Defending Nurse Licenses

Is It Time to Demand Nurse-to-Patient Ratios?

How many patients can one nurse handle? This is a question I often ask myself as I review disciplinary actions brought against nurses for such things as not charting, delaying charting, and worst of all, falsifying charting. I also talk to nurses who quit their job because they know it is impossible to do their job well because they are overwhelmed by the amount of work they need to do. Most nurses don’t feel overworked because they are incompetent or inefficient; it’s because they have been given too many patients to handle. Physically and emotionally, they just can’t do it day after day, month after month. The risk-averse ones leave their job to find a better fit, while the dedicated ones slug it out day after day, hoping that no errors occur.

I had one case recently where a nurse told her superior that the workload was more than she could handle, and asked for help. She was told if she couldn’t handle the workload, maybe it was time to quit. So she did immediately, only to be reported by her employer for patient abandonment; later, she faced disciplinary action from the Nursing Board. It’s a Catch-22.

When nurses are expected to do more work than is reasonable within the time allotted, mistakes can happen, or nurses cut corners. One of the nurses who came to see me told me it was impossible to chart during their shifts, so the nurses had to stay afterwords and complete the charting in the break room. To make matters worse, the employer told them they should have been able to do it while they are on the floor, so they were required to clock out, and were not paid for staying past their shift to finish charting. This happened daily. Besides the fact this is a violation of law (i.e., not getting paid for working), do you think that the quality of charting would be affected? Of course it would.

Is there any mechanism in place for holding administrators and facilities accountable for giving nurses too much work? None that I have seen so far. And who gets all the blame? The lowest on the pecking order are blamed—the nurses—not admin, not the DON or the CN. And when they ask for help, they are looked down upon.

Many years ago I learned about the science of matching up the demand for nurses with prospective patients on various shifts. It was called nursemetrics, and I represented one of the pioneers in the field. I found out there is a science to making sure that enough nurses will be on hand when a shift begins. I hope administrators are diligently implementing such tools.

After seeing the response to my last article, many people seemed to agree that we need a nurse-to-patient ratio law in this state. I wrote to the Board to find out whether this has been or is currently under serious consideration, but I haven’t heard back yet. For now, I would like to briefly share with you the findings of my research.

The only state in the United States of America that has a nurse-to-patient ratio law is California (as of 2015). Nevada is only one of seven states that require hospitals to form a committee that must establish nurse staffing plans, policies and procedures within their organizations. Nurse unions may set forth such requirements, but if they exist, they only exist in unionized facilities and have included such language in their collective bargaining agreements (CBAs).

In passing laws that require nurse-to-patient ratios, there are two approaches. One is to have a fixed model that sets the number of patients per nurse. The benefit of a fixed model is that it provides clear, bright lines as to the ratios, and therefore, it is easy to implement and enforce. Next is a flexible model, where the number of patients per nurse depends upon the type of patients being seen. I favor this model. Nurses I’ve spoken to in California tell me this is the model California uses; the nurse-to-patient ratio for ICU patients versus psyche patients, is different (i.e., fewer patients per nurse in an ICU environment). However, if the statute is too flexible, enforcement problems arise. A balance needs to be struck between total inflexibility and unbridled flexibility where nurses are at the mercy of the administration, with their jobs and licenses on the line.

I would also like to see laws that hold facilities accountable when nurses make errors due to being overworked/stretched too thin. The system shouldn’t be able to blame the nurse in such situations. Further, nurses should not be fired for such administrative violations. Nursing Boards should work more closely with facilities to ensure nurses can avoid these types of mistakes. The objectives of nurse-to-patient ratios are to provide better health care, higher patient safety, and greater work satisfaction. For more information on this topic, go to