The current nurse-to-patient ratio in my ward in Alotau Provincial Hospital which is a 32-bed surgical ward with only 16 nursing/CHW staff is roughly 1:8-10.5 for every 8-hour shift (3-4 staff/shift) if the ward is full. Night shifts can be as low as 2 staff on duty (1:16). This is not safe or practical as the ward caters for general surgical and specialty surgical cases on a daily basis as well as high dependency patients as we do not have a high dependency ward. As a result of the workload, we are restricted to keeping the ward at 75% capacity to maintain a ratio of 1:8 or lower to provide the best care for our patients. Therefore, emergency cases (admissions via ED) take priority and elective cases (admissions via the clinic) have to wait. This adds to the increasing numbers of outpatients waiting for surgery in the province and those waiting for specialist surgery from other provinces. Yes, we need more nurses and CHWs, not to mention a bigger ward but this will take time to fix. The current 8-hour shifts are spreading the staff numbers thin and staff are struggling to provide standard patient care. We have a responsibility to manage our wards and staff management is a big part of that. If nursing power is low or the staff is fatigued from a full ward then patient care suffers.
What is a Nurse‑to‑patient ratio?
A nurse-to-patient ratio is the number of nurses or midwives working in a particular ward, unit or department, in relation to the number of patients they care for.
How does a low Nurse‑to‑patient ratio affect patient care?
The Lancet published in 2014 a landmark study showing that patients’ risk of dying after surgery varied by the number of patients for whom each nurse had responsibility. (6) Studying outcomes of nearly half a million patients in nine European countries, investigators found that each additional patient added to nurses’ average workloads was associated with 7% higher odds of a patient dying within 30 days of admission. Evidence continues to grow that better hospital nurse staffing is associated with better patient outcomes, including fewer hospital acquired infections, shorter length of stay, fewer readmissions, higher patient satisfaction, reduction in medication errors, patient care cost and lower nurse burnout. These all lead to better clinical and economic improvements in patient care.
What is considered a safe Nurse‑to‑patient ratio around the world?
Standardized nurse to patient ratio is an ongoing discussion all over the world that would necessitate a precise nurse‑patient ratio for hospitals to employ.
It is difficult to standardize how many nurses will be sufficient for a particular type of unit/ward of a hospital. The decision on the optimum level of nurse‑to‑patient ratio for a particular unit depends on several factors such as intensity of patients’ needs, the number of admissions, discharges, and transfers during a shift, level of experience of nursing staff, layout of the unit, and availability of resources, such as ancillary staff and technology.
The American Nurses Association supports a legislative model in which nurses are empowered to create staffing plans specific to each unit. Victoria state in Australia was the first region in the world to introduce mandated minimum nurse/midwife-to- patient ratios during 2000 in its public sector enterprise agreement of nurse‑to‑patient ratio, 1:4 on morning shifts, 1:5 on afternoon shifts and 1:8 on night duty shifts, plus an in‑charge nurse on all shifts, who have flexibility to allocate even fewer number of patients to a nurse based on patients’ level of dependency. In 2004, California became the first state of USA to legally define required minimum nurse‑to‑patient ratio, i.e., general medical‑surgical ward 1:5, emergency‑1:4, and critical care units‑1:2 or fewer in all the shifts, which was found to be beneficial for both patients and nurses.
What about PNG?
The largest cadre of PNG’s regulated health workforce are CHWs (39.6%), nurses (32.4%) (totalling 72%), and midwives (12%); 75% of which are female. However, the density of health workers is very low by international standards: 0.7 doctors and 5.3 nurses per 10,000 population, far below the 45 doctors, nurses and midwives per 10,000 population recommended by WHO to meet health needs by 2030. (3) An estimated shortage range of 20000 to 30000 nurses is projected for year 2030. (1) Further, the health workforce is ageing with high turnover due to poor working conditions, limited infrastructure, inadequate clinical and technical skills training. (3) In an article published in the Pacific Journal of Health 2024, supervisors generally considered that graduates were not practice-ready and results highlighted deficits in skills and practice that should be addressed in national curriculum reviews and renewal for both DGN and Certificate IV for CHW programs. (3)
What needs to be done?
