An original article in the August issue of Health Affairs looks at the complexity of the landscape around nurse staffing-related legislation. As it turns out, different state legislatures have taken very different approaches to the issue of hospital nurse staffing ratios, with some states taking no action, and others mandating nurse staffing committees (Connecticut, Illinois, Minnesota, Mississippi, Texas, Colorado, Nevada, Washington), mandating nurse staffing ratios for one unit (Massachusetts, New York, Ohio, Oklahoma, Arizona), or mandating nurse staffing ratios across multiple units (Oregon, California).
The researchers—Nithya Krishnamurthy, Neha Mukherjee, Bevin Cohen, Melissa Mazor, and Jacob M. Appel—begin their article, “Hospital Nurse Staffing Legislation: Mixed Approaches In Some States, While Others Have No Requirements”—by writing that “The decades-long debate over hospital nurse-to-patient ratios has intensified in the wake of the COVID-19 pandemic amid a critical labor shortage that has brought staffing, which is lean under ordinary conditions, to crisis levels across the United States. By nearly all accounts,” they write, “higher levels of nurse staffing are associated with reduced mortality, readmission, falls, infection, and length-of-stay, and they are protective against nurse burnout and turnover. Lower staffing levels, in contrast, drive not only poor outcomes but also racial disparities in care. The list of demonstrable benefits to having nurses care for fewer patients continues to lengthen, and the question of how best to achieve this outcome grows in importance with each addition.”
On the other hand, the researchers note, “there is limited consensus regarding whether and which legislative approaches should be part of national and local strategy for addressing staffing challenges.” And that is where the complexity comes in, as state legislatures are taking such diverse approaches to the issue that it becomes an apples-to-oranges-comparison problem.
The authors note that “Seven states have statutes pertaining to staffing ratios for at least one hospital unit. Of these, California and Oregon have the most comprehensive statutes, with specific ratios for multiple hospital units. California mandates a 1:2 nurse-to-patient ratio in critical care units and labor and delivery suites, a 1:4 ratio for the emergency department, a 1:5 ratio for medical/surgical units, and a 1:6 ratio for psychiatric units, with financial penalties for violations. Oregon mandates the same ratios, except for psychiatry, which is left to the discretion of a multidisciplinary staffing committee that includes unit staff, and labor and delivery, which requires a 1:1 ratio for patients in active labor or experiencing complications, with adults of each hospital every three years.”
The other states that have legislated ratios have mandated ratios in only one unit or along one dimension. Those include Arizona, Massachusetts, New York, Ohio, and Oklahoma, all of which have different mandates of different types. Meanwhile, an additional eight states require nurse staffing committees, with six of those states specifying a percentage of committee members who must be registered nurses.
Interestingly, the article’s authors write, “California, where staffing ratio mandates have been in place for more than a decade, studies evaluating efficacy of the legislation have been mixed, with some reporting improvement in outcomes such as mortality, failure to rescue, and nurse-reported quality, and others finding no significant reduction in falls, decubitus ulcers, or restraint use. In addition, the impact of staffing on nurse-sensitive outcomes varied greatly by unit type, which is significant, as states choose which units to include in staffing mandates.”
Ultimately, the researchers conclude, “Nurse staffing legislation is growing more diversified across the US as states consider and adopt new policies in response to staffing shortages. Legislative interventions increasingly include mandated minimum staffing ratios. Across the eight states that had adopted staffing ratio statutes as of January 2024, there is significant variability in the ratios that have been set and the settings in which they apply.”
Importantly, they note, “No safe staffing legislation has addressed underlying factors that drive inadequate nurse staffing, such as reimbursement models that incentivize or necessitate lean staffing.” Ultimately, they conclude, the diversity of types of legislation will over time yield insights into which approaches might have real impacts—and which might not.
