Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
    Users Online: 193
Home Print this page Email this page Small font size Default font size Increase font size


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 116-124

The Interrelation between nurse-to-patient ratio, nurse engagement, and missed nursing care in King Saud Medical City: Basis for development of nurse–patient quality of care


1 Department of Nursing, King Saud Medical City, Riyadh, Saudi Arabia
2 Department of Critical Care Quality, King Saud Medical City, Riyadh, Saudi Arabia
3 Department of Nursing Office, King Saud Medical City, Riyadh, Saudi Arabia
4 Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
5 School of Nursing, University of North Carolina at Charlotte, Charlotte, North Carolina, USA

Date of Submission19-May-2021
Date of Acceptance09-Jul-2021
Date of Web Publication16-Aug-2021

Correspondence Address:
Mary Rosaclaire Tenorio
Nursing Department, King Saud Medical City, Riyadh
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_74_21

Rights and Permissions
  Abstract 


Background: Healthcare is a substantial industry globally, where nurses comprise the largest percentage of the healthcare system. There is a global nursing shortage and nursing staff retention has become a major human resource challenge. One of the critical indicators of quality of care is nurse-to-patient ratio (n:p ratio), but due to the extreme shortage of nurses, the quality of nursing care may have been affected leading to low nurse engagement results and substantial missed on aspects of nursing care. Identifying these key areas among nurses in King Saud Medical City (KSMC) will contribute to the improvement of staffing conditions at any levels. Aim: The primary objectives were (1) to investigate the impact of patient-to-nurse ratio (p:n ratio) on satisfaction and (2) to explore the impact of p:n ratio on missed care. The secondary objectives were (1) to compare the nurses' satisfaction categories, missed care categories across different hospitals included in our medical city, different age categories, and different education levels and (2) n:p ratio will be compared across hospitals. Methods: This was a cross-sectional analytical study. Setting: This was conducted at KSMC, Riyadh, Saudi Arabia, specifically in areas of main general hospital, medical tower, pediatric and maternity hospital. Outcome Measures: (n:p ratio), nurse engagement/satisfaction, and missed nursing care. Results: Of the total of 384 responses (96% response rate), the majority of respondents were satisfied (n=155, 40.4%), followed by Neutral (n=124, 32.3%), very unsatisfied category included only 17 responses (4.4%) and very satisfied were 35 nurses (9.1%). While responses to the missed care section revealed that overall the majority of missed care opportunities were in the category of never missed (278, 72.4%). As for the p: n ratio, the average was 4.2 (patients) ± 1 (nurse). Furthermore, the ratio of patients-to-nurse was not found to significantly impact overall satisfaction, neither in the univariable model nor in the multivariable model adjusted for age, education, and experience. Interestingly, age category was a significant predictor of nurse satisfaction (higher odds of satisfaction category with higher age category) yielding an adjusted odds ratio (OR) of 1.4 (95% confidence interval [CI]: 1.01–1.8; P = 0.04) although this was a post hoc finding. As for the impact of n:p ratio on missed care, it was significantly associated with missed care in the univariable model, with OR of 1.3 (95% CI: 1.01–1.6; P = 0.037) and an OR of 1.3 (95% CI: 1.02–1.6; P = 0.032) in the multivariable model. When the categories of satisfaction were compared across different hospitals of KSMC, different age groups, and education, there were no differences in any of the Chi-square tests performed. Similarly, there were no statistically significant differences when the missed care was compared across the same subgroups; moreover, it was distinguished that p: n ratio was significantly higher in the maternity hospital. Conclusion: A higher p:n ratio negatively affects missed care opportunities.

