Nurse-to-Patient Staffing Ratios Win Some Hard-Fought Ground

For nearly 2 decades, only one state — California — governed the number of patients assigned to a hospital nurse. Recently, Oregon became the second. Advocates of nurse-to-patient ratios are hopeful other states will follow.

The primary barrier? Hospitals.

Hospital groups and some nurse executives say ratios are a one-size-fits-all response to a dynamic system. They claim that new technologies transforming care delivery make ratios out of step with health system realities. And some hospital leaders argue that ratios would increase costs and threaten patient access.

Even if ratios were a silver bullet, the workforce supply simply isn’t there, they say.

Proponents of ratios say standards are not one-size-fits-all but tailored to units and patient acuity levels. They say staffing ratios could improve hospital recruitment and retention and have been linked to better patient outcomes.

Linda Aiken, PhD, RN, of the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research in Philadelphia, called it shocking that a critical hospital resource remain unregulated: nurses. She cited “tremendous variation” from one health system to the next in how many patients a nurse is assigned, ranging from 1:4 at the best-staffed hospitals to nearly 1:11 at the worst.

Her group showed in a 2002 study that risk of patient death rises 7% with each additional patient a hospital nurse is assigned.

“The evidence is so compelling that it would improve quality of care, it would improve patient satisfaction, and it would even be positive for the bottom lines of hospitals because it would help [hospitals] to avoid a lot of expensive turnover,” Aiken said.

Change Comes Slowly

In 1999, California became the first state to mandate minimum nurse-to-patient staffing requirements in an effort to improve patient safety and working environments. The rules took effect in 2004.

At that time, California’s ratio required at least one licensed nurse — a registered nurse (RN), licensed vocational nurse (LVN), or licensed practical nurse (LPN) — for every six patients on a medical surgical unit. That requirement was soon tightened to at least one licensed nurse for every five patients.

“One of the reasons why California passed ratios 20 years ago is that they had an acute shortage of nurses,” Aiken said, but that shortage ended 2 years after the new law, because nurses were drawn back to hospitals, some added more hours, and nurses from other states came to California.

At that time, similar legislation was being considered in at least 25 other states; but hospitals and other healthcare executives stonewalled those efforts with the exception of staffing requirements for specified units in a handful of states, including Massachusetts and New York.

In August 2023, Oregon Gov. Tina Kotek (D) signed into law a comprehensive “safe staffing” bill that mandated minimum nurse-to-patient staffing requirements across most hospitals for nearly a dozen types of hospital units in the state. The law also charged the Oregon Health Authority with investigating complaints about hospitals that failed to enforce the requirements, according to the Oregon Nurses Association’s (ONA) website.

In addition, the legislation got rid of the hospital “buddy system,” where nurses effectively doubled their own patient load, in order to give a break to another nurse. Hospitals will now have a dedicated nurse to provide those breaks to colleagues, explained Matthew Calzia, BSN, RN, director of Nursing Practice and Professional Development for the ONA, a member of the American Nurses Association (ANA).

The ratios themselves aren’t “a huge jump” from what most hospitals were already doing, he said. “It’s just some adjustments.”

Safe-staffing proponents had to make some concessions around emergency department (ED) ratios, which will be averaged throughout the shift. Those concessions were among “the very hardest pills to swallow” in the legislation and could prove challenging to enforce, Paige Spence, JD, ONA’s director of government relations, said in an email to MedPage Today.

However, she expressed optimism that the bill overall will improve working conditions, strengthen nurse and healthcare worker retention, and ensure patient safety.

“Research shows that better nurse staffing is associated with better patient outcomes, increased patient satisfaction, decreased hospital-acquired conditions, decreased length of stay for patients, decreased chances for patient readmission, decreased patient mortality,” and potentially diminished racial disparities as well, she added.

Most of the ratios take effect in June 2024.

Asked why it was so important to pass ratio policies now, Calzia said hospital turnover rates have risen as high as 30% and even 50% in some critical care units and EDs following the pandemic. While travel nurses provide valuable support, having a permanent team that knows the hospital’s policies and protocols as well as their fellow staff is important.

“It’s hard to explain how when you just don’t have a cohesive team … how impactful that is on individuals providing the care,” Calzia said. “Our hope and our expectation is that this law will help the work environment in hospitals … so that the turnover rates get better and recruitment is better and we can start to rebuild.”

Other State-Based Ratios Disintegrate

In May, a union-led effort to pass nurse staffing requirements in Minnesota crumbled after the Minnesota Hospital Association warned the provisions would “reduce hospital care capacity by 15%” and the Mayo Clinic said it would rescind a billion-dollar investment if ratios were enacted.

