i

NURSE-PATIENT RATIO TOWARDS PATIENT SATISFACTION

DURING COVID-19 PANDEMIC

A Thesis Presented to
The Faculty of the College of Nursing
University of St. La Salle
Bacolod City

In Partial Fulfillment
Of the Requirements for NCM111

CAEZAR JUSTIN E. DE LA BANDA

MARIEL ANN BENNETH B. DE LA TORRE
HENRIETTE JANE L. DE LEON
ANEKA HENNEL C. DEMATA
SARAH NAOMIE B. DESPUES

August 30, 2020

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TABLE OF CONTENTS

TITLE PAGE i
TABLE OF CONTENTS ii
INTRODUCTION 1
Background of the Study 1
Statement of the Problem 3
Hypothesis 3
Theoretical Framework 4
Conceptual Framework 5
Scope and Limitations 6
Significance of the Study 7
Definition of Terms 8
Review of Related Literature 9
REFERENCES 14
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INTRODUCTION

Background of the Study

Nurse expertise is in crucial need during the COVID-19 Pandemic. A large

section of the health workforce is mainly composed of nurses, which are essential in

developing practice and continuing to instill the principles of healthcare in the global

setting. (Nayna Schwerdtle, P. et al., 2020, p.49). The nurse to patient ratio is a reliable

model to ensure the adequate amount of attention given to patients while at the same time

avoiding the gravity of workload assigned to nurses. This distribution allows direct care

and to finish additional management, which can satisfy patients’ needs. However, staffing

levels have been a radical problem in the scope of nursing that affects in rendering

quality patient care.

According to the Department of Health (DOH), the ideal nurse to patient ratio in

the Philippines is 1:12 but the Philippine Nurses Association (PNA) emphasized a 1:60

ratio in government hospitals, which is distant to DOH's exemplary model (Cortez,

2020). One study in the Philippines found out that the amount of stress and burnouts

affects the relationship between nurse practices and outcomes due to unfavorable

workforce environment (Falguera, et al., 2020). In the latest report of the World Health

Organization (WHO) with regards to the global scenario of nurse-to-patient ratio, 55% of

the members reported that less than 40 nursing and midwifery employees per 10,000

population and 23% declared less than 10 (World Health Oragnization, 2020). In the

U.S., Nursing Homes are struggling in doubling their time and effort in maintaining

infection control, which also include patients with suspected cases as the staff shortage
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became prevalent (Xu, H. et al., 2020). Consequently, supply and demand for nurse

employment have been declining recently due to the uncertainty of safety in the

workplace. The number of cases of resignation has increased, and the number of

replacing staff is insufficient. Thus, mandatory overtime is expected as the number of

patients are escalating particularly in the medical-surgical area and development of errors

and moral distress or even moral trauma. While the setback has been progressive in years,

the crisis in the pandemic amplified the complication to a worse case.

Numerous studies relevant to the problem suggests that nurse managers should

direct an effective workplace environment and adapt to the ideal nurse-patient ratio.

According to a study on compiled reviews of research works about nurse-to-patient ratios

and nurse-patient outcomes, the results of high staffing levels have fewer mortality rate

and medication errors (Driscoll, et al., 2018). Methods from a different work used cross-

sectional surveys that involved more than 500 hospital nurses in the Philippines

(Falguera, et al., 2020). Nevertheless, the researchers observed that these studies only

acquired data from compiled related literature and nurses’ responses but lacked

exploration of patient perspective concerning the health workers performance and

experience to quality care. Furthermore, conducting this investigation is relevant in

establishing a strategic plan to enhance effective care in health facilities. It will not only

support the nurses’ well-being but also prioritize the needs of the patients. The study aims

to provide data about the relationship between nurse staffing levels and patient

satisfaction. For the benefit of future and already employed nurses, the data will help

other facilities and institutions understand the importance of a balanced workforce in

rendering quality care to patients and the effect on the recovery phase of the patients.
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Statement of the Problem

The study aims to assess the effect of nurse-patient ratio towards patient

satisfaction. Specifically, it will answer the following research questions :

1. Is there a significant difference on Nurses being able to provide holistic patient

care based on the number of patients per Nurse?