Keywords: Missed nursing care, nurse engagement/satisfaction, patient-nurse ratio


How to cite this article:
Tenorio MR, Aletreby WT, Al Shammari B, Almuabbadi B, Mwawish H, Montegrico J. The Interrelation between nurse-to-patient ratio, nurse engagement, and missed nursing care in King Saud Medical City: Basis for development of nurse–patient quality of care. Saudi J Health Sci 2021;10:116-24

How to cite this URL:
Tenorio MR, Aletreby WT, Al Shammari B, Almuabbadi B, Mwawish H, Montegrico J. The Interrelation between nurse-to-patient ratio, nurse engagement, and missed nursing care in King Saud Medical City: Basis for development of nurse–patient quality of care. Saudi J Health Sci [serial online] 2021 [cited 2021 Nov 30];10:116-24. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/2/116/323883




  Introduction Top


Over the years, nurses were known to be advocates in health care, caring, and supporting their patients. Nurses dealt with various health-care professionals in providing the best patient outcome. They are known to spend most of the time dealing with patients' needs and even in the worse situations, nurses will always be there to alleviate pain and suffering as well as provide the best nursing care needed. Quality care is essential in nursing care and this is a priority in every health care facility. However, nursing shortage has been a human resource concern that nurse staff retention is identified as a major challenge. An increasing evidence indicates deficient nurse-to-patient ratio (n: p ratio) may lead to low patient outcomes, this is a problem that we need to look into. The American Nurses Association Principles for Nurse Staffing (2020) describe that appropriate nurse staffing is a critical requisite for delivering safe, quality health care at every practice level, and in every settings.[1] Evidence demonstrates that nursing care has a direct impact on the overall quality of services received, and when nurse staffing is appropriate, adverse events decline and overall outcomes improve.[2] An initiative was made by the Saudi Patient Safety Center (SPSC) during the 4th global ministerial Patient Safety Summit in 2019 to develop safe nurse staffing levels. This is needed to achieve the highest levels of safe nursing care and to meet the national transformational goals for 2030 that supports the nursing profession in the kingdom.[3] Despite these initiatives, King Saud Medical City (KSMC), Riyadh, is still experiencing an alarming issue related to nursing shortage, which may affect patient outcomes, and nurses work environment and nurse satisfaction. The notion of this research study was to evaluate the present n: p ratio, missed nursing care, and Nurse Engagement among Nurses in KSMC, at the same time identifying its significant differences. The study is focused on bedside nurses who handle patient and implement nursing care, thus excludes the outpatient department and the head of the department.

Specifically, it attempted (1) to investigate the impact of patient-to-nurse ratio (p: n ratio) on satisfaction, (2) to explore the impact of p: n ratio on missed care, (3) to make comparisons of nurses' satisfaction categories, missed care categories compared across different hospitals included in our medical city, different age categories, and different education levels, and (4) n: p ratio was compared across hospitals.

This research was approved by the IRB in KSMC with registration number KACST, KSA: H-01-R-053, dated May 20, 2020.

Objectives

Under the hypothesis that a high p: n ratio may negatively impact either overall satisfaction or missed care opportunities, the primary objective of the study was the impact of p: n ratio on satisfaction, and separately the impact of p: n ratio on missed care. Secondary objectives were comparisons of nurses' satisfaction categories, missed care categories compared across different hospitals included in our medical city, different age categories, and different education levels, while n:p ratio will be compared across hospitals.


  Methods Top


This research used a cross-sectional analytical research design, which utilized an electronic survey to investigate the study objectives. The study was carried out in KSMC, Riyadh, Saudi Arabia. KSMC is a tertiary referral center, with 1200 beds, and over 6000 employees. It is the largest Ministry of Health hospital in the central region of Saudi Arabia. The nursing staff is composed of 4500 nurses divided over four different hospitals, namely maternity, pediatric, main general hospital, and medical tower.

The survey method was the main data collection procedure used in this study divided into two sections, the first section was similar to the nursing engagement and satisfaction survey administered by Health Cluster 1 in Riyadh city, this section in addition to demographic data inquires about the nurses' level of engagement and satisfaction, it includes nine questions to be answered according to a 5-point Likert scale, the scale is interpreted as 1 = strongly disagree/very unsatisfied, 2 = disagree/unsatisfied, 3 = neutral, 4 = agree/satisfied, and 5 = strongly agree/very satisfied. The average of each person's score was calculated and used to derive the overall satisfaction category according to the following ranges: 0 ≤ very unsatisfied ≤1, 1< unsatisfied ≤2, 2< neutral ≤3, 3< satisfied ≤4, 4< very satisfied ≤5 [details of section 1 in [Table S1], Supplementary File], so eventually each respondent is placed in one of five categories of satisfaction.

