The healthcare industry has long contended with the problem of nurse staffing shortages. This critical profession has, over the years, become almost synonymous with long hours, back-to-back shifts, and overwhelming patient loads. In 1999, California became the first state to implement mandated nurse patient ratios and regulations which limited the number of patients any one nurse may have on their roster. Since that time, other states have slowly begun to follow suit in an attempt to make the hospital a safer place for both nurses and their patients.

A controversial topic with mixed statistical results, it can be difficult to know what the exact requirements are in the state where you work. Current regulations are being constantly updated, and it is vital to understand both the legal requirements and ethical concerns, for the combined benefit of your organization, nurses, and patients.

Legislation and Regulation for Mandated Nurse Patient Ratios

As of March 2018, fourteen of the fifty United States have official legislature which mandates controlled nurse staffing ratios. Most do not specify a set proportion, however require hospitals to outline and manage staffing policies which independently specify a standard ratio. Most of these ratios vary by hospital unit.

Legislation for nurse patient ratios by state are as follows:

  • California – statewide mandates set a mandated nurse patient ratios that must be maintained at all times by unit. Largest allowable ratio is 1:6 in initial surgical units, as well as psychiatric care; smallest ratio is 1:1 in the OR. For more unit-specific ratios, follow this link.
  • Connecticut – requires hospitals to maintain a staffing committee which is populated by at least 50% RNs currently providing care. The nurse staffing plan developed by this committee must include a “minimum professional skill mix”, and consider employment practices regarding temporary and travel nurses.
  • Illinois – requires hospitals to maintain a staffing committee which is populated by at least 50% direct-care RNs. Staffing plan must include a means of communication for recommending policy to hospital administration. Nursing performance data must be reviewed by committee semiannually.
  • Massachusetts – statewide mandates set mandated nurse patient ratios of 1:2 in emergency and critical care units.
  • Minnesota – requires a designee to develop a staffing ratio with input from hospital staff.
  • Nevada – requires hospitals to address an annually-updated staffing plan which acknowledges nursing labor unions, implements data from established patient care quality matrices, and protects all nursing staff from retaliation if they refuse a job due to increased patient load levels.
  • New Jersey – requires hospitals to annually disclose nurse patient ratio statistics to the public.
  • New York – statewide mandates set a minimum nurse to patient ratio which must be disclosed to the public. Largest allowable ratio is 1:6 in the healthy postpartum pediatrics unit; smallest ratio is 1:1 in trauma, late-stage labor, and the OR.
  • Ohio – requires hospitals to maintain a staffing committee which is populated by at least 50% direct care RNs, and which seeks input from all RNs on staff.
  • Oregon – requires hospitals to maintain a staffing committee which is populated by at least 50% direct care RNs.
  • Rhode Island – requires all hospitals to submit staffing policies which are annually updated. Policies must specify unit, shift, average number of patients, average number of assigned nurses, and projected number of non-managerial direct care nurses.
  • Texas – requires hospitals to maintain a staffing committee which is populated by at least 60% direct care RNs. Committee must develop nurse staffing policies which considers annually-evaluated plan effectiveness based on nurse-sensitive and patient-care quality outcomes.
  • Vermont – requires hospitals to disclose nurse patient ratio statistics to the public. Also mandates that up-to-date nurse patient ratios for the past seven days be accessible to patients and hospital visitors.
  • Washington – requires hospitals to maintain a staffing committee which is populated by at least 60% direct care RNs. Hospitals must disclose their staffing policies to the public.

Currently, the US Federal government is pursuing legislation which would establish specific nation-wide nurse patient ratio mandates. The highest allowable ratio under this policy would be 1:6 in the Well Baby Nursery, similar to current standards in New York and California.

Final Thoughts on Mandated Nurse Patient Ratios

Central to the conversation regarding the potential for increased regulation of nurse patient ratios is whether these policies are actually efficacious in improving patient outcomes.

One study performed in a number of Massachusetts care facilities following the state’s implementation of their 1:2 critical care unit policy suggests that increasing nurse to patient ratios does not sway patient outcomes. This research compared results from 6 in-state ICUs to 114 out-of-state ICUs, and found no significant difference which could be credited to regulated proportions. Other investigations have come up with conflicting outcomes.

The American Nursing Association supports federal regulations which set minimum nurse to patient ratios, citing not only increased patient safety, but also increased quality of patient care, as well as the emotional wellbeing of direct-care nursing staff themselves.

The issue of nurse patient ratios is an incredibly nuanced problem which requires flexibility and constant reevaluation of policy and hospital census statistics. One solution may be for hospitals to prioritize hiring temporary and travel nurses, to address the ever-changing needs of their patients and the organization as a whole.

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