burden of volume, it creates the burden of workplace frenzy.

A nurse cannot become personable, mindful, and immediately responsive to a patient’s needs and environment if she is overwhelmed with a patient assignment that exceeds rationale thought – either in volume or acuity. High volume or high intensity of patient workloads is not a decent or responsible choice. Both are dangerous. There is precious little time for patients. Rapport, hand-holding, reassurances, complete pain management, or effective patient teaching become pie-in-the-sky dreams of shiny-faced nursing students. Rushed and seemingly (actually?) rude nurses are the result of critical staffing protocols.

Nurses in these short-staffed and frenetic situations function entire shifts without tending to their own toileting needs, nutrition, mental health, emotional health or physical health. They are sad, frustrated, angry, hungry, hurried, harried, disloyal, short-tempered and smart-mouthed. Physicians and hospital leadership are likewise frustrated, angry, punitive and unsupportive of the nurses’ plight – not because of the process (which they have no time or interest to understand), but directly because of the nurses’ own behaviors. …Patients are at risk in this environment!

A human can only take so much stress – physically and emotionally – before a change is necessary. For nurses this change most often results in one of the following:

  • calling-in sick themselves (which results in employee discipline after a threshold has been reached and further short-staffs their unit),
  • suffering a stress-induced illness (which can result in a short or long-term disability),
  • enduring a personal injury (usually a back, hip or knee blow-out),
  • moving their career to an intensive-care environment (thereby creating a vacuum of experienced nurse professionals at the bedsides of medical-surgical unit patients),
  • or leaving the ranks of hospital bedside nursing altogether (furthering the ‘nursing shortage’ regardless of the numbers of graduates nursing schools are able to produce). There is no doubt that a professional nurse will leave a position when the imposed risk – real or imagined – to their career and license is under constant assault in their workplace. It is ridiculous to believe that ‘the nursing shortage just happened one day…out of the blue…for no known reason. Silly nurses.’ Professionals refuse to work under absurd conditions and will resign ignorant leadership – in droves.

Expert clinical nurse professionals should be staffed throughout the hospital in such a way that requires a sane standard be met for the provision of safe nursing care to all patients.