The Benefits of Nurse-to-Patient Staffing Ratio Laws and Regulations

Alexa Davidson, MSN, RN
Updated March 23, 2023
    Mandated staffing ratios are a proven way to ensure patients get the care they need. Find out how nurse-to-patient ratios can improve healthcare.
    Featured ImageCredit: FS Productions / Getty Images
    • For every patient added to a nurse’s workload, the risk of patient harm increases significantly.
    • Mandated nurse-to-patient ratios are a proven way to save lives.
    • California and Massachusetts are the only states with nurse-to-patient ratio laws.

    Most healthcare facilities use staffing guidelines to decide a nurse’s assignment on a given shift. They may follow hospital-specific staffing ratios to ensure nurses have safe workloads. However, current staffing shortages are pushing nurse-to-patient ratios to the limit.

    Could laws and regulations prevent nursing workloads from getting out of control? Learn how nurse staffing ratio laws and regulations can protect patients and nurses.

    Why There’s a Push to Mandate Nurse Staffing

    The nursing shortage has increased since COVID-19. Nurses have left the bedside because of nurse burnout, fatigue, and unsafe working conditions. This postpandemic nursing shortage creates heavier workloads for nurses.

    Nurses remaining at the bedside are assigned higher volumes of sicker patients. As managers and charge nurses make patient assignments, they’re placed in a difficult position: How can one divide up so many patients among so few nurses?

    Safe staffing mandates are the most effective way to hold hospitals accountable.

    Current Safe Patient Ratio Laws

    Currently, two states have laws concerning safe patient ratios. In 2014, Massachusetts enacted a law regulating how many patients a nurse can care for in the intensive care unit (ICU).

    Nurses in Massachusetts should only care for one patient in the ICU. If they must accept a second patient, the nurse should use clinical judgment to determine if the assignment is safe. Nurses must complete an acuity tool to evaluate patients’ stability.

    In 2004, California passed a law for numerical nurse staffing ratios. The law defines how many patients a nurse can care for in acute care, psychiatric, and specialty hospitals.

    Here’s a guideline for standard nurse-to-patient ratios in California:

    • 1:2 ICU
    • 1:3 Step down
    • 1:4 Emergency room
    • 1:5 Medical-surgical

    Since incorporating mandated nurse-to-patient ratios, California has seen improved patient outcomes and staff retention.

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    What Nurse Staffing Laws and Regulations Mean for Patients

    The ultimate goal of staffing ratios is to ensure patients get the care they deserve. When there are limits to the number of patients in a nursing workload, nurses can spend more quality time with patients. Nurses can assess status changes and attend to patients’ needs better.

    Improved Quality of Care

    Linda Aiken, Ph.D., RN, conducted a study examining the correlation between nurse-to-patient ratios and patient outcomes.

    In this study, patients in “well nurse resourced hospitals” had better outcomes. With adequate nurse staffing, patients had:

    • Shorter hospital stays
    • Less hospital-acquired infections
    • Fewer ICU admissions
    • Fewer deaths

    The study found that adequate staffing ratios led to a better quality of care.

    More Affordable Healthcare

    The Centers for Medicare and Medicaid Services (CMS) uses a value-based approach to reimburse hospitals. This incentivizes hospitals to meet quality markers to receive reimbursements.

    One example is the Hospital Readmissions Reduction Program (HRRP). Hospitals will not be reimbursed for a patient’s stay if they are readmitted to the hospital within 30 days of discharge.

    Nurses do not have time to provide thorough discharge teaching during staffing shortages. Patients with complex health needs may be sent home with several medications and care instructions they don’t fully understand.

    Aiken’s study found that readmission rates increased significantly for every extra patient added to a nurse’s workload. Patients admitted for acute myocardial infarction, heart failure, and pneumonia had readmission rates of 6-9% due to short staffing.

    With mandated staffing ratios, nurses will have more one-on-one time with their patients. Patients will have more opportunities to ask questions about their care to avoid readmission.

    Safe staffing ratios allow hospitals to be compliant with programs like HRRP. This adds funds to hospital budgets and may lower healthcare costs.

    Greater Transparency

    Patients deserve to know the nurse staffing ratios at hospitals. This may help guide their decision on where to go for a planned hospital stay. Transparent staffing ratios reassure patients that their health is safe in a hospital’s care.

    Until staffing ratios are mandated in each state, hospitals can be transparent with patients by

    reporting hospital staffing ratios to the public. States that mandate public reporting of hospital staffing include:

    • Illinois
    • New Jersey
    • New York
    • Rhode Island
    • Vermont

    Aiken says the federal government has a responsibility to address nurse-to-patient ratios. She suggests, at a minimum, hospitals should report their ratios to the CMS in exchange for incentives like reimbursements.

    What Nurse Staffing Laws and Regulations Mean for Nurses

    Healthcare leaders are constantly evaluating strategies to address the nursing shortage. To take a root-cause approach, they should consider creating mandated staffing ratios. This can help retain nurses by creating a safer work environment.

    Safer Working Conditions

    In the aftermath of the pandemic, patients come to the hospital with increasingly complex needs. With current staffing shortages, nurses are assigned higher volumes of patients per assignment.

    These two factors cause a major challenge for nurses. By limiting the number of patients a nurse can oversee, there is less margin for error for nurses.

    Nurses will have more opportunities to focus on the complex needs of a typical patient load.

    Higher Pay

    Staffing ratios create a safer workplace, which leads to nurse retention. National Nurses United found that staff turnover is significantly lower in states with mandated ratios than in states without regulation.

    Staff turnover is costly for healthcare facilities. Many hospitals use travel nurses during staffing shortages, which is also expensive.

    Hospitals will save money on training new or temporary nurses by using strategies to promote staff retention. This may open up funds to increase wages for staff nurses.

    Greater Transparency

    Healthcare leaders who commit to safe staffing ratios promise to value nurses. This is leadership’s way of saying they support nurses by giving them the tools to do their job. They’re telling staff that they’re committed to patient safety.

    Better Work-Life Balance

    Would you like to work less overtime? With mandatory staffing ratios, managers will be accountable for adequately staffing your unit each shift. You’ll be able to enjoy your days off without being pressured to come in to cover short shifts.

    How to Advocate for Safe Nurse Staffing in Your State

    Lawmakers are currently advocating for safe patient ratios. In May 2021, Illinois Representative Janice Schakowsky introduced a safe staffing bill to Congress.

    The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act would require hospitals to limit the number of patients a nurse cares for on a given shift.

    Nurses would be legally protected to refuse unsafe assignments — and hospitals could be fined for breaking ratios. The bill has not moved past its introduction in 2021.

    You can bring attention to nurse staffing issues in your state by contacting your local constituents.

    Here are a few other organizations you can get involved with:

    Until federal mandates are placed for nurse-to-patient ratios, you can advocate for safe staffing by joining staffing committees within your hospital. This is a productive way for nurses to have a say in patient workloads within your healthcare setting.