INTRODUCTION

Background

Health care is one of the most prioritized concerns worldwide for it affects

people in dealing with their lives. This interest made all health care facilities aware that

primary care must be rendered on its highest level (Kiblasan, J.E; et al., 2007). In this

instance, staffing plays a vital role where staffs in different levels to cater the health

needs of clients are necessary. A team that is expected to collaborate in the delivery of

high-quality, comprehensive care efficiently.

Staffing in nursing is directly related to nurse to patient ratio, nursing skill mix,

academic preparation, specialized training, and experience. Nurse staffing is dependent

upon staffing patterns and composition which influence the workplace culture and

impact the ability of the nurse to provide adequate care. Whereas, staffing in nursing is

a critical concern for nurse leaders and administrators as it is directly related to nursing

management where appropriate nurse staffing is focused to patient’s safety and well-

being. It is a big challenge to assure worth and consistent service by deploying nursing

staff to secure quality nursing care.

Due to adopted practices of some hospitals and clamor for approval for a

divergent work schedule, Department of Health (DOH) issued Department Circular

no. 2013-0423 prescribing for guidelines on allowing two (2) work shift duty for nurses

in hospitals. Under the previously issued AO no. 2012-0012, hospitals are to maintain

the 1:12 nurse to bed ratio on a three (3) work shifts in twenty four (24) hours. This
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circular is a modification of the latter or the “Rules and Regulations Governing the

New Classification of Hospitals and Other Health Facilities in the Philippines”. Under

the new guidelines, the two work shift schedule is only applicable to general nursing

service, which is required to maintain an authorized nurse to bed ratio of 1:8. It shall

not be applicable to emergency room, operating room, delivery room and all intensive

care units in the hospital, which are still required to maintain the bed ratio under DOH

AO no. 2012-0012 (Health Laws And Places (2013). This is reiterated in DOH

Department Circular No. 2013-0423, which provided guidelines for allowing 12 hours

duty for nurses in hospitals.

It is expected that the delivery of nursing care will bear effects from the

prescribed nurse-patient ratio of 1:12 considering the varied conditions in hospitals.

This study, therefore, delved on this issue in government hospitals in the province of

Catanduanes.

Rationale

Filipinos are known to be compassionate and hospitable citizens. This is why

their nurses are one of the most in-demand health care providers in the world.

Approximately a decade ago, the nursing course was patronized by many - even the

graduates of dissimilar courses. This resulted to massive number of graduates who

could not be accommodated by the government or even the private sector. Although

there are some slots offered, the compensation has not been comparable to those

professionals in other fields. Thus, these nurses have subjected to life-changing

opportunities by applying to more accessible and well-compensated work even beyond

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their job qualifications. Added to that is the fact that throngs of nurses have gone

abroad resulting in brain drain in one of the most needed professionals in the country.

This dilemma has significantly reduced the number of available nurses in the

government and private hospitals in the Philippines. As a result, the ratio of nurse-to-

patient has significantly plummeted. The said downfall among nurses’ count has

significantly affected many factors. Can nurses still provide the ideal quality of nursing

care to patients? In this study, the researcher intends to determine the effects of nurse-

to-patient ratio to the delivery of nursing care among the district hospitals in

Catanduanes.

The legal basis of this study is DOH-Department Circular No. 2013-0423-

“Guidelines for Allowing 12 hours Duty for Nurses in Hospitals”. This Circular refers

to Administrative Order on the “Rules and Regulations Governing the New

Classification of Hospitals and Other Health Facilities in the Philippines” which

requires that every health facility shall have an adequate number of qualified, trained

and competent staff to ensure efficient and effective delivery of quality services. In

determining adequacy of nursing manpower, the ratio of nurses to hospital beds (general

nursing services areas) is maintained at 1:12 as prescribed in A.O. 70-A s. 2002 on the “Revised

Rules and Regulations Governing the Registration, Licensure and Operation of Hospital and

Other Health Facilities in the Philippines.” As stipulated further, all hospitals shall provide

basic hospital functions such as, but not limited to, acute medical and surgical services,

anesthesia services, emergency and outpatient services, nursing service, dental service, with

common diagnostic and support units as pathology, radiology, and pharmacy.

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Current State of Research in the Field

Doctors are perceived—by patients and clinicians—as being the captain of the

health care team, with good reason. But, physicians may spend only 30 to 45 minutes

a day with even a critically ill hospitalized patient, whereas nurses are a constant

presence at the bedside and regularly interact with physicians, pharmacists, families,

and all other members of the health care team. Of all the members of the health care

team, nurses therefore play a critically important role in ensuring patient safety by

monitoring patients for clinical deterioration, detecting errors and near misses,

understanding care processes and weaknesses inherent in some systems, and

performing countless other tasks to ensure patients receive high-quality care ( The

Agency for Healthcare Research and Safety(2018).

Efficiency and patient safety are two important intersecting health policy goals.

Efficiency should not be exploited for political expediency, but instead balanced against

concerns with patient safety. Too often, the concept of efficiency has been used to

justify cost saving or cost containment measures that create further adverse effects.

There is clear evidence that nurse-to-patient ratios have a direct impact on patient

safety, but the government has resisted staffing more nurses on the basis of cost. This

causes a greater cost in terms of human suffering and avoidable medical errors.

Therefore, efficiency-based claims made by the government should be viewed with

caution. Governments should establish a solid evidentiary foundation before advancing

any efficiency claims in the health sector (Archibald, T. (2017).

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Ensuring and maintaining patient safety is an essential aspect of care provision.

Safety is a multidimensional concept, which incorporates interrelated elements such as

physical and psychosocial safety. An effective nurse-patient relationship should ensure

that these elements are considered when planning and providing care. This article

discusses the importance of an effective nurse-patient relationship, as well as healthcare

environments and working practices that promote safety, thus ensuring optimal patient

care(Conroy, T. et al., (2017).

Higher registered nurse staffing was associated with less hospital-related

mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, and other

adverse events. The effect of increased registered nurse staffing on patients safety was

strong and consistent in intensive care units and in surgical patients. Greater registered

nurse hours spent on direct patient care were associated with decreased risk of hospital-

related death and shorter lengths of stay (Kane, R.L., et al., (2017).

Increased nurse-to-patient ratios are associated negatively with increased costs

and positively with improved patient care and reduced nurse burnout rates. Thus, it is

critical from a cost, patient safety, and nurse satisfaction perspective that nurses be

utilized efficiently and effectively(Maass, K., 2017).

Work environment had a large total effect size on quality nursing care. Burnout

largely and directly influenced quality nursing care, which was followed by work

environment and patient-to-nurse ratio. Job satisfaction indirectly affected quality

nursing care through burnout. This study shows how work environment past burnout

and job satisfaction influences quality nursing care. Apart from nurses' work conditions
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of work environment and patient-to-nurse ratio, hospital administrators should pay

more attention to nurse outcomes of job satisfaction and burnout when designing

intervention programmes to improve quality nursing care( Liu, Y. & Aungsuroch, Y.

(2018)

Synthesis of the Art

Nurses have an integral role in the health care system. State-mandated safe-

staffing ratios are necessary to ensure the safety of patients and nurses. Adequate nurse

staffing is key to patient care and nurse retention, while inadequate staffing endangers

patients and drives nurses from their profession. Staffing problems will only intensify

as baby boomers age and the demand for health care services grows, making safe-

staffing ratios an ever-pressing concern. This fact sheet outlines: the workplace and

patient treatment improvements associated with safe-staffing ratios, the dangers of

understaffing for nurses and patients, the high costs of frequent nurse turnover in

hospitals, the potential benefits of safe staffing for addressing nurse retention, the

savings associated with safe-staffing ratios, and the growing popularity of safe-staffing

legislation.( The Department for Professional Employees (2016).

A study was conducted among hospital nurses who currently provide direct

patient care to examine their perspectives on nurse staffing levels in hospitals.

Specifically, the study was designed to measure average patient-to-nurse staffing ratios

among hospital nurses and to examine the extent to which hospital nurses perceive

problems related to understaffing in their hospitals. Special attention is paid to the

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differences between Medical-Surgical nurses with lower and higher patient-to-nurse

ratios for evaluating the relationship between staffing levels and nurses’ perspectives.

The findings that follow provide additional insight into the effects of nurse staffing

levels from the perspective of the nurses directly providing patient care in hospitals

today. Nurses view understaffing as a serious problem when it comes both to the

quality of care that patients receive and to nurse burnout. When it comes to staffing in

healthcare, many studies have been done, much research completed, many conclusions

drawn. The crisis is significant and getting worse. What matters now is what people

should do next. As concerned healthcare professionals, who understand what it’s like

to work in hospitals and who know what it would take to keep experienced caregivers

at the bedside, they have five recommendations. The recommendations are: (1) provide

access to quality health care through increased funding and coverage for the uninsured;

(2) increase support for the health care institutions – and hold them accountable for

expenditures of public dollars; (3) ensure that all hospitals are staffed with adequate

numbers of appropriately trained and qualified nursing and health care staff; (4)

improve policies to recruit and retain experienced healthcare staff through fair

compensation and retirement security; and (5) prevent injuries and illness to both

health care workers and their patients through health and safety programs at all health

care institutions. (Peter D. Hart Research Associates, 2013).

Massive reductions in nursing budgets, combined with the challenges presented

by a growing nursing shortage have resulted in fewer nurses working longer hours and

caring for sicker patients. This situation compromises care and contributes to the
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nursing shortage by creating an environment that drives nurses from the bedside.

(American Nurses Association (ANA).

Increasing the number of nurses may help improve patient satisfaction with

quality of care in Great Britain. Researchers examined a 2010 National Health Service

(NHS) survey of patients discharged from acute and specialist NHS trusts on the

quality of care they received and the number of nurses on their hospital ward. The

researchers also analyzed a survey of registered nurses on areas of missed care due to

lack of time during their shift( Kendall-Raynor, P., 2018)’

A study was conducted to describe the status and prove the relationships of

nurse staffing level with nursing sensitive outcome indicators for adult medical and

surgical inpatients in Korea. Patient and hospital characteristics as covariates on nurse

sensitive outcome were also explored. The study setting was all 46 tertiary hospital

nurse staffing level with six nursing-sensitive outcome rates (urinary tract infection,

upper gastrointestinal tract bleeding, hospital-acquired pneumonia, shock/cardiac

arrest, in-hospital death, and wound infection) were shown. These six nursing-sensitive

outcomes showed an increasing trend as nurse staffing level degraded even after

adjusting for patient and hospital characteristics. When the nursing-sensitive outcomes

between those of group 1 (bed-to-nurse ratio <2:1) and group 3 (between 2.5:1 and

3:1) were compared, the adjusted incidence rate of shock/cardiac arrest showed the

highest difference (1.06%)(Kim, C. & Bae, K., 2018).

Registered nurses are the single largest group of healthcare professionals in the

United States. Yet, the vacancy rate for RNs continues to rise and currently stands at
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7.2 percent. Despite that fact, there is still a growing demand for nurses both in

hospitals and the community. Employment of registered nurses is projected to grow

by as much as 16 percent by 2024, much faster than the average for all occupations,

said the Bureau of Labor Statistics. Growth will occur for a number of reasons.

Demand for health care services will increase because of the aging population, given

that older individuals typically have more medical problems than younger ones. As such,

nurses will be needed to educate and care for patients with various chronic conditions,

such as arthritis, dementia, diabetes, and obesity. Also, the Patient Protection and

Affordable Care Act (ACA) has opened the doors to health care access in numbers

heretofore unprecedented, further increasing demand. (Schumacher Clinical Partners

(2016).

In another article, the writers (Schumacher Clinical Partners, 2016) examined

the reasons for the nursing shortage, its effect on the healthcare industry, what can and

is being done to solve the problem, and the outlook for the future. The factors

contributing to the nursing shortage are multifaceted: a diminishing pipeline of new

nurses due to a faculty shortage that has resulted in thousands of prospective students

being turned away, steep population growth in several states, ACA providing increased

access, and a baby boom bubble that will require intensive health care services. And

these issues are occurring at a time when a significant number of nurses are retiring.

Due to the shortage, nurses often need to work long hours under very stressful

conditions, which can result in fatigue, injury, and job dissatisfaction. Nurses suffering

in these environments are more prone to making mistakes and medical errors. An
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unfortunate outcome is that patient quality can suffer, resulting in a variety of

preventable complications, including medication errors, emergency room

overcrowding, and more alarmingly, increased mortality rates.

"The biggest challenges facing healthcare are the demographic changes that are

pushing expansion of the workforce and the time it takes to educate and train new

health care workers to fill those needs," said Stephen Nichols, MD, chief of clinical

operations for SCP. "It seems to me that the shift away from LVNs and LPNs to RNs

has exacerbated this in the hospital setting. I would expect a return to a larger team

with clear roles would be helpful."

Time trends and seasonal patterns have been observed in nurse staffing and

nursing-sensitive patient outcomes in recent years. It is unknown whether these

changes were associated. Quarterly unit-level nursing data in 2004–2012 were extracted

from the National Database of Nursing Quality Indicators (NDNQI). Units were

divided into groups based on patterns of missing data. All variables were aggregated

across units within these groups and analyses were conducted at the group level. Patient

outcomes included rates of inpatient falls and hospital-acquired pressure ulcers.

Staffing variables included total nursing hours per patient days (HPPD) and percent of

nursing hours provided by registered nurses (RN skill-mix). Weighted linear mixed

models were used to examine the associations between nurse staffing and patient

outcomes at trend and seasonal levels (He, J. et al., 2016).

This study is unique in finding that changes in nurse staffing were inversely

associated with changes in the rates of falls and pressure ulcers at both the time trend
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and the seasonal levels. No causal inference about staffing and patient outcomes can

be made without control for improvements in quality of patient care from other aspects

or changes in patient population over time, or other seasonal factors that may have

influenced patient outcomes at the seasonal level. We hypothesize that increased

staffing levels have contributed to reducing falls and pressure ulcers in recent years,

and that fluctuations in nurse staffing due to seasonal changes in patient volume have

immediate impact on risk for falls and pressure ulcers. More rigorous studies are needed

to test these hypotheses. Besides increasing nurse staffing level, improving nursing

education and working environment to meet the increasing nursing needs, hospitals

also need more flexible seasonal nursing models. With big data, hospitals may build

more efficient nursing prediction and management system combining environmental

factors, patient characteristics, process data, and national or international resources.

A large and increasing number of studies have reported a relationship between

low nurse staffing levels and adverse outcomes, including higher mortality rates.

Despite the evidence being extensive in size, and having been sometimes described as

"compelling" and "overwhelming", there are limitations that existing studies have not

yet been able to address. One result of these weaknesses can be observed in the

guidelines on safe staffing in acute hospital wards issued by the influential body that

sets standards for the National Health Service in England, the National Institute for

Health and Care Excellence, which concluded there is insufficient good quality

evidence available to fully inform practice.

