In intensive care units (ICUs), staffing ratios—the ratio of one nurse-care provider to patients—have been standardized for 30 years. In almost any ICU, one registered nurse (RN) cares for two patients. In the 1990s, the idea of setting standard staffing ratios in other areas gained momentum, as the scope of the current nursing shortage started becoming apparent.
Since then, many states have considered mandated ratios as well as some alternative staffing solutions for all healthcare facilities. This review gives you an update on mandated nurse staffing ratios and alternative approaches for hospitals.

Momentum shift
In 1999, California became the first state to pass legislation mandating licensed nurse–patient ratios for units in acute-care hospitals. By the turn of the 21st century, momentum for mandated ratios had grown. Then, the New York legislative focus shifted from mandated ratios to staffing plans that allow ratio adjustments with input from direct-care nurses. Today, this shift is being played out in states across the country. (See Staffing solutions: State by state in pdf format by clicking the download now button.)
Thirteen states plus the District of Columbia have either enacted legislation mandating nurse-patient ratios, created regulations requiring written staffing plans, or developed an approach using a combination of the two. California, Connecticut, Ohio, Oregon, Rhode Island, New Jersey, Texas, and Washington have adopted staffing plans. In Florida, Vermont, and Maine, a combination of staffing plans and nurse-patient ratios has been proposed. Illinois passed the “Patient Acuity Staffing Plan,” which allows hospitals the flexibility to meet changing patient-care needs but also requires input from direct-care RNs. Although legislation in Nevada passed in 2003, a subcommittee has been appointed to conduct a study on staffing ratios, so the law hasn’t yet been implemented.
In 2008, 13 states introduced nurse-staffing legislation for the first time or as additional legislation. In general, the legislation requires hospitals to put in place and implement staffing plans, or to establish nurse-patient ratios that can be adjusted based on a patient acuity system. The states are Arizona, Connecticut, Florida, Hawaii, Iowa, Montana, Missouri, New Jersey, New Mexico, New York, Ohio, Virginia, and West Virginia.
Only California and Massachusetts have passed legislation on mandatory nurse-patient ratios, and only California has implemented ratios. The California law that passed in 1999 gave hospitals until January 2005 to achieve a 1:5 nurse-patient ratio on all medical-surgical units. However, changes delayed the start of the 1:5 ratio until January 2008. In Massachusetts, the mandatory nurse-patient ratios law has a provision for adjusting staffing ratios based on patient needs. It’s scheduled for implementation in 2010.

Problems with mandatory ratios
The California law says that only licensed nurses providing direct patient care can be included in the ratios. But licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) can account for up to 50% of the licensed nurses on most units, and the law doesn’t distinguish RNs from LPNs and LVNs. Ironically, this law on mandatory ratios also says that licensed nurses may help provide care beyond their patient assignments, if the tasks are specific and time-limited. As you may know, the nurse unions in California supported mandated ratios because they believed they needed the structure of ratios to protect union members and control hospitals’ attempts to reduce staffing.
Other states haven’t followed California’s lead, most likely for a few reasons. First, mandated ratios can foster rigidity. Legislated nurse-patient ratios perpetuate the myth that “a nurse is a nurse” by failing to account for differences in nurses’ skill levels and expertise as well as hospital resources and other support for nursing care. Second, to meet mandated ratios, many California hospitals are laying off unlicensed healthcare personnel, housekeepers, and other support staff. These layoffs may increase the amount of nonnursing work that RNs must do. At least for now, a doubling of California nurse graduates in the last couple of years has helped reduce the nursing shortage and limited the adverse effects of this decision.
In facilities that must increase nursing staff to meet mandated ratios, investments in technology and facilities that would improve care may need to be deferred. However, at least one study shows that hiring more RNs didn’t significantly decrease the hospital’s profit. The study also found that increasing staffing levels for all nursing personnel—RNs, LPNs, and certified nurse assistants (CNAs)—contributes to fewer adverse patient outcomes. Sharing such information with hospital administrators may allay fears that worthwhile hospital initiatives have to take a backseat to hiring nursing staff.

