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Quality Improvement Project: Nurse to Patient Ratio

Nickie Enos
Quality and Safety in Nursing II
NUR 3207
Connie Garrett, MSN, RN
November 27, 2016


Quality Improvement Project: Nurse to Patient Ratio

The quality and safety issue that is currently a problem in the outpatient infusion
center is the nurse to patient ratio. This is a problem because it is leading to high nurse turnover
and dissatisfied patients with the care received in the infusion center. It is leading to long patient
wait times until seated in treatment rooms and long treatment times due to the heavy patient load
for the nurse. The nurse is not able to get patients back to the treatment rooms at scheduled
times. One of the current dashboard issues that the infusion center is addressing is the patients
dissatisfaction with wait times.
Nurse to patient ratios is an issue for nursing in general. Higher percentages of the
nurses in hospitals with poor care environments reported high burnout levels and dissatisfaction
with their jobs (Aiken, Clarke, Sloane, Lake, and Cheney, 2008, p. 228). With higher patient
loads, nurses are not able to assess the patient thoroughly, possibly missing vital information and
are not able to attend to the next patient if one patient is having complications requiring
additional time and resources. Nurses reported high burnout or dissatisfaction with each increase
of one patient per nurse per shift (Aiken, Clarke, Sloane, Lake, and Cheney, 2008). Nurses
acquire more responsibilities with each additional patient per shift, which increases
exponentially, creating unsafe conditions for both nurse and patient. This leads to nurse fatigue
early in a shift due to overburdening and over-stressed environment. There exists a culture of
guilt among nurses when the shift is manageable and quality patient care provided. This is a
strange concept. Unfortunately, higher management perpetuates a culture of guilt among nurses.
Support from managers for nurses to have reasonable nurse to patient ratios is lacking. The
expectation from nurse managers is to take an additional patient, regardless of the acuity of the
patient load.


A quality improvement project that evaluates the wait times from the time patient arrives
at clinic, the actual scheduled time of appointment, and the time the patient is taken to treatment
room by nurse can determine the cause of the patient dissatisfaction of wait times. The National
Database of Nursing Quality Indicators (NDNQI) is a survey nurses take to assess the safety in
their work environment, delivers evidence to support the importance of nurse sensitive
measures in overall patient experience strategy (Press Ganey NDNQI, 2016, para. 1). Using
these evaluation tools, can determine which interventions would be best to trial before making
any definitive changes. The NDNQI is used by nurse managers in assessing the needs of the
nursing staff and can ask for more nurses based on those needs.
Nursing professional practice implications leads to burnout syndrome and high nurse
turnover rate. Job retention is used by some as a measure of patient safety (Amer, 2013, p.
53). Burnout syndrome is generally defined as exhaustion, depersonalization, and reduced
satisfaction in performance (Weber & Jaekel-Reinhard, 2000, p. 512). Nurses that are
chronically under stress due to high patient volume and discharge/admission of patients per shift
experience greater turnover and burnout. The observation made in the infusion center is high
patient turnover rate and the acuity of the patients can require significant amount of a nurses
time. More patients with higher acuity and rapid turnaround with discharges and admissions,
make nursing practice more stressful than ever (Amer, 2013, p. 25). New patients require
almost double the amount of time then established patients. Nurses provide much needed
education to patient and family about medications, discharge instructions, signs/symptoms when
to call MD, and self-care/maintenance until next appointment. When the nurse to patient ratio is
great, education cannot be addressed nor time allotted.


Improving nurse to patient ratios has been researched and found to show care is safer
when nurse-to-patient ratios are reasonable (Amer, 2013, p. 25). Higher nurse to patient ratios
have been documented to improve outcomes such as lower mortality rates, fewer pressure sores,
and less antibiotic use (Amer, 2013). Increasing the number of nurses would help alleviate the
immediate need and help with the nurse to patient ratio. The infusion center is adding five more
chairs/beds for the increased patient volume in the last two years. Retention of current and
experienced nurses would increase morale and job satisfaction among current nurses working in
the infusion center. Amer states, an optimal work environment has adequate staffing, a positive
collaborative environment or supportive nursing culture and resources that encourage life-long
learning (Amer, 2016). Retention of current nurses is cost-effective measure for hospitals. It is
expensive for a health care facility when there is high nurse turnover (Unruh, 2008).
The dashboard below, for BSHSI, shows that the target is not being met which effects
reimbursement from Center for Medicare Services: Medicare and Medicaid.

Dash Board for Bon Secours Health System

Patient Engagement HCAPS overall % top box: Year-to-date 74%, Target 78%
Patient Engagement CG CAHPS- Access:



Serious Safety Event Rate:



CMS Star Ratings- % 4 or 5:


Retrieved from:



Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008, May). Effects of
hospital care environment on patient mortality and nurse outcomes []. The Journal of
Nursing Administration, 38(5), 223-229. Retrieved from
Amer, K. S. (2013). Quality and safety for transformational nursing: core competencies. Upper
Saddle River, N.J.: Pearson Education, Inc.
Press Ganey NDNQI. (2016).
Unruh, L. (2008, January). Nurse staffing and patient, nurse, and financial outcomes. The
American Journal of Nursing, 108(1), 62-71.
Weber, A., & Jaekel-Reinhard, A. (2000, June 21). Burnout syndrome: a disease of modern
society? []. The Journal of Occupational Medicine, 50(7), 512-517. Retrieved from