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In this paper, the researchers explored this apparent contradiction. After

summarizing the evidence review that informed the National Institute for Health and

Care Excellence guideline on safe staffing and related evidence, we move on to

discussing the complex challenges that arise when attempting to apply this evidence to

practice. Among these, the researchers introduced the concept of endogeneity, a form

of bias in the estimation of causal effects. Although current evidence is broadly

consistent with a cause and effect relationship, endogeneity means that estimates of the

size of effect, essential for building an economic case, may be biased and in some cases

qualitatively wrong. They expanded on three limitations that were likely to lead to

endogeneity in many previous studies: omitted variables, which referred to the absence

of control for variables such as medical staffing and patient case mix; simultaneity,

which occurred when the outcome can influence the level of staffing just as staffing

influences outcome; and common-method variance, which may be present when both

outcomes and staffing levels variables are derived from the same survey. Thus while

current evidence was important and has influenced policy because it illustrated the

potential risks and benefits associated with changes in nurse staffing, it may not provide

operational solutions. The study concluded by posing a series of questions about design

and methods for future researchers who intend to further explore this complex

relationship between nurse staffing levels and outcomes. These questions were

intended to reflect on the potential added value of new research given what is already

known, and to encourage those conducting research to take opportunities to produce

research that fills gaps in the existing knowledge for practice. By doing this the
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researchers hoped that future studies can better quantify both the benefits and costs of

changes in nurse staffing levels and, therefore, serve as a more useful tool for those

delivering services( Griffiths, P. et al., (2016)

The association of nurse staffing and overtime with nurse-perceived patient

safety, nurse-perceived quality of care, and care is left undone. Results of the study

showed that a higher number of patients per RN was significantly associated with

higher odds of reporting poor/failing patient safety (OR=1.02, 95% CI=1.004-1.03)

and poor/fair quality of care (OR=1.02, 95% CI=1.01-1.04), and of having care left

undone due to lack of time (OR=1.03, 95% CI=1.01-1.05). Compared with RNs who

did not work overtime, RNs working overtime reported an 88% increase in failing or

poor patient safety (OR=1.88, 95% CI=1.40-2.52), a 45% increase in fair or poor

quality of nursing care (OR=1.45, 95% CI=1.17-1.80), and an 86% increase in care left

undone (OR=1.86, 95% CI=1.48-2.35). Therefore, the findings suggest that ensuring

appropriate nurse staffing and working hours is important to improve the quality and

safety of care and to reduce care left undone in hospitals (Cho, E., 2016).

A study was aimed to explore nurses' perceptions of occupational stress in an

emergency department. The findings comprised three themes: (1) perceived stress, (2)

consequences of stress, and (3) stress management. The results of this study can be

used by hospital management to help them adopt effective strategies, such as support

programs involving co-workers/supervisors, to decrease occupational stress among

emergency department nurses. Future research that explores each of the themes found
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in this study could offer a more comprehensive understanding of nurses' occupational

stress in the emergency department ( Yuwanich, N. et al., 2016).

Mastracci, S. & Hsieh, C.W. (2016) wrote that in the UK’s long-standing

national healthcare system, revelations of several years of neglect and poor oversight

at one hospital might have contributed to nearly 1,200 deaths. The resulting Francis

Report cited, among many factors, undue emphasis on reaching national access targets

and balancing budgets for substandard care. Scholars of emotional labor note these

trends with interest, because emotional labor is essential to nursing practice. But is

emotional labor a universal construct, or is it particular to cultural context? How much

can be imported from one study to the next? We compare nurse job stress in

individualist and collectivist countries and reveal a statistically significant relationship:

The higher a country’s individualism index, the greater the frequency of emotional-

labor-demanding job stress.

A study was conducted to investigate the correlation between nurse shortage

and workload at the Polonnaruwa District General Hospital in Sri Lanka with a random

sample of nurses working in the hospital and using a self-administered questionnaire.

Explanatory research design was used and the statistical analysis confirmed a positive

relationship between nurse shortage and workload. It also shows a significant positive

relationship between workload and the quality of patient care. Furthermore, a negative

relationship was observed between workload and the quality of patient care. In addition,

this study calculates the mean effect of emotional intelligence of these factors, and a

significant correlation is found between emotional intelligence and workload as well as

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work stress. There is a firm evidence that in Sri Lanka, nursing shortage influences the

workload of the employee, finally affecting the quality of patient care. In addition, the

study recognized the capability of nurses to manage their emotions as well as emotions

of others, which has increased their tolerance to control psychological stress in

performing their duty. This study confirms that nurse’s emotional intelligence act as a

partial operating variable for job outcomes of nurses (Hellerawa, K. & Adambarage,

D., 2015).

“Over her 34-year nursing career, Martha Kuhl, a pediatric oncology nurse at

U.C.S.F. Benioff Children’s Hospital Oakland in California, has seen her patient load

more than double. She recalls one night shift when she was the lone nurse on duty with

five patients. “These are all babies that can’t breathe,” she says. “I felt okay at four”

but that last patient “sort of tipped it over the edge where I felt unsafe in being able to

handle all of these patients.” Kuhl’s description sounds like a worst-case scenario, but

in fact she can recall several similar times where “it was impossible to give proper care”

due to understaffing. Mounting data from hospitals nationwide are proving Kuhl

correct: When staffing levels fall below certain nurse-to-patient ratios, the patients are

more likely to suffer or even die. (Jacobson, R. (2015).

In a 2014 study commissioned by the Agency for Healthcare Research and

Quality, part of the U.S. Department of Health and Human Services, researchers

compared hospital care utilization and financial data in California, Maryland and

Nevada. After the law went into effect California patients experienced fewer adverse

events than the others, although the effect was moderate. Patient length of stay in the
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hospital, however, was reduced significantly, a finding that has been replicated in other

studies.

Staffing ratios also appear to reduce the rate of readmissions, many of which

are preventable and constitute a significant cost for hospitals. The Affordable Care Act

(ACA) sets penalties for hospitals with high rates of readmissions. In one 2013 study

researchers at the University of Pennsylvania School of Nursing examined data from

hospitals across the U.S. and found that those with higher staffing ratios had 25 percent

lower odds of being penalized under the ACA for excessive readmissions than ones

with lower staffing ratios but otherwise similar conditions. Another study that year also

from the same school examined 30-day readmissions in California, New Jersey and

Pennsylvania and found that each additional patient per nurse raised readmission rates

6 to 9 percent.

The professional integrity of nurses has been eroded and consequently they

have become more susceptible to anxiety, stress and exhaustion, potentially affecting

care delivery. The authors suggest that the goal of providing high professional

standards is threatened by increased service demands, and there is therefore a need for

nurses to develop effective coping strategies to manage stress resulting from competing

tensions in the workplace (McIntosh, B. & Sheppy, B., 2013).

A study was made that examine the significance of employee voice and

managerial responsiveness in reducing the levels of burnout experienced by nurses.

Data were collected though an online survey of 762 Australian nurses. As hypothesized,

the results showed that both employee voice and managerial responsiveness were
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negatively related to burnout. In addition, managerial responsiveness was found to fully

mediate the relationship between employee voice and burnout. Implications of these

findings are discussed in the context of developing interventions for dealing with

burnout in the nursing profession (Holland, P. et al., (2013).

The evidence about nurse staffing ratios and in-hospital death through

September 2012 was systematically reviewed. From 550 titles, 87 articles were reviewed

and 15 new studies that augmented the 2 existing reviews were selected. The strongest

evidence supporting a causal relationship between higher nurse staffing levels and

decreased inpatient mortality comes from a longitudinal study in a single hospital that

carefully accounted for nurse staffing and patient comorbid conditions and a meta-

analysis that found a "dose-response relationship" in observational studies of nurse

staffing and death. No studies reported any serious harms associated with an increase

in nurse staffing. Limiting any stronger conclusions is the lack of an evaluation of an

intervention to increase nurse staffing ratios. The formal costs of increasing the nurse-

patient ratio cannot be calculated because there has been no evaluation of an intentional

change in nurse staffing to improve patient outcomes, Shekelle, P.G., 2013).

Staggs, V.S., et al., (2012) reported that “Time trends and seasonal patterns have

been observed in nurse staffing and nursing-sensitive patient outcomes in recent years.

It is unknown whether these changes were associated.” Quarterly unit-level nursing

data in 2004–2012 were extracted from the National Database of Nursing Quality

Indicators® (NDNQI®). Units were divided into groups based on patterns of missing

data. All variables were aggregated across units within these groups and analyses were
 18

conducted at the group level. Patient outcomes included rates of inpatient falls and

hospital-acquired pressure ulcers. Staffing variables included total nursing hours per

patient days (HPPD) and percent of nursing hours provided by registered nurses (RN

skill-mix). Weighted linear mixed models were used to examine the associations

between nurse staffing and patient outcomes at trend and seasonal levels. The study

was concluded as: By aggregating data across units we were able to detect associations

between nurse staffing and patient outcomes at both trend and seasonal levels. More

rigorous research is needed to study the underlying mechanism of these associations.

Hinno, S. et al., (2012)The relationship between nursing activities, nurse staffing

and adverse patient outcomes in hospital settings as perceived by registered nurses in

Finland and the Netherlands was investigated and compared the results obtained in the

two countries. It was shown that the patient-to-nurse ratio was on average 8·74:1 and

did not vary significantly between the countries. However, there were fewer registered

nurses and significantly more licensed practical nurses among the Dutch hospital staff

than the Finnish staff. In addition, Finnish nurses performed non-nursing and

administrative activities more frequently than the Dutch nurses and reported more

dissatisfaction with the availability of support services. Frequencies of patient falls were

related to the patient-to-nurse ratio in both countries. Finnish participants reported the

occurrence of adverse patient outcomes more frequently. It was concluded that

significant associations were found between nurse staffing and adverse patient

outcomes in hospital settings. Compared with the Netherlands, in Finland, nurses

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appear to have higher workloads, there are higher patient-to-nurse ratios, and these

adverse staffing conditions are associated with higher rates of adverse patient outcomes.

Tevington, P. (2011) examined the issue of mandatory nurse-patient ratios.

According to him, support for mandatory nurse-patient ratios is drawn from the belief

that regulated registered nurse (RN) staffing will increase positive patient outcomes,

decrease nursing shortages, and increase nurse recruitment and job satisfaction. The

author notes that research support for adequate staffing and balanced workloads of

nurses as important for achieving good patient, nurse, and financial outcomes.

Parumog, J.A.B. (2011) made a study that aimed to determine the medication

administration practices of nurses at Bicol Medical Center. The conclusions gathered

for the findings of the study were the following: Majority of the respondents were

young adults belonging to the age bracket of 18-35 years; female, nurses under Specialty

Employment Program, with 1-5 years of experience and attained 1-24 hours of related

trainings. Data also revealed that the medication administration practices along the

different principles were always practiced. Findings showed that the medication

administration practices under the principle of right client had significant differences

along the principles of right dose, right time and right route and vice versa.

Subsequently, medication administration practices under the principle of right drug had

significant differences along the principles of right dose, right time and right route and

vice versa. Furthermore, right documentation had also significant differences along

principles of right dose, right time and right route and vice versa. Generally, all the

given problems by nurses, experienced in medication administration practices.

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However, there were significant correlations known between along the different

principles were always encountered by the nurses of the Bicol Medical Center but

showed no significant correlation with their medication administration practices.

However, there were significant correlations known between nurses’ compliance to

medication administration practices and their age as well as the length of service. On

the contrary, no significant correlation was noted between nurses’ compliance to

medication administration practices and their sex, position, and related trainings

attended. As an output of the findings, a proposed program was signed to further

improve the medication administration practices of nurses.

The study of Velasco, K.A. (2014) aimed to determine the compliance to safe

medication of nurses at Bicol Medical Center. The study adopted the Benners’ Model

of Skill Acquisition in Nursing: From Novice to Expert. The descriptive-comparative-

correlational study was employed. The respondents were 60 nurses from the selected

wards during the time of study. These nurses were classified as Permanent staff nurse,

SPN, OVG, and RN Heals. The researcher likewise made use of a validated researcher

made-questionnaire and conducted an observation as a tool for gathering data. The

conclusions as revealed by the findings of the study were: (1) most of the nurses in the

selected areas at Bicol Medical Center are novice as described by Benner (2009). There

are more female nurses than the mates. Majority of the nurses were RN Heals with less

than a year of experience, 8SM degree holder and attained 1-24 hours of relevant

trainings/seminars attended. (2) It was found out that compliance to safe medication

administration of nurses along the following areas in the selected wards as observed by
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the researcher and experienced by the nurses themselves were always complied. The

extent of compliance to safe medication administration of the respondents along the

identified areas resulted to always complied. Likewise the researchers' observation

resulted to always complied in the general result but indicators such as preparing and

documenting were rated as sometimes complied. (3) Data also revealed that there are

significant differences in the compliance to safe medication administration in the

different areas according to nurses' experience and researchers' observation. (4)

Generally, the nurses problems are barely experienced however, indicators garnering

the highest mean are interpreted as sometimes experienced. The significant correlation

between the extent of compliance to safe medication of nurses and nurses' problems

is significant (5) Resorts revealed significant correlation exists between the compliance

to safe medication administration and selected characteristic: significant correlation of

age along documenting and monitoring; educational qualification along monitoring;

relevant trainings/seminars attended along patient s name and monitoring; position

along verifying doctor's order, transcribing, and monitoring; length of service along

verifying doctor's order, transcribing, documenting and monitoring. However, sex is

not correlated in complying with safe medication administration. (7) As an output of

the findings, a proposed intervention program was designed by the researcher to

further improve the compliance to safe medication administration.

The study of Baldemoro, F.B. (2016) determined the staff nurses’ attitude and

extent of practice towards the care of the dying patient in a hospital care setting. The

present study applied the exploratory sequential mixed method using a descriptive-
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correlational and qualitative approached. The respondents of the study were 97 staff

nurses currently assigned in a critical and non-critical care where care of the dying

patient is most likely to occur. Based on the finding of the data gathered, it was

concluded that the general demographic status of the respondents in the hospital is

female, with the age bracket of 21-25 years old, majority are Roman Catholic, with 6

months or more length of nursing practice currently assigned in a ward with no relevant

training on the care of a dying patient. The respondents a strong positive care for a

dying patient in the hospital care setting. The Physiological care is the top most aspect

in the extent of practice followed by psychosocial and spiritual care. The Demographic

profiles of the staff nurses have no significant relationship on their attitude and extent

of practice. There is a significant relationship between the staff nurses’ attitude and

extent of practice towards care of the dying along physiological and spiritual care

however no significant relationship was found along psychosocial care. Additionally,

there were problems and barriers nurses identified in the provision of quality care. Thus,

the researcher designed a specialized program to help enhance nurse's attitude and

extent of practice of staff nurses caring for a dying patient in a hospital care setting.

Yamson, M.R.R.. (2016) made a study entitled “Work Environment and Job

Satisfaction of Nurses in a Level Three Hospital in Naga City.” Findings revealed that

(1) Majority of the nurses were young adult, 21 to 30 years old, female, single, had

bachelors degree in nursing, more than half were from general ward, nearly half had

been in service for less than a year to 2 years, almost all on regular status, and mostly

had related trainings attended. (2) Nurses' work environment in terms of: nursing
 23

leadership, ability and support, participation in the hospital affairs/policies, collegial

nurse-physician relationships, adequate staffing and resources-agree, nursing

foundations were moderately favorable. (3) Nurses in the Level Three Hospital in Naga

City were moderately satisfied. (4)There were no significant relationship between job

satisfaction and the nurses' age, sex, marital status, area of assignment, of work

experience but there was a significant relationship in terms of related trainings attended

and the level of satisfaction. There were no variations in terms of educational level and

employment status to the level of satisfaction. The work environment has a significant

relationship with the level of satisfaction. (5) A proposed intervention plan is presented

based on the findings of the study.

