The Magic Nursing Ratio and Missed Nursing Care

What is the ideal nurse-patient ratio? What are the errors that begin to occur when staffing breeches that magic number?

Imagine the busiest shift you’ve ever had...

How many patients were assigned to each nurse? If you don’t know the answer, or if you think the number isn’t particularly important, you should read an important little study previously published in the Journal of Nursing Care Quality.

The study, titled “Nurse Staffing Levels and Patient-Reported Missed Nursing Care”, suggests that nursing care really begins to suffer above a certain nurse-to-patient ratio. It’s actually not because of quick, sloppy work (errors of commission) but rather missed care, (errors of omission.) Maybe the oral care of the ventilated patient was skipped, or the follow up pain reassessment wasn’t timely addressed for the patient with abdominal pain, or bathroom assistance wasn’t provided and now the bed-ridden elderly patient with poor skin integrity is soiled. Even though this was an inpatient study, it’s easy to extrapolate to the ED.The study’s authors asked 729 patients to report the timeliness and consistency in which their nurses delivered care during hospitalization. Patients and their family members determined that the most frequently missed treatments were mouth and hygienic care, ambulation, discharge planning, patient education, being listened to, pain reassessments, and being kept informed.

The study’s authors asked 729 patients to report the timeliness and consistency in which their nurses delivered care during hospitalization. Patients and their family members determined that the most frequently missed treatments were mouth and hygienic care, ambulation, discharge planning, patient education, being listened to, pain reassessments, and being kept informed.
What is the magic nursing ratio number? The study doesn’t tell us –only that the limits are meaningful, and exceeding them has real impact on patient care. In my nine years as an ED nurse, and 12 as a nurse in total, I have seen drastic differences in overall care when nursing ratios exceed 6:1, especially in the emergency department. Blood cultures can get delayed, antibiotic administration can also be delayed, ambulation assistance is not always available, wound care, and punctual cardiac enzyme and repeat bloodwork can also suffer.The key phrase to recognize is “missed nursing care.” The term, which was coined by the study’s author Beatrice Kalisch, RN, Ph.D., describes the required yet delayed patient care that results from understaffing and increased

The key phrase to recognize is “missed nursing care.” The term, which was coined by the study’s author Beatrice Kalisch, RN, Ph.D., describes the required yet delayed patient care that results from understaffing and increased nurse-patient ratios.

So what? We all know the ED is a 24-hour circulating door and sometimes you can’t help being understaffed. Start by recognizing when numbers have broken the 6:1 ceiling and then pay special attention to the following can’t-miss nursing tasks.Early identification of patients with sepsis, or a risk thereof, is imperative. Recognition of vital signs within sepsis protocol parameters and risk factors allows early implementation and management of care for these patients who can become critically ill quickly. As a nurse, we can identify these patients from triage, or based on early and timely assessments of their presentation and history, followed immediately by communicating this to our physician and ED colleagues to initiate care.

Early identification of patients with sepsis, or a risk thereof, is imperative. Recognition of vital signs within sepsis protocol parameters and risk factors allows early implementation and management of care for these patients who can become critically ill quickly. As a nurse, we can identify these patients from triage, or based on early and timely assessments of their presentation and history, followed immediately by communicating this to our physician and ED colleagues to initiate care.We need to immediately identify patients who are at risk for falls, provide ambulation assistance, and implement a proper safety plan to prevent potential injury. This is not just relevant to the elderly and weak patients we see. Intoxicated and altered mental status patients can in fact be a higher risk for falls due to their compromised ability of situational judgment and perception. I remember the sound of dead weight hitting the floor during one of my night shifts. That night each nurse was with about nine patients, and each patient care tech was with 15 patients. While we were zooming around the unit, one of our intoxicated patients had fallen out of bed head first, which resulted in a massive head bleed, and surgical emergency. This is obviously the extreme, but it is a very real piece of the nurse to patient ratio argument. As we completed the Root Cause Analysis on this case, it was pointed out that we only had four nurses on staff that night with a rising census and acuity. Although he was placed as a fall risk at triage as per protocol, we, as nurses can only be in one place at a time and when you have lesser eyes on the patients, occurrences like this have a potential to happen.

