Burnout and stress among nurses is an acute issue. Almost one-third of registered nurses and two-thirds of critical care nurses say that they are planning to leave their direct patient care position in the next year with burnout being a major contributing factor. And nurses that plan to stay are deeply unhappy in their jobs, seeking change in their working conditions like never before, with thirty-eight labor actions thus far this year in the health care and social assistance sector, including the largest health care strike ever at Kaiser Permanente in seven states in October.
The primary driver of this burnout and labor unrest, according to nurses themselves, is not pay or benefit levels, but rather unsafe working conditions that nurses say put them and their patients at risk. In particular, nurses are concerned most about nurse-to-patient ratios across hospital units.
Many nursing groups and unions have been demanding that better working conditions be addressed for years, but policymakers have been slow to respond. The post-pandemic turmoil occurring in the health care workforce, however, may make the lack of progress on nurse-to-patient ratios untenable, and national policymakers are beginning to take notice. Senator Bernie Sanders (I-VT), for example, recently held a Senate Health, Education, Labor and Pensions Committee field hearing at Robert Wood Johnson Hospital in New Brunswick, New Jersey to draw attention to the nursing strike at the hospital, which helped to elevate this issue as a major concern.
There are currently very few policies in place across the country that protect nurses and their patients by limiting the number of patients in a hospital unit that each nurse has under his/her charge. This commentary provides five things to know about the longstanding policy issue of nurse-to-patient ratios, including some of the history of the debate, underlying concerns, and the potential impact for patients.
1. There is a dearth of state rules on nurse-to-patient ratios and the only federal rule is as a condition of participation in Medicare.
California is the only state that has legally defined comprehensive minimum requirements for nurse-to-patient ratios. For each type of care in a hospital setting, California law specifies the maximum number of patients that can be assigned to one registered nurse. Passed in 1999, with final regulations issued by the California Department of Health Services on July 1, 2003, the law provides specific nurse-to-patient ratios for acute care, acute psychiatric, and specialty hospitals that facilities were required to meet as of January 1, 2004. (See Table 1.)
|CALIFORNIA REGISTERED-NURSE-TO-PATIENT STAFFING RATIOS
|Type of Care
|Neo-natal Intensive Care
|Labor and Delivery
|Postpartum women only
|ICU Patients in the ER
|Trauma Patients in the ER
|Step Down, Initial
|Step Down, 2008
|Other Specialty Care, Initial
|Other Specialty Care, 2008
|Source: California Nurses Association, John Kasparak, “California RN Staffing Ratio Law,” Connecticut Office of Legislative Research, February 10, 2004, https://www.cga.ct.gov/2004/rpt/2004-r-0212.htm.
For example, in an intensive/critical care unit, a maximum of two patients can be assigned to one nurse in one shift, and in the postpartum unit, six patients can be assigned to one nurse in one shift. The law requires additional registered nurses (RNs) be assigned depending on patient needs and also restricts assignment of unlicensed staff without demonstrated competency. Hospitals that do not follow the ratio requirements are penalized with a fine, but there are exemptions to these repercussions and limitations to enforcement. Hospitals are excused from the penalty if staffing fluctuations are unpredictable and uncontrollable, and efforts are made to address them. Rural hospitals have the opportunity to request an exemption. The law was strengthened beginning in January 2020, increasing fines on hospitals that repeatedly did not meet the requirement.
During the height of the COVID-19 pandemic, Governor Gavin Newsom gave California hospitals the opportunity to work outside the ratios, which the California Nurses Association (CNA) protested. CNA has continued to protest in California because of what they call unnecessary leniency of the government in giving hospitals waivers from meeting the staffing requirements.
A few other states also have legislation relevant to nurse-to-patient staffing ratios, but their rules are much more limited than in California. For example, Massachusetts and New York have regulations, but they only apply to intensive care units (ICUs). Oregon also just recently passed a law that requires that, as of June 1, 2024, hospitals must have plans in place for specific ratios in a few acute care settings, including the ICU. Other states, such as Illinois, New Jersey, New York, Rhode Island, and Vermont, require public reporting of ratios; this is helpful for transparency, but does little to address understaffing concerns. Other states, such as Connecticut, Colorado, Illinois, Nevada, New York, Ohio, Oregon, Texas, and Washington, require hospitals to have accountable nurse-driven staffing committees. (See Map 1.) There is some indication that the impact of these types of committees varies depending on implementation. For example, a survey in 2019 in Illinois found that only 29 percent of Illinois nurses who responded to the survey indicated their hospital has such a committee. Several states have pending legislation to address safe staffing, ranging from requiring minimum ratios in Georgia, Illinois, Maine, Massachusetts, Michigan, and New Jersey to requiring hospitals to set limits based on patient acuity in Pennsylvania.