Aries, M.T. (2013) conducted an assessment of “Nurse Performance and

Patient Satisfaction on the Care Rendered at Immaculate Heart of Mary Hospital, Inc.,

Rawis, Virac, Catanduanes.” Conclusions were: 1) Most of the staff nurses and the lone

supervisor are in their young adulthood while patients are in their middle age; majority

are females both staff nurses and patients. Most of the staff nurses served for 3-4 years

while most of the patients stayed in the hospital 2-3 days. 2) The performance level of

the staff nurses along the four areas of nursing core competencies as perceived by

respondents is very satisfactory. 3) Respondents rating on patient satisfaction are

outstanding. 4. There is no significant relationship between the assessment of the

respondents on the performance level of staff nurses when their patient care, enabling,

enhancing, and empowering competencies are considered and the patent satisfaction
 24

on the care rendered. 5) The performance of the nurses can be further improve if the

proposed plan will be adopted and implemented in the hospital.

Ignacio, M.C.B. (2015) made a study on the “Quality of Nursing Through

Proper Documentation of the Nursing Service of Universidad de Santa Isabel Health

Services Department: Its Effects on Patient Satisfaction.” This study focused on the

quality of nursing are through proper documentation of the nursing service and its

effects on patient satisfaction as evaluated by medical-surgical patients admitted at

Universidad de Santa Isabel Health Services Department with the city of Naga. The

following conclusions were derived from the findings of the study: 1) Majority of the

patients are 61 years old and above, female, with an income of 9,999 and below, college

graduate/college level and hospitalized for 1-3 days. Majority of the nurses are 21-30

years old, female, single, have been in service for less than a year to 2 years, mostly

from 7-3 or 3-11 shifts, on regular status and have attended related trainings. 2) The

quality of nursing care through proper documentation of the nursing service in carrying

out the following nursing tasks in terms of the following: a) Ethico-Legal-good level,

b) Patient Safety-excellent level, and c) Implementation of care – good level. 3) The

nurses are Medical – Surgical Ward at Universidad de Santa Isabel Health Services

Department have shown quality services as expressed by patients as they were satisfied

with the services that they received. 4) The nurses’ demographic characteristics has a

significant relationship with the quality of nursing care through proper documentation.

There is a significant relationship according to their sex and length of work experience

but no significant relations in terms of age, civil status, related training attended, shift
 25

and designation of nurses. The patients’ demographic characteristics has no significant

relationship with the level of patient satisfaction according to their age, sex, income,

length of hospital stay and educational attainment. 5) There was no significant

relationship in the quality of nursing care through proper documentation and the level

of patient satisfaction.

Sebastian, C.T. (2015) made a study on the “Patient Satisfaction on Nursing

Care Rendered at Eastern Bicol Medical Center, Virac, Catanduanes.” Conclusions

were: 1) The respondents were 21-30 years old, female, high school graduate and

hospitalized for 1-6 days. 2) The respondents agree that there are factors affecting

patient satisfaction. 3) The respondents were satisfied on the nursing care rendered at

Eastern Bicol Medical Center along care, core, and cure aspect. 4) There is a significant

relationship between the profile of the respondents and patient satisfaction along core

and cure aspects, however on the care aspect, does not show significant relationship.

5) There is a proposed plan that if utilized by the nurses will give improvement on the

level of satisfaction among patients at Eastern Bicol Medical Center, Virac,

Catanduanes.

De la Fuente, R.I. (2013) made a study on “Work Environmental Factors

Affecting Staff Nurse Retention Among Selected Hospitals in Legazpi City.” Based

on the findings, the following conclusions were drawn: 1) Majority of the staff nurses

belongs to age range 20-30 years old; female; single; have served for less than five years

in their respective hospitals; earned less than Php20,000 per month and earned

bachelor’s degree. 2) Majority of the respondents “strongly agreed” that the respect
 26

from management and physicians/doctors, safety rules and regulations and safe

working environment influences nurses’ decisions to leave or stay in organization.

Generally, staff nurses “agreed” that the five dimensions of work environmental

factors affecting staff nurse retention namely: compensation and benefits, facilities and

equipment, relationships to co-workers and management, protocols, rules and

regulations and professional growth and development influences their decision to

leave/stay in an organization. 3. A significant relationship exist between the

respondents age, civil status, sex, length of service, monthly salary and educational

attainment along with work environmental factors affecting staff nurse retention. 4)

The plan is proposed to create work environment that will enhance staff nurse

retention.

Gumabon, V.R.D.V. (2014) made a study on the “Nursing Care of Staff Nurses

at Labo District Hospital and Its Implication to Quality Patient Care.” Conclusions

were: 1) majority of the nurses are 21-25 years old, female, single, Roman Catholic,

Bachelor of Science in Nursing Graduate, with family monthly income between

P35,000-P39,000, and with 1-5 years of experience. 2) majority of the nurses have very

satisfactory performance in terms of direct and indirect nursing skills. Majority of the

patients felt that the nurses were outstanding in the performance of direct and indirect

nursing skills. 3) The respondents are very satisfied on the nursing care performance

of staff nurse at Labo District Hospital along care, core, and cure aspect. 4) Both the

nurses and patients agree that there are factors affecting the nurse performance of staff

nurses at Labo District Hospital. 5) There is no significant difference in the level of

 27

performance of the nurses along planning, evaluation, and staff roles and

responsibilities when their age, sex, civil status, religion, education attainment, family

monthly income and years of experience. However, there is a significant difference

between the level of performance of the nurses along planning when their age is

considered along intervention when family monthly income is viewed along

documentation when sex is regarded, along policies and procedures when age ad

religion is considered. 6) The performance of the nurses can be further enhanced if

the proposed plan will be adopted, the nurses will further improve the level of nursing

care, performance of the staff nurses at Labo District Hospital specifically along direct

and indirect nursing skills.

Tubalinal, L.V. (2016) did a study on the “Nurse-Physician Collaboration

Towards Quality Health Care Delivery at Eastern Bicol Medical Center, Virac,

Catanduanes.” Conclusions were: 1) The respondents were 36 years old and above,

female, with 16-20 years of service and assigned at Medical/Surgical/ICU. 2) Nurses

and physicians are getting more positive actions on their collaboration to deliver quality

care to patients. 3) Nurses often have collaboration towards physician on their work

often collaborate with nurses regarding procedures in the ward. 5) There is significant

relationship between the profile of the respondents and the attitude towards nurse -

physician collaboration. 6) There is no significant relationship between the

collaborative practices of nurse and the collaborative practices of the physician. 7)

There is a plan that if utilize could improve the collaborative practices of the nurses

and physicians towards the delivery of care.

 28

Tibor, A.M.B. (2014) made a study on the “Effects of Patients’ Confidence to

Health Care Team on their Treatment Progress of Ligao City.” Conclusions were: 1)

The respondents strongly agreed that personal, interpersonal as well as social systems

developed the confidence of the patients towards the health care team. 2) The patients'

level of confidence to health care team was high. 3) The respondents strongly agreed

that confidence was developed to the health care team when there was closer nurse-

client relationships/interaction thus, brought about progress on their treatment. 4)

There is no significant relationship between the factors that develop the confidence of

the patients and the level of confidence to health care team. 5) There is no significant

relationship between the patients' level of to health care team and its effects on their

treatment progress. 6) The proposed plan was focused on how the clients’ confidence

to the health care team was maintained and/or highly improved.

Oaferina, S.D. (2014) conducted a study on the “Efficiency of Health Care

Delivery Services of Philhealth Accredited District Hospitals in Camarines Sur.”

Conclusions were: 1) Mostly of the indigent clients belong 40 or more age bracket; high

school graduates, monthly income of less than Php5,000. As for the medical and

nursing professionals, majority are aged 20-25 years old; holders of nursing bachelors

degree as well as with masteral units. Lastly, mostly the monthly salary of less than

Php5,000. 2) The Philhealth accredited district hospitals in Camarines Sur are efficient

on healthcare delivery services specifically on delivering the services in room and board,

having qualified professionals, drugs and medicines and laboratories. 3) Leadership

and management as well as the human resource management are considered factors
 29

affecting the level of efficiency of healthcare delivery services of the Philhealth

accredited district hospitals. 4) Monthly income of the clients plays significant role in

the efficient service on drugs and medicines. 5) Problems can be minimized and

eventually enhances the healthcare delivery services in the Philhealth accredited district

hospitals in Camarines Sur through the implementation of the propose plan.

Abaño, P.C. (2015) assessed the Level of Job Satisfaction and Organizational

Commitment of Nurses in Private Tertiary Hospitals of Daet, Camarines Norte.

Conclusions were: 1) The nurses in the Medical and ICU have the lowest level of job

satisfaction in alt the parameters used, but in terms of Payment/Benefits received by

the nurses, all the areas expressed a level of moderate satisfaction, while their

counterpart nurses in the DR/OR and OPD-ER manifest a higher level of job

satisfaction. The difference in the job satisfaction level of the different areas of

assignment of the nurses vary from significant to highly significant. Thus, job

satisfaction is a function of the nature of area of assignment of the nurse. The level of

job satisfaction of the nurses depends on their area of assignment. 2) In terms of the

level of organizational commitment in the different areas of assignment of the nurses,

the DR/OR and Medical nurses reveal the lowest commitment in terms of loyalty to

institution, while the nurses from all the areas are much committed along this parameter.

However, the test reveal that there is no significant difference in the areas of assignment

in terms of their loyalty to institution. On upholding that standard of profession, the

OPD.ER group manifest the highest level of commitment. Very Much Committed.

The rest of areas manifested a level of Much Committed. Nonetheless, the difference
 30

is not significant among the areas of assignment. The parameter on Projecting Better

Image to Patients and Community, revealed that the OPD-ER group are very much

committed, while the Medical, DR/OR, ICU, and PEDIA groups show the lowest

level of commitment. The test revealed that the difference is significant among the

different areas whereby rejecting the null hypothesis at 5% level of acceptance. 3)

There is a significant difference in the job satisfaction of the nurses, but organizational

commitment in terms of projecting better image is accepted. 4) The nurses’ assigned

at the medical ward and ICU have the lowest job satisfaction compared to other areas

of assignment. 5) The program address the needs of the nurses for better job

satisfaction and organizational commitment.

Martizana-Cepriaso, J. (2011) correlated the “Relationship Between Caring and

Burnout Among Staff Nurses at Camarines Norte Provincial Hospital.” The

conclusion and recommendation flowing from the findings of the study are following;

the result shows that most of the respondents are young adults, majority are female

and are predominantly single. The Gross family income of the respondents is on the

bracket of 24,000 and above. Most of the respondents are handling 20-30 patients

daily and have been in the nursing practice for less than a year and attended trainings

and seminars for 33-40 hours per year. Caring of respondents along Assurance of

Human Presence, shows a high level of caring to the patients with an overall mean

rating of responses of 339. Along Respectful Deference to others an overall mean

rating of 3.46, shows a high level of caring. Along Professional Knowledge and Skills,

Majority of the respondents show high regard for the patients as manifested by a mean
 31

rating of 3.4. Caring of respondents along Positive connectedness, shows a high level

of caring with a mean rating of 3.28. The mean rating of 3.54, shows a high level of

caring along attentiveness to others experience. This study shows that the respondents

exhibited a high to moderate levels of burnout in the dimension of emotional

exhaustion with a mean rating of 31.72. In the level of burnout along depersonalization

the results reveals that the entire staff of Camarines Norte Provincial Hospital exhibited

a high level of burnout with a mean rating of 16.98. In the burnout dimension of

personal accomplishment, majority of staff of Camarines Norte Provincial Hospital

exhibited a moderate level of burnout with a mean rating of 33.33. This study shows

that there is no correlation between the respondents profile and level of caring. Also,

there is no significant relationship between respondents profile and level of caring.

Lastly, there is no significant relationship between caring and burnout.

In a study she conducted, Gonzales, F.C.D (2012) claimed that “Nursing is a

demanding job and for nurses it can often feel as though there are not enough hours

in the day to complete all of their tasks.” Focusing on the effect of nurse-patient ratio

on nurses, the following conclusions were drawn: 1) From the eight hours duty of a

staff nurse 199.85 or 3 hours and 33 minutes of Nursing Care Hours were allotted for

the eleven key areas of responsibility in which some of these had been considered of

relative importance and measured the nurse’s regularity in performing these

responsibilities while some were not. Most of them were done very often or they

exceeded the requirement while only a few were done Always. Many of the nurses put

emphasis on priority tasks for their safety and protection secondarily on quality of care
 32

for patients. The 3 hours and 38 minutes of Nursing Care Hours left are consigned to

perform support and delegated activities which the nurses know are not in their job

description. 2) Personal as well as professional reactions of the nurses had been shown

in the time allotment for patient care responsibilities, support and delegated activities.

Some of the personal ones are for maintaining harmonious relationship among the

health care providers and personal necessities while the professional reactions include

the need to follow protocol, standards, policies and the stated job description. The

reactions of the nurses describe their feelings about the patient care responsibilities,

which they think should be their priority but the workload increases as they are given

and are expected to perform support and delegated activities as well.

Nicolas, E.A. (2012) conducted a study entitled “Patient Satisfaction with the

Delivery of Health Services at Dr. Fernando B. Duran Sr. Memorial Hospital

(DFBDSMH)”. The following conclusions were drawn: 1) Patients’ level of satisfaction

along facility, service, drugs, medicines and supplies, equipment, and interpersonal

relationship of DFBDSMH is satisfactory. 2) The factors affecting patients’ level of

satisfaction are: a) Staff-related which include staff inter-action with patients and team

work, care and concern shown by the staff, and the knowledge and skills of the doctors

and nurses; b) System-related which include cleanliness of wards, corridors and toilets,

cost of treatment, prompt service and convenience.

“Registered nurses are the single largest group of healthcare professionals in the

United States. Yet, the vacancy rate for RNs continues to rise and currently stands at

7.2 percent, according to a report from NSI Nursing Solutions.” Despite that fact, there
 33

is still a growing demand for nurses both in hospitals and the community. Employment

of registered nurses is projected to grow by as much as 16 percent by 2024, much faster

than the average for all occupations, said the Bureau of Labor Statistics.

The factors contributing to the nursing shortage are multifaceted: a diminishing

pipeline of new nurses due to a faculty shortage that has resulted in thousands of

prospective students being turned away, steep population growth in several states, ACA

providing increased access, and a baby boom bubble that will require intensive health

care services. And these issues are occurring at a time when a significant number of

nurses are retiring.

Due to the shortage, nurses often need to work long hours under very stressful

conditions, which can result in fatigue, injury, and job dissatisfaction. Nurses suffering

in these environments are more prone to making mistakes and medical errors. An

unfortunate outcome is that patient quality can suffer, resulting in a variety of

preventable complications, including medication errors, emergency room

overcrowding, and more alarmingly, increased mortality rates (Schumacher Clinical

Partners, 2016).