The second section of the survey is adopted with permission from the missed nursing care survey devised by[4] commonly known as MISSCARE. The survey requires respondents to report the hospital's unit in which they practice, then it proceeds to questions related to missed opportunities of nursing care divided into missed opportunities regarding patients' assessment (8 questions), missed individual needs interventions (6 questions), missed basic needs interventions (7 questions), and missed planning interventions, giving a total of 24 questions [details in [Table S2], Supplementary File]. Each question is answered according to a 5-point Likert scale with the following interpretation: 1 = never missed, 2 = rarely missed, 3 = occasionally missed, 4 = frequently missed, and 5 = always missed, while a value of 0 indicates not applicable. Responses are averaged (excluding inapplicable values) and the average is used to categorize missed opportunities of care as follows: 0.5< never missed ≤1.49, 1.5≤ rarely missed ≤2.49, 2.5 ≤ occasionally missed ≤3.49, 3.5≤ frequently missed ≤4.49, and 4.5≤ always missed ≤5; accordingly, overall responses of each individual are placed in one of the five categories. The second part of MISSCARE survey includes 16 questions pertaining to perceived reasons of missed care, divided into three categories of communication, materials, and labor intensity.

The survey included a statement at the beginning that outlines the current study and informs that responding to the survey will be considered as the responder's consent to participate in the study; furthermore, the study was reviewed and approved by the institutional review board of KSMC.

Data management

To facilitate data interpretation, demographic variables such as age, gender, and level of education were considered as categorical data. Age was described as 18-30, 31-40, 41-50, 51-60, and more than 60 years old, while level of education was classified as diploma, bachelor's, and master's degrees. Similarly, the level of experience was in categorical order of <2 years, 2–5 years, 5–10 years, and more than 10 years. Likewise, overall satisfaction and missed nursing opportunities were arranged in categorical order, while p: n ratio was considered as a continuous whole number variable, rather than n: p ratio for easiness of calculations and comprehension.

Sample size calculation

KSMC employs 4500 nurses in different hospitals of the city, we estimated that for a 95% confidence level and 5% error margin of the survey, a sample size of 354 responses is required, we inflated the sample size to 400 to account for nonresponses. Nurses were chosen randomly by a computer-generated random numbers list of 400 from the 4500 total nurses using their ID card number.

Chosen nurses were contacted via the official KSMC E-mail, offered a summary of the study, and provided with an electronic form of the survey, they were sent two E-mail reminders a week apart.

Statistical method

Survey results were summarized as count (percentage) for categorical variables, whereas continuous variables were summarized as mean ± standard deviation (SD), each variable with a corresponding 95% confidence interval (CI).

For the purpose of the primary objective, an ordered logistic regression model was used with n: p ratio as an independent factor while overall satisfaction as the dependent in one model, and missed opportunities of care in the second. Each logistic regression model was univariable once and multivariable once adjusting for age, education, and experience. Results of the models were reported as odds ratios (ORs) along with corresponding 95% CI and P values.

Secondary variables were analyzed by Chi-square test or Fisher's exact test as appropriate when comparing categorical variables, and by ANOVA test when comparing continuous variables, each presented with corresponding 95% CI and P value. All statistical tests were two-tailed, and considered statistically significant with P < 0.05. A commercially available statistical software package was used (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX, USA: StataCorp LP) to analyze the data.


  Results Top


The survey response rate was 96% (n=384). The majority of respondents were females (n=382, 99.5%), mostly in the age category of 31–40 years (n=235, 61.5%), as for experience the category of 5–10 years included the highest number (n=155, 40.4%), followed by more than 10 years (n=125, 32.6%). The majority of responses came from diploma holders (n=290, 75.5%), and were mostly divided between the pediatric hospital (n=176, 46.2%) and the maternity hospital (n=155, 40.7%). [Table 1] provides details of demographic data.
Table 1: Demographic data

Click here to view


The majority of respondents were satisfied (n=155, 40.4%), followed by neutral response (n=124, 32.3%). About 4.4 % (n=17) were very unsatisfied while 9.1% (n=35) very satisfied. Responses to the missed care section revealed that overall the majority of missed care opportunities were in the category of never missed (n=278, 72.4%). As for the p: n ratio, the average was 4.2 ± 1 [Table 2] and [Figure 1].
Table 2: Overall satisfaction, missed care opportunities, and patient-to-nurse ratio

