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Nurse-Patient Ratios : A Biased View

nurse-patient ratio

 This controversial article on nurse-patient ratios was deemed to be biased and not acceptable for publication as is in a major nursing journal. They are probably right.

There are two sides to the nurse-patient ratios discussion, basically answering “Should nurse-patient ratios be mandatory (as they are in California)?” The purpose of this article is to give nurses information on pending and opposing bills on nurse-patient ratios and to persuade him/her to take part in the national discussion. nurse-patient ratios

At lunch Ashley quietly listened to a colleague on her Med Surg unit who had just returned from Washington, D.C, where she attended a national nursing rally on mandated minimum nurse-patient ratios organized and sponsored by Show Me Your Stethoscope. She was excitedly persuading others to get involved, exclaiming “You are in favor, aren’t you?”  

Ashley doesn’t know if she’s in favor of mandated ratios or not. She doesn’t enjoy getting involved in politics and was a bit turned off by the zealous approach. At the same time, Ashely herself has been victim to “Nursing’s Dirty Little Secret” on her unit.

That same night, Ashley was asked to stay over an additional four hours due to sick calls on night shift. She agreed to stay help out but wasn’t told she was going to have 7 patients with a possible admit until change of shift. Read The REAL Story Behind Ratios.

Nurse-Patient Ratios: A Biased View

The next day, Ashley decided to learn more about mandated ratios. She read a journal article about mandated minimum nurse-patient ratios and how large nursing organizations including the Association of Nurse Executives (AONE) and the American Nurses Association (ANA) oppose them. AONE and ANA support alternative legislation requiring hospitals to establish nurse-driven staffing committees, as more flexible and inclusive of nurses’ input.

Now Ashley is thoroughly confused. Don’t healthcare providers, nurses, and professional organizations all want the same thing? Safe, quality, cost-effective care?

Ashley is soon to find there’s no simple answer to the question “Should minimum nurse-patient ratios be mandated?”

Here’s a simplified explanation.  I’ll call the opposing sides Team Ratios (support mandated ratios) and Team Staffing Committee (support hospital-based staffing committees). Both cite patient safety and quality care.

Team Ratios (Supports Mandatory Nurse-Patient Ratios)

Proposes standardized, federally mandated minimum nurse-patient ratios which would apply to all hospitals nationwide. It’s pretty simple:

Nurse-Patient Ratio Nursing Unit(s)
1:1 Emergency trauma, OR
1:2 Critical Care Units
1:3 Emergency, Peds, Stepdown, Telemetry
1:4 Med-Surg
1:6 Post-partum (3 mother-baby couplets)


Legislation: The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act in the Senate (S.1063) with a similar bill in the House of Representatives (H.R. 2392).  

Supporters: National Nurses United (NNU), grassroots nursing groups

Team Staffing Committee (Opposes Mandatory Nurse-Patient Ratios)

Propose minimum nurse-patient ratios  be determined by individual facility staffing committees. Hospital-based, nurse-driven staffing committees will consider intensity of patient care and workflow (admissions, discharges, and transfers). “Nurse-driven” is defined as a committee composed of 55% direct care nurses.

Legislation: The Registered Nurse Safe Staffing Act (H.R. 2083/S.1132)

Supporters: The ANA, the American Hospital Association (AHA), and AONE, among other national organizations.

Currently the only state to have mandated minimum nurse-patient ratios in every nursing unit is CA. MA has mandated ratios in ICU only. Five states require public disclosure of staffing ( IL, NJ, NY, RI, VT) and seven states have hospital staffing committees (CT, IL, NV, OH, OR, TX, WA).

Registered Nurses and Patient Outcomes

Constant attention by a good nurse may be just as important as a major operation by a surgeon.

Dag Hammarskjold

Evidence shows  that the level of nurses and patient outcomes are positively linked. (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Needleman, Buerhaus, Mettke, Stewart, & Zelevinsky, 2002; Silber et al., 2016).