At the federal level, the only regulated standard that hospitals in the country must meet relevant to staffing is found as a condition of participation in the Medicare program. This requirement states that “The nursing service [in the hospital] must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.” Senator Sherrod Brown (D-OH) and Representative Jan Schakowsky (D-IL) have repeatedly introduced federal legislation—the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act—that mimics much of California’s law, but it has not yet moved forward.
2. Efforts to establish nurse-to-patient ratios are opposed by hospitals and hospital networks, which say they will limit necessary flexibility and exacerbate the nursing shortage.
For decades, nursing associations across the country have been advocating for policy change to ensure what they deemed “safe staffing” in hospitals. The California Nurses Association (CNA) was successful in shepherding such an effort in 1999 after a grassroots campaign, gathering broad support among nurses, and patients and hosting a large rally in Sacramento. The group was successful at the time in part because of the backlash taking place against managed care organizations, which were especially prominent in California and perceived as more interested in profit than patient care—a theme that also resonates today. The request from California nurses built upon a movement that began during the AIDS epidemic, when nurses at San Francisco General Hospital demanded specific ratios as part of their contract for the first time. CNA began advocating for legislation in the early 1990s to remove this issue from negotiations with hospital management.
Despite this history and grassroots effort, it was not smooth sailing for this California legislation. The staffing bill was first introduced in committee in the early 1990s, and finally passed by the legislature in 1997, only to be vetoed by Governor Pete Wilson. It passed again in 1999, and finally was signed into law by Governor Gray Davis. In California, even though nurses groups and other advocates of staffing ratios were able to overcome opposition by hospital industry and business groups, those forces continued to oppose the legislation. In 2003, for example, the California Hospital Association filed a lawsuit to block the legislation’s implementation, and when the lawsuit failed, the association lobbied then-governor Arnold Schwarzenegger to block certain ratios from going into effect. Schwarzenegger attempted to do so, but a state court overturned the governor’s exemption.
Today, National Nurses United (NNU)—the biggest nurses union in the country, of which CNA is now an affiliate—is currently one of the main leaders in the fight for strong nurse-to-patient ratios across the country and at the federal level, arguing that the California experience shows that these ratios help protect nurses and patients (see below). Other major proponents of legislation to set staffing ratios for nurses are grassroots organizations such as Show Me Your Stethoscope and Nurses Take DC. Nurses Take DC did a survey of registered nurses in 2021 and found that only 30 percent of surveyed nurses believed that staffing levels were based on patient needs and only 15 percent felt that nurse-to-patient ratios in their units or facilities were safe.
The main opposition to nurse-to-patient ratios comes from hospitals and hospital networks who often say that decisions about staffing should be driven by specific acuity and patient needs and that hospital leaders need to be able to make customized, flexible decisions about patient needs and flow in their particular facility. Hospitals also argue that such ratios would exacerbate the current nursing shortage, prevent hospitals from hiring other staff that are needed for care, and threaten overall health care access for patients because they would force some hospitals to close units and/or entire facilities if they are unable to meet the ratios.
In Minnesota, in one of the most recent fights for legislated ratios, the power of the hospital system in politics was in clear view. The Minnesota legislature was close to passing a Keeping Nurses at the Bedside Act that included set nurse-to-patient ratios, championed by the Minnesota Nurses Association. The Minnesota Hospital Association opposed the bill from the start, saying that it would cut hospital capacity in the state significantly. However, the bill continued progressing until Mayo Clinic—one of the most prominent health systems in the country, headquartered in Minnesota—threatened to pull billions of dollars in investments in the state if the bill went through. At first, the legislature moved to exempt Mayo Clinic from the requirements, but then quickly discarded the bill entirely once such a carveout was critiqued by other Minnesota hospitals that would not be exempt.
Historically, not all opposition to staffing ratios is from hospitals and business groups, however. Another, perhaps surprising, opponent of staffing ratios has been the American Nurses Association (ANA). The ANA, unlike NNU, is not a union that represents its members’ interests in collective bargaining, but rather an organization whose mission is to advance nursing as a profession. The ANA has been opposed to legislating on nurses ratios because the organization argues that nurses need independence and flexibility when it comes to staffing. In fact, the ANA was part of an effort that killed a Massachusetts 2018 ballot measure to implement nurse to patient ratios in hospitals. The measure failed 70 percent to 30 percent. At the time, the Massachusetts Health Policy Commission had said that the measure would increase costs in the state from $676 million to $949 million and opponents, including ANA, said that it would significantly reduce access to care. Recently, however, the ANA has come out in favor of minimum nurse-to-patient ratios, suggesting that momentum on the issue might be changing.