Click here to view
Figure 1: (a) Overall satisfaction. (b) Missed care

Click here to view


Primary outcomes

The ratio of patients to nurse was not found to significantly impact overall satisfaction, neither in the univariable model nor in the multivariable model adjusted for age, education, and experience. Adjusted OR was 1.13 (95% CI: 0.9–1.4; P = 0.26). Interestingly, the age category was a significant predictor of satisfaction (higher odds of satisfaction category with higher age category) yielding an adjusted OR of 1.4 (95% CI: 1.01–1.8; P = 0.04) although this was a post hoc finding.

As for the impact of n:p ratio on missed care, it was significantly associated with missed care in the univariable model, with OR of 1.3 (95% CI: 1.01–1.6; P = 0.037) and an OR of 1.3 (95% CI: 1.02–1.6; P = 0.032) in the multivariable model. In this analysis, no other variable showed a significant association with missed care opportunities [Table 3].
Table 3: Ordinal logistic regression of nurse-to-patient ratio association with overall satisfaction and missed care

Click here to view


Secondary outcomes

When the categories of satisfaction were compared across different hospitals of KSMC, different age groups, and education, there were no differences in any of the Chi-square tests performed [Supplementary File, [Figure S1], [Figure S2], [Figure S3]].

Similarly, there were no statistically significant differences when the missed care was compared across the same subgroups [Supplementary File, [Figure S4], [Figure S5], [Figure S6]].

The p: n ratio was significantly higher in the maternity hospital (ANOVA P < 0.001) [[Figure S7], Supplementary File].


  Discussion Top


Remarkably, the impact of n: p ratio on missed care was significantly associated with missed care in the univariable model, with OR of 1.3 (95% CI: 1.01–1.6; P = 0.037) and an OR of 1.3 (95% CI: 1.02–1.6; P = 0.032) in the multivariable model. In this analysis, no other variable showed significant association with missed care opportunities [Table 3]. Hence, the higher the n: p ratio, it can negatively affect the missed nursing care, yet the ratio of patients to nurse was not found significantly impact overall satisfaction neither in the univariable model nor in the multivariable model adjusted for age, education, and experience. Interestingly, age category was a significant predictor of satisfaction (higher odds of satisfaction category with higher age category). The result of the study similar to the research of Kalisch,[5] a qualitative study specific to missed nursing care, used a semi-structured focus group interview with nursing medical-surgical units in two hospitals with a 210-bed hospital in the southern region and a 458-bed regional medical center in the northern region of the United States. A total of 107 registered nurses (RNs), 15 licensed practical nurses, and 51 nursing assistants working in medical–surgical patient care units were interviewed in 25 focused groups. The study revealed that important elements of nursing care are being missed on a regular basis in acute care hospitals in medical-surgical units. These findings shed light which may contribute to poor patient outcomes. In addition, Kalisch and Lee[6] highlighted the missed nursing care on Magnet versus non-Magnet Hospitals disclosed that Magnet Hospitals had significantly less missed care and Magnet Hospital staff reported less staffing and communication problems.

In our study, age was a significant predictor of satisfaction, but the ratio of patients was not found to significantly impact the overall satisfaction; nonetheless, the results in the study of Al-Faouri I et al. (2021)[7] indicate that “missed nursing care” is negatively associated with job satisfaction and the number of RNs per shift, and positively with the n: p ratio. The results of this study indicated that there was a significant relationship between “missed nursing care” and the age of the participants; this result could be explained by the fact that the majority of nurses in Jordan are young; wherein, younger nurses might be more enthusiastic about work and they might work with caution to prove themselves. The results also indicated a negative relationship between “missed nursing care” and participants' satisfaction. In terms of missed care and unit characteristics associated with intention to leave by Tschannen D. et al., (2010),[8] four variables were found to be significantly related to nursing turnover missed care, skill mix, absenteeism, and gender. Larger amount of missed care was associated with higher turnover rates which state that the more missed nursing care, the higher the dissatisfaction with current position and with their occupation. Alharbi et al., (2020)[9] revealed that the current shortage of nurses jeopardizes the quality and safety of patient care globally, and is particularly serious in Saudi Arabia with respect to nurse outcomes, 64.4% of participants reported being moderate or very satisfied with their jobs, although the mean score of emotional exhaustion was 25 (SD 13.28) which is suggestive of moderate levels of burn out Maslach et al., (1996)[10] and 56.1% reported being somewhat to very likely to leave their current jobs within the next year.


