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Pamela Tevington, BSN, RN-C, is Medical-Surgical Staff Nurse,Capital Health, Trenton, NJ.

Mandatory Nurse-Patient Ratios

T he issue of mandatory nurse-patient ratiosremains widely controversial among many vestedstakeholders, including nurses, patients, physi-

cians, unions, nursing organizations/lobbyists, re -searchers, employers (in particular, hospitals), and federaland state governments (Douglas, 2010). Support formandatory nurse-patient ratios is drawn from the beliefthat regulated registered nurse (RN) staffing will increasepositive patient outcomes, decrease nursing shortages,and increase nurse recruitment and job satisfaction(Unruh, 2008). According to Blakeman Hodge and col-leagues (2004), better RN staffing results in higher qualitypatient care (e.g. decreased hospitalization). What are theimplications of mandatory nurse-patient ratios? What arethe alternatives?

BackgroundIn the early 1990s, health care financing and hospital

restructuring led to a decrease in licensed caregivers andan increase in unlicensed caregivers (service aides). At thesame time, managed care requirements led to increasedpatient acuity and decreased hospital lengths of stay.Mandatory nurse-patient ratios became law in Californiain 1999 with the passage of California Assembly Bill 394,which mandated minimum, specific, and numericalnurse-patient ratios in hospitals. Passage of this legisla-tion led to changes in nurse staffing levels; RN workloadsincreased and RN job satisfaction decreased. Retainingand recruiting RNs became more difficult for hospitals(Blakeman Hodge et al., 2004). Additionally, the state ofCalifornia was reported to have one of the lowest nursepopulations in the nation (Buchan, 2005). These factors,combined with negative media attention related topatient care, gained the attention of stakeholders such asthe Institute of Medicine (Buerhaus, 2010a). However, thesuccessful lobbying for Bill 394 was due to the combinedefforts of the California Nurses Association (CNA),California Hospital Association, and the ServiceEmployees International Union over several years(Blakeman Hodge et al., 2004). Although motivated dif-ferently, these stakeholders influenced the bill’s passage.Each stakeholder submitted nurse-patient ratio recom-mendations to the California Department of HealthServices. The final bill, which was to be implemented in2004, mandated a nurse-patient ratio of 1:5 in medical-surgical units (smaller ratios were assigned to specialtyunits) (Buchan, 2005). Citing financial reasons, California

Governor Arnold Schwarzenegger sought to delay this billuntil 2008. However, he was overruled by a lawsuit filedby the CNA in 2005. The victory by CNA mandated the1:5 nurse-patient ratios in medical-surgical units whichare still in force (Longest, 2006).

AlternativesBill 394 is one type of state legislation pertaining to

staffing requirements. Two other types of state regulationidentified by the American Nurses Association includereporting/public disclosure and staffing plans/commit-tees. Currently, seven states have legislated staffing plans.Additionally, five have legislated public disclosure/publicreporting (see Table 1) (DeVandry & Cooper, 2009).

With use of staffing plans/committees, hospitaladministrators and nursing staff jointly determine andimplement staffing plans that will produce the bestpatient outcomes. Although there are some pronounceddifferences among participating states’ requirements, themajority of committees are required to include staff nurs-es and leaders (e.g., nurse managers and chief nursingofficers) as well as hospital administrators. Potential prob-lems arising from such committees include conflictingideas between nursing staff and administrators, increasedfinancial costs, and lack of consistent implementation ofstaffing plans by hospitals. States participating in publicreporting/disclosure either must report staffing patternsto a state agency or make the staffing information public(DeVandry & Cooper, 2009).

As an RN in a state that participates in public report-ing, I can attest to my hospital’s participation. In front ofeach nursing station, a daily census sheet is displayedwith the census and staffing. However, most patients andtheir families seem oblivious to the daily census sheet.Instead, patients often ask their individual nurses howmany patients they are assigned. Despite the positive

ProfessionalIssues Pamela Tevington

TABLE 1.State Staffing Regulations

States with Legislative Staffing Plans

States with Mandated Public Disclosure

Nevada New York

Texas New Jersey

Ohio Vermont

Connecticut Rhode Island

Illinois Illinois

Washington

Oregon

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attributes of planning committees and publicreporting/disclosure (e.g., increased nursing involvementand organizational accountability), problems remain intheir successful implementation and overall effectiveness.