This study commissioned by the Agency for Healthcare Research and Quality,

part of the U.S. Department of Health and Human Services, Researchers compared

hospital care utilization and financial data in California, Maryland and Nevada. After

the law went into effect California patients experienced fewer adverse events than the

others, although the effect was moderate. Patient length of stay in the hospital, however,

was reduced significantly, a finding that has been replicated in other studies. Staffing
 34

ratios also appear to reduce the rate of readmissions, many of which are preventable

and constitute a significant cost for hospitals. The Affordable Care Act (ACA) sets

penalties for hospitals with high rates of readmissions (Agency for Healthcare Research

and Quality, 2014).

Hospital nurses are being forced to ration care because they do not have enough

time to properly look after patients. "Care is needed but is often not done because of

insufficient time. There is a strong relationship between RN staffing levels and the

prevalence of care being left undone - and, the better the practice environment the

smaller the volume of care that is left undone." Nurses' vigilance at the bedside is

essential to their ability to ensure patient safety. It is logical, therefore, that assigning

increasing numbers of patients eventually compromises nurses' ability to provide safe

care (Support Solutions, 2018)

Support for mandatory nurse-patient ratios is drawn from the belief that

regulated registered nurse (RN) staffing will increase positive patient outcomes,

decrease nursing shortages, and increase nurse recruitment and job satisfaction. The

author notes that research support for adequate staffing and balanced workloads of

nurses are important for achieving good patient, nurse, and financial outcome

( Tevington, P., 2011).

A study conducted by Kane, R.L., et al., (2017) intended to assess how nurse-

to-patient ratios and nurse work hours were associated with patient outcomes in acute
 35

care hospitals, factors that influence nurse staffing policies, and nurse staffing strategies

that improved patient outcomes.

Aiken, L.H., et al., (2012) reports on findings from a comprehensive study of

168 hospitals and clarifies the impact of nurse staffing levels on patient outcomes and

factors that influence nurse retention. The effectiveness of nurse surveillance is

influenced by the number of registered nurses available to assess patients on an ongoing

basis.

Gap Bridged by the Study

The related literature and studies cited in the synthesis provided worthwhile and

valuable information that guided the researcher in taking appropriate steps to conduct

the research regarding the effects of nurse-patient ratio on the delivery of nursing care.

The analysis of the previous researchers showed that the studies are partly related, only

that, they differ on the scope and objectives of the present study.

Finally, it was found out that there were no general studies conducted focusing

on the implementation of DOH Circular on nurse patient-ratio and its effects on the

delivery of nursing care specifically among the district hospitals in Catanduanes and

this is the gap that this study hopes to bridge.

Problem in the Field

The shortage of nurses in hospitals has been a long-term crisis of the Philippine

healthcare system. According to the Department of Budget and Management, the

standard ratio of staff nurses to patient in government hospitals is 1:12; while in critical
 36

units, a ratio of 1 staff nurse to 3 patients is the ideal. In real setting, especially in

provincial areas where hospitals are with minimal bed capacity, the ratio of nurse to

patient most likely exceeds the standard quality due to understaffing. This is why

numerous job-to-order nurses are put into service with the same workload as regular

staff nurses resulting to poor commitment because of below minimum wage earnings.

This eventually results to non-renewal of contract affecting the institution and the

employee.

The relationship between nurse-to-patient ratios and patient outcomes likely is

accounted for by both increased workload and increased stress and risk of burnout for

nurses. Missed nursing care—a type of error of omission in which required care

elements are not completed—is relatively common on inpatient wards. The high-

intensity nature of nurses' work means that nurses themselves are at risk of committing

errors while providing routine care. Human factors engineering principles hold that

when an individual is attempting a complex task, such as administering medications to

a hospitalized patient, the work environment should be as conducive as possible for

carrying out the task. However, operational failures such as interruptions or equipment

failures may interfere with nurses' ability to perform such tasks; several studies have

shown that interruptions are virtually a routine part of nurses' jobs. These interruptions

have been tied to an increased risk of errors, particularly medication administration

errors. While some interruptions are likely important for patient care, the link between

interruptions and errors is one example of how deficiencies in the day-to-day work

environment for nurses is directly linked to patient safety.

 37

Longer shifts and working overtime have also been linked to increased risk of

error. Nurses who commit errors are at risk of becoming second victims of the error,

a well-documented phenomenon that is associated with an increased risk of self-

reported error and leaving the nursing profession. In their daily work, nurses are also

frequently exposed to disruptive or unprofessional behavior by physicians and other

health care personnel, and such exposure has been demonstrated to be a key factor in

nursing burnout and in nurses leaving their job or the profession entirely.

All of these factors—the high-risk nature of the work, increased stress caused

by workload and interruptions, and the risk of burnout due to involvement in errors or

exposure to disruptive behavior—likely combine with unsafe conditions precipitated

by low nurse staffing increase the risk of adverse events, thereby affecting the delivery

of quality nursing care to patients.

Objective of the Study

This study aimed to assess the implementation of the DOH Circular on Nurse-

Patient Ratio and its effects on the delivery of nursing care among the district hospitals

in Catanduanes. Specifically, the following objectives were set: (1) To determine the

characteristics of the hospital along: a. number of patients admitted; b. census per

month; c. type of patients admitted; d. number of departments; and d. length of stay;

(2) To determine the nursing functions done by staff nurses in the five district hospitals;

(3) To determine the effects of implementation of nurse-patient ratio in the delivery of

nursing care; and, (4) To recommend measures to adhere to the implementation of the

DOH Circular.
 38

Conceptual Theories

A major theory that influences this study is the Systems Theory. Systems theory

was proposed in the 1940's by the biologist Ludwig von Bertalanffy and furthered by

Ross. von Bertalanffy was both reacting against reductionism and attempting to revive

the unity of science. He emphasized that real systems are open to, and interact with,

their environments, and that they can acquire qualitatively new properties through

emergence, resulting in continual evolution. Rather than reducing an entity (e.g. the

human body) to the properties of its parts or elements (e.g. organs or cells), systems

theory focuses on the arrangement of and relations between the parts which connect

them into a whole (cf. holism). This particular organization determines a system, which

is independent of the concrete substance of the elements (e.g. particles, cells, transistors,

people, etc). Thus, the same concepts and principles of organization underlie the

different disciplines (physics, biology, technology, sociology, etc.), providing a basis for

their unification. Systems concepts include: system-environment boundary, input,

output, process, state, hierarchy, goal-directedness, and information (Principia

Cybernetica, 2018).

Relevant to this study, Betty Neuman's Systems Model provides a

comprehensive holistic and system-based approach to nursing that contains an element

of flexibility. The theory focuses on the response of the patient system to actual or

potential environmental stressors and the use of primary, secondary, and tertiary

nursing prevention intervention for retention, attainment, and maintenance of patient

system wellness (Nursing Theory, 2018).

 39

Another theory this study anchors on is the Theory of Caring. According to

Watson’s theory of caring, “Nursing is concerned with promoting health, preventing

illness, caring for the sick, and restoring health.” It focuses on health promotion, as

well as the treatment of diseases. According to Watson, caring is central to nursing

practice, and promotes health better than a simple medical cure. The nursing model

also states that caring can be demonstrated and practiced by nurses. Caring for patients

promotes growth; a caring environment accepts a person as he or she is, and looks to

what he or she may become (Wayne, G., 2016).

The Philosophy and Science of Caring addresses how nurses express care to

their patients. Caring is central to nursing practice, and promotes health better than a

simple medical cure. Watson believes that a holistic approach to health care is central

to the practice of caring in nursing. This led to the formulation of the 10 carative factors:

(1) forming humanistic-altruistic value systems, (2) instilling faith-hope, (3) cultivating

a sensitivity to self and others, (4) developing a helping-trust relationship, (5) promoting

an expression of feelings, (6) using problem-solving for decision-making, (7) promoting

teaching-learning, (8) promoting a supportive environment, (9) assisting with

gratification of human needs, and (10) allowing for existential-phenomenological

forces. The first three factors form the “philosophical foundation” for the science of

caring, and the remaining seven come from that foundation.

Describing her theory as descriptive, Watson acknowledges the evolving nature

of the theory and welcomes input from others. Although the theory does not lend itself

easily to research conducted through traditional scientific methods, recent qualitative

 40

nursing approaches are appropriate. Watson’s theory continues to provide a useful and

important metaphysical orientation for the delivery of nursing care. Watson’s

theoretical concepts, such as use of self, patient-identified needs, the caring process,

and the spiritual sense of being human, may help nurses and their patients to find

meaning and harmony during a period of increasing complexity. Watson’s rich and

varied knowledge of philosophy, the arts, the human sciences, and traditional science

and traditions, joined with her prolific ability to communicate, has enabled

professionals in many disciplines to share and recognize her work.

Conceptually, therefore, this study proposes that the hospital environment is

considered an open system. Legal directives coming from agencies like the Department

of Health influence the operational management, specifically, nurse-patient ratio, as in

the case of this study. Such nurse-patient ratio as 1:12, as prescribed by the DOH in

AO no. 2012-0012 and Department Circular No. 2013-0423 put pressure on hospitals

who are not able to limit their nursing staffing to such standard due to certain

constraints.

This study describes the views of the respondents on the effects of the nurse-

patient ratio on the delivery of quality nursing care. Subsequently, the views of the

patients on such issue are also described. The results of such investigation provide

basis for determining intervention measures for adhering to the DOH Circular on 1:12

nurse-patient ratio.
 41

SYSTEM’S THEORY
BETTY NEUMAN'S WATSON’S THEORY
MODEL OF CARING

Characteristics of the
Hospital
a) Number of patients
Descriptive- admitted
b) Census per month Nurse’s Effects of
Qualitative c) Type of patients
admitted Functions Implemen-
d) Number of
departments
tation
e) Length of stay

Recommended
Measures to Adhere
Implementation

Output
Delivery of Quality
Nursing Care

Figure 1. Conceptual Framework Model

 42

METHODOLOGY

Research methodology is the specific procedures or techniques used to identify, select,

process, and analyze information about a topic. It allows the reader to critically evaluate a

study’s overall validity and reliability. The methodology section answers two main questions:

How was the data collected or generated? How was it analyzed?

Discussion of research design, sources of data, and participants of the study,

research instruments, data gathering procedures and data analysis were presented.

Research Design

This study used the qualitative approach of research. Qualitative Research is

primarily exploratory research. It is used to gain an understanding of underlying reasons,

opinions, and motivations. It provides insights into the problem or helps to develop ideas or

hypotheses for potential quantitative research. (Sep 16, 2011).

Qualitative research approach seeks to tell the story of a particular group’s

experiences in their own words, and is therefore focused on narrative research.

Participant observation and in-depth interviews were considered as research design.

This was used to determine the perception of respondents relative to the effects of

nurse-patient ratio on the delivery of quality nursing care as stipulated in the objectives

of the study.

Sources of Data

Data can be defined as the quantitative or qualitative values of a variable. Data is plural

of datum which literally means to give or something given. Data is one of the most important

and vital aspect of any research studies and is thought to be the lowest unit of information
 43

from which other measurements and analysis can be done. Data can be numbers, images,

words, figures, facts or ideas. Data in itself cannot be understood and to get information from

the data one must interpret it into meaningful information. There are various methods of

interpreting data. Data sources are broadly classified into primary and secondary data. In this

study, the researcher used the primary data source which means that original data has been

collected specially for the purpose in mind. It was collected from the original source first hand.

It has not been published yet and is more reliable, authentic and objective. Primary data has

not been changed or altered by human beings; therefore its validity is greater than secondary

data.

The primary source of data are the permanent or regular nurses of the five

district hospitals in Catanduanes who are mandated to promote holistic care which

means that the whole person is considered including physical, psychological, social and

spiritual in relation to management and prevention of the disease.

Further saturation of data will be done through interview with patients who are

admitted in each of the five district hospitals and who receive services that promote

health, prevent illness, and achieve optimal recovery from or adaptation to health

problems.

Participants of the Study

Qualitative research focuses on understanding the intervention of phenomenon

and exploring questions like “why was this effective or not?” and “how this is helpful

for learning?” The intent of qualitative research is to contribute to understanding,

hence, subject selection is purposeful; participants are selected who can best inform

the research questions and enhance understanding of the phenomenon under study(J.
 44

Sargeant, 2012). A total of five (5) senior nurses or nurses who had the most number

of years assigned in all of the wards of each of the five district hospitals were used as

respondents of the study. These nurses were officially endorsed by the Chief of

Hospital and the Chief Nurse whom they considered primarily with the extent of

knowledge and expertise in the area under study. Additional interview was conducted

on five (5) patients with at least three (3) days of confinement and soon to be

discharged during the month of May 2018, each coming from the five district hospitals

of Catanduanes. They were thoroughly oriented about the flow of the study and the

interview process.

Tools

There were two interview guides that were prepared: (a) nurse interview guide

contained questions that related to the delivery of nursing care in the different hospitals;

and (b) patient interview guide contained questions related to the patient’s experiences

in the hospital relative to nursing services.

Ethical Consideration

Ethics refers to moral principles or values that generally govern the conduct of

an individual or group. Researchers have responsibilities to their profession, clients and

respondents, and must adhere to high ethical standards to ensure that both the function

and the information are not brought into disrepute.

In recent years, ethical considerations across the research community have

come to the forefront. This is partly a result greater awareness of human rights and

data protection and also a result of increased public concern about the limits of any
 45

inquiry. To preserve the integrity of the respondents of this study, the researcher

assured the participants to the study that the information supplied would be kept in

strict confidentiality. Since an electronic recording was made during the interview, the

approval of the interviewee was first sought.

Data Analysis

Data Analysis is a process of applying statistical practices to organize, represent,

describe, evaluate, and interpret data. It is a method in which data is collected and

organized so that one can derive helpful information from it.

The purpose of qualitative analysis is to interpret the data and the resulting

themes, to facilitate understanding of the phenomenon being studied. It is often

confused with content analysis, which is conducted to identify and describe

results(Patton M. Q., 2002).

To analyze the qualitative data, the data were coed and categorized according to

the sub-problems of the study. Themes provided basis for the conclusions of the study.
 46

RESULTS

Presented herein are the findings of the study based upon the information

gathered and are shown according to the objectives of the study.

Characteristics of the Hospitals

Table 1
Characteristics of the Hospitals
(May 2018)
TYPE OF PATIENTS TOTAL LENGTH OF STAY
NAME OF Bed Implem No. of No. of Nurse- ADMITTED
HOSPITAL Capacity -enting Patients Staff Patient Med OB Ped NB Med OB Ped NB
Beds Admitted/ Assigned Ratio
Census for
the Month
Hospital 25 28 239 1/shift 1:21-25 63 61 57 58 204 108 228 102
A
Hospital 25 25 139 1/shift 1:11-15 57 25 35 22 165 48 102 41
B
Hospital 10 13 84 1/shift 1-5:10 31 17 23 13 76 32 65 24
C
Hospital 25 35 158 1/shift 1:16-20 67 20 52 19 231 35 167 33
D
Hospital 25 25 64 1/shift 1:5-10 29 13 13 9 94 22 36 15
E

Table 1 reflects the number of patients admitted for the month of May in each

of the five (5) hospitals. Hospital A scored the highest number of patients (239) almost

equally distributed among the medical, OB, pediatrics and new-born departments.

