Mandated Staffing Ratios May Not Be The Answer To Improved Care

• Not all nursing leaders agree that mandated staffing ratios can help staffing or care as a one-size-fits-all approach.
• The American Organization for Nursing Leadership (AONL) states ratios can’t help nursing shortages.
• Mandated staffing ratios have existed in California since 1999; some data shows it saves lives.

Rose Sherman, EdD, RN, NEA-BC, FAAN called mandated nurse staffing ratios a “conundrum” and, alongside the American Organization for Nursing Leadership (AONL), does not support nurse staffing legislation. She argued that staffing ratios would not help address nursing shortages across the U.S., which she called “magical thinking” and “naive.”

The discussion, however, does not address how the ratios could result in a safer working environment for nursing staff or better patient outcomes. We spoke with two nursing leaders about mandated ratios and their thoughts on California, the only state with ratio laws since 1999.

Mandated Staffing Ratios: What the Numbers Show

Sherman proposed working environments have significantly changed since research assessed the impact of staffing ratios, including a rapidly aging population and a post COVID-19 environment in which more nurses have less experience and patient acuity has dramatically increased.

She believes that the gig economy could make it impossible to build strong work cultures and create powerful team relationships, even within the healthcare industry. To support her thesis, she interviewed two executives from AONL and included their concerns about the American Nurses Association (ANA) Nurse Staffing Task Force and the potential unintended consequences of their recommendations.

We spoke with Teresa Sanderson, a consultant helping nurse entrepreneurs and hospice liaisons and the founder of Nurses Feed Their Young, working to help improve nursing culture.

“Mandated nurse staffing ratios do little to resolve the overall issue of the nurse staffing crisis,” she said. “These mandates make it more difficult for organizations to staff their facilities based on the acuity of patients and completely disregard nursing judgment related to staffing needs.”

The AONL leaders supported the majority of the recommendations by the ANA, including that “appropriate staffing is a critical component of optimal patient care.” However, they believe mandated staffing ratios would remove real-time clinical judgment and flexibility from floor nurses.

Christine Frazer, Ph.D., MSN, is a senior core faculty member at Walden University. She is a nurse, educator, and researcher and serves on the Editorial Board for Teaching and Learning in Nursing.

“Although nurse burnout existed prior to COVID-19, the research conducted by myself and colleagues showed overwhelming evidence that nurse burnout increased during the pandemic,” she said. “I like how Carol Bradley, in her article, noted that nurses at the bedside have a unique perspective in addition to the critical knowledge they have regarding the ever-evolving changes that take place when it comes to patient care needs.”

The Impact of Staffing Ratios on Patient Care and Nursing Shortages

ANOL states that legislating staffing ratios does not consider differences in the variation of patient type, care teams, and size and location of hospital facilities. By not considering these differences, the leadership fears that patient care will ultimately suffer, and ratios should not be a one-size-fits-all approach.

“Additionally, a mandated ratio will not magically make the work environment for nurses “better” nor “guarantee” safer care. There is more to the “work environment” that goes beyond just a ratio,” Frazer concurred.

In an editorial in early 2024, Amy Thomas, MSN, APRN, FNP, system chief nurse executive for the Hawaii Pacific Health System, agreed with ANOL leaders. She wrote that evidence from California, the only state to have a comprehensive law addressing staffing ratios in place, has not experienced improvements in workforce shortages.

“Nursing clinical judgment is essential to solving the day-to-day changes in patient acuity, or the severity of a patient’s illness, and flexibility is needed,” she wrote.

While this is true, it is evident from many news stories that hospital management has not considered nursing clinical judgment when determining staffing without mandated ratios. This has been the basis for many nursing strikes that have occurred across the country in the past year.

“Positive practice environments foster healthy work environments where nurses can grow, thrive, be safe, and stay well,” Sherman wrote in her interview with AONL leaders. To achieve a positive practice environment, hospitals must care for patients and nurses, protecting both by utilizing appropriate nurse-to-patient ratios that account for influencing factors. Sanderson noted that changes in the workplace post-COVID have impacted nurses and their focus on mental health, safe work environments, and patient outcomes.

“As a nurse of more than 30 years, I now see nurses standing up and saying as a group, “You cannot pay us enough to work under these conditions.” Self-care and life balance have become sacred to nurses who have experienced burn-out, anxiety and depression,” she told Nurse Journal.

How States Are Prioritizing Care with Staffing Rules

There is no simple answer to this complex healthcare challenge that affects patient outcomes, safety in the workplace, and nursing shortages across the country. In Sherman’s interview, she asked the AONL leadership what alternative strategies they were pursuing to help improve the working environment for nursing staff.

They noted that the role the organization serves is to convene thought leaders so they can collectively transform patient care and champion diversity and belonging in communities. Yet, according to National Nurses United, one of the largest nursing unions and professional associations, the California safe staffing ratio is saving lives.

There are decades of data showing safe staffing reduces patient mortality and readmission to the hospital and improves recovery. The National Nurses United (NNU) noted that 10 years after the law was enacted, a 2010 University of Pennsylvania study demonstrated that California lives were saved. The study suggested that if the 1:5 ratio were matched in surgical units in New Jersey, the hospital would have 14% fewer deaths, and Pennsylvania would have 11% fewer deaths.

In her editorial, Thomas noted that two of the unintended consequences of staffing ratio mandates in California have included reduced access to care and additional costs to patients and insurance companies.

“When it comes to staffing ratios, there is a starting point that must be in place, just when it comes to scheduling alone,” Frazer noted. “However, by simply having a one-size fits all ratio approach is simply not the best answer.”

According to the NNU, the California law has provisions of minimum standards for nurse-to-patient ratios. These were lifted during the COVID-19 pandemic to ensure that all patients physicians wanted to admit could be admitted.

The waiver was lifted on February 8, 2021, which Health Leaders reported was welcome news to the California Nurses Association. Many of the 100,000 members had actively protested the waiver and some had considered going on strike.

“This is an incredible victory for patients and nurses because we know that safe staffing saves lives,” said Zenei Triunfo-Cortez, RN, and a president of the California Nurses Association and National Nurses United. “It was our collective action as a union that defeated the money and lobbying power of the hospital industry, which we know is focused on the bottom line, not safe patient care.”

Anita Girard, DNP, RN, chief nursing officer, and vice president of nursing at Los Angeles-based Cedars-Sinai, echoed the benefits the ratios have for California nurses.

“Many of the nurses that we hired have expressed how much they appreciate ratios being defined in the state of California,” Dr. Girard said.

While California is the only state legally required to meet minimum staffing ratios, other states use rules to define nurse staffing. Some hospitals use staffing committees of at least 50% clinical nurses, while others have a planning committee that must report to the public at least once a month.

Massachusetts mandates a staffing ratio only in the ICU, while New York hospitals only report staffing numbers when requested by the state. Frazer suggested input is needed from nurses, leaders, and other staff to consider all factors influencing staffing.

“The research conducted with my colleagues (Sullivan, Sullivan, Weatherspoon, & Frazer, 2022) identified contributing factors to burnout,” said Frazer. “Some of these factors include job stress, inadequate pay, and staffing.”

Meet Our Contributors