Current Legislation/Priority SettingAlthough California remains the only state with man-

dated nurse-patient ratios, 17 states have introduced sim-ilar legislation (Buerhaus, Donelan, DesRoches, & Hess,2009). Bill A660 of the New Jersey Legislature was intro-duced on January 12, 2010, and referred to the Assemblyof Health and Senior Services Committee (State of NewJersey 214th Legislature 2010). The identical bill, S963,was introduced on February 4, 2010, and referred to theSenate Health, Human Services, and Senior CitizenCommittee. These bills call for specific, minimum nurse-patient ratios in both hospital and ambulatory units asfollows:• 1:6 in medical-surgical units (reduced to 1:5 after the

first year) and behavioral units.• 1:4 in step-down, telemetry, or intermediate care

units and for non-critical emergency rooms.• 1: 2 for critical or trauma patients (e.g., intensive care

units and burn units) and post-anesthesia units.• 1:1 for every patient under anesthesia.Pediatric and maternal health specialties have diverse andexplicitly detailed requirements. Additionally, these billsattempt to include some fundamentals of staffing com-mittees (e.g., staff nurse involvement) (State of New Jersey214th Legislature, 2010).

The continued interest in mandatory staffing billssuch as A660/S963 is related to several critical issues.Studies have associated increased RN staffing with anincrease in patient safety, quality of care, and patient sat-isfaction (Aiken, Clark, & Sloane, 2002; Dall, Chen, Seifer,Maddox, & Hogan, 2009; Kane, Shamliyan, Mueller,Duval, & Wilt, 2007), as well as a decrease in patientlength of stay, and nurse burnout and turnover (Douglas,2010). In addition, health care delivery has undergonedramatic changes (e.g., increased managed care) with eco-nomic implications. Increased regulation by federal agen-cies such as the Centers for Medicare and MedicaidServices (CMS) has had a major impact on hospital reim-bursement. In 2008, CMS established new regulationslinking Medicare hospital payment to patient outcomes(Buerhaus et al., 2009). Eight conditions (e.g., falls withinjury and catheter-associated urinary tract infections)were cited as never conditions, creating additional medicalcosts that will no longer be reimbursed. Finally, thenation’s increasing nursing shortage, which is partly dueto an aging nursing workforce with fewer graduates toreplace retiring nursing personnel, has affected hospitalstaffing negatively (DeVandry & Cooper, 2009).

Social, Ethical, Economic, andEnvironmental Implications

Research support for adequate staffing and balancedworkloads of nurses as essential to achieve good patient,

Professional Issues

nurse, and financial outcomes has led 17 states to intro-duce mandatory nurse-patient ratio legislation (Unruh,2008). However, lessons can be learned from Bill 394 andserious implications need to be addressed if other statesare to follow California’s lead. Primarily, no empirical evi-dence supports the specific numbers assigned throughmandatory ratios with better patient outcomes(Blakeman Hodge et al., 2004). Passing legislation withpossible far-reaching effects on nurses, patients, hospitals,and other stakeholders without sufficient evidence ispotentially dangerous. Additionally, once passed into law,legislation is difficult to change if research disproves itseffectiveness and public and private support of the nurs-ing profession could be affected negatively (Buerhaus,2010b). Another major concern with mandatory nurse-patient ratios is ignorance of critical factors, such as nurseeducation, skills, knowledge, and years of experience. InBill 394, only 50% of the mandated nurses must be RNs,which implies minimal differentiation between licensedprofessional nurses and RNs (Chapman, 2009).Mandatory staffing ratios also ignore other critical criterianecessary for adequate staffing decisions, includingpatient acuity and required treatments, length of stay,team dynamics of staff, physician preferences, environ-mental limitations, variations in technology, and avail-ability of ancillary staff (Douglas, 2010). Finally, manda-tory ratios are inflexible and do not allow for the dynam-ic changing of patient needs that nurses recognize and forwhich they should have input (Douglas, 2010).

Since the passage of Bill 394 in 1999, three studies(Bolton et al., 2007; Donaldson et al., 2005; Greenberg,2006) found no significant impact on nursing effective-ness (Douglas, 2010). To accommodate mandatorystaffing ratios, California hospital administrators havemade difficult decisions and changes. These includereduced hiring and dismissal of ancillary staff, holdingpatients longer in the emergency room, hiring moreagency and per diem nurses, and cross training nurses tocover breaks (Douglas, 2010). This has increased econom-ic costs for employers (e.g., increased bonuses necessaryfor nursing recruitment) and has led to increased work-load for nurses (e.g., having to perform more non-nursingtasks) (Chapman, 2009). To accommodate mandatorystaffing ratios, employers also have used other tactics tosave money, including decreased funding for supplies(e.g., equipment), environmental changes (e.g., upgrad-ing to single patient rooms), and educational costs (e.g.,tuition reimbursement) (Buerhaus, 2010a). Additionally,employers may choose simply to be non-compliant withregulations and pay a fee (e.g., $50 per patient per day)that is less costly than adhering to assigned mandates(Buchan, 2005). Through strict adherence to mandates,and with no input from nurses related to changes inpatients’ needs, employers may impact patient care qual-ity and adversely affect nurses’ workload and autonomy.Ignoring the dynamic interaction of technology, capital,and economic and labor supply variables may impose theincreased cost of labor on hospitals, taxpayers, and nurs-es themselves (Buerhaus, 2010a). Finally, allowing gov-ernmental intervention and entanglement through

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Mandatory Nurse-Patient Ratios

inflexible mandates may decrease nurses’ power and abil-ity to advocate for evidence-based practices for bestpatient outcomes (Douglas, 2010).

