3 Reasons we need mandatory nurse ratios

nurse-ratioAll nurses have horror stories about when their ratio of nurse to patient got out of hand.  My personal nightmare occurred when I was told that, due to call offs, my assignment for the eight hours of night shift would be twelve patients.

Wait, I said, did I hear that right?

Yes, unfortunately, I had heard right.  That night is largely a blur in my memory except for an incident with my similarly frazzled CNA.

She approached me and said, “Mr. So-and-So has a blood pressure or 180/90.”  I looked at her, my hands poised over the keys in a frantic push to chart.  I said, “Do I have a patient by that name?”

Ratios are a big problem in the nursing industry today.  California currently has state mandated ratios for nurses in hospitals, but the rest of the country has been slow to adopt this in the legislature.

That isn’t without reason.  Some lawmakers and even some nurses are dead set against ratios hitting the law books.  This editorial outlines the reasons for why they feel this way.

I could not disagree more.  Since I experienced the horrors of non-ratio nursing, I feel there are three distinct reasons why ratios are not only a good idea but necessary.

Protect the Patient

When my CNA told me of a questionable blood pressure, I had no idea who she was talking about.  I had twelve patients and each of them was essentially a room number to me.

I don’t care how good you are: remembering the particulars of twelve patients is not possible and not safe.  I did eventually consult my notes and discovered who the man was.

But I hesitated, and that’s not safe in an acute care environment.  It meant that I only knew as much as what I had written down four hours before after my initial assessment.

Obviously, a nurse with a herd of acute care, sick patients is going to get in trouble.  It’s the patient who will suffer in the end, and how can you blame the nurse who is clearly overworked?

Some would say to simply not accept an assignment of that size, but honestly, who does that?  First, you could end up losing your job, and second, there may not be anyone to come help you.

When patients become sicker and sicker, the amount of patients a nurse has needs to be controlled to protect them from the harm of an over worked, all too human nurse.

Protect the Nurses

Nurses need protection, too.  Our licenses are certainly on the line when we are forced to take a group of patients that are well beyond the abilities of any normal human to care for.

Does anyone consider the psychological impact that high ratios can cause?  Stress, burnout, and depression are all well-known side effects of the nursing profession.

Um, maybe that has something to do with overworking them?

Besides wearing a nurse down to a blunt nub, ratios can mean harrowing consequences for a nurse.  My patient with the high blood pressure could have gone south quick, becoming sick, possibly dying, and it would have been my fault.

Nursing is hard enough as it is.  Psychologically, you have to be Iron Man or some other similarly invincible superhero.

However, when our patients suffer, it hurts us.  PTSD should be recognized as a risk of working as a nurse, particularly when he or she did they best they could and still fell short due to understaffing.

Keep Facilities Honest

Let’s face it, folks: a facility is going to try their best to get away with as few nurses for as many patients as possible.  They are in the business of caring for people, but most are still looking at that bottom line.

At my facility, we had a “matrix” that told us how many nurses could be kept depending on census, and many facilities use this scheme to determine how many nurses are needed.  Unfortunately, when the numbers were below the recommended matrix, there were no nurses on white horses to ride to the rescue.
Additionally, the matrix usually stretched the nurse as thin as possible.  It didn’t take into account the acuity of the patient, looking instead at raw numbers.

Common sense seems to inform a great deal of nursing care, but it doesn’t really translate over into management.  For this reason, some outside force needs to impose the rules of ratios to keep patients and nurses safe.

I have read tales of nurses in states with mandatory ratios finding that all their support staff has been fired.  Again, this is a case of the facilities either not understanding the pressures on nurses or not caring.

Through legislation, mandatory nurse ratios, and commonsense managerial oversight, we could make this a profession that is far more pleasant than it is now.  As the baby boomers become older and the so-called shortage kicks into high gear, this aspect of nursing care may be  more important than ever.


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