“The odds of patient mortality increased by 7% for every additional patient in the average nurse’s workload in the hospital and that the difference from 4 to 6 and from 4 to 8 patients per nurse would be accompanied by 14% and by 31% increases in mortality respectively”  (Aiken, et al., 2002 p.981) as published in the Journal of the American Medical Association (JAMA).

The problem is defining and actualizing safe nurse-patient ratios. Even while patient safety is so strongly tied to nurse-patient ratios, many nurses do not when or how to refuse a patient assignment.

Financial Burden

Critics warn that mandated nurse-patient ratios will significantly increase hospital costs and overburden the system. The nursing shortage will be exacerbated. Critical access and rural hospitals will suffer. (Buerhaus, Donelan, DesRoches, & Hess, 2009).

Policymakers…considering a mandate similar to California’s might also consider pairing the mandate with initiatives to increase the pool of available registered nurses in the workforce” (Spetz, et al, 2009, p.17).

Proponents maintain that adding nurses will save money in the long run and that cutting labor costs is a costly short term approach. My Dad called it “stepping over a dollar to pick up a dime”. Nurses can help reduce costly hospital acquired infections, prevent re-admissions, monitor quality metrics, and more under pay- for- performance (McHugh,Berez, & Small, 2013).

Other activities that affect the bottom line include reducing nurse turnover, improving efficiency and workflow, managing resource utilization, and ensuring that non-nurse work be reduced. Nurses should spend more time in value-added activities and less time in activities such as hunting down supplies (Upenieks, Akhavan, Kotlerman, Esser, & Ngo, 2007b)

It’s puzzling that opponents of mandated minimum ratios claim it will be too expensive.

The language used by Team Staffing Committee reads” the staffing committee will “establish upwardly adjustable minimum ratios for each unit and for each shift of the hospital” (Senate Bill 1132, Registered Nurse Safe Staffing Act”).  

How will that not also be expensive? 

Staffing Committees: Nurse Input or Tokenism?

Opponents of mandated ratios say that nurse involvement is essential in creating staffing plans and staffing committees empower nurses. (ANA, 2010a).

But are all staffing committees functional and do they truly empower nurses or are they committees in name only that lack influence and authority?

Depending on individual hospital and committee leadership, staffing committees will vary in effectiveness and in their authority to make changes. “Effectiveness of committees can be dependent on the interpretation of the chief nursing officer and therefore vary widely from facility to facility not due to patient population but by CNO influence (Seago, Davidson, & Waldo, 2012, p.135).

Empowerment & Purpose

Committee effectiveness requires a safe culture that encourages nurses to speak up. The 55% direct care nurse membership requirement does not guarantee that the majority will prevail if fear or bias of authority exists. As one nurse in Texas so aptly described “Our nurse manager hijacked our “Staffing Committee” from the get-go”

Committees can easily drift off topic and focus can shift away from the original charter directive, which is to determine staffing ratios. Without skilled facilitation, staffing committees can instead easily become clinical best practice or performance improvement committees (Fitzpatrick, Anen, & Soto,2013.) In the article Nurse Staffing:The Illinois Experience Fitzpatrick, et al., (2013, p. 227) reported that 35% of survey respondents were not clear about their role on the committee and 30% requested an “overview of the organization’s strategic plan.”

Variable Accountability

Concern exists that hospitals with staffing committees are not held accountable and do not hold themselves accountable to their staffing plans. A leader in the grassroots mandated ratios movement, registered nurse Doris Carroll, says flatly, “I’m in Illinois.I know other hospitals don’t comply with Illinois law. We are ready for a change.”

Texas Testimonial

Deena Sowa McCollum has worked as a nurse manager in three large hospital systems in Texas where staffing committees are in effect. She shares her experience:

“The staffing committee is given the budget constraints for each unit.

Let’s say 5 West is budgeted to provide 6 hours of nursing care per patient day (HPPD), which translates to 10 registered nurses on duty every 24 hours when the census is full.  

