Strategic Optimization of Nurse-Patient Ratios Across Units and Shifts in a Teaching Hospital

Background and objective: Appropriate nurse staffing is essential for ensuring patient safety, maintaining quality of care, and optimizing healthcare resources.Conventional fixed nurse-to-patient (N:P) ratios do not adequately account for variations in patient acuity and nursing workload across hospital units and work shifts.This study aimed to determine unit-specific and shift-specific N:P ratios based on patient acuity using a time-and-motion approach.Methodology: A descriptive observational time-and-motion study was conducted over three months in nine inpatient units of a tertiary care teaching hospital.A total of 192 nursing observations involving Level 4 and Level 5 registered nurses were proportionately allocated across the three shifts (morning, evening, and night) using stratified random sampling.Nursing activities were observed using a non-participatory, nonconcealed observational technique.Three investigator-developed data-collection forms were used to record observations systematically.The preliminary data collection form was used to document patient-related information, including patient acuity category, nursing activities performed, and the duration of each observed activity during the respective work shift.The nursing activity log served as a structured observation form to classify nursing activities as direct or indirect care and to document the time spent on each activity.The patient acuity assessment form was used to classify patients into predefined acuity categories based on their nursing care requirements, and the assigned category was subsequently used to estimate nursing care time and determine the recommended N:P ratio.Results: Indirect nursing activities accounted for the largest proportion of productive nursing time, with documentation representing the major component, particularly during night shifts.Nurses spent an average of 3 hours 4 minutes 41 seconds on direct care, 4 hours 39 minutes 3 seconds on indirect care, and 1 hour 5 minutes 55 seconds on personal activities per shift.Direct nursing activities varied across work shifts, with greater assessment and patient education during morning shifts and longer care implementation during night shifts.The acuity-based workload algorithm demonstrated substantial variation in staffing requirements across hospital units and shifts, with lower N:P ratios during morning shifts due to higher nursing care demands and relatively higher ratios during night shifts.Conclusion: Nursing workload varies with patient acuity, hospital unit, and work shift, indicating that a single fixed N:P ratio is insufficient across all inpatient settings.An acuity-based staffing approach provides a practical framework for estimating nursing workforce requirements, optimizing resource allocation, supporting nurse workload management, and improving the quality and safety of patient care.