Changing Practice: Nurse-Patient Ratio

Sarah, Sal, Shannon, Yesenia

Why Nurse-Patient Ratios interested our group:
● 1 student nurse: 2 patients during school
● Upcoming ratio for job can be upwards of 6 patients depending on unit
○ Inflicts stress onto new graduate nurse
○ Difficult transition
● 42CFR 482.23(b) - Requires Medicare hospitals to have adequate numbers
of RNs, LPNs and other staff member to take care of all patients as
needed.
○ But what does adequate mean?
● Safer ratios save lives.
IOM Competencies: Patient-Centered Care
“Identify, respect, and care about patient’s differences, values, preferences, and
expressed needs; listen to, clearly inform, communicate with, and educate patients;
share decision making and management; and continuously advocate disease
prevention, wellness, and promotion of healthy lifestyles, including a focus on
population” (IOM, 2003, para. 1).

● Positive effects of implementing Nurse-Patient Ratio:

○ Allowing time to implement preferences in client care leading to increased quality care
○ Increased patient outcomes
○ Decreased readmission rate
○ Decreased medication error
○ Better patient education
IOM Competencies: Evidence Based Care
“Integrate best research with clinical expertise and patient values for optimum care, and
participate in learning and research activities to the extent feasible” (IOM, 2003, para. 3).

● Positive effects of implementing Nurse-Patient Ratio:

○ More time to phase in EBP into daily patient care
○ Increased positive patient outcomes
○ Decreased length of stay related to complications
○ Decreased rates of nurse burnout
○ Decrease in patient readmission leading to Increased profits!
IOM Competencies: Quality Improvement
“Identify errors and hazards in care… measure quality of care in terms of
structure, process, and outcomes in relation to patient and community needs,
design and test interventions to change processes and systems of care, with the
objective of improving quality” (IOM, 2003, para. 4).

● Positive Effects of Implementing Nurse-Patient Ratios:

○ Patient safety is increased
○ Increased patient satisfaction
○ Implementation of patient preferences
○ Decreased adverse events
○ Decreased length of stay
 few decades has
overwhelmingly shown
that safe staffing levels
and ratios help improve
patient outcomes in
mortality, adverse events,
complications, failure to
rescue, quality of care,
costs, and length of stay.
Safe staffing also help
decrease nurse burnout
and job dissatisfaction”
(National Nurses United,
2018, p. 2).
Ethical Principles

● Nonmaleficence- To do no harm. This includes incorporating interventions and selecting

specific care that will do the least amount of harm and provide the best outcome.

-Ensures the safety of the patient and community in all aspects of delivery
-Nurses are required to report treatments that might be causing harm to a patient. This also includes suicidal or homicidal
ideations.

● Beneficence- acting for the good and welfare of others.

-includes attributes like kindness and charity

-”actions guided by compassion”

(Gaines, 2020)
Code of Ethics Provisions.

“Revised in 2015 to include 9 provisions, the ANA’s nursing code of ethics now includes interpretative statements
that can provide more specific guidance for nursing practice (Gaines, 2020)”.

The two concepts below are only 2 out of 9 of the provisions made in 2015, and both concepts support our choice
of Ethical principles.

1. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes
action consistent with the obligation to provide optimal patient care.

2. The profession of nursing, collectively through its professional organization, must articulate nursing values,
maintain the integrity of the profession, and integrate principles of social justice into nursing and health
policy.

(Gaines, 2020)
American Nurse Association

● Safe staffing is one of the RN Action items of the American Nurse

Association (ANA).
● The approaches are aimed to recognize the unique characteristics of each
hospital and unit.
● ANA advocates for safe staffing approaches that include:
○ Allows RNs to go through orientation prior to working
○ Have a policy to receive and investigate complaints
○ Permits civil monetary penalties when warranted
○ Includes protection for whistleblowers
○ Mandate public reporting of information regarding staff

(American Nurse Association, n.d.)

Oklahoma Nurse Practice Act

Provides education, certification and licensure of RNs and LPNs.

The Oklahoma Nurse Practice Act is used to facilitate the health and safety of
the public. It promotes the compliance of nursing laws and provides guidance
for violations. Additionally, it defines the RN, LPN, and APRN practice scope.

