Nurse-to-Patient Ratios – What to Know From the Experts

The Benefits of Nurse-to-Patient Ratios

“Insufficient staffing is the greatest pain point for nurses,” Peterson says. “It has a cascading effect. It can lead to physical injury if there aren’t enough people to do the work. It can lead to nurse dissatisfaction and moral distress. There’s a lot that goes into understanding the impacts of poor staffing both on patients and on nurses themselves.”

The problem is largely mathematical: too few nurses for too many patients leads to poor outcomes for both nurses and patients. Advocates of nurse-to-patient ratios believe that the solution can also be largely mathematical. So far, the research supports those beliefs. A 2011 study found that in California, which mandates and enforces nurse-to-patient ratios, nurses have a higher satisfaction rate than they did before; patients receive more hours of nursing care per day; and other patient outcomes (such as length of stay) have improved. 

Further research from 2018, in both California and abroad, established links between lower nurse-to-patient ratios and better patient outcomes. Similar results were found in Queensland, Australia, where nurse-to-patient ratios were established in 2016. 

“A nurse-to-patient ratio provides a concrete measurement to the nurses and the hospitals about how many nurses are needed to provide safe patient care,” Allen says. “And once that ratio is exceeded, the safety of the patient begins to be compromised. It is a transparent standard of care that has been established through years of research and practice by nursing and medical associations.”

Conversely, a lack of nurse-to-patient ratios can exacerbate poor staffing issues. Both Peterson and Allen point to the Covid-19 pandemic as an example: the extraordinarily overburdened nursing workforce was pushed to its absolute limits, and now many nurses are considering retiring early rather than continuing in a workplace that doesn’t support them to the full extent of their abilities.

Different Approaches to Nurse Staffing

To date, California is the only state that requires minimum ratios of nurses to patients in hospitals. The required ratios range from one nurse per patient in ORs and trauma units to one nurse for every eight healthy babies in a nursery ward. While research shows these ratios to have had a positive impact, the approach has been slow to catch on elsewhere. 

Some states, like New Jersey, require hospitals to post their staffing ratios for patients to see but do not require them to be within any particular range. While this transparency is a step in the right direction, it comes with challenges: consumers need to know that the information is available, and they also need to understand what they’re reading. Nurse-to-patient ratios are still a relatively unconsidered concept in the patient community, and publicized staffing ratios are rarely conveyed in the most reader-friendly manner.

Several other states (Connecticut, Illinois, Nevada, Ohio, Oregon, and Texas) require hospitals to have staff committees that oversee nurse-to-patient ratios, but they do not explicitly define what those ratios must be. These staff committees sound good in theory, Peterson says, but their efficacy in practice is questionable.

“For many years, ANA has supported nurse staffing committees,” Peterson says. “But what we find is unless you have an enforceable piece that requires that the hospital actually staffs to the levels determined by the staffing committee, it’s considered completely advisory. And most don’t take the advice.”

“Without an enforced ratio, hospitals understaff units, and we just get by with the amount of staff we have,” Allen says. “In cardiac ICUs when some patients should be one-to-one, due to low staffing without ratio enforcement, this ratio become one-to-two and sometimes one-to-three.”

Some states, like Washington, are attempting a hybrid approach, which establishes a baseline staffing standard and allows a staffing committee to determine and advise if more needs to be done. This would provide a floor—i.e., a minimum nurse-to-patient ratio—and still allow institutions to decide their staffing needs beyond that based on patient flow. Peterson is optimistic that iterations on such a model could work. Meanwhile, in states like New York, nurses have taken a more direct approach.

The Power of Collective Action

In 2019, more than 10,000 nurses threatened to walk off their jobs at three of the biggest hospital systems in the state. Their demands were simple: the establishment of safe staffing ratios. 

In what was hailed as a landmark victory, the hospital systems agreed to hire another 1,450 nurses and establish minimum ratios of nurses to patients. They also promised to raise annual pay for nurses by 3 percent, allocate $25 million annually to hire additional nurses, and have an independent neutral party monitor the staff ratios to ensure they are met and maintained. 

“The contract agreement was good on paper, but has not been upheld by the hospitals,” Allen says. “Nurses and hospital administrators spent lots of time developing staffing plans that have ratios built into them, but the victory in 2019 had no enforcement mechanisms in place to actually hold the hospitals accountable to following these improved staffing guidelines.”

The clock is ticking towards another big change. Approximately 30,000 NYSNA nurses have contracts expiring either at the end of 2022 or the beginning of 2023, marking the first time so many public and private sector nurses will be bargaining simultaneously. A We Love NY Nurses campaign has taken shape to bolster nurses’ position. Allen and the NYSNA are optimistic.

“We are learning from past mistakes as we begin negotiations on our new contracts this year,” Allen says. “We plan on renewing and improving these agreements in 2022 with bold and transformative staffing proposals. A new paradigm for 2022 is that we are actively organizing for and demanding an on-time contract now. We plan on exacting consequences on all NYC employers that fail to deliver a fair contract by December 31, 2022—up to and including strikes.”

Earlier in the year, NYSNA and New York nurses won a key victory when the state passed new safe staffing laws. The laws create staffing committees (comprising at least 50 percent nurses and frontline caregivers) and automatically include contractual staffing ratios negotiated by NYSNA in a facility’s staffing plan. (This creates a floor that’s functionally similar to the hybrid approach from Washington described above.) While these don’t fix all the upcoming contract issues, they form an important precedent and pave the way for future universal nurse-to-patient ratios.

“There is still a huge amount of work that needs to be done before nurse-to-patient ratios become the standard,” Allen says. “It will take a change in our culture, continued advocacy and collective action from nurses, and the enactment of laws locally and federally that force hospitals to invest more in their patients and the nurses caring for them.”

The Future of Nurse Staffing

Nurse-to-patient ratios are only one part of safe, effective, and equitable nurse staffing policies. But they are an important part. Ultimately, the future of nurse staffing should be determined by nurses, and nurses are stronger when working together. There are several ways new, aspiring, and veteran nurses can pitch in. 

“New nurses can join unionized hospitals, or support their peers at unionized hospitals who are in contract negotiations now,” Allen says. “Unionized hospitals often set the standard for wages, benefits, and working conditions that are then replicated by non-union hospitals to stay competitive. I would also encourage newer nurses to consider organizing with their co-workers into a union—there is power in numbers. There is a lot of education and support you can get when you are part of a union.”

Professional nursing associations are another important resource for nurses at all stages of their careers. Especially at the state level, these associations are powerful centers of advocacy. Mandating nurse-to-patient ratios will almost certainly need to be enacted by the state, rather than federal, government, and state nursing associations are well-positioned to lobby them on this axis. Nurses can take action on the individual level, too, asking questions of their current and potential employers around staffing and normalizing conversations around staffing.

“A lot of approaches can be taken,” Peterson says. “But, for one, nurses need to educate themselves. They need to engage in understanding what’s happening in their state, and I think they really need to talk to each other about it.”

“We should all be invested in raising standards for our patients and the nursing profession,” Allen says.