We need to immediately identify patients who are at risk for falls, provide ambulation assistance, and implement a proper safety plan to prevent potential injury. This is not just relevant to the elderly and weak patients we see. Intoxicated and altered mental status patients can, in fact, be a higher risk for falls due to their compromised ability of situational judgment and perception. I remember the sound of dead weight hitting the floor during one of my night shifts. That night each nurse was with about nine patients, and each patient care tech was with 15 patients. While we were zooming around the unit, one of our intoxicated patients had fallen out of bed head first, which resulted in a massive head bleed, and surgical emergency. This is obviously the extreme, but it is a very real piece of the nurse to patient ratio argument. As we completed the Root Cause Analysis on this case, it was pointed out that we only had four nurses on staff that night with a rising census and acuity. Although he was placed as a fall risk at triage as per protocol, we, as nurses can only be in one place at a time and when you have lesser eyes on the patients, occurrences like this have a potential to happen.Timely administration of medications, therapeutic effect of medication administration reassessments, and repeat bloodwork drawing is a pivotal factor in the emergency room for all patients. Physicians depend on the timely repeat lactate for the ICU patient after fluid resuscitation and likewise for the 2nd set of troponin and cardiac enzymes for the ACS patient. Standard of care, core measures, and guidelines are enforced nationwide which depend on timely antibiotic administration and with every 30-60 minutes of delay can have potential negative effects on patient outcome and quality of care. As for pain reassessments after medication administration, we will better control pain if it is addressed early, frequently, and evaluated timely.

Timely administration of medications, therapeutic effect of medication administration reassessments, and repeat bloodwork drawing is a pivotal factor in the emergency room for all patients. Physicians depend on the timely repeat lactate for the ICU patient after fluid resuscitation and likewise for the 2nd set of troponin and cardiac enzymes for the ACS patient. Standard of care, core measures, and guidelines are enforced nationwide which depend on timely antibiotic administration and with every 30-60 minutes of delay can have potential negative effects on patient outcome and quality of care. As for pain reassessments after medication administration, we will better control pain if it is addressed early, frequently, and evaluated timely.Bottom line: Missing or delaying the necessary but often regarded “little things”, ambulation assistance, pain reassessments, timely medication administration and blood drawing, patient and family education, etc., can lead to negative effects on patient outcome, decreased quality of care, and also contribute to lesser patient satisfaction.

Bottom line: Missing or delaying the necessary but often regarded “little things”, ambulation assistance, pain reassessments, timely medication administration and blood drawing, patient and family education, etc., can lead to negative effects on patient outcome, decreased quality of care, and also contribute to lesser patient satisfaction.Nurses and physicians have long been counterparts and each come with their “own set of busy”. However, it’s the nurse who will be with the woman experiencing a miscarriage in the gyn room, the nurse who will remain four feet away from the intoxicated patient, and the nurse who will give a heads up about the potentially critically ill patient. On top of that we have the interruptions in care, family questions and concerns, phone calls, call lights, and of course every other potential “Nurse duty” which in the ED, can come at the drop of a dime, and can be extremely time-intensive duties. So, the more patients we have, the more of those cares can often be missed or delayed.

Nurses and physicians have long been counterparts and each come with their “own set of busy”. However, it’s the nurse who will be with the woman experiencing a miscarriage in the gyn room, the nurse who will remain four feet away from the intoxicated patient, and the nurse who will give a heads up about the potentially critically ill patient. On top of that we have the interruptions in care, family questions and concerns, phone calls, call lights, and of course every other potential “Nurse duty” which in the ED, can come at the drop of a dime, and can be extremely time-intensive duties. So, the more patients we have, the more of those cares can often be missed or delayed. My message to our colleagues? Let’s always be a team, and identify at-risk patients together, keep a watchful eye together, collaborate on department specific plans to help when staffing is low and numbers are high, and always understand that patient care, even assisting with someone who needs to walk to the bathroom, is everyone’s duty. That is how we are going to continually ensure that the best care is delivered.