The  committee can make recommendations for a staffing plan but may not increase the budget. For example, they can recommend allocating 6 nurses on day shift and 4 on night shift, or 5 and 5.

They could even recommend changing the skill mix by forgoing unit secretaries and instead have 11 nurses on duty -as long as if it doesn’t put them over budget.  

Still it is usually a 7 patient load with an aide and a clerk for a 21 census in acute rehab and if there is an empty bed you will take 8 because your director says you can safely do it based off his or her evaluation of the unit at that time. Also, they say the grid is a GUIDE it is NOT set in stone. It’s based off the unit director or manager’s assessment of the unit. That is how this “safe staffing law” works in Texas.”

While there are hospitals in Texas with safe nurse-patient ratios, likewise  there are Texas hospitals with unsafe nurse-patient ratios. Mandated ratios eliminate variability.


Peter Beurhaus (2010) strongly cautions that allowing unions or government to mandate nurse-patient ratios will erode the support of public and private sectors.

Buerhaus’s fears have not played out. Nurses remain the most trusted profession, mandated nurse-patient ratios notwithstanding. Teachers in states with mandated teacher-student ratios are considered no less professional than teachers in states without ratios.

Trust is built over time. Hospital mergers, acquisitions and turnover in nursing leadership mean nurses may deal with revolving administrations, each with a different perspective on staffing committees. Trust cannot be legislated. Unions exist where employee-employer trust is eroded. Improving working conditions is key to avoiding unions (Buerhaus, 2009). Employers who value professional development and shared governance models will predictably  retain quality nurses with similar values.

Rigid or Right?

Critics argue that mandated ratios are inflexible and rigid.

In fact, ratios are not inflexible but are upwardly adjustable. In my facility in California, patients on continuous bladder irrigations (CBIs) with hourly assessments and oncology patients receiving IV chemotherapy are 1:3 or 1:2 on our Med Surg unit although ratios call for 1:5.

Ratios are not downwardly adjustable. Under the proposed mandated ratios, a patient on Med-Surg will never have a nurse who is assigned more than four patients (currently CA is 1:5 but would change to 1:4).

If numerical ratios are deemed rigid, the same must be said of static metrics used for staffing such as HPPD and Average Daily Census.

At All Times

Maintaining safe patient ratios at all times has proved challenging especially at breaks and mealtimes. The “at all times” language is used by opponents (Douglas, 2010) to criticize mandated ratios as challenging and inconvenient to enforce. CA organizations are grappling to find the best way to provide safe coverage “at all times”. Some hire “break nurses” while others use float pools and charge nurses to ensure clinical bedside nurses get their breaks and mealtimes without leaving patients unattended or other nurses with double patient loads.The increased handoff reports this generates is not ideal (Douglas 2010) but ratios do not drive the requirement for uninterrupted breaks, labor laws and employment policies do.

[Tweet “The real problem is providing off the clock mealtimes for nurses, relieving them of all duties, while providing safe care for patients. The real problem is providing off the clock mealtimes for nurses, relieving them of all duties, while providing safe care for patients“]

It makes no sense to establish minimum ratios that are important at some times but not at other times. This would mean that patient safety requirements do not have to be in effect during staff meetings, inservices, or potlucks. The “at all times” clause ensures accountability and prevents abuse.

Simplistic vs Analysis Paralysis

Critics say mandated ratios are overly simplistic and reflect a one size fits all mentality. The complexity of healthcare with all the variables that go into staffing decisions (intensity of care, range of conditions, experience level of staff, physical plant, etc) precludes a simplistic numerical ratio. (Douglas, 2010). “Numbers alone do not provide a complete picture of nurse staffing.”

(Upenieks, Kotlerman, Akhavan,Esser, & Ngo, 2007a, p.18).

There is more to the staffing equation than nurse-patient ratios, but they are an essential part of the equation.