  Conclusion Top


Since the result of the study shows that a higher p: n ratio negatively affects missed care opportunities, the management may look into the implementation of the appropriate n: p ratio according to the unit patient acuity and the Nurse Staffing Levels for Patient Safety and Workforce (2019). The white paper explains in detail the significance of the appropriate P: N ratio and its relationship to the quality of care. Moreover, further research on nurse staffing and nursing care in tertiary hospitals in Saudi Arabia are needed to support our nurses and the organization in creating evidence-based programs in intensifying nurses' retention, improve job satisfaction and patients' outcomes.

Limitation

The majority of the respondents were coming from pediatric and maternity hospitals. There was less percentage of respondents coming from other hospitals such as main general hospital and medical tower; hence, this is the limitation of this study. A specific research on those hospitals on p: n ratio, missed nursing care, and satisfaction may consider as those areas include critical units so that comprehensive results may be gathered and definite recommendation and outcome can be made in details to those units.

Acknowledgment

The authors would like to thank Dr. Beatrice Kalisch and co-author Dr. Reg Williams for allowing us to utilize the MISSCARE Survey in our Medical City.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Supplemenary Figures and File Top






















 
  References Top

1.
ANA's Principles for Nurse Staffing 3rd Edition 2020. American Nurses Association www.Nursingworld.org. Available from: https://cdn2.hubspot.net/hubfs/4850206/PNS3E_ePDF.pdf. [Last accessed on 2021 Jul 01].  Back to cited text no. 1
    
2.
Aiken LH, Sloane D, Griffiths P, Rafferty AM, Bruyneel L, McHugh M, et al. Nursing skill mix in European hospitals: Cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf 2017;26:559-68.  Back to cited text no. 2
    
3.
Saudi Patient Safety Center, International Council of Nurses, Nurse Staffing Levels for Patient Safety and Workforce Safety. SPSC and ICN White Paper. Riyadh, Saudi Arabia; 2019. Available from: https://spsc.gov.sa/English/Documents/Joint%20Statement%20from%20SPSC%20%20ICN%20on%20World%20Patient%20Safety%20Day%202019.pdf. [Last accessed on 2021 Jul 01].  Back to cited text no. 3
    
4.
Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm 2009;39:211-9.  Back to cited text no. 4
    
5.
Kalisch BJ. Missed nursing care: A qualitative study. J Nurs Care Qual 2006;21:306-13; quiz 314-5.  Back to cited text no. 5
    
6.
Kalisch BJ, Lee KH. Missed nursing care: Magnet versus non-Magnet hospitals. Nurs Outlook 2012;60:e32-9.  Back to cited text no. 6
    
7.
Al-Faouri I, Obaidat DM, AbuAlRub RF. Missed nursing care, staffing levels, job satisfaction, and intent to leave among Jordanian nurses. Nurs Forum 2021;56:273-83.  Back to cited text no. 7
    
8.
Tschannen D, Kalisch BJ, Lee KH. Missed nursing care: The impact on intention to leave and turnover. Can J Nurs Res 2010;42:22-39.  Back to cited text no. 8
    
9.
Alharbi AA, Dahinten VS, MacPhee M. The relationships between nurses' work environments and emotional exhaustion, job satisfaction, and intent to leave among nurses in Saudi Arabia. J Adv Nurs 2020;76:3026-38.  Back to cited text no. 9
    
10.
Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd edition. Mountain View, CA: CPP, Inc.; 1996.  Back to cited text no. 10
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
Supplemenary Fig...
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed1434    
    Printed18    
    Emailed0    
    PDF Downloaded111    
    Comments [Add]    

Recommend this journal