An amended bill excluded ratios but did include a study on nurse staffing and retention, as well as provisions around student loan forgiveness and workplace violence protections, according to KSTP-TV.

In Washington state, a legislative attempt to pass staffing ratios also got gutted.

“Our argument as the Nurses Association was if we don’t do something drastic… the healthcare system is going to collapse in a way we haven’t seen before,” said Katharine Weiss, MPA, director of government affairs for the Washington State Nurses Association. The reason, she said, was because RNs were being assigned sometimes double the recommended patient load, and so many of them were leaving their jobs.

“But legislature and government in general tend to shy away from big drastic changes,” including ratios, Weiss said.

The final bill that passed in Washington includes nursing ratio enforcement only where hospitals or health systems are noncompliant with staffing plans enacted in collaboration with nurse staffing committees, following an investigation, and as part of a “corrective action plan,” Weiss said.

The Controversy Continues

While most hospitals continue to push back on the bills, Kevin Mahoney, MBA, CEO of the University of Pennsylvania Health System in Philadelphia, has emerged as an unlikely champion.

After the Pennsylvania House of Representatives passed a ratio bill in July, Mahoney and Aiken penned an op-ed in Penn Live arguing that minimum nurse-to-patient ratios are an evidence-based solution to staffing and burnout challenges.

Staffing standards shouldn’t be enacted in a vacuum, and reimbursement structures and regulatory frameworks also need to be overhauled, Mahoney wrote in an email to MedPage Today. “But we should not be afraid to follow the evidence toward new approaches when the status quo is broken.”

The ANA also recently threw its support behind nursing ratios, following a vote of its membership in 2022. However, the group clarified that ratios are just one solution of many.

“This work to address the national nurse staffing crisis at all levels and using all solutions and levers, including legislation and minimum nurse-to-patient ratios, is imperative,” wrote ANA President Jennifer Mensik Kennedy, PhD, MBA, RN, in an email to MedPage Today.

Staffing ratios have also been endorsed by members of Congress. Back in March, Rep. Jan Schakowsky (D-Ill.) and Sen. Sherrod Brown (D-Ohio) reintroduced a bill to enact minimum nurse-to-patient staffing requirements nationally, but the barriers to passage are high.

Most hospital association leaders and many nurse executives remain opposed.

“From a patient care standpoint, this is the worst time to be looking at one-size-fits-all solutions, and nursing ratios at best are one-size-fits-all,” said Chip Kahn, president and CEO of the Federation of American Hospitals in a phone interview, during which a press representative was present.

As for the idea that ratios would improve retention and allow hospitals to rebuild their workforce, Kahn said those arguments reflect a “Pollyanna view” of the hospital experience during and after the COVID-19 pandemic.

Right now, there’s a growing number of nurses who are aging out of the profession. At the same time, younger nurses are less inclined to choose hospital care, because of the aftermath of the pandemic. And on top of it all, there’s a tight labor market, Kahn said. “You can’t make somebody … out of whole cloth. You have to have a supply.”

Maureen White, RN, executive vice president and chief nurse executive for Northwell Health, based in New Hyde Park, New York, agreed.

With Walmart, Amazon, and CVS all looking to break into the healthcare market, there are more opportunities for nurses outside of traditional hospital care than ever before, White said.

“COVID taught us what happens when you don’t have enough registered nurses,” she said. “So we need the flexibility to be resourceful enough and to be open-minded enough to look at other potential care models and to test those care models now, when we’re not in a crisis situation.”

While she supports “appropriate staffing,” instead of focusing on a single component of the care team, hospitals should be looking at the “total care team,” White argued.

For example, nurses should be allowed to focus on responsibilities that use the “higher level-thinking” and “acute assessment skills” they are trained in while delegating other activities — feeding patients, transporting patients, and even teaching patients about their medications — to other members of the care team.

“The nurse can only do so many things,” White said.

Transformations in patient care delivery, with new ways of leveraging data and artificial intelligence, could free up nurses to spend more time on direct patient care, Kahn said. “I think the arbitrariness of a specific number actually may make it more difficult to move the needle in terms of innovation and clearly in terms of cost,” he said.

On that issue of cost, White also saw a problem.

“Where’s the money coming from?” she asked. “Because reimbursement for healthcare is on a downward trend. All the expenses are on an upward trend.”

These arguments from huge for-profit health systems and even non-profit health systems frustrate Calzia, he said, because these institutions wield so much power and influence yet appear entirely focused on their “bottom line.”

“You’re not paying attention to how bad your work environment is,” he said to these hospital executives.

National nurse turnover rates in hospitals are 25% and higher, and while artificial intelligence and virtual nursing can support direct care nurses within the boundaries of state-based ratios, “you can’t do this with the expectation of pushing that direct care nurse harder,” Calzia argued.

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