The Interrelation between nurse-to-patient ratio, nurse engagement, and missed nursing care in King Saud Medical City
Authors: Tenorio Mary Rosaclaire , Aletreby Waleed Tharwat , Al Shammari Batla , Almuabbadi Basel , Mwawish Huda , Montegrico James 
Published: August 2021

Background:
Healthcare is a substantial industry globally, where nurses comprise the largest percentage of the healthcare system. There is a global nursing shortage and nursing staff retention has become a major human resource challenge. One of the critical indicators of quality of care is nurse-to-patient ratio (n:p ratio), but due to the extreme shortage of nurses, the quality of nursing care may have been affected leading to low nurse engagement results and substantial missed on aspects of nursing care. Identifying these key areas among nurses in King Saud Medical City (KSMC) will contribute to the improvement of staffing conditions at any levels.

Aim:
The primary objectives were (1) to investigate the impact of patient-to-nurse ratio (p:n ratio) on satisfaction and (2) to explore the impact of p:n ratio on missed care. The secondary objectives were (1) to compare the nurses' satisfaction categories, missed care categories across different hospitals included in our medical city, different age categories, and different education levels and (2) n:p ratio will be compared across hospitals.

Methods:
This was a cross-sectional analytical study.

Setting:
This was conducted at KSMC, Riyadh, Saudi Arabia, specifically in areas of main general hospital, medical tower, pediatric and maternity hospital.

Outcome Measures:
(n:p ratio), nurse engagement/satisfaction, and missed nursing care.

Results:
Of the total of 384 responses (96% response rate), the majority of respondents were satisfied (n=155, 40.4%), followed by Neutral (n=124, 32.3%), very unsatisfied category included only 17 responses (4.4%) and very satisfied were 35 nurses (9.1%). While responses to the missed care section revealed that overall the majority of missed care opportunities were in the category of never missed (278, 72.4%). As for the p: n ratio, the average was 4.2 (patients) ± 1 (nurse). Furthermore, the ratio of patients-to-nurse was not found to significantly impact overall satisfaction, neither in the univariable model nor in the multivariable model adjusted for age, education, and experience. Interestingly, age category was a significant predictor of nurse satisfaction (higher odds of satisfaction category with higher age category) yielding an adjusted odds ratio (OR) of 1.4 (95% confidence interval [CI]: 1.01–1.8; P = 0.04) although this was a post hoc finding. As for the impact of n:p ratio on missed care, it was significantly associated with missed care in the univariable model, with OR of 1.3 (95% CI: 1.01–1.6;P= 0.037) and an OR of 1.3 (95% CI: 1.02–1.6; P = 0.032) in the multivariable model. When the categories of satisfaction were compared across different hospitals of KSMC, different age groups, and education, there were no differences in any of the Chi-square tests performed. Similarly, there were no statistically significant differences when the missed care was compared across the same subgroups; moreover, it was distinguished that p: n ratio was significantly higher in the maternity hospital.

Conclusion:
A higher p:n ratio negatively affects missed care opportunities.