● This promotes patient safety by allowing a nurse a regulation to refer to

when overworked and understaffed. One RN practice scope is “providing
safe and effective nursing care rendered directly or indirectly” p.1… can
you as a nurse do this if your patient load is too high?

(Oklahoma Board of Nursing, 2020)

Federal Legislation
May 8, 2019 :
H.R. 2581, Amendment to the Public Health Service Act (2019):

Aims to establish direct care RN to patient staffing ratio requirements in

hospitals and for other purposes.

Currently referred to the Subcommittee on Health since May 9, 2019.

State Legislation
63 OK Stat § 63-1-1925.2v2, Reimbursements from Nursing Facility
Quality of Care Fund - Staffing ratios - Name and title posting - Rule
promulgation - Appeal - Nursing Facility Funding Advisory Committee
(2019).

Established staffing ratios for nursing facilities and Intermediate Care

Facilities for Individuals with Intellectual Disabilities.

Policy changes based on date, the most recent of which was January 1,
2020.
Peplau’s Theory

- Therapeutic relationship is fundamental for development

- Peplau’s 3 main phases:
- Orientation
- Working
- Resolution
- This nursing theory requires nurses to establish an interpersonal
relationship with the client. If unable to do so, the process would be
broken.

(Fitzpatrick,2018)
Nursing Implications
Increased workloads leads to
decreased retention rates
worsening the nursing shortage in
the unit.
Nursing Implication
Inadequate nurse-to-patient ratios
leads to nurse burnout and negative
patient outcomes, and negative unit
morale.
Professional implications

1. As a new RN my workload may require me to lean on more experienced

nurses and in turn, lead to both of us becoming burnt out.

2. Higher patient-to-nurse ratios can cause less one-on-one time with my

patient… leading to high incidence of falls

3. Nurse shortages may not allow me to practice my clinical skills such as blood
draw and lead me to depend on other interprofessional staff members

4. As an RN, I would be unable to facilitate higher patient satisfaction rates due

to being overworked
(Sharma & Rani, 2020, p. 2631).
 References

Amendment to the Public Health Service Act, H.R. 2581, 116th Cong. (2019). https://www.congress.gov/bill/116th-congress/house-bill/2581/text

American Nurses Association. (n.d.). Safe Staffing. Retrieved from RN Action ANA: https://ana.aristotle.com/SitePages/safestaffing.aspx

Fitzpatrick, J. (2018). Peplau's Theoretical Model. In Encyclopedia of Nursing Research (4th ed.). Springer Publishing Company.

https://www-r2library-com.webproxy2.ouhsc.edu/resource/detail/0826133045/ch0016s0347#goto=ch0016s0347bib3254

Gaines, K. (2020, September 4). What is the Nursing Code of Ethics. Nurse.org: https://nurse.org/education/nursing-code-of-ethics/

Institute of Medicine. (2003). Institute of medicine core competencies. Health professions education: a bridge to quality.

https://med.und.edu/continuing-medical-education/_files/docs/iom-competencies.pdf
National Nurses United. (2018). RN staffing ratios: a necessary solution to the patient safety crisis in U.S. hospitals.

https://www.nationalnursesunited.org/sites/default/files/nnu/graphics/documents/Ratios-ANecessarySolutiontothePatientSafetyC

risisinUSHospitals.pdf

Oklahoma Board of Nursing. (2020, May 21). Oklahoma Nursing Practice Act. Retrieved from https://nursing.ok.gov/act4.html

Reimbursement from Nursing Facility Quality of Care Fund - Staffing ratios - Name and Title Posting - Rule promulgation - Appeal -

Nursing Facility Funding Advisory Committee, 63 OK Stat § 63-1-1925.2v2 (2019).

https://law.justia.com/codes/oklahoma/2019/title-63/section-63-1-1925-2v2/

Sharma, S., & Rani, R. (2020). Nurse-to-patient ratio and nurse staffing norms for hospitals in India: A critical analysis of national

benchmarks. Journal of Family Medicine & Primary Care, 9(6), 2631–2637.

https://doi-org.ezproxy.cameron.edu/10.4103/jfmpc.jfmpc_248_20