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Considerations for nurse-to-patient assignment ratios during the COVID-19 pandemic

Changing how we assign staff may help preserve the health workforce

Nov 15, 2021, By: Crystal McLeod, Candace Collins
A nurse in full protective scrubs leaving over a patient with an oxygen mask.
At the most basic level, a balanced pandemic assignment should ensure rotating distribution of isolation rooms. Designating confirmed and suspected COVID-19 patients to one group of nurses is ideal for infection control, but the increased workload associated with these patients can make such a model unsustainable.

Takeaway messages

  • Nurse-patient assignments are more equitable when workload, versus nurse-to-patient ratio, is accounted for.
  • The COVID-19 pandemic appears to increase the workload of nurses. As such, the influence of COVID-19 should be considered by nursing leadership when creating nursing assignments.
  • There is little literature on nurse-patient assignments, especially during the COVID-19 pandemic. The strategies outlined in this article for assignment creation are merely a stepping stone toward more concrete guidelines.

In the early days of the novel coronavirus disease (COVID-19) pandemic, experts worried how nurses could provide high-quality care in the face of rising acuity and patient volumes. The focus, rightfully, was placed on patients and their safety. In order to optimize staffing, alterations to nursing schedules, shifts and patient assignments were made (Catania et al., 2021; Kluger et al., 2020). Furthermore, some nurses were redeployed to completely new clinical settings to manage staffing inadequacies (Catania et al., 2021; Gao, Jiang, Hu, Li, & Hou, 2020). As a whole, the nursing profession courageously responded to their assignment changes with flexibility, resiliency and a sense of duty (Catania et al., 2021; Schroeder, Norful, Travers, & Aliyu, 2020).

Yet, over a year into the pandemic, there is a need to reassess how nurse-patient assignments are being created. Nursing staff are reporting increasing occupational burnout, trauma and even resignation from their positions in the health-care field (Andrew, 2021; Chen et al., 2021). We can both attest to observing the departure of wonderful, skilled nurses from the nursing profession entirely because of COVID-19 and the difficult sacrifices the pandemic caused them to make.

We argue in this article that the health-care field should not wait to address the exhaustion and hardship of the pandemic among nurses until these resignations grow and instead should think about how nursing assignments are contributing to the problem at hand. Ultimately, without losing sight of patient safety and infection control, this article focuses on creating nurse-patient assignments that consider the toll of COVID-19 and promote preservation of the workforce through workload. A discussion of other assignment-making pandemic considerations and lessons learned is also included.

Workload and nursing assignments

Nurse-patient assignments seek to equitably divide patient care among nurses and have been traditionally assessed in terms of nurse-to-patient ratios (Allen, 2015). As such, a low nurse-to-patient ratio implies that each nurse is caring for more patients than what is typical — for instance, because nursing resources are exceeded — and adverse patient outcomes could result (Allen, 2015). One of the most relevant adverse outcomes that is associated with inequitable staffing, which has occurred during the COVID-19 pandemic, is the spread of hospital-acquired infections, leading to unit outbreaks (Allen, 2015).

However, contemporary research shows that workload is a more accurate means of assessing nurse-patient assignments (Acar & Butt, 2016). Workload is defined as the total work a nurse must complete in an allotted time frame per patient (Acar & Butt, 2016). Factors that affect nursing workload include patient acuity, nurse competence, continuity of care, nursing interventions, environment and patient characteristics (Acar & Butt, 2016; Allen, 2015). Workload is a broad and complex concept to quantify, but specific examples may include the frequency of medication administration and patient agitation (Allen, 2015).

Currently, there is a paucity of literature examining how nurse-patient assignments affect organizational outcomes (Acar & Butt, 2016; Allen, 2015). What is known is that equitable assignments determined through a measure of workload can improve nursing satisfaction and retention (Allen, 2015). Likewise, researchers suspect that the downstream effects of fair nurse-patient assignments could extend to reduced lengths of stay, improved patient outcomes, higher patient satisfaction and overall lower health-care costs (Acar & Butt, 2016; Allen, 2015).

When less experienced nurses are aggregated in one area, there can be a loss of policy compliance and increased performance-related stress.

Does COVID-19 increase nursing workload?