Total length of stay was longest for pediatric patients (228 days). The lowest admittance

was for Hospital E, with mostly medical department patients. Total length of stay was

longest for pediatrics patients (228 days) and medical department patients (94 patients).

All hospitals under study are on Level I status in terms of service capability,

which are owned locally by the government. Except Hospital C, which has 10-bed

capacity, all the four (4) hospitals have 25-bed capacity. Bed occupancy is as low as 29

percent for Hospital E, 59% for Hospital C, 70% for Hospital A & D, and as high as
 47

76 percent for Hospital B. This implies that the different hospitals under study are

primary hospitals with same bed capacity of 25 and only one with a bed capacity of 10

but have different bed occupancy rate. This difference was due to the distance of the

hospital, services rendered and availability of equipment and supplies.

Hospital A is a 25-bed capacity hospital and was built on the year 1959 through

the concerted effort of Cong. Jose M. Alberto and its municipal mayor. There were

only 15 personnel then under the stewardship of the first Chief of Hospital. In the year

1962, after its relocation to its present site, Hospital A derives its fund and other

resources from the national government under the Department of Health (DOH).

With the implementation of R.A. 7160 in 1992, Hospital A, including all its assets and

liabilities, was devolved to the provincial government of Catanduanes. As per DOH

standards, the hospital has been downgraded few years back because of deficiencies in

manpower/facility and equipment. At present, Hospital A is a Level I facility providing

health care services to several municipalities. Basic hospital services offered are OB-

Gyne, Medical, Pediatrics, & Surgery, however, no major and some minor operations

are done at present due to lack of supplies/equipment and manpower. Ancillary

services include Radiology, Laboratory, Dietary, Pharmacy, Dental, Out-Patient

Department and Ambulance Services.

Hospital B became operational only in October 1968 by virtue of Republic Act

5673 and was converted into a 50-bed capacity secondary hospital with budgetary

allocation coming from the national government. The hospital was devolved to the

provincial government sometime in 1991 as mandated under Republic Act 7160 and
 48

was downgraded/converted to a 25-bed capacity primary hospital due to low bed

occupancy rate which can be attributed to substandard hospital facilities, lack of

medicines and medical supplies and equipment. Hospital B is located almost a

kilometer from the town proper serving the health needs of the people. Patients from

the adjoining district and coastal barangays also come for treatment. At present, the

hospital is manned by the Chief of Hospital and caters services to OB-Gyne, Surgery,

Medical, and Pediatric patients. X-ray, laboratory, dietary, pharmacy, dental, and

ambulance services are also available.

Hospital C is an authorized 10-bed capacity hospital with an implementing bed

capacity of 13 which is categorized as Primary by the Department of Health and the

Philippine Health Insurance Corporation, and is located about 20 kms away from the

poblacion proper. Services include Medical, Pediatrics, OB-Gyne and Minor Surgical

cases. There is also secondary laboratory services w/ blood chem exam, pharmacy, and

hopefully radiologic services. Hospital C has Medical and Pediatric Wards, Labor

Room, Delivery Room, and OB Ward. Patients who wants to avail of radiologic

services, as well as complicated OB cases and those for major surgical procedures are

referred to the nearby hospital and the Eastern Bicol Medical Center in the capital town.

With the implementation of Republic Act 7160, hospital operations was under the

supervision and control of the provincial government. Appropriations for the

Maintenance and Other Operating Expenses (MOOE) of the hospital is very limited

compromising the effective and efficient delivery of quality health services to its

clientele majority of whom are financially handicapped.

 49

Hospital D is actually a misnomer because since 1980 when the hospital was

upgraded from a 25-bed capacity to 50-bed capacity hospital, it has become a general

hospital because services are not only catered to pregnant mothers, newborn and

children, but patients of all ages. This hospital is serving not only the municipalities of

its town, but also several municipalities nearby. They are offering out-patient, in-patient

as well as ancillary services like dental, laboratory, pharmacy and dietary. Presently,

Hospital D is a primary hospital with an authorized bed capacity of 25 beds, however,

40 beds are available for occupancy. The devolution to the provincial government has

brought about many difficulties, but the whole Hospital D has always stand up to the

challenge of trying its best to continuously strengthen and improve the quality of

services rendered to its clients.

Hospital E is a primary care facility with authorized bed capacity of 25 beds and

is catering its services to the barangays of its municipality and the neighboring

barangays of other towns. Services offered includes : (I) Medical Services – Emergency,

Medicine, Minor Surgery, OB-Gynecology, Pediatric, and Out-Patient Service; (II)

Ancillary Services – Dental Service, Dietary, Pharmacy, Laboratory (CBC, fecalysis,

urinalysis, pregnancy test, RBS, NBS); & (III) Other Services – Nebulization, Nutrition

Counseling, Ambulance Conduction, Health Education/Counseling Services, Physical

Examination, Medical Certificate/Medico-Legal, Immunization, Well-Baby, Suturing.

Nursing Functions

In hospitals like a doctor, nurses play an integral role in serving the care to patients.

After the doctor’s consultation and diagnosis, nurse work begins. She mainly focuses on
 50

helping patients and meet their needs including emotional, social, physical, cognitive, &

spiritual. Nurses facilitate patient optimal wellness, health and functioning in the care of

communities, individuals, and families.

Nursing documentation and admission assessment encompasses all written and/or

electronic entries reflecting patient care to include patient’s history, general appearance,

physical examination and vital signs completed at the time of admission. When asked if they

have enough time completing the front sheets and entries in the logbook after the doctor’s

admitting orders, the respondents answered as follows:

Nurse A - “Mai. Lalo pag sobra-sobra pasyente mai mo aram kung ano iinuton mo.” (No,
especially if there’s plenty of patients. You’ll have no idea which one to do first.)

Nurse C - “Bukong sa gabos na oras nagigibo na makumpleto, ga late charting na ngani kami
minsan pag dakor talaga naa-admit.” (Not all the time, we even do our charts after
admitting pool of patients.)

Nurse D - “Minsan dai talaga kaya kumpletuhon gabos o minsan man nariringawan sa
kadakulan nin gibo kaya tiga endorse mi na lang o kaya pag next duty saka na lang ifill-upan.”
(Sometimes we really cannot complete everything or we forget to log because of piled
up works. We, then, tend to endorse the unfinished stuff or fill them up on our next
work shift.)

As a patient advocate, it’s the nurse’s duty to ensure that the care provided is affordable

or sufficient. Generally when a patient is not well, then it’s the nurse duty to determine the

exact needs of the patient, inquire each and everything about his/her health and take care of

it. When asked if they were able to explain clearly and completely patient’s rights, sign consent

to care, what to expect, and how to prepare for and make requests for diagnostic tests, the

answers were as follows:

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Nurse B - “Minsan nariringaw su pag-explain ng patanos kaya dai maiwasan na may pasyente na
naguguluhan buda mag-ribong na ang payo.” (Sometimes, we forget to thoroughly orient the
patients which often results to their confusion and anger.)

Nurse E - “Iyo man, pero pag dakol talaga ang gibuhon may backlogs din kami
minsan.”(Somehow, yes. But if there’s lot of work to be done, we commit few
backlogs, too.)

Nurse’s workload has increased over recent years, and patients in hospital beds are

more acutely ill; as such, ward rounds must be taken into account alongside numerous other

skilled interventions when staffing levels and patient dependency are being reconsidered.

When asked about if they can attend ward rounds and make ward nursing referrals for patients

needing immediate attention, the nurse respondents answered as follows:

Nurse A - “Pag mi ko toxic na pasyente or gapabata, nakaiba ko sa ward rounds. Pero pag ikan,
gasolo minsan yan doctor namo paga rounds.” (There are times that the doctor do the rounds
all alone because the nurse attends to patients w/ serious cases and sometimes during
deliveries.)

Nurse D - “Nakaiba ako sa rounds pag bakong busy sa station. Pero pag igwang ga toxic na
patient, priority tlga irefer.” (I can attend ward rounds whenever it’s not busy in the nursing
station. But if there’s a coding patient, it’s always a priority for us to refer immediately.)

Patients need substantial instructions at discharge for continuing care. Attending to

these needs has increased the time registered nurses must spend on discharge duties making it

much more time consuming. When asked if they were able to instruct patients clearly and

completely what to do, what to expect and properly coordinate their care when they left the

hospital, the nurse respondents answered as follows:

 52

Nurse A - “Pag duagi discharge, ok lang, kaya man. Pero pag kadakor, ikan talaga nalilimutan
kaya minsan gabarik yan pasyente ta mahingunay.” (There are times that we forgot to
instruct patients completely that they tend to go back to the hospital to verify.)

Nurse C - “Minsan mai talaga mauswag ta solo man sana kami sa duty kaya minsan pag puno
sa ER mai na gaatinder sa ward. Pag ikan for discharge pigadagri ko na lang ka tawan yu home
meds buda babasahon.” (Sometimes I really cannot accommodate the needs of all the
patients since I’m on a solo duty. If there’s too many patients in the ER and I have a
patient for discharge coincidently, I simply read and hand the instructions to the
patient for discharge.)

Nurse D - “Kadalasan iyo. Pero igwa talagang oras na baging gamadari kmi pirmi ta dakol
gibuhon kaya kung arin su asa instructions, yun man lang ang nasasabi nimi.” (Often times, yes.
But there are times when I’m in a rush and I just say what’s in the discharge instruction.)

Effects of Implementation

Nurses’ Perspective

The nurse respondents are coded as follows: Nurse A, Nurse B, Nurse C,

Nurse D, and Nurse E. All have long period of working in the hospitals with Nurse A

having 26 years; Nurse B with 27 years; Nurse C with 26 years; Nurse D with 32 years;

and Nurse E with 28 years of experience. All of the nurses have been working all along

at the hospital they were currently connected.

There are many different fields a nurse can enter. In each, nurses
encounter certain environments, patients and challenges. Nurses working in a
hospital oversee patient care, administer treatment and operate medical equipment.
Efforts are being made to improve hospital working environments to better serve
patients. Asked to describe their current work setting, the respondents answered as
follows:

Nurse A – “Habang gahuray, lalong gasakit yan trabaho. Kadakor nadagdag, lalo na mga

paperworks. Yu numero nin pasyente doblehon o triplehon don sa dapat sanang ratio nin pasyente sa
 53

sadong nurse na 1:12. Ata kapapagar na, kagagamo pa”. (The work keeps getting harder as

the years go by. Given the scarcity in nursing staff, the workload especially the paper

works were increased. The number of patients are 2-3 times bigger than the ideal nurse-

patient ratio of 1:12. So all in all, very stressful).

Nurse B – “Ang hospital mi 25-bed capacity hospital, na aside sa mga dati ming pasyente, dagdag

su sa Hemodialysis Unit and Mental Health (Acute Psychiatric Unit).” (Our hospital is a 25-

bed capacity hospital that caters hemodialysis unit and mental health (acute psychiatric

unit).

Nurse C –“ Kalain na ta sa sobra sobrang trabaho boda kahuray gaka ikan off duty ta kurang yu

taho.” (Negative work environment due to excessive workload and long work periods

without breaks.)

Nurse D “Mapagal, naka stress ta kulang ang staff.” (Busy, stressful, understaffed).

Nurse E – “Nakangalo minsan.” (Sometimes stressful).

Modalities of Nursing Care refers to the manner in which nursing care is organized

and provided. It depends on the philosophy of the organization, nurse staffing and client

population. Asked whether they had a buddy nurse and if primary or functional nursing was

practiced, the following were the responses.

Nurse A – “Haros pirmi ikan, bihira lang na mai. Problema pag buko na office hours boda kung

weekends o holidays, gabos na pasyente namo paghari sa emergency room, sa ward, sa delivery room

lalo na, ta kami pa mapabata kun ikan mga budos. Kurang na kurang talaga kami sa taho.” (Most

of the time, yes I have. But after office hours and during weekends and holidays, we
 54

have to do the job all alone. From ER, to all wards, and to DR due to understaffing.

We practice primary nursing.)

Nurse B – “Iyo, igwa ako kaiba. Functional nursing kmi.”(Yes, I have a buddy nurse and we

practice functional nursing.)

Nurse C – “Ikan, ga functional nursing kami.” (Yes, we practice functional nursing.)

Nurse D – “Igwa akong kaiba, primary nursing kami ta gabos piggigibo mi.” (Yes/Primary

Nursing).

Nurse E – “Dai, solo lang. Primary nursing kami uya.” (None, we practice primary nursing).

The nurse patient ratio is a number to describe the number of patients assigned to

each nurse. Nurse patient assignments are based on the acuity or needs of the patient for

nursing care. The respondents were asked as to the number of patients they attended to in a

shift, and the answers were as follows:

Nurse A – “Mga 12-17 na pasyente kada shift kung ikan kaiba. Pag mai, mga 20-35 na pasyente

kada duty.”(There’s 12-17 patients per nurse per shift. If without buddy, we get 20-35

patients in a shift;

Nurse B – “Mga 17-22 na pasyente kada shift.”(I usually have 17-22 patients in a shift.).

Nurse C – “Mga sampuro hanggang kinse.” (10-15 patients)

Nurse D – 20-30 patients;

Nurse E – 10-15 patients;

The respondents were also asked whether they experienced being the lone nurse

on duty and how many patients they attended to; and, the answers were as follows.

Nurse A – “Oho, asa treinta y cincong pasyente.” (Yes, with 35 patients).

 55

Nurse B – “Sa beinte kong taon sa serbisyo, kadalasan solo lang ako gaatinder sa( kinseng pasyente

kung iaverage.” (For almost 20 years, I have been doing solo duty with 15 patients in

average).

Nurse C – “Ikan, doseng pasyente yu inatinderan ko.” (Yes, there were 12 patients.)

Nurse D – “Iyo nagsolo na ako, mga treinta hanggang kuwarentang pasyente.” (Yes – 30 to 40

patients.)

Nurse E – “Pirmi kaming solo, ang kaibahan mi nursing attendant sa sampulo hanggang kinseng

pasyente.” (Most of the time, yes, with 10-15 patients.)

After such experience of being a solo nurse, the respondents claimed to have

felt as follows:

Nurse A – “Kapinagar ko, matapos man u shift ko ma chart pa sana ko. Baga na ko mag iyak

ninyon ta nakaparibod ako, aga na sa 3-11 kong shift boda dili pa ko nakapanhapon. But then,

siyempre maogma ta nakaya man maski painano.” (Very exhausted. I started charting at the

end of the shift and went home early am after my 3-11 shift not able to eat my dinner.

But then, I felt happy and contented, though tired, because I was able to survive the

day’s work.)

Nurse B – “Magayon sa pagmati na nkatao ka nin tunay na serbisyo sa mga pasyente mo, pero dai

ko itanggi na nakangalo talaga pag solo.” (I feel fulfilled, but I will not deny the exhaustion

every after a solo shift).

Nurse C – “Buko lang na ginhawa ko yu pagar, pati utak ko dili na gagana pakatapos nin shift

ko.” (Physically and psychologically jeopardized, exhausted.)

 56

Nurse D – “Maogma siyempre ta maski dakul ang pasyente natapos ko man ang trabaho ko!”

