Hospital Nurse Staffing Isn’t Created Equal

• A new study published in “Health Affairs” looks at how varied hospital nurse staffing mandates are throughout the United States.
• California implemented the first state-level nurse staffing mandate more than two decades ago, but a federal mandate has failed to gain enough support in the legislature.
• Within the nursing industry, opinions differ on whether or not staffing ratios should be governed by politicians or among nurses themselves.

Hospital nurse staffing mandates aren’t created equal — and don’t even exist in some states.

A new “Health Affairs” study analyzed how legislatures across the United States approach staffing ratios. The authors found that it differed from state to state, hospital to hospital, and, in some cases, unit to unit. As of January 2024: 

• Seven states had enacted staffing-ratio laws for at least one hospital unit. 
• Eight states required nurse staffing committees. 
• Eleven states required nurse staffing plans. 
• Five states had pending legislation. 
• One state banned minimum staffing requirements.

Opinions differ in the nursing community on whether staffing ratios should be implemented through legislative mandates or by “nurse-centered committees.” 

No National Consensus

California was the first state to establish minimum nurse-to-patient ratios, doing so in 1999. More than two decades later, a federally mandated nurse staffing ratio has yet to be realized. 

Sen. Sherrod Brown and Rep. Jan Schakowsky, both from Ohio, reintroduced the Nursing Staffing Standards for Hospital Patient Safety and Quality Care Act in March 2023, but it has seen little movement. 

If approved, it would require hospitals: 

• To implement and submit staffing plans to the Department of Health and Human Services (HHS). 
• Post a notice about their staffing ratios in each unit and maintain records of actual staffing ratios. 
• Follow procedures to determine their staffing ratios.

Under the measure, nurses would be allowed to “object to, or refuse to participate in, an assignment” if it violates staffing ratios or if they aren’t qualified to take on the assignment. Hospitals that retaliate or discriminate against a nurse for objecting to an assignment could face civil monetary penalties from HHS.

Advocacy groups like National Nurses United have endorsed the legislation.

“The bill’s introduction is a direct response to the escalating staffing crisis in hospitals across the country,” NNU President Deborah Burger, RN, said at a press conference. “Tens of thousands of nurses have spoken out, marched, and struck for safer patient care conditions over the last year, sounding a clarion call for action. Nurses know the quality of our health care system is on the line and depends on the passage of this bill.”

The American Nurses Association (ANA) also threw its name behind the bill, stating that combining policy with “other nurse-led staffing standards and solutions” will improve working environments and patient outcomes. 

Opinions on Hospital Nurse Staffing Ratios

Sarah Delgado, DNP, RN, ACNP, wrote for the American Association of Critical-Care Nurses (AACN) that better staffing correlates to better patient outcomes, but staffing ratios can’t be looked at in a silo.

“As nurses and leaders, we must work to improve the dire situation with nurse staffing, just as nurses and patients work to improve the situations that illness and injury create,” wrote Delgado, a clinical practice specialist in strategic advocacy for AACN. “Including direct care nurses in all staffing decisions, acknowledging that ratios matter, advocating for system-level change while innovating care delivery, and improving the work environment are essential steps forward.”

ANA considers safe staffing a legislative priority and advocates for state-level policies that focus on staffing committees, mandated ratios/standards, or mandated staffing level disclosures. 

However, the American Organization for Nursing Leadership (AONL) disputes the idea that government mandates are the way to go, calling the approach “short-sighted and counterproductive.”

“Government-mandated ratios do not account for an individual patient or the health care team’s needs in an ever-changing environment nor do they account for the variability among health care organizations,” AONL stated in July 2023. “… Typically based on traditional nursing care models, static mandated ratios limit innovation and do not utilize advanced capabilities in technology or interprofessional care teams to support data-driven-decision making and collaborative practice.” 

The Bottom Line

A new research study from “Health Affairs” reinforces that nurse staffing ratios vary greatly across the nation, and there’s no consensus on how to approach safe staffing ratios. While a federally mandated nurse staffing ratio has support from some nursing groups, others contend that a top-down approach doesn’t take into account the individual needs of patients and health care teams. 

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