3. Evidence from California’s experience generally supports implementation of nurse-to-patient ratios but has not calmed opposition’s concerns.
When the California legislature passed its law in 1999, a group of researchers from the California Workforce Initiative at the University of California, San Francisco analyzed the issue to provide recommendations on specific ratios that the state could set. The researchers also cautioned that there may be particular unintended consequences, such as ratios motivating some hospitals to reduce staffing if they exceeded standards, and that there could be significant cost implications of implementation, because nursing costs, on average, were one-sixth of a hospital’s budget. They warned that it was hard to tell from existing literature at the time what specific ratios should be but that higher ratios tended to be associated with better patient outcomes, such as “decreased risk-adjusted mortality; decreased urinary tract infection, thrombosis, and pulmonary complications in surgical patients; decreased pressure ulcers; decreased pneumonia; lower rates of postoperative infection; and fewer medication errors.” However, they also found that hospitals considered “best practice” according to several sources did not necessarily have better staffing than other hospitals, which called into question whether higher ratios were necessary for quality care.
The passage of time since the implementation of ratios in California has provided sufficient opportunity to study the issue. When the Massachusetts ballot was considered, the Massachusetts Health Policy Commission synthesized relevant research and concluded in 2018 that there were four key takeaways from California’s experience: there was (1) a significant increase in nurse staffing in California hospitals and (2) a moderate effect on wages for registered nurses, but (3) no systematic improvements in patient outcomes and (4) not enough study of implementation associated system costs to draw conclusions on that issue. Regarding patient outcomes, some studies found an association between increased staffing and shorter hospital stays, and fewer pressure ulcers and hospital acquired infections, but many of the impacts on patient outcomes were mixed in part because results depended on what the staffing situation was like in the hospital prior to the legislation.
One seminal study in particular, drilling down on data from California’s experience and projecting what similar nurse-to-patient ratios would achieve in Pennsylvania and New Jersey found a few important results. California nurses were significantly more likely than Pennsylvania and New Jersey nurses to report a “reasonable workload,” “enough registered nurses on staff to provide quality patient care” and “enough staff to get work done.” And the study found that if New Jersey and Pennsylvania were to implement the California nurse-to-patient ratios, there would be 13.9 percent fewer surgical deaths in New Jersey and 10.6 percent fewer in Pennsylvania. There is also some indication, found in separate research, that the impact of increased staffing ratios may have a differential impact on Black patients as compared to white patients. Researchers theorize that this may be because of more complex needs of Black patients based on structural discrimination that has shaped higher risk social needs and co-morbidities.
One study found that if New Jersey and Pennsylvania were to implement the California nurse-to-patient ratios, there would be 13.9 percent fewer surgical deaths in New Jersey and 10.6 percent fewer in Pennsylvania.
A 2018 RAND Corporation analysis conducted with reference to the Massachusetts ballot initiative concluded that it was possible that some of the research looking at impacts on patient outcomes from the ratios did not look closely enough at differences across different types of patients, suggesting that more acutely ill patients might have benefited more from the increased ratios, but that this was not captured.
Another study found that hospitals in California did employ fewer ancillary staff after the ratios were implemented, such that nurses had to take on some additional duties such as bathing patients. It also found that hospitals did have some challenges with staffing during meal times and breaks for nursing staff, considering that meeting ratios was a requirement at all times under the California law.
Analysis outside the California experience indicated greater nurse staffing was consistently associated with decreased odds of hospital-related mortality among ICU patients, unselected surgical patients, and medical patients, and an additional study in Michigan of adults age 65 and older found that increased nurse staffing levels were associated with decreased risk of inpatient mortality.
Thus, while some of the research from the body of literature looking at increased nurse staffing may be mixed, in general it is safe to conclude that the benefits are positive for patients. However, the analysis from the Massachusetts Health Policy Commission that estimated expected costs to hospitals in Massachusetts of implementing a similar rule to California has a strong chilling effect, especially in states that have larger populations and considering hospitals with smaller financial margins.
4. The cause of the nursing shortage is disputed and it may be more related to nurses unwilling to work in current conditions.
