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The Real Story Behind Nursing Ratios

I support mandated nurse-patient ratios


Jake reaches in his pocket and pulls out a crumpled scrap of paper scribbled with “101.2 temp Room 2112” and hands it to Ashley, the registered nurse.  Ashley nods and says nothing but is inwardly alarmed because she knows a temperature plus a source of infection can be a sign of deadly sepsis. She once saw a deadly case from a

spider bite.  This patient has a deep red streak running up his painfully swollen forearm from an untreated cat scratch.

She grabs a computer to check 2112’s labs and antibiotics, but out of the corner of her eye spots the confused elderly man in 2118 pulling out his IV. She sprints to stop him but is too late. He was in the middle of a blood transfusion and now there is blood everywhere.

Simultaneously a surgery nurse in green is pushing a gurney towards  Room 2114. The patient is Mrs. Brown, a post-op knee replacement patient who is groggy and moaning in pain. There’s an emesis basin on the pillow by her head. A sign she’s nauseated.

Mrs. Brown will immediately need a patient controlled analgesia (PCA) machine that allows her to self-administer morphine injections to control her knee pain. PCA machines are complex to program and require full and mindful attention during set-up to avoid narcotic overdose. Ashley will have to closely monitor her patient for signs of respiratory depression while on the PCA. Ashley makes a mental note to make sure to get Mrs. Brown up before the end of her shift to ambulate for early mobility.

The daughter of the patient in Room 2116 is standing in the hall, coffee cup in hand, glaring at Ashley because her mother asked for more coffee earlier. Ashley will have to make a fresh pot of coffee herself in the cramped food room. Sometimes she feels like a waitress.  Stressed, Ashley feels guilty and avoids eye contact. Ashley knows the family doesn’t understand that she really wants to bring their mom a nice fresh steaming cup of coffee.

Ashley feels the phone in her scrubs pocket vibrate. It’s the Lab. “Your patient in 2120 has a critically low potassium level.” Low potassium levels cause erratic and dangerous heart beats. While calling the doctor, Ashley rushes to Room 2120 to apply a telemetry monitor to monitor her patient’s heart rhythm, essential with a low potassium. It’s an isolation room so first she must laboriously gown, mask and glove before entering the room. Stepping in the room, Ashley realizes her patient has soiled herself.  The patient is a 74-year-old woman, weak, and embarrassed. Ashley senses her discomfort and expends energy trying to make her comfortable by calmly making small talk, and trying not to appear rushed.

Ashley has only  five patients but even with five patients, things can spin out of control. Luckily, Ashley is in California, where staffing levels are mandated and Ashley cannot be assigned more than five patients on a medical surgical nursing unit. In most states, there are no set ratios.

That same day, in similar units across the nation, a nurse who works at a world-renowned hospital in the mideast has seven patients. Another nurse in Florida is just glad he doesn’t have eight patients like the day before. Yet a third nurse in Tennessee has six patients.

None of these nurses have yet had time to read the recent report in BMJ revealing that medical errors are the third leading cause of death in the United States, but they would not be surprised. Each of them is doing their best to keep their patients safe, sometimes against the odds.

Mandated nurse patient ratios are needed to ensure safe staffing levels. Patients deserve the attention of a nurse who is not too busy to safely oversee their care. Nurses need and deserve manageable patient loads and improved working conditions.

Thousands of nurses are gathered in Washington, DC in May to raise awareness around safe staffing and the efforts need to continue. Nurses must call for legislators to support safe staffing ratios and hold hospitals accountable to ensuring patient safety.

It’s time to speak up and support safe nurse patient ratios across the nation. #NursesTakeDC  Find out about Nurse-Patient Ratios: A Biased View here

Nursing’s Dirty Little Secret

Do You Have What it Takes to be an ED Nurse?

Until next time friend,

Nurse Beth

AuthorYour Last Nursing Class: How to Land Your First Nursing Job..and your next!” 