(Great! Work accomplished!)

Nurse E – “Kagagamo.” (I felt stressed.)

To the nurse-respondent’s understanding, quality nursing care means as follows.

Nurse A – “Pag natatao ta sa mga taho lalo na sa mga pasyente yu tortor na serbisyo na kaipuhan

nila. “ (Being able to provide ideal service to others/to patients especially; attending to

their needs appropriately.)

Nurse B – “Para sako, ini su pag nagibo mo on time su gabos na kaipuhan mong itrabaho. Saka

pag feel mo na nakuntento su mga pasyente sa mga ginilibo mo.” (For me, it is being able to do

all the designated task on time and to leave the patient with satisfaction in rendering

health care services).

Nurse C – “ Pag natatao mo yu dapat na serbisyo sa mga taho sa paagi nin pag ataman sa kila

nin responsable, magarang na pakihoron horon na gasabot sa namamati nin kada sado. Dapat gabos

na pasyente, naalagaan nin madiyag, mai dapat nin ga daan.”(Quality nursing care is meeting

human needs through caring, empathetic, respectful interactions within which

responsibility and advocacy form an essential and internal foundation. Quality nursing

care is patient safety, no morbidity and mortality cases. It can be achieved through

positive and healthy working environment.)

Nurse D – “Pag natauhan mo nin maingat, nasa oras, asin tamang serbisyo ang saimong pasyente,

yan pigaapod na quality nursing care sako.” (Quality nursing care is the degree to which

care or services is delivered safely, timely, efficiently, and effectively.)

 57

Nurse E – “Pag tinao ta sa pasyente ta ang magkakanigong serbisyo sa salud sa maski ano man

na paagi buda nakatuwang sa pag ayad ninda.” (It is when we provide comprehensive

nursing care in various health care settings which thereby could promote quality of life.)

Despite the number of patients, the nurse-respondents thought differently as to

whether they were able to provide quality nursing care.

Nurse A – “Mai, masyadong kadakor u pasyente para sa sadong nurse. Dili na a assess nin tortor

yu mga pasyente ta mai na ngani nakakahoron horon sa kadakuran nin gibo. Mapunta lang sa

pasyente ta matao nin burong boda mapalit swero, maliban don, kun dili mag reklamo yu bantay na

ikan namamati pasyente niya, mi na yun. Kadinakor na mga suraton, sobra sobrang trabaho sa

sadong shift.” (No, there’s too many patients to attend to, no more nurse-patient

interactions at all; just give medicine or follow up/change IVF if the patients or

watchers have no other concerns. Workload is too much to complete in an 8-hour

shift.)

Nurse B – “Sa hiling ko, iyo. Maski dakul sinda, ang mga pasyente mi kaya stable man. ” (I

believe so, yes. Even we have several patients in a shift, our patients are usually stable.

Nurse C – No.

Nurse D – “Iyo, teamwork boda kooperasyon nin gabos –gahagad ako tuwang sa nursing assistant

ko boda sa mga bantay pasyente, boda sa pasyente mismo para sa ikaaayad niya, (kaipuhan kong

maghagad tuwang ta daing mapilian, kulang talaga ang tawo. Basta dapat kung anong priority yun

na ngona ang enoton, importante pati commitment, nasa puso na pag serbi.” (Yes, teamwork and

cooperation – involving nursing assistant and patient participation in the care process,
 58

you have to, no choice. Time management – plan care/ prioritize. Commitment and

dedication.)

Nurse E – No.

The nurse-respondents were likewise asked whether they believed the nurse-to-

patient ratio in the hospital meets the standard?, and if not, what was the underlying

cause? The answers were as follows.

Nurse A – “Mai lamang, kurang yan piga offer nin gobyerno na mga job vacancies para sa nurse

kaya dili ga tama don sa ratio nin nurse sa pasyente. Ikan mga job order nurses na hari yan pondo

sa probinsiya na yan trabaho pareho sa trabaho nin sadong staff nurse pero haros kabanga lang nin

sweldo namo yu pga resibe nila kaya minsan baga dili ga seryoso boda naharang sila magloog sa

sobrang trabaho.” (No, there’s no job vacancies enough to meet the ideal ratio. We have

provincial-funded job order nurses who does the job equivalent to ours but receives

wages half our salary, thus poor commitment and job dissatisfaction is the problem.)

Nurse B – “Samo iyo ta mga minor cases man sana piga treat mi uya. Kung igwa man mag abot

na mga kritikal, pigarefer mi diretso sa mga dakulang ospital.” (Yes, it is met in our hospital

most of the time because we only cater minor cases and send critical ones in a tertiary

hospital right away).

Nurse C - “Mai. Siguro dahil sa kakurangan sa budget para mag hire nin bagong nurses. Sado

pa, yu sweldo, kurang, buko lamang na kaoomok kaya gahari dito sa hospital.“(No. Understaff,

due to budget deficit for hiring new nurses, and wages is not competitive for nurse’s

retention in the workplace.)

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Nurse D - “Sa totoo lang, dai, pagal na grabe ang nurses sa sobrang trabaho. Kulang na kulang

ang nurses.” (Honestly NO, after all, nurses become more exhausted – work overload

– shortage of nurses.)

Nurse E – “Dai. Kulang kaya ang nursing staff mi uya.” (No. due to understaffing.)

The nurse respondents were subsequently asked what they thought were the

effects on the delivery of quality nursing care in the hospital; they answered as follows.

Nurse A – “How we deliver care to our patients directly affect the hospital –.”

Nurse B – “Kalain siyempre yan epekto. Yu mga nurses ta kurang, pirming mga pagar tapos

kurang pa yu sweldo, dili nakatao nin magayon na serbisyo sa mga pasyente, yan luwas, kahelak

man lugod yu mga pasyente.” (Unhealthy work environments negatively affect the

performance of nurses, patient care outcomes and patient safety, and also decrease in

nursing workforce.)

Nurse C -“Apektado siyempre yan gabos. Sa nurse, pag kadakor trabaho, minsan mainit na uro,

minsan nakunsensiya ta dili natatao yu dapat na itaong serbisyo sa pasyente. Ikan oras na dili natatao

yu burong sa oras or ikan ngani minsan nasasara pa, madyag ngani ta Paracetamol sana. Sa pasyente,

nahuhuray yan pag istar sa hospital, kurang yan pakihoron horon nin nurse kaya minsan dili isi kun

ano pa yu namamati nin pasyente. Minsan yan bedside care mi na, pgahuno na lang sa mga bantay

ta mi talaga kaya.” ( Generally, all are affected. Nurses experienced burnouts, feeling of

guilt for being not able to provide ideal patient care, lapses, medication errors. Patient’s

hospital stay is prolonged, no nurse-patient interaction at times leading to lack of

complete physical assessment and poor nursing care.)

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Nurse D – “Kulang ang istoryahan kang nurse saka mga pasyente manungod sa helang ninda sa

kadakulan ning trabaho” (Lessened nurse-patient interaction due to work

overload.)

Nurse E – “Dai mi natatao ang dapat na serbisy osa pasyente ta kulang kami sa staff.” (We

cannot meet the standard quality of service due to understaffing.)

Patient’s Perspective

To validate and augment the data sourced from the nurses, five patients, each

representing a hospital, were interviewed. The patient respondents are coded as

follows : Patient A, Patient B, Patient C, Patient D, and Patient E.

For many patients, the admission into a health care facility is a stressful, frightening,

and isolating experience. The patient experience is a significant component of high quality care

and patient satisfaction. Health care institutions must understand patient needs and

experiences in order to effectively translate this into methods to provide high quality, efficient

services (Lambrou et al., 2014; Norton-Westwood et al., 2010). When asked how clear and

complete the nurse’s explanations were about tests, treatments and what to expect.;

and, how well nurses explained how to prepare for diagnostic tests (CBC, U/A, F/A,

BLOOD CHEM, CHEST X-RAY, ULTRASOUND). The answers were as follows.

Patient A ---“Poon pa lang paglaog ko sa ospital na ini, kinaholon na nin doktor pamilya ko kaya

aram na ninda helang ko boda kung pano ninda ko matuwangan.” (Right after I got here, my

family was informed about my condition and in what way they could help me.)
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Patient B --- “Pigsabihan ako, pero minsan gahapot ako utro pag dai ko nasabutan.” (I was

instructed, but sometimes I tended to ask again for clarification.)

Patient C ---“Iso, pagloog ko tinarman na ko ning nurse na ikan gigibohon na mga eksaminasyon

sa ako para maaraman kun tayon ta pigakalintura da ko. Kahinapdos pati pagaturon ko.” (Yes,

I was informed by the nurse upon admission that I should undergo several tests to

know why I have fever. I have difficulty in swallowing.)

Patient D - “Iyo tabi, paglaog ko sinabihan na ako nin nurse na duty.” (Yes, I was informed

by the nurse on duty).

Patient E ---“Tig eksplikar man ninda nin marinas.” (They explained it well.)

In hospitals, lots of people visit in a day either from village or city. People who are not

educated requires more consultation care as compared to educated one because it’s a matter

of someone’s health. For this purpose, effective communication in the healthcare system is

necessary that can improve outcomes in the healthcare environment. Sometimes a patient

will be confused about certain procedures & steps, the nurse clears all doubts and convince

their patients that they can recover quickly if they take care of themselves. The patient-

respondents were asked about the nurses’ willingness to answer patient’s questions and

how well nurses communicated with patients, families and doctors, how much their

families were allowed to help in patients’ care. The answers were as follows.

Patient A---“Iso tbi, pigasimbag man ako diretso ning nurse pag ikan ako gustong maisihan boda

nakiistoryahan man sa pamilya ko kun gabisita. Ikan lang talaga oras lalo na aga na mi mo sila

nakakahoron ta kadakor pasyente. (Yes, the nurse informs my family about my condition

and how they can help me recuperate, but there are times, mostly in the morning that

we cannot talk to them because of so many patients).

 62

Patient B--- “Ok man. Gasimbag sinda nin patanos kung bako sinda solo. Gahapot kung ano pa

ang namamati. Gatalam sinda kung ano mga bawal gibuhon o kaunon pati su bako. (Yes, they

answer to querries properly if they have their buddies. They told me what things/food

I should avoid.

Patient C--“Iso gasimbag man diretso pag pigahingunay. Nakiistorya man pag mi siya pasyente.

Pagloog ko sana tinarman na yu asawa ko na baad mga dawha o tatlong ardaw ako ma confine ta

ipaagi sa swero yu burong ko tapos kun ano yan mga pwede ko kaonon. Mas magayon da lugaw ta

mahapdos tuturnan ko. “(Yes, the nurse communicates well with me and my family if

there are no other patients. My husband was informed by the nurse that I shall stay in

the hospital for 2-3 days because my medication will be given intravenously, and

suggested that I should eat soft diet for my painful throat.)

Patient D-“Iyo tabi, pag igwa ko hapot, simbag man nin malinas ang nurse boda nakiistoryahan

man samo pag igwa siya ning oras. Poon pa lang paglaog ko sa ospital na ini, kinaholon na nin

doktor pamilya ko kaya aram na ninda helang ko boda kung pano ninda ko matuwangan.” (Yes,

the nurse answers my questions and communicate with us if she has extra time. Right

after I got here, my family was informed about my condition and in what way they

could help me.)

Patient E-“Gasimbag sinda sa mga hapot mi. Tigatalman ninda mga kapamilya ko na magtabang

sa pag atinder sako. Gi-inform pati kami sa mga bagong findings.” (They answer to our queries

and encourage my family members to participate in caring. They keep on updating us

about my condition as well.)

 63

Building positive relationships begin with friendliness and courtesy. It is

important that nurses be specifically trained in behavioral health to help increase their

comfort level. Treating people like people, not cases or conditions, affirms patient’s

basic human dignity and self-respect. When asked about the courtesy and respect they

were given; friendliness and kindness and how often nurses checked on patients and

how well they kept track of how patients were doing and willing to be flexible in

meeting patient’s needs, the answers were as follows:

Patient A ---“Maboboot gabos na nurse dito. Approachable, dili ka masupog magtaram kun ano

kaipuhan. Ikan lang time na bihira maghingunay yu nurse ta minsan mga busy man pero pag

pigatarman ko nin namati ko nakiistoryahan man boda pigahuno ko kun ano gigibohon ko.” (All

nurses here are friendly and kind. Approachable and always willing to help. But there

are times the nurse has less patient interaction due to work overload but attends to

patients needs whenever necessary.)

Patient B --- “Kadakulan man uya mga maboot. Pag busy lang, halos dai mo makahulon ta sigeng

punta kung sain sa hospital boda ma birada, pero nasabutan ko man. Iyon ngani, gahapot sinda

kung ano pa ang kamatean.” Baging pirmi man, pag igwang igibo na kaipuhan approval gahapot

sinda kung ano desisyon ko.” (Most of the nurses here are nice, but, if they’re busy, we

barely could speak to them because they go back and forth of the hospital. And as I

said, they ask if we still have some health concerns to be addressed. When there’s a

procedure that needs my consent, they ask for my preference.)

Patient C ---“Mga maboot man sila. Buda uya sna sila pirmi ta harani kami sa istasyon. Ikan

lang oras na pag kadakor mga pasyente dili talaga kami nabibisita, pag matao sana burong, dangan.”
 64

(They’re all courteous, often visit us because the patient’s ward is just beside the nurse’s

station. But there are times if patients are numerous that they don’t have the time, only

when giving meds that they have time to communicate with us.)

Patient D ---“Maboot nurses mi uya. Pgakumusta man ko minsan pag bako siya busy.” Minsan,

gahapot man. Boda gatao advise kung anong mayad.” (Nurses here in our hospital are

friendly and kind, and find time to check on me if she’s not busy. And give

advice/suggestions on how things will be easier for the patient.)

Patient E ---“Mabubuot sinda boda magalang. Gatalam sinda mag sabi sainda pag igwang namati

na lain. Gahanap sinda nin paagi para sana matauhan kami nin marinas na serbisyo.” (They are

kind and polite. They frequently ask us to report any discomfort and find a way to give

us the utmost care.)

Being flexible and rolling with the punches is a staple of any career, but it’s

especially important for nurses. A great nurse is flexible with regards to working

hours and responsibilities. The patient-respondents were asked about how well the

nurses adjusted their schedule to patients’ needs and if they respond quickly to their

call and make them comfortable and reassure them. The answers were as follows.

Patient A ---“Maski gamu-gamo yu mga nurse natatawan pa man ako nin oras. Minsan sa

kadakuran gibo, pagabura ko lalo na mapapalit nin swero, nahuray huray nin dwagi, pero minsan

man sana. Kadalasan diretso man gapunta pag kaipuhan.” (Though busy, nurses can still find

time to assist me in my needs. There are times when the nurse is busy that I have to

wait for a while to let her follow up my IVF, but mostly, they attend to my needs

quickly.)
 65

Patient B --- “Napansin ko baging may fixed na oras sinda mag tao nin bulong. Baging para sako

dakulang pakatipid ito sa oras boda energy. Pag dai masyado pasyente, madari sinda apudan, gapunta

sinda diretso. Pag medyo busy, medyo awat mag punta. Pigaenot ninda kung sisay

pinakanangaipuhan.”(I noticed that they give medications in particular times. I think it

saves their time and energy. If there are few patients, they are easy to approach and

respond immediately when called. But if it is full house, it takes a while for them to

accommodate some. They prioritize patients with urgent needs.)