One of the central issues in the debate over nurse-to-patient ratios is about the apparent shortage of nurses. In a recent poll, 94 percent of senior hospital executives said that addressing this nursing shortage was “critical” and that their systems did not have enough nurses available to address a health crisis. On the other hand, nurses groups, including the NNU, say that there are plenty of nurses in this country—it’s just that there is a shortage of nurses willing to work under current working conditions. Many people with nursing licenses have left bedside care, with rates especially high among younger nurses, and a recent survey from 2023 indicated that nearly a third of nurses were planning to leave bedside care within one year. A separate study found that more than 800,000 nurses were planning to leave bedside care by 2027, and those planning to leave were disproportionately new, younger nurses, citing stress and burnout. Perhaps not coincidentally, 62 percent of survey respondents also said that their workload levels had increased since the start of the pandemic.
Analysis of relevant data indeed suggests that there isn’t a shortage of nurses, but rather a shortage of currently employed nurses. Looking at the number of active registered nurses licenses versus the number of employed registered nurses, only 58 percent of registered nurses with licenses are employed as registered nurses in 2022 across the country, a slight decrease from 2021 and 2020 levels at 60 percent. The percentage of licensed nurses actively employed ranges from state to state, with a high of 73 percent employed in South Dakota to a low of 31 percent employed in Vermont. (See Map 2.) While it is difficult to discern a relationship between the states that have addressed safe staffing in policy and the states with higher percentages, California—which has had nearly two decades experience with nurse-to-patient ratios—is among the states with the highest rate of registered nurses with licenses employed as registered nurses.
5. The growth in the use of contract nurses aggravates existing problems for staff nurses and hospitals alike.
From both the hospital and on-staff nursing perspective, the increase in use of contracting services for nurses—often known as travel nurses—is aggravating the situation.
Travel nurses are registered nurses who most commonly are employed by staffing agencies and work in short-term roles in facilities all around the world. Travel nursing began in the 1970s in New Orleans, when hospitals needed an increased number of nurses to care for sick tourists in town for Mardi Gras. The use of travel nurses then became more popular as a way to fill in for nurses who were out for family leave. Because of the high need for nurses during the pandemic—especially in certain hospital systems because of high numbers of COVID-19 patients but also nurses being quarantined because of illness and exposure—the use of travel nurses skyrocketed. In January 2019 there were 14,328 postings for travel nurses and this number more than doubled to 31,309 in January 2022.
Many nurses are attracted to the idea of being travel nurses because of higher pay and increased flexibility. Before the pandemic, travel nurses earned between $1,000 and $2,000 a week. In part because of the increased demand for nurses that started during the pandemic, that rate has dramatically increased and can be between $3,000 to $5,000 per week in certain cities, especially in areas with critical needs. For example, because of the longstanding strike at Robert Wood Johnson Hospital, New Jersey has had a dramatically increased demand for travel nurses and is now the highest paying state for travel nurses in the country.
The use of contract nurses can aggravate existing problems for on-staff nurses and hospitals alike. One of the reasons that hospitals cite for not being able to increase investments in nurses to meet higher nurse-to-patient ratios is that they are already spending such a large portion of their budgets on labor, especially since the pandemic—when they increasingly had to turn to contract or travel nurses to fill major workforce gaps. Hospital leaders have said that labor expenses were 20.8 percent higher in 2022 versus 2019, in part because contract labor expenses increased a whopping 258 percent. These labor cost increases present a major budget challenge for hospitals, because labor accounts for half of the hospital budget. The higher pay offered for contract nursing also results in staff nurses leaving permanent positions for travel nurse positions, especially in rural and other underserved areas, which exacerbates staffing and access challenges.
On the other hand, from the staff nurses’ perspective, travel nurses are making the situation worse because not only are they draining significant resources from hospital budgets that could better fund staff nursing, but also travel nurses often have fewer patients assigned to them, and, if they are in a hospital where they feel there are unsafe conditions, they also know that their time with the hospital is short term so they can be less concerned about the conditions.
The issue of improving nurse-to-patient ratios in hospitals is an acute one and at the forefront of many labor disputes in the health care sector. It is one of the main issues that nurses cite as a reason for burnout, stress, and leaving their positions at the hospital bedside. It is not straightforward from a political or economic perspective, but still an important one for policymakers to grapple with as part of considering broad transformative changes needed to address burnout among health care workers. The research suggesting lives that could be saved if California’s nurse-to-patient ratios were implemented more broadly is powerful and, at a minimum, even if legal protections don’t go that far, increasing accountability for improving nurses working conditions and ensuring patients are getting the care they need is imperative.