The 1918 influenza pandemic saw an abrupt decline in nurse-to-patient ratios, especially among community nurses (Keeling, 2010). In some cases, nurses saw a tripling of patients under their care. A similar effect was anticipated during the COVID-19 pandemic but has been less reported on to date. Instead, an emphasis has been placed on how COVID-19 has disrupted nurse-patient assignments through workload.

Arguably, the most pronounced effect of COVID-19 on nursing workload has been in isolation settings, where confirmed and suspected patients under infection control procedures receive treatment (Gao et al., 2020). Nurses report the care of isolation patients as more demanding due to stringent infection control procedures, a lack of proximity to human resources, uptake of tasks previously assigned to other staff, fear of exposure to COVID-19 and sickness leading to staff shortages (Gao et al., 2020). This research struck a chord with us as we, too, have been required to assess, lift and mobilize COVID-19 patients without the assistance of other health-care professionals, who are unable or reluctant to enter the patient’s room.

Moreover, in nursing settings not directly impacted by the care of COVID-19 patients, workload is felt to have increased through the restructuring of resources. Restructuring may include staff shortages from redeployment, mass training and less experienced nurses caring for acutely ill patients (Catania et al., 2021). Higher rates of mental and physical fatigue, stress, confusion, grief and occupational burnout secondary to the changing workload are thought to further burden nurses contributing to pandemic efforts (Catania et al., 2021; Gao et al., 2020; Schroeder et al., 2020). Consequently, COVID-19 can be reasonably connected to greater work and stress within nurse-patient assignments across various clinical settings.

Assignment creation in a pandemic

There is no true guideline to creating nurse-patient assignments, and the majority of nursing leadership relies on the knowledge of organizational practices to create fair assignments. Assignment creation is also a time-restricted activity, with most nurse leaders reporting approximately 30 minutes to prepare an assignment (Acar & Butt, 2016). Metrics and tools to create electronic assignments have been proposed in the past that introduce new technology to nursing leadership. Yet these tools have been met with mixed reviews, and the process continues to be largely manual (Acar & Butt, 2016). This article does not seek to widely disrupt current practices, offer a new methodology for nurse-patient assignment creation, or ignore the complexity of making an assignment under usual health-care conditions. We argue that the detailed process of creating nurse-patient assignments should continue as normal but with greater attention to COVID-19 and the pandemic’s related effects.

Research on the relationship between COVID-19 and workload is limited. Yet, in recognizing that COVID-19 compounds the challenges of the nurse-patient assignment, the literature has offered a few strategies for nurse leaders. The authors, who have worked clinically during the pandemic and felt the challenges first hand, present these strategies as relevant to their personal experience and professional practices. That being said, unvalidated, these strategies may serve as only an opportunity to reflect and deliberate on future directions in assignment creation for COVID-19 or in future infectious disease outbreaks.

If changes on assignments are going to be made, much of the research reviewed for this article strongly encourages nurse leaders to obtain input from nursing staff before implementing such changes (Gao et al., 2020; Schroeder et al., 2020; Simpson, Whitt, & Berger, 2021).

COVID-19 nurse-patient considerations

Rotation of staff

At the most basic level, a balanced pandemic assignment should ensure rotating distribution of isolation rooms. Designating confirmed and suspected COVID-19 patients to one group of nurses is ideal for infection control, but the increased workload associated with these patients can make such a model unsustainable. In a study of non-COVID-19 patient-care settings, Kluger et al. (2020) found that nurses could safely rotate out of assignments in three-day blocks without increasing infection risk. Understanding what is an acceptable time frame for nurses working in COVID-19 isolation to rotate schedules and assignments in future research would greatly assist in implementing this strategy. Tracking or rotating nurses’ isolation assignments may be delegated as an individual or administrational task depending on the practice setting.


Beyond regularly rotating staff in and out of isolation, there are several other factors that add to the complexity of assignment creation in a pandemic. Lack of personal protective equipment (PPE) and medical accommodations required by some of the nursing staff reduce the pool of potential staff able to care for confirmed or suspected COVID-19 patients (Catania et al., 2020; Gao et al., 2020). However, nursing staff who are not able to care for isolated patients can minimize the workload of colleagues in isolation by taking on staff training, assisting less experienced staff or being assigned more complex non-COVID-19 patients. Everyday nursing interventions that make up a large part of the workload, such as patient admissions, wound dressings and blood product transfusions, are also excellent opportunities for these nursing staff to contribute (Allen, 2015).

