Most patients can confirm that nurses play a pivotal part in the provision of quality patient healthcare, both in the United States and around the world. Any nurse, however, can tell you that a good nurse faces innumerable and exceptional challenges when it comes to delivering the kind of care that patients desire and expect.
High nurse-to-patient ratios are only one of these challenges. Discover more about nurse-to-patient ratios, why they are important, and how nurses can advocate for appropriate nurse-patient ratio laws.
Understanding Nurse-to-Patient Ratio Laws
Often driven by restrictions imposed by understaffing in healthcare settings, high nurse-to-patient ratios mean that the average nurse is responsible for a relatively high number of patients. This can cause countless problems for nurses, patients, and healthcare organizations alike.
Thankfully, some state governments have enacted border-to-border nurse-to-patient ratio laws that address the range of issues associated with high nurse-to-patient ratios. Read on to gain a better understanding of nurse-to-patient ratio laws, their purpose, and how they function. A number of U.S. states have implemented these laws with subtle variations in their specific legal requirements.
What Are Nurse-to-Patient Ratio Laws?
Nurse-to-patient ratio laws are regulations that mandate a minimum number of nurses for a certain number of patients in specific healthcare settings. These laws aim to ensure adequate staffing levels in order to provide safe and effective patient care. While there are currently no federal laws that regulate the number of patients that nurses can care for, specific states have passed legislation that stipulates limitations on nurse-to-patient ratios for various nurses who are practicing under various circumstances. The American Nurses Association (ANA) announced its official support of minimum nurse-to-patient ratio mandates in 2023.
States With Nurse-to-Patient Ratio Laws
The following states have implemented laws that explicitly address nurse-to-patient ratios. Significant variations exist both in the specified ratios and requirements across these different states:
- California – The first state to pass a nurse-to-patient ratio law, California mandated an average medical-surgical (med-surg) nurse-to-patient ratio of 1-to-5 in 2004. California has also mandated a 1-to-1 nurse-to-patient ratio in the operating room and a 1-to-2 nurse-to-patient ratio in labor/delivery and intensive critical care. Furthermore, pediatric patients in California are guaranteed a 1-to-4 nurse-to-patient ratio.
- New York – The state government of New York requires a 1-to-2 nurse-to-patient ratio in all hospital intensive care units (ICUs). In addition, New York requires hospitals to provide on-call coverage for registered nurses (RNs) to ensure that staffing ratios can be maintained when scheduled nurses cannot report to work.
- Oregon – Under Oregon state law, ICUs must maintain ratios of at least 1-to-2 in ICUs and 1-to-5 in med-surg units. Oregon also requires that certified nursing assistants (CNAs) care for no more than seven patients on the day shift and 11 patients on the night shift.
- Massachusetts – This state stipulates a standard 1-to-1 nurse-to-patient ratio in the ICU. Though critical care nurses may be assigned a second patient if standardized acuity tools deem it reasonable, no ICU nurse can be assigned a third patient under state law.
While Connecticut doesn’t explicitly require healthcare providers to adhere to any specific nurse-to-patient ratios, state law mandates that hospitals support nursing staff committees, which actively comment on and advocate for limited patient coverage (among other issues crucial to that state’s nurses).
Four other states — Pennsylvania, Georgia, Maine, and Illinois — currently have active lobbying or bills pending in favor of legislation that establishes firm nurse-to-patient ratio limits or nursing administrative bodies that govern acceptable nurse-to-patient ratio limits.
Why Are Nurse-to-Patient Ratio Laws Important?
In the states that do not have nurse-to-patient ratio laws on the books, officials generally rely on individual healthcare providers to schedule enough nurses on each shift to offer safe and effective care for their patients. Both within state government and without, reasonable people generally agree that ignoring nurse-to-patient ratios is ill-advised, dangerous, and simply not an option. The number of patients assigned to each nurse can have a substantial impact on patient safety, nurse well-being, and the overall quality of healthcare.
For people who have worked in a hospital or even received treatment in one, the impact of nurse-to-patient ratios is generally rather obvious, but numerous peer-reviewed studies have also confirmed the supreme importance of regulating nurse-to-patient ratios.
Improved Patient Safety and Outcomes
Adequate nurse staffing, as mandated by state nurse-to-patient ratio laws, has been linked to reduced patient mortality rates, fewer medical errors, and improved overall patient outcomes in a broad range of categories. Published in the public health journal Medical Care, a 2021 study of hospital nurse staffing legislation in New York revealed that each patient added to a nurse’s workload clearly increased the likelihood of undesirable outcomes, including patient death.
These findings confirmed earlier conclusions described in periodicals such as the Journal of Nursing Administration, which reported surgical mortality rates that were more than 60% higher in poorly staffed hospitals, and the American Journal of Infection Control, which tied each additional patient per nurse with a 12% jump in the risk of dying in the hospital.
After looking at a broad scope of factors and making informed projections, the Medical Care study ultimately concluded that “improving hospital nurse staffing would likely save thousands of lives per year.”
Reduced Nurse Burnout and Improved Job Satisfaction
Reasonable nurse-to-patient ratios benefit nurses as well as patients. In a world that desperately needs more nurses, nurse burnout has become a prevalent problem. Nurse-to-patient ratio laws can help alleviate the daily workload for nurses, which leads to greater job satisfaction and higher job retention rates.
While each nurse can take personal steps to prevent nursing burnout, no amount of self-care can replace a healthy work environment with an appropriate division of work. A 2022 study in the International Journal of Environmental Research and Public Health used extensive surveys to draw a clear line between elevated patient numbers and low nursing morale, concluding that nurses with heavier workloads were substantially less satisfied with their jobs and more likely to leave them.