Substantial within-country variation in hospital nurse staffing persists, giving rise to calls for public policy interventions to establish minimum safe staffing standards in hospitals. In 2018, the International Council of Nurses, representing national nursing associations worldwide, issued their Position Statement on Evidence-Based Nurse Staffing, concluding that plenty of evidence supports taking action now to improve hospital nurse staffing, echoing Nightingale’s call to action over 150 years ago, that if we have evidence and fail to act, we are going backwards. Despite these statements reducing nurse to patient ratios is not an easy task.
Why do we have low Nurse‑to‑patient ratios?
- Nursing shortage:
- A nationwide shortage of nurses can limit the available workforce, impacting staffing levels.
- Financial constraints:
- Hospitals often prioritize cost control, leading to a tendency to staff with fewer nurses to maintain funding for other priorities.
- Fluctuating patient census:
- Predicting the exact number of patients needed on a given shift can be challenging, leading to potential understaffing during high-volume periods.
- Lack of regulation:
- Not all hospitals have mandated nurse-to-patient ratios, leaving staffing decisions largely up to the hospital administration.
The Alotau example and a possible 12-hour shift solution
So, what about a 12-hour shift? The math:
16 staff split into 2 groups which makes 8 per group per day. Morning shift with 5 staff (1:6) and night shift with 3 staff (1:10.5). As most of the work is done during the day, night staff numbers can be lower than day staff. If these groups of 8 worked for 15 days in a month, 2 groups will cover one month, this will total 180 hours as compared to the 8-hour shift for 20 days in a month which is 160hours. Staff working for 20 days (8-hour shifts) get 8 days off where as staff working for 15 days (12-hour shifts) can get 15 days off.
Of course, there are other ways to improve work efficiency and staff performance but we need solutions now. The health system is crumbling under the pressure of an increasing population and we need practical and innovative solutions to maintain health care services.
References
- National Health Workforce Accounts (NHWA), 2020 except. Latest available data are displayed. Includes multiple data sources such as the OECD/Eurostat/WHO EURO Joint Data Collection, labour force survey, census data and estimates from WHO for shortages. Stock and density projection by 2030 based on a simple stock and flow model. See full report for further details. NR=Not reported. Data as of 10 March 2020.
- https://www.who.int/data/gho/data/indicators/indicator-details/GHO/nursing-and-midwifery-personnel-(per-10-000-population)
- Kililo, Mary; Dopsie, Julie; Passingan, Sulpain; Kep, Julie; Joseph, Nina; Kitau, Russel; Roroi, Mary; Rossiter, Chris; Sim, Jenny; Brown, Di; Havery, Caroline; Moloney, Ali; and Rumsey, Michele (2024) “Preparedness for Practice of Health Professionals in Papua New Guinea: a Cross-sectional Survey of Nurses and Community Health Workers.,” Pacific Journal of Health: Vol. 7: Iss. 1, Article 23. DOI: https://doi.org/10.56031/2576-215X.1063 Available at: https://scholarlycommons.pacific.edu/pjh/vol7/iss1/23
- Sharma SK, Rani R. Nurse-to-patient ratio and nurse staffing norms for hospitals in India: A critical analysis of national benchmarks. J Family Med Prim Care 2020;9:2631-7.
- Rassin M, Silner D. Trends in nursing staff allocation: The nurse‑to‑patient ratio and skill mix issues in Israel. IntNurs Rev 2007;54:63‑9.
- McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. Lancet. 2021 May 22;397(10288):1905-1913. doi: 10.1016/S0140-6736(21)00768-6. Epub 2021 May 11. PMID: 33989553; PMCID: PMC8408834.
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