Skill mix

A nuanced consideration, perhaps most helpful to organizations with primarily novice staff, is to ensure a skill mix across the patient-care setting. When less experienced nurses are aggregated in one area, there can be a loss of policy compliance and increased performance-related stress (Catania et al., 2021; Gao et al., 2020). Having senior nurses work alongside novice nurses can promote more efficient, safe, high-quality work (Gao et al., 2020). If few senior nurses are available, nursing leadership can improve the assignment by keeping in close contact with these less experienced staff (Gao et al., 2020).

Support staff

Just outside the realm of nurse-patient assignment creation is support staff; their utility can help strengthen sub-optimal assignments. Support staff, like personal support workers, Helping Hands or Pandemic Partners, can be instrumental in reducing nurse workload (Allen, 2015; Simpson et al., 2021). Depending on organizational policies, support staff can help alleviate workload by completing certain tasks and taking on other special assignments (Gao et al., 2020; Simpson et al., 2021). One study noted that support staff were especially helpful during the pandemic by connecting patients with family via iPads, Zoom and FaceTime (Simpson et al., 2021). In our own experiences, Helping Hands nurses during the third wave of the pandemic were invaluable to managing tasks outside the isolation room while primary nurses provided care inside.

Ride the waves, enjoy the reprieves

The waves of illness created by COVID-19 make for organic periods of higher and lower case numbers. It is important for nursing leadership to recognize lower case numbers as an opportunity for reprieve for nursing staff. Allowing time for nurses to participate in mental health, education and social initiatives may improve the quality and delivery of patient care in subsequent waves (Catania et al, 2021; Kluger et al., 2020). Also, clear communication of changes in policy or department procedures should continue to occur between waves as this can leave nurses feeling more prepared as cases begin to rise or fall (Gao et al., 2020; Schroeder et al., 2020). Finally, in the first wave of the COVID-19 pandemic, staff nurses felt solidarity with and appreciation for managers who were involved and readily available to staff as cases rose (Catania et al., 2021). Nurse leaders should exercise flexibility in their own schedules and commitments to uphold this standard for any impending waves of infectious disease.

Designating staff to aerosol-generating medical procedures?

Medical procedures such as tracheal intubation and bronchoscopy have been believed during the COVID-19 pandemic to increase the risk of disease transmission by aerosolizing the virus (Harding, Broom, & Broom, 2020). For nurses, who often assist in these procedures, the risk of inhaling and developing an infection is exacerbated by anxiety and a poor knowledge of clinical guidelines for aerosol-generating medical procedures (AGMPs). To resolve such concerns, the organization we work for has used dedicated staff, often termed the “intubation team,” to conduct AGMPs during the pandemic. These dedicated staff ensure strict compliance with AGMP guidelines and can prevent waste of PPE (Harding et al., 2020). Not much is known of the impact of working on these dedicated AGMP teams, but we would imagine similar assignment and workload considerations need to be given to these staff as to those working in clinical isolation settings.

Lessons learned

As the delta and other variants of COVID-19 continue to spread across Canada, uncertainty remains as to when the pandemic will end and what hospitalization rates can be expected going forward (Aziz, 2021). Resolution of the pandemic, although the best possible outcome, does not mean that infectious disease outbreaks will cease altogether either.

We hope that this article presents a guide to what has been learned from the COVID-19 pandemic about nurse-patient assignments and offers possible solutions to any similar scenario that arises in the future. So much has been learned in the health-care field from this unprecedented time in history, and we only wish to carry such learning forward to strengthen the nursing profession.

Acknowledging the informal nature of assignments, we wished to identify COVID-19 as an important consideration in nurse-patient assignment creation and prompt discussion of how this factor may be accounted for in the future. Strategies proposed for pandemic assignment are only a starting point from the initial literature, and our hope is that a larger conversation can be sparked in the nursing profession. Forthcoming research on nursing workload and infectious disease management should increase our understanding of how this pandemic changed nursing care, well-being, workplace morale and distribution of work. Additionally, nurses sharing how their own experiences and assignments have impacted them throughout the pandemic may provide better insitutional insights to assignment management in the future.


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Crystal McLeod is a registered nurse at London Health Sciences Centre and an independent researcher. Her research interests include pediatric nursing, geographic health disparities and childhood disease.
Candace Collins is an acute care registered nurse and a nurse practitioner student at Western University. She is passionate about nursing education, rural health and spending time with family.