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San Antonio
ICU Ratios

Tom recently reached out to share his own project and survey results. Working in the San Antonio area, Tom has been collecting data on ICU ratios as they relate to nurse satisfaction and burnout. The results are quite interesting.

Download the original paper and data here


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Let's take a moment to talk about employee retention. As we exit the pandemic and move into the post-pandemic era, employers are beginning to look at retention and are seeking strategies to attract and retain experienced staff. There is a short window in which to act before these experienced nurses leave or are hired by the competition, and that window is already closing. So I think it would benefit us as an industry to take an evidence-based look at one of the elephants in the room - staffing ratios - to see if they actually contribute to the retention problem. Specifically, today I want to look at staffing ratios and their effect on nurses’ self-reported happiness and burnout.


I periodically survey San Antonio nurses to get their opinions on various facets of our jobs. I have recently closed my Spring 2022 survey, and I’m beginning to pull useful data out of it. For this post, I’m looking specifically at our city’s ICUs. I chose the ICU because there is a fairly deep pool of data to pull from, and adding one patient to the ratio yields significant changes in the data. I will be crunching data for other specialties as well, but focusing on this single area allows me to get some data out more quickly.


Enough intro, let's dig into some data!

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To start out, I wanted to get a baseline look at city wide data. Across all of the city’s ICUs I found the following data: 55% of nurses report that they usually or always get a lunch, 39% of nurses report being happy at work, and 66% of nurses report feeling burnt out. The survey also asked nurses to report their “average nurse to patient ratio in the last 6 months”, and 37.5% reported a 2:1 ratio while 63% reported 3 or more patients per nurse.


Of the nurses who report 2:1 ratios, I got the following data: 

Usually get a lunch: 75%

Happy at work: 56%

Burned out: 38%


Whereas for the nurses who report 3+:1 ratios, I got the following data:

Usually get a lunch: 44%

Happy at work: 28%

Burned out: 84%


That's a significant difference. Adding 1 patient to the nurse’s assignment reduced the likelihood of that nurse taking their lunch by almost 60%, reduced happiness by 50%, and increased burnout by about 220%. 


Roughly 1 in 3 nurses who leave the profession report burnout as their reason for leaving [Shah Megha K et al]. This means that any meaningful strategy to improve retention must address employee burnout. The fact that increasing a nurse's assignment by one patient increased their burnout by more than 200% provides a clear path forward for improving retention: reduce ratios.


While facilities argue that increased ratios are needed to remain profitable, research does not bear that out. Increased quality of care delivered and decreased bouncebacks, errors, and turnover save more than 2 times the cost of the additional nurses needed to reduce ratios by one patient per nurse. [McHugh Matthew D et al] So increased ratios not only significantly increase burnout, but they also decrease the quality of care and thus compensation provided to the facility.


I would like to also take a moment to discuss nurses taking their lunches. While I am very much a fan of eating, in my surveys I ask about lunches because I use them as an approximation of workload. Nurses who don't take lunches, in my experience, do so because they are too busy to take 30 min out of their day for a meal. If lunch is a good indicator of workload, I would expect to see lunches taken decrease as workload increases. Seeing a 60% decrease in the likelihood of taking lunch as a result of one additional patient appears to support this indicator.


In discussions with hospital management and leadership, I have repeatedly been told that tripling an ICU assignment with a downgrade patient is safe/appropriate because downgrade patients are less sick than ICU patients. The data here does not appear to support this line of thinking. If a downgraded patient truly did not increase nursing workloads, I would expect to not see a significant impact on lunches or burnout metrics. The time has long since come for grid staffing to be abandoned in lieu of an acuity based.

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