Come visit me at Ask Nurse Beth career column at for all kinds of  entertaining and informative career questions and answers, and to submit your own question :)


About Beth Hawkes (146 Articles)
Nice to meet you! I'm a Nursing Professional Development Specialist in acute care, a writer, speaker and career columnist.

36 Comments on The Real Story Behind Nursing Ratios

  1. Any thoughts about legislation for the ratio of CNA to Patient especially in nursing homes it’s horrifying totally not enough time to take care of 12 to 17 patients for 1CNA. Call lights unanswered for 20 to 40 min, soaked briefs, bed sores, falls, dehydration, all due to not enough staff.. it is simply not feasible to properly care for 12 to 17 patients in a nursing home. The CNA is responsible for self cares like dressing changing/toileting transfers for meals or helping to feed those more dependent.. if you have or know someone in a nursing home then you know what goes on… it’s inhumane and all about profits for owners of these nursing homes or hospitals.

  2. Most hospitals don’t employ LPN/LVN’s in california.

  3. Doris Friedel // May 13, 2016 at 9:38 am // Reply

    Yes CA has mandated ratios, but I’ve noticed they don’t have as many CNA’S. Some hospitals don’t have any, while others have 1 for a unit of 30 patients. More charting is required than 10 years ago, and people are more demanding, thinking they are the only patient you have.

  4. Jen Waldrop Hanson // May 13, 2016 at 9:10 am // Reply

    I work in a rural hospital. Sometimes I am the only RN working with an LPN. We staff only 2 nurses for the whole facility. We can take up to 15 patients. We cover the ER also and answer the phone after 5 PM and on weekends. One recent day our census showed that we had 3 patients. 1 pt was fairly self sufficient, the second one a new pneumonia pt who was weak and needed assist to BR and for cares, the other one was a confused lady that had low hgb and platelets, I was transfusing 2 units of blood on her, she was showing signs of CHF so called the Dr and received order to give IV lasix and place a foley, all this was done, I also had 4 Out patients coming, 3 of whom had IV medication, the LPN’s in our facility can’t do IV anything, nor give blood. Then we had 3 ER’s pt’s,(RN has to do intial assessment) One of them I admitted (Again only RN can do this) for pain management and placed a foley d/t urinary retension (1250 cc returns with clamping 2 times so didn’t get bladder spasms) (I had to do because LPN was assisting with suturing a 3 year old. One I transferred to a larged facility because they were having a STEMI, couldn’t find X-Ray so I did the EKG myself, alerted Dr. who had went back to the clinic. Then another clinic practitioner called and received another admit. Then later clinic called and wanted a pt to receive IV fluids as outpatient, so I put them on the schedule via computer called the office who gave them a HAR # so that it would all be billed correctly and so that I could open the chart via Epic charting. Then my confused lady pulled out her catheter, blood all over, family upset, family requesting a courtesy tray for meals, family wanting coffee and cookies…. Meanwhile I ran between my 2 new admits starting IV’s and doing admission paperwork and charting before I was past the initial due times on the computer where a red flag shows up which flags the state surveyors to notify them how come care was delayed. Then my confused ladys family decided to stop all care after I had finally transfused the blood so we transferred her back to the nursing home (attached to our facility) at 4:45 PM. AT 5 pm the office staff left and I and my co-worker answered 14 phone calls in 2 hours after that. I had no breaks, no meals in 12 hours. I used the bathroom 1 time in that whole time. We have no ancillary staff. I actually stayed until 8 PM to finish charting. When I was talking to my Director of Nurses (My boss) about my day (She had taken the Friday off and would normally assist if it got this busy) I was told, “you know, by all rights we should be able to take care of 5 patients each.” So 5 patients with ancillary staff to assist and not answering all of the calls for a whole facility and covering an ER does sound reasonable to me. Thank goodness every day isn’t like this. Last night I had only 1 patient in the hospital, 1 scope pt to recover and then send home, and 2 ER’s all shift (1 was a psych pt that still didn’t have placement when I went home at 11:30 PM) I felt like I was on vacation.