One size does not fit all, but if it fits most, it’s the safe thing to do. As an example, most ICU patients warrant a 1:2 ratio, like MA and CA have enacted. For public safety, upwardly adjustable baseline minimum ratios must be established.  Firemen, policemen and ambulance companies do the same.

The purpose of legislation is not to mandate exemplary staffing and provide for every nuance, but to protect the public from unsafe staffing.”

My California Experience With Nurse-Patient Ratios

As an RN practicing in California both before and after ratios, in three different hospitals, as a clinical nurse and as a nurse manager- here’s my experience.

I have yet to meet a nurse in California who is in favor of repealing mandated ratios. Most California nurses (including nurse managers) believe ratios have improved conditions for nurses and outcomes for patients (Aiken, et al., 2010; Tellez & Seago, 2013).

Prior to mandated ratios, I had up to 7-8 patients on Med Surg and on one unforgettable Saturday I agreed to come in, I had 9. Nursing’s Dirty Little Secret 

Later in my career as a manager, I was held accountable to the “grid”. The grid used hours per patient day (HPPD) and census to determine staffing. Often hospitals also employed varying acuity systems. The acuity systems I have worked with were easily manipulated by staff or disregarded by management, and were always trumped by the staffing grid. When I had my monthly meetings with the financial officer, he was not at all interested in patient acuity, but in budgeted HPPD and census.


Evidence does not support definitive improvement of nurse-sensitive indicators in California under mandated ratios.

(Bolton, et al. 2007; Spetz, Harless, Herrera, & Mark, 2013 ). Likewise, evidence does not exist to support the benefits of staffing committees.

Until such time as we have more research, I support mandated nurse-patient ratios as the greater good for the most patients. I vote for Med-Surg RNs to have no more than 4 patients, and yes, at all times. Read The Reality Behind Ratios.

As a profession, it’s not enough to say ‘We want more nurses” without demonstrating how we will provide value-based care.  If we have more nurses, then we need to deliver the best care; reduce falls, prevent infections and readmissions, educate our patients and families. Read 7 Things You Can Do To Support Safe Staffing.

Finally, each one of us needs to get involved “Nurses have the responsibility to be involved in the political process to ensure patients’ rights and needs are the focus of any legislation being proposed “ AMSN Staffing Standards for Patient Care, 2016. As Joan Ekstrom Spitrey urges us “Nurses Need to be the Change“.

Learn more about ANA’s Safe Staffing (staffing committees).

Learn more about NNU’s Safe Staffing (mandated ratios).

Best wishes,

Nurse Beth

AuthorYour Last Nursing Class: How to Land Your First Nursing Job..and your next!” 

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Academy of Medical-Surgical Nurses (2016). AMSN Staffing Standards for Patient Care. Accessed December 2016

Fitzpatrick, T., Anen, T., & Soto, E. M. (2013). Nurse staffing: the Illinois experience. Nursing Economic$, 31(5), 221-229.

McHugh, M. D., Berez, J., & Small, D. S. (2013). Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Affairs, 32(10), 1740-1747.

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346(22), 1715-1722.

Seago, J. A., Davidson, S., & Waldo, D. (2012). Oregon nurse staffing law: is it working?. Journal of Nursing Administration, 42(3), 134-137.

Silber, J. H., Rosenbaum, P. R., McHugh, M. D., Ludwig, J. M., Smith, H. L., Niknam, B. A., … & Aiken, L. H. (2016). Comparison of the Value of Nursing Work Environments in Hospitals Across Different Levels of Patient Risk. JAMA surgery.

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Jama, 288(16), 1987-1993

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health services research, 45(4), 904-921.

AONE, 2003. Policy Statement on Mandated Staffing Ratios. Accessed December 2016

Bolton, L. B., Aydin, C. E., Donaldson, N., Brown, D. S., Sandhu, M., Fridman, M., & Aronow, H. U. (2007). Mandated nurse staffing ratios in California: a comparison of staffing and nursing-sensitive outcomes pre-and post regulation. Policy, Politics, & Nursing Practice, 8(4), 238-250.