Policy Modification and NurseInvolvement

While California remains the only state with mandat-ed nurse-patient ratios, increased legislative activity with-in the last 2 years demonstrates some stakeholders (e.g.,nursing unions and state governments) are lobbyingactively for mandatory nurse-patient ratios (DeVandry &Cooper, 2009). Nurses will be challenged to become moreknowledgeable about what is best for their profession andtheir patients, and to consider more action (e.g., politicallobbying and advocacy).

The most powerful stakeholders and lobbyists for theprofession of nursing are the American Nurses Associa -tion (ANA) and the American Hospital Association,which are both opposed to mandatory nurse-patientratios (Rajecki, 2009). The ANA (2010a) acknowledgeddetermination of appropriate nurse staffing levels is prob-lematic due to budget realities, nursing shortages, andapparent lack of data to guide and make adequate staffingdecisions. However, mandatory nurse-patient ratios donot consider many critical factors (e.g., patient acuity).Implementing legislation with a single focus does notempower nurses to use their expertise for best patient out-comes, and fails to make health care facilities accountable(ANA, 2010b; DeVandry & Cooper, 2009). Instead, theANA supports legislation with recommended guidelinesfor establishing nurse staffing based on critical factors(census, patient acuity, nursing experience, available sup-portive resources). The Registered Nurse Safe Staffing Actof 2009 (S. 54) is a possible solution (DeVandry & Cooper,2009). Two critical components of the bill require staffnurses to be involved actively in the development of unit-based staffing plans and hold hospitals accountable fortheir proper implementation (ANA, 2010a). In effect, thisbill combines the use of staffing plans and public report-ing. The ANA (2010a) support of safe staffing and S. 54 isbased on belief in the need for an organizational environ-ment that values both patients’ individuality and nurses’skills/knowledge to create and implement high-qualitypatient care. This environment should encompass neces-sary organizational outcomes (e.g., financial stability),and nursing workload and satisfaction. It also should pro-duce safe, quality, and evidence-based patient care.

Having the support of the ANA for S. 54 instead ofmandatory ratio legislation is a positive and necessaryfirst step toward successful policy making/policy modifi-cation. However, much more work is needed by the nurs-ing profession for its successful implementation. First, theprofession must produce quality research to support itsnursing plans and utilize evidence-based tools for properapplication (e.g., patient acuity systems [PAS]). Tools suchas PAS usually are computerized and customized toenable nurses to document interventions and selectattributes from departmental lists. After an acuity level isdetermined, appropriate staffing recommendations are

calculated (Beck, 2009). Second, nurses at all levels needto become involved in lobbying. Increased involvementmust begin at an individual level (e.g., joining a profes-sional nursing organization or writing to a legislator) andalso include group efforts (e.g., research or attendingpolitical rallies). Nurses must recognize their worth, andadvocate in an effective manner for what is truly best forthemselves and their patients. Third, nurses must be ableto work cooperatively and competently with other stake-holders involved in determining appropriate nursestaffing (e.g., hospital administrators and physicians) toincrease stakeholder support and foster a climate thatcontinues to promote nursing at private and public levels(Buerhaus, 2010b). Finally, the nursing profession mustobtain the political knowledge and power employed byother powerful special interest groups (e.g., AmericanMedical Association) to ensure their employers will beheld accountable for obligations imposed on them bygovernmental laws.

ConclusionThe premise behind mandatory nurse-patient ratios is

that minimum, specific, guaranteed nurse staffing willproduce better patient outcomes and alleviate nurseworkloads and increase job satisfaction. However, this hasnot been proven (DeVandry & Cooper, 2009). TheAmerican Nurses Association advocates legislation thatwill empower nurses to create valid, reliable unit andpatient-specific staffing plans, and require public report-ing as outlined in The Registered Nurse Safe Staffing Act(ANA, 2010a). Passage of this bill would promote thevalue of the nursing profession and facilitate evidence-based practice. In addition, it would limit governmentalinvolvement and allow nurses to utilize their knowledge,expertise, and skills to provide effective care.

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Professional Issues

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