  5. It’s not just the number, it’s the acuity. I’ve worked a surgical NICU for years. We don’t stop taking patients because we don’t have nurses. I’ve taken two critical patients on oscillators, a fresh post op with a new surgical case, an ECMO baby with a fresh tracheostomy, a surgical NEC case with a new cardiac baby on multiple drips… the list goes on. There is a mentality in nursing management that a body is a body; it doesn’t matter how sick the patient, they get treated the same as the one who is just about to get sent home (even though that one still needs multiple med teaching, trach care, PICC line pulled, etc…)

  6. And this is why so many errors exist. It also shows a poor use of personnel. Getting coffee, while appreciated by the patient and family, does not require an RN it. The RN should be focused on the immediate post op patient, and the patient with dangerously low potassium. She needs the physician for additional orders for potassium and monitoring. An aide or LVN/LPN could be caring for the elderly confused patient, and monitoring the blood transfusion patient. As shown, with current acuities, even 5 patients can be overwhelming. Better utilization, plus limiting patient loads would be better and safer for all.

    • The problem with this, is when you staff with ratios and want to not go out of business, you can’t afford as many ancillary (non-nursing) staff members because you now have more nurses for the same number of patients. The money for those nurses has to come from somewhere and usually it comes from the other staff positions.

  7. As a pre-nursing student this is enlightening. Thanks for painting such a clear picture of how easy it is to become overwhelmed on a shift.

  8. As a former house supervisor, why don’t you comment on how a post-op joint replacement patient should prob not be near (perhaps not on same floor) as a patient with cellulitis (+/- sepsis) which is a nurse management error. Also, why wasn’t PCA set in the PACU, programmed by pharmacy? Additionally, I’m amazed that her peripheral vision can see around and thru patient doors to see the confused elderly male pulling out his IV. If you’re going to alert your audience about the excessive workload of nurses,1) be real, and 2) get to the heart of the matter with nursing workload — paper/computer work!!!!! Why is a patient’s ED chart 60% nursing entries and <40% physician entries/data. Start fighting jahco/press ganey (small caps on purpose) and I have no doubt Rn's could very effectively, safely and most important graciously handle 5,6 or perhaps 7 patients.
    Granted admin obviously must fight insurers better to get the hospital properly paid for care giving, so that RNs are not used as revenue enhancers — most of your documentation (as well as docs) is for revenue purposes… there is so much to say…

    • I believe I made the point I intended to make- that the intensity and complexity of the job are not understood by the public.

      Btw, my facility did recently start having PCAs started in PACU- thank goodness, for the patients- but I have yet to hear of a facility where Pharmacy programs them (they program hard stops, but not for individual orders/patients).

      The burden of computer work is huge, but that is not going to change anytime soon, if ever. What CAN change is nurse patient ratios. Thanks for your comments.

    • I have four daughter’s who are nurses, one of them is in ER and another one is in critical care, and I get to hear the stories (often at dinner which used to gross me out but I’ve grown accustomed to).

      The anecdotal evidence of my daughter’s experiences fully supports Nurse Beth’s assertions.

      Hospital administrators contend with two factors that affect their staffing decisions. Number 1 is profit and number 2 is the shortage of qualified nurses. If the business managers of hospitals won’t deal with the problem of under-staffing then maybe it is time we contact our legislators to propose that the state regulate the ratios. Good nurses are getting burned out and, more importantly, patients are at risk for preventable problems that can and do lead to death.

    • Quit charging nursing as a subset o f room and board. Nuring care should be billed separately, just like lab, x-ray, and other disciplines. Charge based on acuity and there will beenough money to staff at more appropriate levels. Its all about the money.

      • Humana gold would go broke.. almost every one of their patients has an extra 5 comorbidities and terrible compliance issues.