Buerhaus, Donelan, DesRoches, & Hess, 2009. Registered Nurses’ Perceptions of Nurse Staffing Ratios and New Hospital Payment Regulations. Nursing Economics, 27(6), 372-376.

Buerhaus, P. I. (2010). It’s time to stop the regulation of hospital nurse staffing dead in its tracks. Nursing Economics, 28(2), 110.

Douglas, K. Ratios: If it were only that easy. Nursing Economics Vol .28 No 2A DD IN  

Spetz, J., Chapman, S., Herrera, C., Kaiser, J., Seago, J. A., & Dower, C. (2009). Assessing the impact of California’s nurse staffing ratios on hospitals and patient care. A report prepared by the Center for California Workforce Studies for the California HealthCare Foundation. Issue brief found at

Tellez, M., & Seago, J. A. (2013). California nurse staffing law and RN workforce changes. Nursing Economics, 31(1), 18.

Upenieks, V. V., Kotlerman, J., Akhavan, J., Esser, J., & Ngo, M. J. (2007a). Assessing nursing staffing ratios variability in workload intensity. Policy, Politics, & Nursing Practice, 8(1), 7-19.

Upenieks, V. V., Akhavan, J., Kotlerman, J., Esser, J., & Ngo, M. J. (2007b). Value-added care: a new way of assessing nursing staffing ratios and workload variability. Journal of Nursing Administration, 37(5), 243-252.


About Beth Hawkes (146 Articles)
Nice to meet you! I'm a Nursing Professional Development Specialist in acute care, a writer, speaker and career columnist.

6 Comments on Nurse-Patient Ratios : A Biased View

  1. I am a 55yr old associate degree RN with some hearing loss. Please advice me on some career choices for the future. I need a job. I have prior authorization and Disease Mangement skill along with HEDIS. I have been hands off for three years.

  2. Mike vonTschudi // August 2, 2017 at 2:59 pm // Reply

    I’m sorry you couldn’t get this post accepted for publication anywhere. It’s clearly a timely and controversial topic that deserves an open debate.

    Personally I’m not sold on the idea of mandatory nursing ratios, and professionally lean towards the AHA position that such decisions should be made locally, not nationally or in state house chambers.

    For the past decade California has been a national laboratory on nurse : patient ratio’s so I’m curious…where’s the data? While I wouldn’t argue that patient satisfaction/HCAHPS Is a meaningful metric to judge success or failure it’s all we have….thanks to nursing’s abject silence and lack of opposition to such measures being imposed upon us from those who couldn’t walk a step in our shoes, much less a mile. Is there data coming out of CA that I’m not aware of showing higher rates of patient satisfaction across the board? What about staff retention? Are there fewer numbers of bedside staff nurses planning transition to advance practice primarily because of workload issues 2º mandated patient ratios?

    Is there another approach available to us in the profession to transfer some of the workload onto licensed technicians or certified assistants…or changing assignment paradigms that are worth exploring?

    • Hi Mike! 🙂

      I really like the idea of open debate and would love to hear more like this.

      There is a lot in the literature that correlates patient outcomes with staffing levels of nurses- but as yet, nothing to show the effect on nurse-sensitive indicators, HCAPS, and retention.

      But then there is absolutely nothing to show the efficacy of “staffing committees”. So to nurses who have 7 or more patients on medsurg floors under “staffing committees”, I’d have to ask “How’s that working for you all?”

      I love your thought of transferring workload to techs…I have always said that nurses are too tasky, when what we really need to do is delegate the
      tasks…and think. Assess. Plan.

      Honestly, I can’t think of any task (FS, dsg change, suction etc etc) that cannot easily be taught to a tech. But some nurses allow their tasks to become their identity.

      • Mike vonTschudi // August 2, 2017 at 5:22 pm // Reply

        I would think that Aiken and colleagues would be churning out papers based upon the success of the California mandated nursing ratio measures by the tree load. Yet there are none (that I’m aware of).

