What with hospital downsizing, budget cuts, and a nursing shortage in the United States, it’s no wonder that an American Nurses Association survey found that 54% of their nurse respondents didn’t have sufficient time to spend on each patient.[1] The past two decades have seen overcrowding and understaffing that has led to longer hours and more stressful shifts for nurses, and as a result, higher burnout rates and lower retention rates. To combat this serious problem, in 2004, California became the first state to implement a law requiring all of its hospitals to limit the number of patients its nurses could treat at any given time.[2] Since then, many other states have been looking to follow suit, or at least regulate staffing ratios more closely, so it’s crucial to study not only the specific benefits of such laws, but also the detriments they can pose. Below is a list of those advantages and disadvantages to help enlighten you on this important issue:


Benefits of Required Minimum Nurse-to-Patient Ratios:

  • Published studies have shown that appropriate nurse staffing helps decrease nurse fatigue, thus promoting increased safety as well as job satisfaction.[3] Lowering nurse-to-patient ratios decreases nurse burnout, including chronic fatigue, irritability, insomnia, depression, weight gain, and other potential health risks that come from being overworked in a stressful environment.[4] One study found that a lower percentage of California nurses experienced both high burnout and dissatisfaction when compared with nurses in states without minimum staffing ratios.[5] Regulated ratios allow nurses to give better value-based care while also maintaining their own health.
  • Retention and recruitment rates also improve drastically with minimum nurse-to-patient ratios. The year California’s law went into effect, the California Board of Nursing reported that applications for nursing licenses increased by more than 60%, and by 2008, vacancies for registered nurses in the state’s hospitals plummeted by 69%.[6]
  • Patient mortality and the number of preventable mistakes – including patient falls, pressure ulcers, central line infections, and healthcare-associated infections – are all proven to decrease after minimum nurse-to-patient ratios are instigated.[7] After enacting its law, California hospitals saw procedural mistakes decline as well as outcomes improve – fewer patients got sick in hospitals, more recovered, and fewer suffered post-treatment complications that required them to return.[8]


Drawbacks of Required Minimum Nurse-to-Patient Ratios:

  • The largest concern that accompanies this change is that of its cost. Minimum nurse-to-patient ratio laws impose steep fiscal costs on hospitals and allow them little say in regards to staffing decisions.[9] Funding for nursing programs would need to be increased, and hospitals would be required to hire more nurses and increase their salaries and benefits so as to attract enough employees to fill the positions required. California’s transformation was certainly an investment, and not all states have the ability to spend the money required to enact such a law.[10]
  • Ratio laws might cause patients to wait longer for treatment. For patients waiting for admission into a ward, even if a bed is available and there isn’t much activity in the ward, nurses wouldn’t be able to see them due to the ratio requirement law.[11] Additionally, such laws don’t account for larger emergency situations happening within the hospital or the city that might require drastic action and changes in staff assignments.[12]
  • Though some studies have shown that lower nurse-patient ratios improve patient outcomes, others show that the California minimum law has had a limited impact on adverse events in hospitals and mixed effects on quality.[13] Though there is little doubt that nurses are benefited by this law, it is less clear how a patient may benefit.


Though everyone may not agree on the extent to which nursing-to-patient ratios should be turned into law, it’s clear that this topic is one that isn’t going away. As healthcare needs morph in this constantly shifting political, economic, and social climate, finding ways to provide better care for both nurses and patients will always be a relevant discussion.

[1] “Health experts debate the merits of nurse-staffing ratio law,” NursingLicensure.org, n.d. http://www.nursinglicensure.org/articles/nurse-staffing-ratios.html

[2] Ibid

[3] “Optimal Nurse Staffing to Improve Quality of Care and Patient Outcomes: Executive Summary,” Avalere Health LLC, Sept. 2015, http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-StaffingPlansRatios/Optimal-Nurse-Staffing-ES-Sep15.pdf

[4] Safe Staffing Ratios: Benefiting Nurses and Patients,” Department for Professional Employees AFL-CIO, May 2016, http://dpeaflcio.org/programs-publications/issue-fact-sheets/safe-staffing-ratios-benefiting-nurses-and-patients/

[5] Ibid

[6] Ibid

[7] “Optimal Nursing Staffing”

[8] “Health experts debate”

[9] Ibid

[10] Ibid

[11] Ibid

[12] Ibid

[13] Wilson Pecci, Alexandra, “Nurse-patient Ratio Law in MA Raises Cost, Quality Concerns,” HealthLeadersMedia.com, June 23, 2015,  http://www.healthleadersmedia.com/nurse-leaders/nurse-patient-ratio-law-ma-raises-cost-quality-concerns