      • Julia Harbeck // May 14, 2016 at 5:10 am // Reply

        As a nurse who is occasionally a patient please don’t give insurance companies another reason to increase charges, I can’t afford this “affordable care “as it is

    • Patrick, if you were in the same scenario as Nurse Beth, could you please explain to us how you would have handled this situation, step by step? I find that the house supervisors have been removed from the trenches so long that they soon forget the reality of it all. Anyone who seems to think that Rn’s could graciously handle 6 & 7 patients, with the acuities they have today, is totally removed from reality or just doesn’t care about proper, safe patient care.

    • Susan Daniel Harris // May 13, 2016 at 7:58 pm // Reply

      First of all, I’ve worked at several hospitals in several different states and the pharmacy NEVER programs the PCA’s, the RN does according to the physician order, with another RN verifying the physician order, setup, dosage, etc.. Additionally, the PCA’s are not usually set up in PACU, but are instead set up when the patient returns to the floor. If you are a nurse, you should know this. Also as a nurse, you would be surprised how much you can see going on with your other patients while in one patient’s room. A lot of this depends on how the station and patient rooms are setup and aligned. To be real, the heart of the matter IS nursing workload which includes patient safety, patient acuity, paper/computer work, adequate supportive staff, and so on and so forth. If you are a nurse, you should know this. Finally, dealing with the Joint Commission (formerly JCAHO, not jahco) can indeed be a pain in the rear at times, but important safety measures and new protocol that benefit patients have been developed and implemented as a direct result of their recommendations. Fighting the Joint Commission and disregarding Press Ganey survey’s will get you nowhere fast. While the survey’s are not always a true representation of the real picture, they are a stepping stone toward improvement of the system as a whole. If you are a nurse, you should know this.

    • Jami Leithren // May 14, 2016 at 7:00 pm // Reply

      I can assure you that this is an accurate depiction of some hospitals. It’s not right, but it’s where I was, in a step down unit with 5 patients (instead of 3-4 which is the norm), literally no support staff, and a nurse manager who didn’t care because she was high on power. Oh, and did I mention I was a new grad? It’s a wonder someone didn’t die. This is a problem that needs to be addressed.

      • “high on power” good! I’ve been thinking a lot about this lately, well put.When nurse managers go to the dark side.

  9. Michelle Norvell // May 8, 2016 at 1:42 pm // Reply

    I agree with safe pt ratios based on acuity and numbers but as an ED nurse I and my co workers have gotten overwhelmed due to these safe staffing numbers, at night our MSP unit will max out as 6 pts, I know that is a heavy load esp MSP I floated for 7 years before going to my true love the ED, but we are overwhelmed by boarders waiting for a bed upstairs and we can not control the pts that come in the front door or via EMS! So the one night that left us with 28 boarders in a 30 unit ED, 6 nurses including charge and triage after 2am and pts in the waiting room, stretchers in the hall and w/c’s in every corner was the worst night in my career as a nurse and sad to say this is becoming the norm, at least 2-3 even 10-12 pts waiting as boarders in the Emergency department. I have been a floor nurse at night with 8 to 10 pts, but based on the acuity is what mattered most because I a might have 10 pts who sleep and are mostly self care or I would have 5 or 6 totals it just depended on the team you got that night. Things are much better now for sure but please don’t forget about the ED nurse and the pts stuck in the ED

    • You are right. It’s getting to where an inbetween unit is needed, not ED, but admitted holds

    • I agree. ED nurses probably have the least control. Would it help to have an actual unit just for admitted ED holds?

      • Doris Friedel // May 13, 2016 at 9:42 am // Reply

        I worked at a hospital in CA where floor nurses took over care of admitted patients in ED. We started admission paperwoek, gave meds, and freed up the ED nurse.

        • That sounds like a great idea, but what about the nurses left on the floor? If you remove a floor nurse then the other nurses on that floor need to take up the slack and their patient load/acuity goes up, so we are right back where we started.