        Clearly there are issues with the “staffing committees” as well. I’m wondering how to balance the need for a hospital to be full (or nearly so) AND provide adequate staffing. A hospital needs to serve the patients in their care and transferring them to a unit that may be short staffed gets them out of the Emergency Department where, I think we can all agree, admitted patients receive sub-standard care. (Disclaimer: this is NOT an attack on ED nurses).

        What about incremental or a (though it brings the vapors to some)…market-based approach to staffing by putting it in the public domain? Post on a daily basis what the nurse : patient ratio is in the lobby of every hospital AND require disclosure to patients or families by the provider requesting admission in the ED? Instead of having local hospital systems compete for business…(.oops I mean) patients based upon a catchy commercial or who has the newest shiny building, compete where the evidence (at least according to Aiken, et al) indicates it matters the most.

        The issue of delegation is a sticky one for some. Off the top of my head I would add sheath pulling to your list of acceptable delegation tasks. I think it was in the late 90’s when suggestions were made at a national level that some chores traditionally reserved for RN’s, routine med passes in nursing homes and/or med/surg floors for example, could be performed adequately and safely with property trained/certified/licensed techs. The national nursing organizations were, if memory serves, in a perpetual state of histrionics over the issue. These are the same organizations that in the late 80’s sold nursing out to NANDA, resulting in the transformation of nursing to that of a “cost centre,” and thus an expense to be controlled rather than an investment to be made. These same organizations were also silent during the imposition of HCAHPS on our profession. Silent!

        • I have thought the same about Aiken and maybe we just need more studies.

          I think we need incentives to attract and retain more nurses. Like my idea that I offer every year and so far is ignored- If hospitals provided a twice monthly housekeeper to each nurse starting at their 3 year anniversary, and increased it to weekly at, I don’t know, 5-10 years, it’d be hard to leave, Especially if they did windows. Or lease them a car (no taxes). Ok, just kidding. Not really.

          There are some states that have legislated transparent staffing, and the number of nurses (and, I believe, staffing plan) is publicly posted each shift. As in at the nurses station Love it.

          Here in CA, nursing assistants can’t even perform finger sticks any more. It really doesn’t take a nursing college education to do this. Yes, nurses and nursing organizations themselves have contributed to turf wars. Not that long ago, only doctors started IVs, removed sheaths and (a little further back) took blood pressures.

          A LOT, of nursing energy was misspent on NANDA. Please don’t say NANDA again. I have not yet forgiven them.

          • Mike vonTschudi // August 2, 2017 at 7:35 pm //

            In this area many facilities are starting to provide onsite daycare for employees. It’s something. I like the idea of housekeeping incentives but in the age of mega hospitals it might be cost prohibitive across the board. Perhaps a lottery would be more appropriate?

            No one other than a RN can do FS here either…or check stool guiac’s, etc. Makes one wonder why litmus paper as the gold standard for checking NG placement is still part of the CCRN exam still exists…but that’s for another post 😉

            Not sure how the legal profession works in CA, but in FL they advertise freely. “Did your 99 year old great grandmother get a bedsore? You should sue…and I wanna be your lawyer!” I’m frankly surprised that they haven’t figured out a way to litigate care standards and staffing.

            I don’t want to see the idiots in congress attempt to micromanage staffing. They’ve done such a great job with everything else. I love the idea of transparent and publicly disclosed staffing, updated daily. It sure as hell beats the nefarious and meaningless ER “wait times” that literally every hospital system in my area uses to attract patients to THEIR ER. If patients and their families make the connection with staffing and care, as I believe they’re smart enough to do—with nursing organizations at the forefront (actually advocating for patients instead of their bottom line…or acting as political surrogates).

            NANDA. NANDA. NANDA. 😉 It was only the start. The death knell of modern nursing was the profession’s acquiescence to HCAHPS…equating reimbursement to the whim of human satisfaction.

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