Support for alternative staffing systems
Because of these issues, the American Nurses Association (ANA) doesn’t endorse mandated nurse-patient ratios. Instead, the ANA endorses staffing systems with requirements that RNs who provide direct patient care have input into staffing decisions and that the level and intensity of care be reflected in the staffing system. (See Requirements for staffing systems in pdf format by clicking on the download now button.)
In a few states, some interesting alternatives to mandated nurse-patient ratios have evolved. In New Jersey, hospitals are required to publicly post the ratio of healthcare workers, including RNs, LPNs, and CNAs. Illinois also has a public disclosure law, but disclosure is upon request only. These initiatives give consumers the information they need to choose a hospital and to apply pressure on hospitals to hire adequate staff. Traditionally, of course, hospital administrators have cut costs by cutting the nursing staff because nurses’ salaries make up almost 50% of a hospital’s operating budget.
Today, the demand for nurses continues to grow, and well-publicized reports and research suggest that nurses are vital to maintaining patient safety and quality patient outcomes. However, for the first time, the supply of nurses is shrinking without administrative intervention. An aging nursing workforce, decreased enrollment in nursing schools, and rising nurse turnover rates signal that this nursing shortage is different.

What’s an optimal staffing level?
One assumption that underlies the staffing discussion is that there’s an objective optimal staffing level or ratio that will provide the best of all possible patient outcomes. Unfortunately, research hasn’t yet discovered the ratio, and the relationship between the cost of hiring more nurses and the outcomes for patients remains poorly understood. Nurse researchers haven’t consistently investigated the same staffing variables and outcomes in their studies, making it difficult to link staffing levels to a specific outcome.
In our market-driven healthcare system, nurse staffing levels are optimal when the effect of nursing care on patient outcomes equals the cost of nursing care. If the benefit of nursing is greater than the cost, more nurses are needed. If the cost of another RN is greater than the benefit, fewer RNs are needed.
American hospitals haven’t defined optimal levels of nursing staff in those terms because they haven’t been paid by the quality of care they deliver. But in October 2008, new regulations by the Centers for Medicare & Medicaid Services changed hospital reimbursements for Medicare and Medicaid patients. No longer will hospitals be reimbursed for the treatment and increased length of stay associated with adverse events, such as hospital-acquired infections and pressure ulcers. This fundamental change in reimbursement may just spur hospitals to invest in nursing. How­-ever, the first report on mandated nurse staffing ratios shows no relationship between the incidence of patient falls or the prevalence of pressure ulcers and staffing ratios on medical-surgical units. Still, previous research does indicate that different nurse-to-patient ratios do cause detectable differences in mortality rates.

Evolving awareness
Where does that leave us? Our awareness of staffing issues is evolving, while legislative efforts move forward and research linking staffing levels to patient outcomes continues. Keeping ourselves up-to-date on these issues will prepare us to help our profession and the patients we serve.

Selected references
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-1993.
Bacon C, Mark BA. Nurse staffing: a national legislative update. Proceedings of the 2007 International Nursing Administration Research Conference. 2007:101.
Donaldson NE, Burnes Bolton L, Aydin CE, Brown D, Elashoff JD, Sandhu M. Impact of California’s licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. Policy Polit Nurs Pract. 2005;6(3):198-210.
Gerardi T. Staffing ratios in New York: a decade of debate. Policy Polit Nurs Pract. 2006;7(1):8-10.
White K. Policy spotlight: staffing plans and ratios. Nurs Manage. 2006;37:18-22, 24.
Visit www.AmericanNurseToday.com/journal for a complete list of selected references.

Milisa Manojlovich is an assistant professor at the University of Michigan School of Nursing in Ann Arbor.