          • Doris Friedel // May 13, 2016 at 2:43 pm //

            The hospital hired travelers to work in the ED.

          • That’s great and very smart of the hospital. Sounds like you work for a facility that cares about their patients and their staff. Very unusual in this day and age.

    • Same with Labor and delivery and nursery. I have had many nights with all rooms filled, women laboring in the recovery area, the intake area, the halls, anywhere we cound find a nook for them. And their acuity was high for each patient. C-sections pulled 2 nurses for duration. Craziness! And NO ONE is either willing nor appropriately traindd for L&D!

    • I recently had a similar experience in the ED where I work. I was in charge and had 10 patients (only for a short time, but those hours were so stressful it felt like its own shift). We don’t have staffing ratios, just a hard stop when you run out of inpatient beds… so I can imagine the similarity to beds blocked because of ‘safe staffing’ – what is safe about people waiting in the ER? nothing. What is safe about patients who are admitted waiting in the ER… yes, they should technically be receiving the same care in the ED.. but with our charting the inpatient units use a completely different but compatible charting system. We know how to read orders, but what about the ‘mandated protocols’ and ‘core measures’ that we have had ZERO inservice on… but we’re still held accountable. 4 of our 29 rooms have a bathroom, otherwise we have to assist with bedpans, BSC, or help them ambulate to the bathrooms. We have had admitted patients holding in the hallway… and at one time when I was an ER nurse in Texas, I had seven patients with two of those patients in the hallway, one in a wheelchair and the other on a blanket, seated on the floor. (seriously). There are bigger problems than nurse to patient ratios… because when you run out of nurses, it doesn’t mean they stop coming into the ED.

  10. Donna Parsons // May 8, 2016 at 12:12 pm // Reply

    so what happens in these situations? like what’s happening to the man who’s pulled his iv out while the nurse tends to this/these other situations?

    • In real life, the man with the blood all over would get immediate attention, then probably the returning post-op knee patient. The patients with just as important needs (like a low potassium and possible sepsis) may get lost in the chaos or may have delayed treatment- and that’s dangerous 🙁

    • Angela DeAnn Wilson // May 8, 2016 at 11:22 pm // Reply

      We prioritize the priorities. All these scenarios happen and you have to make a choice. IV Blood administration would come first comes, secure the blood, restart the IV and begin administration as you have a deadline for the blood transfusion or you have to throw it out.You walk out of the room where the lady has soiled herself after putting on the telemetry. Call the tech to help if they can. Page the MD to get orders on the fever, or hopefully you have standing orders… CXR, blood cultures, CBC, BMP, and urine culture, also talk about the telemetry patient and get an order. Tell a nurse you need to her to help you sign off on a PCA in room ### on a fresh post-op in about 10 minutes, Grab the tylenol for your fever as you grab the antinausea and PCA pump and the narcotics.. Head to the post op, assess, give meds, set up PCA. Go back to lady with telemetry after observing her rhythm. If there is trouble order a EKG and call the MD. If not done…help clean up the lady. Meanwhile radiology and lab is at bedside for the high fever pt. Follow up on results, page MD. Hang new IV antibiotics. Get our patient a cup of coffee and chug one down for yourself. Go back to your post op to ensure airway and response to pain medication. Oh and don”t forget to document everything as you are doing it

      • Donna Parsons // May 9, 2016 at 5:07 am // Reply

        Angela, is there ever anything about having someone stay with a patient who’s getting a blood transfusion; guess thinking of Michelle’s comment above about patients being mostly self-care; of course you don’t know if they are or not till you actually have them? in other words, would you know if, say, a patient who’s getting a blood transfusion also has dementia and might be prone to do that?

      • If people only knew!!

      • Well put. I’m exhausted now 🙂

  11. Deena Sowa McCollum // May 8, 2016 at 2:12 am // Reply

    Wow! You nailed it Beth! As always thank you for your work and words!
    Your fan

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