2. Is there a significance in the delivery of holistic care towards patients on Nurses

working at different areas?

3. Is there a significant difference in the delivery of patient care on Nurses working

regular hours compared to Nurses working overtime?

4. Is there a significant difference for the nurse in the delivery of patient care based

on the average number of patients a nurse handles per week?

5. What possible policies or proposed recommendations can be made to increase

patient satisfaction with the current Nurse-to-Patient Ratio?

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Hypothesis

1. There is no significant difference in Nurses being able to provide holistic patient

care based on the number of patients per Nurse.

2. There is no significance in the delivery of holistic care towards patients on Nurse

working in different areas.

3. There is no significant difference in the delivery of patient care on Nurses

working regular hours compared to Nurses working overtime.

4. There is no significant difference for the nurse in the delivery of patient care

based on the average number of patients a nurse handles per week

Theoretical Framework (IN PROGRESS)

This study leans towards Betty Neuman’s Health Care Systems Model, is based

on the general system theory and reflects the nature of living organisms as open systems

in interaction with each other and with the environment (Lawson, T., p. 232). The theory

basic components of an open system, the stress and the reaction to stress. The nurse and

patients, as a person that gathers inputs from a stimuli from the environment and reacts to

it depending on the client system or according to Neuman’s theory it is the 5 variables in

interaction with the environment, physiological, psychological, sociocultural,

developmental and spiritual.

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According to the Core, Care and Cure Model of Lydia Hall, a nurse functions in

all 3 aspects, the body, the person and the disease. Hall’s theory showed the improvement

in patient-nurse communication, self-growth and self-awareness. As what Hall believed,

more professional nursing care and teaching is needed, nurses and patients are not to limit

with only knowing but also to modify the processes (Pokorny, M., p. 19)

Based on Jean Watson’s Theory and Philosophy of Transpersonal Caring calls

nurses to go beyond procedures, tasks and technique in practice to have a therapeutic

outcome in the nurse-patient relationship. Watson’s theory has 10 different carative

factors that describes how a patient attains and maintains health, focusing on the human

caring process. Humans cannot be separated from itself, the unity and harmony of the

mind, body and soul (Willis, D. & Leone-Sheehan, D., p. 71)

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Conceptual Framework

The focus of the study is to determine the patient’s level of satisfaction in relation to the

nurse-patient ratio in the area. The performance of the nurse is an independent variable

that will affect the dependent variable which is the patient’s level of satisfaction. Factors

such as the nurse-patient ratio, working hours and the delivery of care given by the nurse

are the determinants of the quality of care and if the patient is satisfied with the service

provided by the nurse. Thus, knowing if there are significant changes with the patient’s

level of satisfaction in relation to the nurse-patient ratio, programs for nurses can be
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established to provide quality care for the patient and improve patient’s satisfaction.

Figure 1. Conceptual Model

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Scope and Limitations

The Primary focus of the study is on the Nurse to Patient ratio which affects the delivery

of holistic care for Patients Satisfaction in Corazon Locsin Montelibano Memorial

Regional Hospital, Bacolod City, Negros Occidental in where the study is being

conducted. It should be noted that this secondary level of hospital care caters to patients

of both Northern and Southern Negros Occidental, thus a larger hospital staff is present to

undergo the study. It should also be considered that the study conducted is taking place

during the COVID 19 pandemic and as such, is at full bed capacity and the researchers

are unable to conduct and collect actual data on site and will instead be collected via

online survey.

Nurses who will take part in the study are all working at the same hospital. Among the

nurses that are part of the demographic are categorized according to the ward they are

stationed at. These include Nurses who worked at the following area: Emergency Room,

Adult Medical Station and Isolation Ward. Moreover, the criteria in choosing the nurses

who are part of the study are all employed under the hospital for more than 5 years

already.
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Significance of the Study

This study hopes to establish an understanding on the importance of adequate

nurse staffing levels in hospitals. Furthermore, the study is conducted to benefit the

following:

Hospital Supervisors. This study will aid them to organize and establish an

adequate workforce in their respective corporations to manage and provide better

services.

