The States With Nurse-Patient Ratio Laws

With the historic wave of nurse strikes over the past few years, one complaint unanimously stands at the forefront: unsafe nurse-patient ratios.

Nurses across the country are working with union representatives for safer nurse staffing conditions, despite considerable backlash from health systems.

Another piece of the puzzle are state-regulated nurse staffing laws, which have started gaining traction in multiple states. The specific aspects of these staffing laws vary, but they all establish mandatory staffing guidelines that employers must follow. If employers do not comply with staffing laws, they risk fines or other penalties.

Nurse staffing ratios are also being fought for on the federal level, as legislation proposing nationally standardized nurse staffing requirements was reintroduced in Congress in March of this year.

The push for staffing laws is certainly controversial, particularly among hospital and health system executives, but supporters say it will help address the nation’s ongoing serious nursing shortage. In fact, research indicates that proper nurse staffing improves patient outcomes and results in greater overall satisfaction for both patients and staff.

However, healthcare system executives tend to argue against nurse-patient ratio laws, with some representatives stating that doing so could severely affect patient care delivery. Others claim that nurse-patient ratio mandates do not address some of the underlying issues causing understaffing, such as poor pay and benefits. Opponents also argue that mandated ratios threaten hospitals financially and increase dependence on contracted staff.

Regardless of where you stand on the issue, mandatory nurse-patient ratios have already been implemented in the following four states, and it appears there is even more change on the horizon.

Oregon is the most recent state to adopt nurse-to-patient ratios for all hospitals. Under the new law, hospitals will be required to comply with certified nursing assistant (CNA) ratios of no more than seven patients on day shift and eleven on night shift. Beginning in June 2024, intensive care units (ICUs) will be required to staff at least one nurse for every two patients and medical-surgical units must staff at least one nurse to every five patients.

The new law also requires more staff breaks and a dedicated nurse to care for patients while the other nurse takes a break (rather than using the “buddy system” of handing off patients to another nurse, essentially doubling their patient assignment for the duration of the other nurse’s break). A fine of up to $5,000 per instance could be imposed on hospitals that violate the new law.

California is currently the only state with mandatory nurse-to-patient ratios across all units and specialties. The California RN Staffing Ratio law, which went into effect in 2004, requires the use of a standardized patient classification system to determine patient acuity and appropriate nurse staffing. It also restricts unsafe floating practices, requiring an orientation period and proof of clinical competence before assigning a nurse to a clinical area different from their home unit. It also forbids hospitals from cutting back on licensed practical nurse/licensed vocational nurse (LPN/LVN) and CNA programs as a result of the mandated ratios.

The Safe Staffing for Quality Care Act was passed in 2021, requiring all hospital ICUs in New York to comply with a 1:2 nurse-to-patient ratio. The law also requires hospitals to provide on-call coverage for registered nurses, ensuring that staffing ratios can be maintained in the event the scheduled nurses cannot report to work. The legislation was spurred by state lawmakers during the COVID-19 pandemic in response to overburdened medical staff.

A Massachusetts law enacted in 2014 requires a 1:1 nurse-to-patient ratio in the ICU. Critical care nurses may be assigned a second patient based on the assessment of unit staff nurses and a standardized acuity tool. Under the law, assigning an ICU nurse a third patient is strictly forbidden under any circumstances.

In July 2023, the Pennsylvania House of Representatives passed a safe staffing bill. Also known as The Patient Safety Act, the bill requires hospitals to set appropriate nurse-patient ratios based on patient acuity. The legislation has advanced to the state Senate floor and is awaiting a vote there.

A Georgia House of Representatives bill called the Safe Patient Limits Act was introduced in 2020. The bill would require hospitals and other healthcare facilities to limit the number of patients that may be assigned to a registered nurse (RN). The bill is undergoing review and awaiting a vote in the full legislature.

The Maine Quality Care Act would require the establishment of minimum staffing ratios for RNs at healthcare facilities across the state. It would also require hospitals to maintain staffing records and report staffing ratios to the department of health. The bill has advanced to the state’s Committee on Labor and Housing and is awaiting a vote there.

An Illinois bill called the Safe Patient Limits Act could limit the number of patients that may be assigned to an RN in specific situations (or on specific units). The bill would also require hospitals to use a patient acuity system to determine appropriate staffing needs and forbids assigning nurses to clinical areas in which they have had no training or orientation.

It would also require all temporary or agency nurses to receive the same amount of training that is given to permanent staff. The bill is awaiting a state House vote.

A New Jersey bill has been introduced in the state Senate that would mandate nurse-to-patient ratios across all specialties. It would require the implementation of a patient acuity system, and that system must be approved by at least half of the unit staff nurses prior to taking effect. It would also forbid hospitals from including nurses functioning in a supervisory role (such as a nurse manager) in the projected unit staffing numbers. The legislation is currently awaiting a state Senate vote.

In lieu of mandated staffing ratios, some states participate in public reporting systems. These systems are designed to hold states accountable for safe staffing ratios by requiring them to report their staffing ratios on a regular basis. The following states currently disclose their staffing ratios via a public reporting system:

Another way hospitals are assessing and addressing nurse-patient staffing issues is through hospital-based staffing committees.

These committees develop hospital-wide nurse staffing plans based on unit and patient acuity. Staffing committees are typically composed of a majority of direct-care nurses, as they are the ones who best understand workload realities and patient needs. When implemented appropriately, nurse-led staffing committees can be an effective tool for hospital leadership to connect with nursing staff and understand the underlying issues contributing to short staffing.

The following states currently have either laws or regulations in place that require hospitals to address nurse staffing internally through the creation of staffing committees:

Nurse-patient ratios are a controversial topic, but the push for safer nurse staffing will continue to gain momentum as nurses fight for legislative change at the state and federal levels. Establishing safer nurse-to-patient ratios is an essential piece of the nurse staffing crisis that ultimately protects the welfare of both nurses and patients.