Hospital nurse staffing ratios: overdue safety imperative or outdated mentality?

On August 17, 2023, Oregon’s governor made history by signing the second-ever comprehensive nurse-to-patient hospital ratio law in the US. The last time such a law was enacted was 1994, in California. The CA and OR laws at a high-level (and following roughly the same template, despite being two decades apart), set a minimum number of nurses who must be staffed per patient in each hospital ward.

Staffing standards have long been a priority issue for nurse advocacy groups and aligned legislators throughout the two decades separating the CA and OR laws, and many states have had a ratio bill be raised at least once in that period. Over the last three years, there has been a big, renewed push, both at the federal-, and state-level: a staggering 15 individual states have introduced their own version of a ratio bill since 2021. However, while OR was a breakthrough, the recent bills have failed in over half the states in which they have been attempted. 

Understanding the renewed push for staffing standards (and the arguments and forces against them) relates closely to the pressing issue of ensuring sustainability in the nursing workforce, as well as safe patient care in hospitals - in the face of a mounting crisis of nurse shortages that we face industry-wide.

What are the sides of the debate?

The recent surge of legislation can best be understood as a reaction to a worsening state of understaffing in hospitals. Direct care nurses are increasingly vocal that they are asked to take care of too many patients to manage safely. Nurse staffing ratios are positioned as both an issue of patient safety and of fair workplace conditions: i.e., improper ratios cause burnout. Unions, such as the ANA and the NNU have made ratio laws core to their platforms. There have been several recent prominent strikes specifically regarding unsafe staffing practices.

Advocates for staffing ratio laws position the laws as a response to worsening understaffing and nurse burnout

On the other side of the debate, most hospitals, as represented by organizations such as the American Hospital Association (AHA), and its owned subsidiary the nurse trade organization AONL, oppose nurse ratios. The advocacy battle, both at the federal- and the state-level, is essentially between the AHA and AONL and the nursing unions. 

The hospitals’ argument is that ratios are an ineffective tool to accomplish the goals of improving nurse experience and patient safety, and come at a steep financial cost to them. In Maine, where a bill is currently pending, the Hospital Association lays out their argument: ratio laws are a rigid tool that is expensive for hospitals to implement, and that they do not fix the underlying problem, that there are not enough nurses for the care patients need.

For and against ratio laws

The causal relationship between higher nurse-to-patient staffing and better patient outcomes is well-documented. CA, now going on its third decade with ratios implemented, is often cited in ongoing legislation (and like OR, most bills copy the CA model in part or entirety). As one example, researchers ran a retrospective comparison between care delivered by hospitals in CA, PA and NJ in 2006. The study showed that because of the enforcement of ward-level minimums, CA had an overall higher nurse-to-patient ratio than PA and NJ. This in turn led to better patient outcomes (like lower mortality), and also indicators of lower nurse burnout and better retention. 

Proposed staffing laws continue to follow the CA model in part or entirely

Those opposed to ratios counter that ratios are overly rigid, that they unadvisedly attempt to replace the judgment of nursing leadership and do not incorporate factors specific to each facility such as support staff, clinical need, and even the nuances of a facility’s physical layout. Critics point out that CA, though often cited as a success story, has stumbled with unintended consequences, such as the underuse of support staff (i.e., with more nurses staffed, hospitals reverted to having RNs conduct non-clinical tasks like bathing patients). Critics therefore question that legally mandated ratios are a solution to burnout and retention: they say that shifting nurses away from clinical care, as well as a related loss of autonomy around personal and meal breaks, has been a dissatisfier in CA. 

Another path: technology for tailored staffing decisions

Now may be the time that the mandate for legal nurse-to-patient ratios is the absolutely most crystal clear to executives and legislators alike, and OR is unambiguously a breakthrough.

Eight of the state bills attempted since 2021 have failed, while only one (Oregon) has passed

Yet, the majority of recently attempted state laws have failed. Further, even with ratios enacted, the practical reality remains that there is a growing nationwide nursing shortage, which is already visibly causing delayed treatment.

At In-House Health, we believe that in all future scenarios for nursing at hospitals, insights appropriately matching nursing labor to clinical need are sorely needed. For that reason, we developed the first-of-its-kind “Workload Score” (WLS), a method of rating the amount of clinical workload for patients, combining insights from patients currently hospitalized and those scheduled for upcoming procedures.

In-House's platform ensures efficient and consistent staffing based on clinical complexity and nurse experience

Our methodology addresses where static nurse-to-patient ratios fall short, including more accurate prediction and tailoring of staffing to reflect legal or internal minimums (where applicable). This approach allows nursing teams to specifically resource themselves to the needs of patients, which naturally varies not just due to census, but also to clinical task requirements and the level of experience of the nursing team. We believe that management tools like ours, along with bedside resources like AI automation and virtual nursing can be part of a technology-driven path for innovating ourselves out of the nursing shortage crisis.

About the author

Ari Brenner is a repeat healthcare technology entrepreneur and the founder and CEO of In-House Health, a predictive nurse team modeling platform powered by clinical Machine Learning.