Head Nurse. Being able to read this the study, head nurses are able to benefit

from the study as it provides them the relevant information in planning and implementing

roles to their members in a medical ward or unit. Understanding said study provides head

nurses with an overview of providing team members with the optimal tasks while

maintaining patient satisfaction in the ward.

Nurses. Results of this study may help nurses in having an in-depth

understanding of their rights and to know how their overall health impacts how they

deliver their care.

Patients. This study will be of benefit to them as it contains data that

demonstrates the relation of patient satisfaction and adequate staffing that may aid

hospitals in creating a system that will supply them with quality care.

Future Researchers. The ideas presented may be used as reference data in

conducting new researches or in testing the validity of other related findings. Moreover, it
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could then inspire them to do more in-depth research about the effectiveness of sufficient

hospital staffing.

Definition of Terms

Nurse-Patient Ratio. Conceptually, it is the quantitative relation between two

amounts showing the number of times one value contains or is contained within the other.

(Oxford Languages)

Operationally, ratio refers to the number of nurses on duty and the number of

patients they are assigned to in their respective areas.

Nurse Shortage. Conceptually, it is a state or situation in which something

needed cannot be obtained in sufficient amounts. (Oxford Languages)

Operationally, shortage is our description of the situation on the quantity of staff

nurses in Corazon Locsin Montelibano Memorial Regional Hospital.

Workload. Conceptually, it is the amount of work or of working time expected or

assigned. (Merriam-Webster Dictionary, Eleventh Edition)

Operationally, workload refers to a number of tasks given and the length of shifts

assigned to hospital nurses.

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Review of Related Literature

This review includes research studies, methodologies, incidence, and findings

related to the research problem. This review is presented using the thematic approach.

Studies Related to Mandatory Overtime among Nurses

Patient dissatisfaction towards health care services increased as Nurses who

worked an average of 13 hour shifts or more had increased. (Stimpfel, Aiken, Sloane,

2012). A comparison between nurses who had worked <8 Hours shift and those who had

worked >12 hours had observed that the latter are reportedly unable to discuss patient

care with the next shift nurses or have less opportunity to do so when compared to nurses

who worked scheduled hours. It was also noted that important patient information was

better disclosed upon endorsement with nurses working on scheduled shifts.(Emmanuel,

Dall’Ora, Ewings, Griffiths,2020).

A longer shift for the nurse increases the possibility of work burnout for the nurse. A

decrease of patient satisfaction towards their care was observed when an increase of

nurses with more than thirteen hour shifts has occurred. Patient satisfaction was higher

under the increased proportion of nurses who are working less than eleven hours per

shift.(Stimpfel, Aiken, Sloane, 2012).

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Studies Related to Patient Safety and Satisfaction

Nurses are unable to perform nursing management and interventions properly in

due time. This implies that patient safety might be possibly affected under Nurses with a

heavy workload which will hinder proper decision making of the health care providers

(Kaur & Gujral, 2017). An extension of work hours on nurses disregard their health and

state of well being. This can adversely affect a nurse's capability to provide safe and

quality patient care.(Stimpfel, Aiken, Sloane, 2012).

COVID-19 psychologically affects nurses who are unable to attend proper

COVID-19 training as well as those who worked part time jobs. Frontline nurses will be

positively affected such as job satisfaction, decreased psychological stress levels and

decreased intent to resign from the profession if proper handling of COVID-19 is met.

(Labrague & De los Santos, 2020).

Studies Related to Nurse-Patient Ratio

The shortage in nurse staffing has been a recurring problem globally where in 6

patients are assigned or under the care of only 1 nurse. During this time of COVID19

pandemic, nurses that are migrating to other countries may affect the issues and mitigates

the nurse-patient ratio shortage in hospitals and as well as other health care settings such

as clinics and homes (Tayaben & Younas, 2020).

