Giovanna? Nursing Leadership and Management

Giovanna 

Nursing Leadership and Management

Adjusting the patient-to-nurse ratio for patients requiring step-down care compared to medical-surgical patients is crucial for several reasons, primarily related to patient safety, quality of care, and nurse workload.

The arrival of the vascular surgeon in the unit has not only increased the complexity of care (greater acuity), but it also made a detrimental impact on the workload for the nursing staff Despite the average daily census (ADC) remaining at the budgeted 20 patients, the acuity of care has changed because 30% of these patients would require step-down care.

Maghsoud et al. (2022) explained that patients in step-down units often require more intensive monitoring and interventions than those in medical-surgical units, because they may be recovering from surgery, experiencing complications, or needing frequent assessments. For example, a post-operative patient may need regular pain management, wound care, and monitoring for signs of early sepsis.

Higher acuity patients in step-down units can deteriorate more quickly than medical-surgical patients. Adequate staffing levels ensure that nurses can respond promptly to changes in a patient's condition. For example, if a step-down patient experiences sudden hypotension, a nurse needs to be available to intervene swiftly, administer medications, or activate a rapid response code (Pérez-Francisco et al., 2020). Additionally, a proper nurse-to-patient ratio allows for better individualized care. For instance, if nurses’ workload is increased, they may miss critical signs of distress in step-down patients or may not have enough time to educate patients about their recovery, leading to poorer outcomes (Maghsoud et al., 2022).

Both step-down nurses and medical-surgical nurses possess unique skill sets tailored to their specific patient populations. However, step-down nurses typically have more specialized skills for handling patients who require higher acuity care because of their critical thinking skills to prioritize care effectively. Step-down nurses often care for patients who have just been transferred from the ICU. For example, they are skilled in monitoring vital signs closely, recognizing subtle changes that may indicate deterioration. In addition, step-down nurses frequently engage in patient and family education regarding complex discharge plans, medication management, and lifestyle changes after critical illness or surgery (Wakefield et al., 2023).

According to Pérez-Francisco et al. (2020), adjusting ratios helps mitigate nurse burnout and anxiety (especially if nurses are not trained to address critical patient needs). Overloaded nurses in high-acuity settings are at risk of fatigue, which can lead to medical errors.

If the patient-to-nurse ratios are high in a step-down unit, there will likely be a need for additional Full-Time Equivalent (FTE) caregivers to manage the increased acuity of patients effectively. The current HPPD (number of hours of nursing care a patient receives in a 24-hour period) is 7.59, as acuity increases, it will be necessary to add FTEs to ensure adequate care without using continuous overtime. Nurok et al. (2024) explained that to determine the exact number of additional FTEs the ADC is needed which is 20 patients; therefore, in the 70% would be medical- surgical (14 patients) and 30% would be step-down (6 patients).

Financial reports indicate for the 6 months OT expense is $125,000, which is unfavorable to the budget, and it was explained earlier OT to fill staffing gaps will eventually diminish the quality of the care delivered to the patients and it could negatively affect nurses’ mental health (Pérez-Francisco et al., 2020). Adjusting ratios helps mitigate nurse burnout. Overloaded nurses in high-acuity settings are at risk of fatigue, which can lead to errors. In this scenario, hiring additional FTEs could reduce OT cost, improve patient care quality and mitigate anxiety related to acuity of care (Griffiths et al., 2020). For example, if the step-down patient-to-nurse ratio is 3:1, 2 FTEs would be needed to manage the 6 high-acuity patients. Therefore, two critical care nurses would be needed to address step-down patients. However, Yang et al. (2019) explained that after-hours surgery (approx. 6 hours) is associated with significantly increased postoperative mortality and morbidity, which might be related to state of urgency. Additionally, not only hiring RNs is typically lower than the cumulative cost of OT, but also the nurse manager (and ultimately the hospital) would take into consideration their workers’ mental health care (Pérez-Francisco et al., 2020).

Finally, the nurse leader should a revised staffing grid to Human Resources (HR) and the Chief Financial Officer (CFO) because it would ensure that staffing levels align with patient acuity and volume, which is crucial for maintaining high-quality patient care. It also would reduce the risk of errors, adverse events, and burnout among nursing staff, which ultimately enhances patient safety, and by aligning staffing levels with actual needs, the organization can avoid overstaffing or understaffing, which can lead to increased labor costs or compromised care (Griffiths et al., 2020).

In conclusion, while both roles are crucial to patient care, step-down nurses generally have more specialized skills and training related to higher acuity care. Their expertise in managing complex patient needs, advanced monitoring techniques, and collaboration with multidisciplinary teams positions them to handle critical situations effectively. The need for additional FTE caregivers in step-down units when patient acuity increases and ratios exceed recommended levels. By evaluating the current patient load and adjusting staffing based on the acuity of care required, healthcare facilities can enhance patient safety, improve outcomes, and reduce nurse burnout.

Revised Grid

It was assumed that patient to nurse ratio for step-down patients ideally would be 3:1 and medical-surgical patients would be 5:1. However, patient to nurse ratios should be also calculated based on patients who just arrive at the unit after surgery (especially those who need high acuity of care). Normally, during the weekend there is no surgeries.

Shift Type (RNs)

Step Down (6 patients)

Medical- Surgical (14 patients)

Day Shift

3

3

Night Shift 

3

3

Weekend Shift 

2

3

First 6 hours post-op

Patient-Nurse Ratio

(2:1)

After 6 hours post op 

Patient-Nurse Ratio

(3:1)