Enhanced Quality of Care and Patient Satisfaction
Nurses who are happy with their jobs tend to provide better care, and patients who are better cared for tend to report higher levels of satisfaction. Adequate nurse staffing allows nurses to offer their patients increased and more personalized attention. This, in turn, can lead to improved communication, better pain management, and numerous other factors that directly influence overall patient satisfaction.
For example, patients generally feel less satisfied with hospital stays that extend too long. A provider of nurse staffing solutions, Health Carousel lists shorter hospital stays among the many improved healthcare outcomes for hospitals with lower nurse-to-patient ratios.
In fact, patient satisfaction is statistically linked to nurse-to-patient ratios in various ways. A 2018 observational study titled “Patient Satisfaction with Hospital Care and Nurses in England” showed that patients clearly notice and feel the effects of insufficient nurse staffing.
Reduced Hospital Readmissions
There is ample evidence to suggest that appropriate nurse-to-patient ratios contribute to lower hospital readmission rates. After all, sufficient staffing enables nurses to prioritize patient education, providing in-depth instructions regarding hospital discharge and follow-up care. By getting their patients to adhere to recommended medical guidelines at home, nurses can dramatically reduce the likelihood of them requiring a return hospital visit.
As reported in the American Journal of Infection Control, the odds of readmission within 60 days increase by 7% with each patient added to the average nurse’s workload. The scholarly journal Nursing Economic echoed these findings with a study that tied higher staffing levels to significantly lower heart failure hospital returns and readmissions.
Economic Benefits for Healthcare Systems
To remain above specific nurse-to-patient ratio limitations, many healthcare organizations must hire more nurses. Despite the up-front expenses associated with these staffing gains, numerous studies have shown significant potential long-term cost savings for organizations that faithfully adhere to nurse-to-patient ratio laws.
Few things can boost overall hospital expenditure quite like patient complications. When the health conditions of a patient worsen during a hospital stay, costs can quickly escalate out of control. This may become a catastrophic financial problem if the hospital can be considered liable for the complications that a patient experiences.
Nurses with fewer patients are better equipped to provide the kind of attentive care that prevents patient complications. Fewer patient complications, careful patient education, and the overall ability to spend more time with patients can reduce the length of the average hospital stay and keep patients from returning to the hospital.
The cost savings associated with these results are well-established. The 2021 observational study “Patient Outcomes and Cost Savings Associated with Hospital Safe Nurse Staffing Legislation” examined the results of hospital nurse staffing legislation in Illinois — ultimately determining that costs associated with hiring more nurses are offset by savings through shorter hospital stays and fewer hospital readmissions. These final findings echo those of the 2021 Medical Care study on hospitals in New York: “Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.”
Challenges and Controversies Surrounding Nurse-to-Patient Ratio Laws
Although nurse-to-patient ratio laws have significant advantages, there are also challenges and controversies associated with their implementation and enforcement.
Cost and Staffing Implications
We have already outlined how the cost benefits of low nurse-to-patient ratios can offset the expenditures associated with hiring more nurses. However, up-front investments in new hires might be undue for healthcare organizations that are already under significant financial strain. Furthermore, healthcare facilities trying to comply with nurse-to-patient ratio laws may encounter trouble recruiting and retaining enough nurses.
Flexibility and Adaptability Concerns
People have also voiced valid concerns that rigid nurse-to-patient ratios may limit flexibility in staffing decisions and hinder the ability to respond to fluctuations in patient acuity or workload. Potential solutions to these concerns include incorporating flexibility mechanisms into ratio laws and basing ratios on real-life staffing models.
Potential for Unintended Consequences
Any of the above nurse-to-patient ratio regulatory challenges and concerns can lead to negative results — such as increased reliance on unlicensed assistive personnel or the closure of small healthcare facilities that are unable to comply with the law. For this reason, all nurse-to-patient ratio legislation should be subject to ongoing evaluation so adjustments can be made to address any unintended consequences.
What Is the Recommended Average Nurse-Patient Ratio?
While appropriate nurse-to-patient ratios vary depending on the specific nursing department, studies and organizations (from Nurse.com to Trusted Nurse Staffing) generally concur that the maximum nurse-to-patient ratio for the average of all nurse occupations is four patients for every nurse.
What Is the Average Nurse-Patient Ratio in the United States?
Because different nursing departments in different healthcare facilities can have radically different nurse-to-patient ratios, statistics on the average ratio in the United States can be difficult to pinpoint. However, the National Institute of Nursing Research estimates that the average U.S. nurse-to-patient ratio ranges from 4.3 to 10.5 patients per nurse.
Nurse-Patient Ratio Advocacy and Endorsement
Major nursing organizations, including the American Nurses Association (ANA), the American Association for Critical-Care Nurses (AACN), and the U.S. Department of Health and Human Services (HHS), have strongly endorsed a federal mandate for nurse-patient ratios. Nursing organizations recognize that safe staffing levels are critical for ensuring patient safety, improving care, and reducing burnout. The goal of advocating for standardized nurse-patient ratios is to create a healthier work environment and better care experiences for both nurses and patients alike. The ANA is actively pushing for federal legislation to make the nurse-patient ratios mandatory.
Nurses and healthcare professionals who are interested in advocating for safe staffing have a few ways to get involved. Joining professional organizations such as the ANA or AACN provides access to resources and updates on legislative efforts. Additionally, nurses can participate in advocacy by contacting their state and federal representatives or attending legislative days organized by nursing groups. The ANA also have online advocacy platforms for nurses to send letters to lawmakers in support of the nurse-patient ratios legislation. For more information on the legislation and advocacy, visit the ANA’s official advocacy page at ANA Advocacy and help play a role in shaping policy and improving nursing care for the future.
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