Patient C ---“Pagakaaga, galibot yu nurse ta mangarigos da yu mga pasyente pag mai man

pigakalintura. Buda pigatarman kami na dapat pirmi malinig yu among palibot kun kaya man

namo maghiwas hiwas. Oho, apurado pag gabura yu pasyente. Pag ikan siya dili mabayaan na gibo

pgasugo yu midwife.” (Every morning we are told by the nurse that we should take a bath

if we have no fever and maintain cleanliness at the ward if possible. Yes, they respond

quickly. If she cannot leave the patient she’s attending to, her midwife buddy is the one

who respond to the call.)

Patient D ---“Pag aga ang duty, medyo busy kaya minsan kulang ang natataong oras sa ward.”

Iyo tabi. Agad-agad nakapunta man ang nurse pag nag apod ang pasyente boda gahagad tuwang.”

(Morning duty nurses are busy that sometimes they lack time doing bedside duties.

Yes, the nurse responds quickly if the patient needs help.)

Patient E ---“Gapunta sinda diretso pag bakong busy. Dagos man sinda gaasikaso sa mga

kaipuhan mi.” (They immediately attend to my needs if they are not busy. They attend

to our needs immediately.)

 66

Nurses play a vital role in patient safety. After the doctor’s visit or diagnosis,

it’s a nurse duty to prevent medication errors and ensure patients receive the correct treatment

and therapy. The patient-respondents were asked how well things were done by the

nurses, like giving medicine and handling of IVs. The answers were as follows.

Patient A ---“Mi ko matataram, puro mga batid yu nurses dito.” (I have no comment, they

are all competent).

Patient B --- “Minsan naawatan sinda mag palit ng swero, lalo pag busy.” (Sometimes it takes

a while for them to change dextrose, especially if they are busy.)

Patient C ---“Ah una iso. Kabinatid mga nurse dito sa amo.” (Oh yes, they know well what

they are doing.)

Patient D ---“Iyo man tabi. Natatao man sa oras ang mga bulong pag dai nag abot na bag ong

pasyente.” (Yes, medicine were given on time if there were no newly admitted patients.)

Teamwork and collaboration is the ability to function effectively within

nursing and interprofessional teams, fostering open communication, mutual respect,

and shared decision-making to achieve quality patient care. The patient-respondents

were asked about the teamwork between nurses and other hospital staff who took

care of the patients and if privacy and restful atmosphere is provided, the answers

were as follows:

Patient A ---“Gatarabangan yu nurse, midwife buda IW sa pag atinder sa ako kaya nagigibo

man maski painano yu kaipuhan nin pasyente. Malibok lang minsan buda mainit sa kwarto lalo

na pag kadakor pasyente. Nakakaturog man ako pero pag lado na talaga.” (Though busy, the
 67

nurse, midwife and admin aide work as a team in catering for my needs. There are

times that the environment is not conducive to sleep because of so many patients.

Patient B --- “Magaan ta gaturuwangan sinda pag bako masyadong mapasyente. Iyo man,

komportable ako uya.” (The work becomes easier for them because of teamwork. Yes, I

am comfortable here.)

Patient C --- Oho, gatarabang tabang sila pag atinder sa ako. Pag pigahagnaw ako, yu midwife

pigatamongan ako buda ga hot water bag, tapos yu IW pigabutangan ako ilaw, yu nurse gatao burong.”

Nakakaturog ako magayon ta buko masyadong dakor pasyente ninto.” (Yes, each one has a task

to do. When I have fever and chills, the nursing attendant put blanket on me and apply

hot water bag, the IW provide droplight while the nurse administer medication. The

patients is not that much. I can rest and sleep well during my stay.)

Patient D ---“Iyo tabi, turuwang tuwang sinda kaya madari ang trabaho. May oras lang na

maribok pag dakol and pasyente.” (Yes, they worked as a team and were able to finish their

tasks on time. It’s noisy sometimes when patients are many.)

Patient E ---“Magayon ang iribahan boda koordinasyon ninda. Tahimik uya sa hospital.” (They

have a good rapport and coordination. This hospital is peaceful.)

Hospital discharge describes the point at which inpatient hospital care ends,

with ongoing care transferred to other private, community or domestic environments.

Reflecting this, hospital discharge is not an end point but rather one of multiple

transitions within the patient’s care journey. When asked how clearly and completely

the nurses told them what to do and what to expect, and efforts exerted to provide for

their needs when they left the hospital, the answers were as follows:
 68

Patient A --- “Iso, natawan man ako instruction pag inum nin burong buda iskedyul ko nin

pagbarik para sa checkup. Problema lang ta medyo nahuray ako magluwas ta kadakor kaming ma

discharge. (Yes, I was given instructions on how to take my medicine at home and when

to come back for follow up. The only problem is that my discharge was somewhat

delayed because there were many patients for discharge and the staff on duty is all

alone.)

Patient B --- “May instruction daa na itao bago ako magparibod boda pig remind ako ning mga

bawal.” (As they said, they’re going to give me an instruction before I get to be

discharged and reminded me of things to avoid.)

Patient C ---“Iso tabi, tinarman ako kun ano gigibohon ko pagluwas ko buda kun ano tutumaron

ko burong sa baray. “(Yes, I was properly instructed on what to do after discharge and

the medication I’m going to take.)

Patient D ---“Pigsabihan ako kung pan o ako mainum bulong buda mabalik para sa follow up

checkup pkalipas sarong semana. Medyo naawat lang ako magluwas ta dakol papel na papirmahan.”

(I was instructed how to take my home medications and return for follow up after a

week. There were so many papers to accomplish before discharge so I was able to go

home late.)

Patient E ---“Tig-paliwanag ninda ang mga dapat pati su dai pag na discharge na ako. Gi-pa balik

ninda ako para sa follow-up tsek up.” (They explained clearly the dos and don’ts after

discharge and asked me to come back for checkup.)

Intervention Measures
 69

The nurse-respondents were asked as to what management intervention

measures does the management recommend to address the negative effects on the

delivery of quality nursing care in the hospital. The following were the answers:

Nurse A---“Dapat mag create yan provincial government nin plantilla positions for nurses para ma

attract mag apply yan nurses sa mga hospitals boda magdagdag supply nin mga burong boda gamit ta

sado man yun sa nakadagdag sa stress nin mga nurses pag mi na nagagamit tapos tambak yan

pasyente.” (They should offer more plantilla positions for nurses to attract nurse

applicants and focus attention on supplies and medicines availability which also

hampers the delivery of quality nursing care.

Nurse B---“Meeting tungkol sa mga problema ng hospital boda kung pano mapapadari trabaho.

Gapa survey din sinda.”(Regular management committee meetings addressing concerns

of the employees and enhancement of the healthcare service system. Patient

satisfaction surveys.)

Nurse C---“ Paggibo nin paagi para mapagayon yan sistema nin panggogobyerno. Pag kuntentado

yan gatrabaho, natural, yan pigatrabahuhan, kuntentado man.” (Creation of a positive work

environment where policies, procedures, systems and standards fulfill institutional

goals and achieve personal and professional satisfaction and growth of employees in

the workplace.)

Nurse D---“Dagdagan ang mga job order nurses” (Hiring more job order nurses).

Nurse E---“Magkahang nin mga bakanteng posisyon para sa nurses para mapunuan ang

pangangaipo nin mga ospital.” (Placing job vacancies enough to meet the needs of the

hospital.)
70
 71

DISCUSSION

The interpretation of results and the implications of the findings are discussed

in this part. Discussion still follows the arrangement of the sub-problems.

Characteristics of the Hospitals

As found out during the hospital visits by the researcher, the nurse-patient ratio

of each of the five hospitals was revealed as follows. It is shown that two hospitals fell

within the required ratio of 1:12 by A.O. 70-A s. 2002 on the “Revised Rules and

Regulations Governing the Registration, Licensure and Operation of Hospitals and

Other Health Facilities in the Philippines. These are Hospital E and Hospital C.

The remaining three hospitals had nurse-patient ratios observed to be way

above the prescribed one. (a) Hospital A was reported to have a 1:21-25 nurse-patient

ratio, which almost doubled the standard; (b) Hospital D also registered a much higher

nurse-patient-ratio at 1:16-20; and (c) Hospital B still exceeded the standard with a ratio

of 1:11-15.

Cross-checking the data of nurse-patient ratio with data on number of patients

for the month of May, it can be gleaned that the number of patients admitted explains

the high nurse-patient ratio, as expected. Hospital A had a total admittance of 239

patients in May 2018, thus, the nurse-patient-ratio was 1:21-25. Likewise, Hospital D

had monthly total admittance of 158 during the same period, thus, the nurse-patient

ratio was 1:16-20. Hospital B had 139 total monthly admittance, thus, the nurse-patient

ratio was 1:11-15.

 72

Nursing Functions

Performance of nursing functions is influenced by many factors, nurse-patient

ratio might be one of them. This discussion attempts to determine this.

The nurse-patient ratio of Hospital A, it must be recalled, was 1:21-25 and

Hospital D was 1:16-20, respectively. It appears, then, that the nurses of Hospital A

and Hospital D could not function as highly as the nurses from the other hospitals due

to the very high number of patients the nurses attended to.

The above analysis implies that the performance of nursing functions in hospital

is largely affected by the nurse-patient ratio. Understaffing of nurses then adversely

affects the implementation of nursing functions. There were related studies reviewed

by the researcher which attest to these findings.

A related study in the United States tackled this issue. American Federation of

Teachers (AFT) Healthcare commissioned Peter D. Hart Research Associates, Inc., to

conduct a study among hospital nurses who currently provide direct patient care to

examine their perspectives on nurse staffing levels in hospitals. Specifically, the study

was designed to measure average patient-to-nurse staffing ratios among hospital nurses

and to examine the extent to which hospital nurses perceive problems related to

understaffing in their hospitals. Findings from the study have shown that higher

patient-to-nurse staffing ratios are associated with higher mortality rates and greater

incidence of medical complications and errors, lower job satisfaction, and more

burnout among nurses (Peter D. Hart Research Associates, 2013).

 73

Moreover, Kane, R.L., et al., (2017) conducted a study that intended to assess

how nurse to patient ratios and nurse work hours were associated with patient

outcomes in acute care hospitals, factors that influence nurse staffing policies, and

nurse staffing strategies that improved patient outcomes. Higher registered nurse

staffing was associated with less hospital-related mortality, failure to rescue, cardiac

arrest, hospital acquired pneumonia, and other adverse events. The effect of increased

registered nurse staffing on patients safety was strong and consistent in intensive care

units and in surgical patients. Greater registered nurse hours spent on direct patient

care were associated with decreased risk of hospital-related death and shorter lengths

of stay.

Aiken, L.H.. et al., (2012) reported on findings from a comprehensive study of

168 hospitals and clarifies the impact of nurse staffing levels on patient outcomes and

factors that influence nurse retention. Specifically, they examined whether risk-adjusted

surgical mortality and rates of failure-to-rescue (deaths in surgical patients who develop

serious complications) are lower in hospitals where nurses carry smaller patient loads.

The findings offer insights into how more generous registered nurse staffing might

affect patient outcomes and inform current debates in many states regarding the merits

of legislative actions to influence staffing levels. Registered nurses constitute an

around-the-clock surveillance system in hospitals for early detection and prompt

intervention when patients’ conditions deteriorate. The effectiveness of nurse

surveillance is influenced by the number of registered nurses available to assess patients

 74

on an ongoing basis. Thus, it is not surprising that we found nurse staffing ratios to be

important in explaining variation in hospital mortality.

Effects of Nurse-Patient Ratio on the Delivery of Nursing Care

The nurses from the three hospitals with nurse-patient ratio way above the

standard of 1:12 ratio, consistently felt that the workload in their hospitals was stressful.

As time passed by, the paper work has become voluminous adding to the overload in

the wards.

Nurse A, which had the highest overload with a nurse-patient ratio of 1:21-25,

strongly felt that “The work keeps getting harder as the years go by. Given the scarcity in nursing

staff, the workload especially the paper works were increased. The number of patients are 2-3 times

bigger than the ideal nurse-patient ratio of 1:12. So all in all, very stressful.” Nurse B, with a

nurse-patient ratio of 1:11-15, also declared that “(Our hospital is a 25-bed capacity

hospital that caters hemodialysis unit and mental health (acute psychiatric unit).” These

additional services have made the nurse’s job much more stressful due to the many

patients they cater to.

Due to such excess workload, the hospital management seemingly made

adjustments, especially in the assignments of the nurses. Nurse A further claimed that

“Most of the time, yes I have. But after office hours and during weekends and holidays, we have to do

the job all alone. From ER, to all wards, and to DR due to understaffing. We practice primary

nursing.” Nurse E stated that “None, we practice primary nursing.” Meanwhile, Nurse D,

declared that “Yes, we practice functional nursing.”

 75

The above findings showed that due to overloading of nurses, the hospital

management had to adopt the buddy system wherein a nurse-on-duty is assisted by

another nurse to perform all the functions by themselves. In another case, the nurse

buddy was assigned but doing different work from the nurse-on-duty.

Being the lone nurse on duty can make things so stressful and tiresome for the

nurse. Nurse B stated that “For almost 20 years, I have been doing solo duty with 15 patients

in average.” Nurse A had to endure the most, “Yes, with 35 patients! In such situation, the

nurse is not able to perform the needed nursing functions as the same respondent

claimed, “No, there’s too many patients to attend to, no more nurse-patient interactions at all; just

give medicine or follow up/change IVF if the patients or watchers have no other concerns. Workload

is too much to complete in an 8-hour shift.”

Certain coping mechanisms were adopted by the nurses when they experienced

being the lone nurse-on-duty. The most dramatic was the experience of Nurse D, with

a nurse-patient ratio of 1:16-20, “Yes, teamwork and cooperation – involving nursing assistant

and patient participation in the care process, you have to, no choice. Time management – plan care/

prioritize. Commitment and dedication.”

To further describe the challenge placed on the hospitals due to the nurse-

patient ratio, the respondents were asked whether this requirement on nurse staffing

has been met. Nurse A stressed that “No, there’s no job vacancies enough to meet the ideal

ratio. We have provincial-funded job order nurse who does the job equivalent to ours but receives wages

half our salary, thus, poor commitment and job dissatisfaction is the problem.” Likewise, Nurse C
 76

claimed, “No. Understaff, due to budget deficit for hiring new nurses, and wages is not competitive

for nurse’s retention in the workplace.”

The feeling of Nurse B was different, however. “Yes, it is met in our hospital most

of the time because we only cater minor cases and send critical ones in a tertiary hospital right away,”

the respondent claimed.

It is worth reiterating here the responses of the nurses when asked about the

effects of the low number of nurses relative to the patients in the hospital. Nurse D

said that shortage of nurse caused “Lessened nurse-patient interaction due to work overload.”

