As per the ‘Nursing a Nation’ Report, the nurse to patient ratio is 1:6 and the ratio differs from general ward to specialized units. It also changes with patient load. In the morning shift, the nurse patient ratio is 1:6, in the afternoon shift, it is 1:8 and in the evening shift it is 1:10. Most of the time it goes beyond that.
A clinical nurse in JDWNRH who has been serving for 10 years shared his experience and observation over the years. In the medical ward there are 30 beds, and sometimes depending on the situation, it can go up to 35 beds. So the nurse to patient ratio also depends on the situation.
He said one nurse handles 6 patients in the morning, 8 patients in the afternoon shift, and 10 patients in the evening shift. Although taking care of 6 patients is fine, however, the scenario is different. He said most of the time, a nurse is unable to provide the proper nursing care to the patient because there is a lot of administrative work and clerical work that nurses have to handle apart from providing nursing care, and this is why nurses are all bogged down.
He said 1:6 is fine, if all those additional administrative and clerical work are handled by the management. That is why the actual nursing care to the patients is missing, he further added.
Citing as an example, he said, if a nurse has to do suction on a patient, then the nurse has to check everything whether the suction machine works or not. All the machine maintenance work is also done by the nurses. He said actually the nurse’s job is to only do the suctioning. So having to do all the work apart from providing nursing care to patients, 1:6 is very heavy for them, and 1:10 is arduous, he added.
Having to prepare oral medication and injections for 30 patients at 12 pm and 2 pm, which takes almost one hour for preparation, is highly challenging, and runs a high risk of making errors.
Another former clinical nurse in one of the regional hospitals said the nurses in Bhutan have a nurse to patient ratio of 1:10 or even more, whereas internationally, it is even considered illegal to have that kind of number since it leads to errors and is not safe for either patient or nurse both.
“I felt like I was walking on a knife everyday when I went to work. Just waiting for that one mistake I may make and everything is doomed. I worked in a district hospital and I was prescribing medication, giving injections without order, suturing wounds, applying POP, which is all out of my scope of practice as a nurse. I wasn’t trained to do it, although I did it with perfection. I wasn’t qualified enough to do it. The BMHC guideline for nurse’s job description mentions none of the above jobs I did. Time and again, there would be office orders circulating that nurses won’t be allowed to prescribe antibiotics or IV medications” she said.
She said there was no nursing essence to what she was doing. “I was just working and compromising my own safety and that of my patients’.”
Sometimes nurses even go on handling 16 patients by one nurse.
The nurse-to-patient ratio is the concern globally. Some parts of the world such as California, USA, and Queensland, Australia have passed the law for the minimum nurse-to-patient ratio, which has scientifically been found to be beneficial for the patients and healthcare system.
Studies have shown that appropriate nurse staff helps to achieve clinical and economic improvements in patient care, including enhanced patient satisfaction, reduction in medication errors, incidences of fall, pressure ulcers, healthcare-associated infections, patient mortality, hospital readmission and duration of stay, patient care cost, nurses’ fatigue, and burnout.
As per the international source, California became the first state of USA to legally define required minimum nurse-to-patient ratio, that is in general medical-surgical ward 1:5, emergency-1:4, and critical care units-1:2 or fewer in all the shifts, which was found to be beneficial for both patients and nurses, and now other US states have also considered laws on minimum nurse staffing standards
Meanwhile, as of December 2020, there are 1,529 nurse midwives distributed across 49 hospitals in Bhutan. The current average national density of nursing workforce is estimated at 18.5 nurses per 10,000 people (WHO, 2020). The density estimation varies among different dzongkhags as the density in Thimphu, which is most populous dzongkhag has 45 nurses per 10,000 people, and Gasa with the lowest population is estimated at 15 nurses per 10,000 people.
To provide quality health care services, MoH has set a standard of nurse patient ratio to 1:6 or 1:4 or 1:3 in different non-critical care settings and 1:1 or 1:2 in critical settings.