Nurse to Patient Ratio. Ethical Issues

Subject: Nursing
Pages: 5
Words: 1194
Reading time:
5 min
Study level: College


As with most other professions, all nursing profession practitioners are bound by rules and regulations that govern how they go about their duties. These rules and regulations are sometimes legally enforceable. Nurses also face numerous ethical issues in the line of duty. While some of these ethical issues are resolved by following the ethical standards and guidelines for nurses, others rely primarily on the nurses’ principles and value system to be solved. These values may sometimes not be in line with the legal obligations of the nurse. Legal standards stipulate what is right or wrong according to the laws of the land whereas ethics are standards for professional behavior. Hall (2005) articulates that while ethical standards that hinge on personal beliefs and principles may suffice when caring for a loved one in a home setting, they may not be irrefutable when dealing with strangers in the work environment.

This paper shall set out to give a detailed and conclusive description of the controversial mandated nurse to patient ratio in California. Personal values and professional ethics that are paramount in the nursing practice shall also be identified and duly outlined. The paper shall also examine the extent to which legislated patient ratios have been effective in creating a viable environment not only for the practitioners (nurses) but also for the patients that they cater to.

A brief history of the Mandated Nurse to Patient Ratio

Zerwekh and Claborn (2006) reaffirm that laws emanate from the society’s ethics and moral values which are documented. Of particular significance is that laws are enforceable through the judicial branch and as such there may be repercussions for violating the same. Several laws regarding nurses have been passed through the years. Some have been beneficial to the cause while others have been deemed as insufficient. The roots of the Mandated Nurse to Patient Ratio can be traced back to 1999 in California where the first bill (Assembly Bill 394) was passed. This bill was geared towards stipulating the minimum staffing levels for nurses in the hospitals. By definition, the Nurse-Patient Ratio refers to the number of patients an individual nurse should be assigned to while at work. This bill was brought into the limelight as a result of various documentation that showed the acute shortage of nurses in California.

According to Crisp et al (2005), multiple cases were cropping up which revealed that a large number of nurses were being overworked at the hospitals that they represented. In North Carolina, the current ratio stands at 1:4 irrespective of the prevailing conditions but amendments have been proposed to make it 1:1 or 1:2 in the future depending on acuity, age, and the need for nursing assistance of the patients.

Implications of the Nurse-Patient Ratio to nurses

Hall (2005) contends that the implementation of these ratios has been very helpful in many hospitals. As mentioned earlier, there is a general shortage of registered nurses in almost every country. As such, the ones who are available are often overworked in a bid to cater to the needs of the fast-growing number of patients daily. Working in such conditions may have serious side effects on anyone. Factors such as stress and fatigue are therefore common faces in such situations and these may lead to anxiety, depression, and lack of concentration. These may in turn have detrimental effects on the nurse’s health, professionalism, and judgment. Therefore, the Nurse-Patient Ratio has indeed offered a means through which the nurses can shed off some of their workloads and perform optimally under a tranquil environment.

Raised controversies about the ratios

Considering the professional manner in which nurses are expected to act, it may be argued that the nurse-patient ratio only plays a secondary role in the decision-making process of the nurse since it holds no scientific backing. In addition to this, the ratios do not consider the patient case mix whereby some patients may need more and closer attention than others, the attitudes and skills of the nurses differ depending on the education and work experience.

Professional ethics are those ethics that are stipulated by professional nursing bodies e.g., the International Council of Nurses which endorses the international codes of ethics for nurses. They state the expected professional behavior which should be exhibited by a nurse in his/her duties. According to the International code of ethics for nurses (2005), the nurse’s fundamental responsibilities include promotion of health, prevention of illness, restoration of health, and the alleviation of suffering. With these responsibilities comes the code for respect for all and upholding the sacred right to life. Using the ratio system neither facilitates nor guarantees that the nurses will uphold these codes. In fact, the society for health systems fears that the use of ratios may consequently lead to the development of inefficient and suboptimal healthcare systems in the future (Byers and White, 2004)

Hall (2005) reasserts the fact that the use of ratios may have detrimental effects on healthcare organizations. He states that many of these organizations have raised genuine concerns about increased costs (salaries, uniforms, insurance covers, and other overhead costs) to meet the required level of available nurses, others fear foreclosure since they cannot meet the standards set by the legislation, others claim that the system is unfair especially since hospitals are different with different resource bases and patients’ inflow. As regarding the patients, some have contended that using the ratio system will lead to an increase in healthcare costs and departmental diversions (doctors refusing to admit patients since they have reached the stipulated limit). Evidently, a considerable percentage of the factions that are affected by this system seem to vote against it.

Personal opinion

Nursing ethics require nurses to protect and promote the interests and wellbeing of the people in their care. This is following the nursing code of ethics which explicitly states that nurses place immense value in quality nursing care and refrain from providing services that are deemed as below standard and therefore unacceptable.

In an ideal situation, the legal and ethical requirements of the nursing practice are spelled out. However, this is not always what happens in the field. In some cases, specific laws may be ambiguous and as such open to different interpretations by individuals. In such a case personal experience and bias will dictate what outcome will be seen. Owing to the variance in ethical interpretation by individual nurses, it is impossible to produce a conclusive set of standards to be followed stipulating all the relevant laws and ethical issues. The standards which exist only act to serve as guidelines and best practices for the practitioners (Mathieson, 2006). As such, the relevance of such a system is yet to be realized and healthcare providers should stick to using staffing guidelines that are more applicable and inclined towards better service provision to the targeted audience.


This paper has in detail established the relationship between the legal and ethical issues in the nursing practice. While it has been observed that there is a need for a regulatory framework to address the staffing issue in this state, better means need to be developed such that efficiency and justice prevail in this profession.


Byers, J. (2004). Patient safety: principles and practice. NY: Springer Publishing Company.

Crisp, J., Potter, P. A. and Perry, G. A. (2005). Potter & Perry’s Fundamentals of Nursing. (2nd ed). Australia: Elsevier Australia.

Hall, L. (2005). Quality work environments for nurse and patient safety. USA: Jones & Bartlett Learning.

Mathieson, F. (2006). Examining the Law and Ethics Surrounding Palliative Care. Primary health care, Vol 16 no 4.

Nemie, J. K. (2009). Challenges for the Nursing Profession in Malaysia: Evolving Legal and Ethical Standards. Journal of Nursing Law. New York: 2009. Vol. 13, Iss. 2; p. 54-63

Zerwekh, G. J. and Claborn, C. (2006). Nursing today: transition and trends. (5th ed.). Elsevier Health Sciences.