Nurse E said, “We cannot meet the standard quality of service due to understaffing.” Nurse A

stressed that “How we deliver care to our patients directly affect the hospital –.Generally, all are

affected. Nurses experienced burnouts, feeling of guilt for being not able to provide ideal patient care,

lapses, medication errors. Patient’s hospital stay is prolonged, no nurse-patient interaction at times

leading to lack of complete physical assessment and poor nursing care. Finally, Nurse C stated

that, “Unhealthy work environments negatively affect the performance of nurses, patient care outcomes

and patient safety, and also decrease in nursing workforce.

Generally, the findings showed that not all of the hospitals could satisfy the

standard nurse-patient ratio and this situation caused the nurses not being able to

render adequately the needed nursing care by the patients. To validate and augment

the findings, the patients were also interviewed and the findings were somewhat more

favorable than the insights contributed by the nurses.

The related literature found similar findings as this study. The nurse-to-patient

ratio is only one aspect of the relationship between nursing workload and patient safety.
 77

Overall nursing workload is likely linked to patient outcomes as well. A sophisticated

2011 study showed that increased patient turnover was also associated with increased

mortality risk, even when overall nurse staffing was considered adequate. Determining

adequate nurse staffing is a very complex process that changes on a shift-by-shift basis,

and requires close coordination between management and nursing based on patient

acuity and turnover, availability of support staff and skill mix, and many other factors.

The causal relationship between nurse-to-patient ratios and patient outcomes

likely is accounted for by both increased workload and increased stress and risk of

burnout for nurses. Missed nursing care—a type of error of omission in which required

care elements are not completed—is relatively common on inpatient wards. In one

British study, missed nursing care episodes were strongly associated with a higher

numbers of patients per nurse. Burnout among clinicians (both nurses and physicians)

has consistently been linked to patient safety risks, and some studies show that higher

numbers of patients per nurse is correlated with increased risk of burnout among

nurses (SupportSolutions UK 2018).

The high-intensity nature of nurses' work means that nurses themselves are at

risk of committing errors while providing routine care. Human factors engineering

principles hold that when an individual is attempting a complex task, such as

administering medications to a hospitalized patient, the work environment should be

as conducive as possible for carrying out the task. However, operational failures such

as interruptions or equipment failures may interfere with nurses' ability to perform such

tasks; several studies have shown that interruptions are virtually a routine part of nurses'
 78

jobs. These interruptions have been tied to an increased risk of errors, particularly

medication administration errors. While some interruptions are likely important for

patient care, the link between interruptions and errors is one example of how

deficiencies in the day-to-day work environment for nurses is directly linked to patient

safety (Agency for Healthcare Research and Quality, 2014).

Longer shifts and working overtime have also been linked to increased risk of

error, including in one high-profile case where an error committed by a nurse working

a double shift resulted in the nurse being criminally prosecuted. Nurses who commit

errors are at risk of becoming second victims of the error, a well-documented

phenomenon that is associated with an increased risk of self-reported error and leaving

the nursing profession. In their daily work, nurses are also frequently exposed to

disruptive or unprofessional behavior by physicians and other health care personnel,

and such exposure has been demonstrated to be a key factor in nursing burnout and in

nurses leaving their job or the profession entirely.

The patients were interviewed to determine the performance of the nurses given the

nurse-patient ratio in the respective hospitals.

Hinno, S. et al., (2012) investigated the relationships between nursing activities,

nurse staffing and adverse patient outcomes in hospital settings as perceived by

registered nurses in Finland and the Netherlands and to compare the results obtained

in the two countries. It was shown that the patient-to-nurse ratio was on average 8·74:1

and did not vary significantly between the countries. However, there were fewer

registered nurses and significantly more licensed practical nurses among the Dutch
 79

hospital staff than the Finnish staff. In addition, Finnish nurses performed non-nursing

and administrative activities more frequently than the Dutch nurses and reported more

dissatisfaction with the availability of support services. Frequencies of patient falls were

related to the patient-to-nurse ratio in both countries. Finnish participants reported the

occurrence of adverse patient outcomes more frequently. It was concluded that

significant associations were found between nurse staffing and adverse patient

outcomes in hospital settings. Compared with the Netherlands, in Finland, nurses

appear to have higher workloads, there are higher patient-to-nurse ratios, and these

adverse staffing conditions are associated with higher rates of adverse patient outcomes.

Liu LF(1), et al., (2012) conducted a study designed to gain insight into the

workload of nurses employed at medical institutions and to determine the relationship

between nurse workload and nurse-sensitive patient safety outcome indicators. The

study showed that nurse overtime working hours were positively associated with the

following nurse-sensitive patient safety outcome indicators: patient falls,

decubitus/pressure ulcers, near errors in medication, medication errors, unplanned

extubation, hospital-acquired pneumonia, and hospital-acquired urinary tract infections;

risks of patient falls, decubitus/pressure ulcers, unplanned extubation, hospital-

acquired pneumonia, and hospital-acquired urinary tract infections significantly

increased when the patient-nurse ratio exceeded 7:1. Thus, nurse workforce and nurse-

sensitive patient outcome indicators are positively correlated. The results of this study

will help professional nursing groups define suitable nursing workforce standards for

medical institutions.
 80

Intervention Measures

The intervention measures recommended by the nurse-respondents to alleviate

the effects of nurse-patient ratio on the delivery of nursing services were composed of

the following.

“Hiring more job order nurses.” Augmentation of nurses in the hospitals

where nurse-patient ratios far exceed the set-standard needs to be implemented so as

to allow nurse to deliver the proper nursing care to patients. Most possible is the hiring

of job order nurses who can serve as nursing attendants to nursing staff. The needed

compensation is lesser than regular nurses, thus, will not be a burden to the

management.

Otherwise, the problems associated with lack of nurses in hospitals will

continue. Ceneta, S.B. (2009) conducted the study on “Patient-Nurse Staffing Ratio in

Tabaco City Hospitals: Its Impact to Nurses’ Job Satisfaction and Burnout.

Conclusions were: 1) The internationally accepted standard of 1:3 patient-nurse staffing

ratio is not observed in the hospitals covered by this study, for nurses are required to

handle more than 3 to 10 patients in the six hospital areas or wards. 2) The nurses' level

of job satisfaction is slight or low, white only very few nurses are not burnout, implying

that handling many patients in excess of the recommended patient-nurse staffing ratio

has adversely lowered their job satisfaction, while the number of nurses who suffer

from burnout is much higher than those who are not burnout. 3) Despite tie reported

level of fob satisfaction and perceived burnout, relationship exists between the nurses'

job satisfaction and perceived burnout and the patient-nurse staffing ratio, which
 81

means that the nurses’ stress tolerance has prevailed over the difficult working

condition in their hospital.

“Providing enough job vacancies to meet the needs of the hospital .”

“Management should offer more plantilla positions for nurses to attract nurse

applicants.” For more assurance of long-term benefits to patients through the

employment of more nurses on regular employment, the affected hospitals should

employ more nurses. Otherwise, should the current nurse shortage continue, the ill

effects brought about Maass, K. (2017) declared that increased nurse-to-patient ratios

are associated negatively with increased costs and positively with improved patient care

and reduced nurse burnout rates. Thus, it is critical from a cost, patient safety, and

nurse satisfaction perspective that nurses be utilized efficiently and effectively. To

address this, we propose a stochastic programming formulation for nurse staffing that

accounts for variability in the patient census and nurse absenteeism, day-to-day

correlations among the patient census levels, and costs associated with three different

classes of nursing personnel: unit, pool, and temporary nurses. The decisions to be

made include: how many unit nurses to employ, how large a pool of cross-trained

nurses to maintain, how to allocate the pool nurses on a daily basis, and how many

temporary nurses to utilize daily.

“Focus attention on supplies and medicines availability which also

hampers the delivery of quality nursing care.” Being able to provide for the needed

supplies and medicines assures the nurses to deliver the needed care by the patients.
 82

Hence, management should give more effort to making it possible that needs are

provided for.

Parumog, J.A.B. (2011) made a study that aimed to determine the medication

administration practices of nurses at Bicol Medical Center. The conclusions gathered

for the findings of the study were the following: Majority of the respondents were

young adults belonging to the age bracket of 18-35 years; female, nurses under Specialty

Employment Program, with 1-5 years of experience and attained 1-24 hours of related

trainings. Data also revealed that the medication administration practices along the

different principles were always practiced. Findings showed that the medication

administration practices under the principle of right client had significant differences

along the principles of right dose, right time and right route and vice versa.

Subsequently, medication administration practices under the principle of right drug had

significant differences along the principles of right dose, right time and right route and

vice versa. Furthermore, right documentation had also significant differences along

principles of right dose, right time and right route and vice versa. Generally, all the

given problems nurses' experienced in medication administration practices.

“Creation of a positive work environment where policies, procedures,

systems and standards fulfill institutional goals and achieve personal and

professional satisfaction and growth of employees in the workplace .” Another

effective way of improving the performance of nurses in their jobs is to improve also

the work environment. The work environment influences much the physical and
 83

psychological readiness of nurses to perform well. These are dependent on a healthy

work environment.

Verulava, T., et al., (2018) made a study to measure the work environment

characteristics, job satisfaction and to evaluate the association between these

variables. The study showed that the nurse shortage is caused by a variety of reasons,

including the inability of the health care system to keep nurses in a workplace. Due to

the economic situation, nurses' annual salary is very low. The hospitals are trying to

reduce the number of nurses or not to hire additional nurses due to economic reasons.

Nurses have less will to work with the existing working conditions. Policy makers

should address many issues: improving recruitment, retention and return in order to

keep or increase already few number of nurses. The development of programs to

improve the nurse practice environment, especially staffing and resources, could

improve nurse retention and thereby slow down the nursing shortage. Yamson, M.R.R..

(2016) made a study entitled “Work Environment and Job Satisfaction of Nurses in a

Level Three Hospital in Naga City.” Findings revealed that (1) Majority of the nurses

were young adult, 21 to 30 years old, female, single, had bachelors degree in nursing,

more than half were from general ward, nearly half had been in service for less than a

year to 2 years, almost all on regular status, and mostly had related trainings attended.

(2) Nurses' work environment in terms of: nursing leadership, ability and support,

participation in the hospital affairs/policies, collegial nurse-physician relationships,

adequate staffing and resources-agree, nursing foundations were moderately favorable.

(3) Nurses in the Level Three Hospital in Naga City were moderately satisfied. (4)There
 84

were no significant relationship between job satisfaction and the nurses' age, sex,

marital status, area of assignment, of work experience but there was a significant

relationship in terms of related trainings attended and the level of satisfaction. There

were no variations in terms of educational level and employment status to the level of

satisfaction. The work environment has a significant relationship with the level of

satisfaction. (5) A proposed intervention plan is presented based on the findings of the

study.

“Regular management committee meetings addressing concerns of the

employees and enhancement of the healthcare service system.” Health care

leaders make decisions and implement activities affecting nurses’ performance on the

job. Management should meet frequently to tackle the problems of nurses and provide

solutions. Nurse-patient ratios should be discussed by managers so as to determine or

identify what needs to be done to tackle the situation.

Chapman, S., et al., (2009) conducted a study to present an analysis of qualitative

data from interviews with healthcare leaders about the impact of nurse staffing ratios.

Twenty hospitals (including public, not-for-profit, and for-profit institutions)

representing major geographic regions of California were approached. Hospital leaders

do not believe that ratios have had an impact on patient quality of care. Findings related

to nurse satisfaction were mixed. Increased RN staffing improved satisfaction with

patient workload, but dissatisfaction with issues of decision-making control (e.g.,

decisions on when best to take a meal break) were taken out of the nurse's hands to
 85

meet ratio requirements. Further research should continue to monitor patient

outcomes as other states consider similar ratio regulations.

“Conduct patient satisfaction surveys.” Getting the true picture of the state

of nursing services in the hospitals can be best done by surveying the views and

perceptions of the patients. By so doing, management can effectively address the need

to enhance nursing care in their hospitals.

Senarath, J. et al., (2013) made a study entitled: "Patient satisfaction with

nursing care and related hospital services at the National Hospital of Sri Lanka" The

study aimed to assess patient satisfaction with nursing care and related hospital services,

and association between satisfaction and patient characteristics at the National Hospital

of Sri Lanka (NHSL). The authors implied that: “Quality can be improved by assuring

comfort, cleanliness, sanitary facilities in wards, and provision of general and

personalized instructions. Nursing staff should understand patient characteristics and

their expectations when providing care.”

Aries, M.T. (2013) conducted an assessment of “Nurse Performance and

Patient Satisfaction on the Care Rendered at Immaculate Heart of Mary Hospital, Inc.,

Rawis, Virac, Catanduanes.” Conclusions were: 1) Most of the staff nurses and the lone

supervisor are in their young adulthood while patients are in their middle age; majority

are females both staff nurses and patients. Most of the staff nurses served for 3-4 years

while most of the patients stayed in the hospital 2-3 days. 2) The performance level of

the staff nurses along the four areas of nursing core competencies as perceived by

respondents is very satisfactory. 3) Respondents rating on patient satisfaction are

 86

outstanding. 4) There is no significant relationship between the assessment of the

respondents on the performance level of staff nurses when their patient care, enabling,

enhancing, and empowering competencies are considered and the patent satisfaction

on the care rendered. 5) The performance of the nurses can be further improved if the

proposed plan will be adopted and implemented in the hospital.

Conclusion
The Conclusion: Nursinis d
The purpose of this study is to determine the implementation of DOH Circular on Nurse-Patient

Ratio and its effects on the delivery of nursing care in the five district hospitals in Catanduanes.

Based on the findings, the following conclusions are drawn:

Two hospitals in the study fell within the required ratio of 1:12 by A.O. 70-A s.

2002 on the “Revised Rules and Regulations Governing the Registration, Licensure

and Operation of Hospitals and Other Health Facilities in the Philippines. The

remaining three hospitals had nurse-patient ratios observed to be way above the

prescribed one.

The findings imply that the performance of nursing functions in hospital is

largely affected by the nurse-patient ratio. Understaffing of nurses then adversely

affects the implementation of nursing functions.

The intervention measures recommended by the nurse-respondents to alleviate

the effects of nurse-patient ratio on the delivery of nursing services were mostly to

address understaffing, enhancing work environment, management actions, and

augmentation of resources and supplies.

 87

Recommendations

According to the authors of one study: “The implications of doing nothing to

improve nurse staffing in low staffed hospitals are that a large number of patients will

suffer avoidable adverse outcomes and patients will continue to incur higher costs than

are necessary.”

Thus, the following are the additional recommendations by the nurse researcher

to address the : (1) Appraisal of nurses on their performance should be regularly

monitored and acknowledged by the Chief Nurse and recommend to the Chief of

Hospital to provide incentives to keep them inspired and become productive; (2)

Continuous updating on quality nursing care may facilitate the maintenance of a strong

and positive commitments among the staff and job-order nurses thus gain respect and

admiration of their clients and supervisors; (3) Harmonious relationship through

interpersonal relationship program be institutionalized for an improved

communication and team spirit between and among staff nurses and their supervisors;

and (4) Finally, the national government and the Department of Health, through the

policymakers, should monitor developments in nurse staffing issues closely in order to

determine if additional legislative measures are needed to increase nursing supply and

reduce adverse patient outcomes, thereby ensuring delivery of quality healthcare.

 88

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