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In a study by Stimpfel, Aiken, and Sloane, findings show that the intention of nurses to

quit their jobs because of burnout experiences and job dissatisfaction are most likely to

occur to nurses that have to work for 10 hours longer duty hours than those who have

shorter working shifts (Stimpfel, Aiken, Sloane, 2012). Moreover, studies show that a

higher workload and increasing number of patients assigned to one nurse will result in

poor patient outcomes given the observed variables and factors observed (Emmanuel,

Dall’Ora, Ewings, Griffiths,2020).

Studies Related to Medication Errors Caused by Heavy Workload

In hospitals, the most common concern in the practice of health care workers and

students are creating medication errors. These critical mistakes can risk the patient’s

safety. If this happens, it will be a burden on the patient’s part, which will require longer

days of hospitalization, questioning the credibility of the system, or can be a potential

cause of death (Webster & Anderson, 2002). A study was conducted in khatam-al-anbia

hospital with more than 300 nursing staff and 62 intern students in Iran. Findings showed

that workload caused by tiredness (97.8%) and drug calculation (77.4%) in nursing

students were the most common cause of medication error. It was suggested then that

nurse-managers should be in-charge of establishing workshops about drug preparations

(Gorgich, et al., 2016).

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Studies Related to Maximum Hospital Capacity

Hospitals have reached maximum capacity due to the rising number of COVID-19 cases

in the country. There are 456 level 2 or 3 hospitals in the Philippines as of the moment

and have a total bed capacity of 67, 119 excluding specialty hospitals. There are a total of

only 2,335 critical care beds in 450 Intensive Care Units in the country to cater critical

COVID cases and other serious illnesses. Also, the number of cases alone would require

approximately 21% of our healthcare workers. The country has 3.7 doctors and 8.2 per

10,000 population as of the moment. The World Health Organization prescribes a ration

of 1 doctor and 1 nurse per 1,000 persons. This signifies that the country is in dire need of

healthcare workers to cater COVID patients and patients with other conditions. With the

rapid increase of patients, healthcare workers are forced to accommodate more than what

they can handle. (University of the Philippines COVID-19 Pandemic Response Team,

2020)
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Synthesis of the Reviewed Literature

The gathered studies and research findings have provided the proposed research

with important data that represents past and as well as current situations in hospitals

about the effects of nurse-patient ratio to the outcomes evaluation and patient care

satisfaction. According to the read studies, nursing workforce size in hospitals has shown

great effects on the outcomes of patients such as safety and quality of care. The research

studies focused on the nurse to patient ratio and the impact concerning longer shifts and

the relationship to low staffing rates. The previous research studies suggested variables

that although were salient and conclusive, were limited in coordination with each

research scope. These presented and investigated variables resulting in nurse-burnouts

such as time constraints, low staff levels, endorsements, heavy workload, and overflow of

patients in the hospitals, are said to affect the quality of patient care provided. Today,

with the emergence of COVID 19, hospitals are now always beyond maximum bed

capacity, ventilators are limited, there is a shortage in PPEs, nurses are quitting their jobs,

and nurses are forced to work overtime. This is further burdened by the rapid

transmission of infection from a COVID19 positive patient to the nurse thus causing an

additional shortage. Now that the COVID 19 Pandemic has brought numerous changes to

society especially to the health care setting, the need to further recognize factors and

conduct a research study with regards to the experiences of nurses that often lead to job

dissatisfaction and resignation from the profession leading to an increasing staff shortage

and as well as the impact to patient care and risk of medical errors or workplace hazards.
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References

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sensitive patient outcomes in acute specialist units: a systematic review
and meta-analysis. Retrieved from Sage Pub:
https://journals.sagepub.com/doi/pdf/10.1177/1474515117721561

Emmanuel, T., Dall’Ora, C., Ewings, S., Griffiths, P. (2020). Are long shifts,
overtime and staffing levels associated with nurses’ opportunity for
educational activities, communication and continuity of care assignments?
A cross-sectional study. Retrieved from
https://www.sciencedirect.com/science/article/pii/S2666142X20300011

Gorgich, E., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016, August 1).
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