MANDATED MINIMUM

STAFFING RATIOS: A
COMPLEX POLITICAL ISSUE
NIKKI SESSER
YOUNGSTOWN STATE UNIVERSITY
NURS 6900 HEALTHCARE ISSUES AND TRENDS
 INTRODUCTION
• Lower nurse to patient ratios
• Better patient outcomes
• Less incidence of nurse burnout and stress
• 14 States with legislation for Nurse Staffing (Huber, 2020): 
• California, Connecticut, Illinois, Massachusetts, Minnesota, New Jersey, New York, Nevada,
Ohio, Oregon, Rhode Island, Texas, Washington, Vermont 
• California only state with minimum mandated ratios 
• Massachusetts ICU only ratio
• Issues concerning Implementation
• Cost burden 
• Nursing Shortage
HISTORICAL ASPECTS 

• California Model
• Safe Staffing Law – AB 394 – Signed October 10th, 1999 (Press, 2021)
• All hospital units must run with set minimum nurse to patient ratios (Huston, 2020)
• 1:6 – med/surg and post partum units
• 1:5 – oncology, skilled nursing, and rehab facilities
• 1:4 – ER, stepdown, peds, antepartum, post partum couplets, 
• 1:2 – ICUs, Neonatal ICU, Labor and Delivery
• Ratios must be followed "at all times"
• Need to hire additional nurses to fill in for breaks
HISTORICAL ASPECTS
• American Hospital Association opposes federally mandated minimum ratios
• Mandated Staffing is a "one size fits all" approach (Volpe, 2021)
• States with legislation requiring hospitals to have staffing committees:
• Connecticut, Illinois, Nevada, Ohio, Texas and Washington
• Staffing committees run by nurses (Legislative Services Committee, 2008)
• Ensure units have skilled nurses to care for complex patients
• Units are staffed for changes in patient census and patient condition

• States requiring public reporting of staffing: 

• Illinois, Nevada, New Jersey, New York, Rhode Island, and Vermont 
SIGNIFICANCE TO NURSING

High nurse to patient ratios are associated with Burnout

Burnout is related to negative patient outcomes (Gutsan et al., 2018)

Falls, alarm fatigue, low patient satisfaction, Medication errors

2019 Study by Chen et al. - High ratios are correlated with nurse job dissatisfaction
Intent to leave their jobs was related to
1409 RNs given self-administered
client related burnout, personal burnout, Negatively impacts the nursing shortage
questionnaires
and job dissatisfaction 
 SIGNIFICANCE TO NURSING

• High ratios are correlated with negative patient outcomes 

• >1:4 responsible for a 7% increase in hospital mortality related to (Gutsan et al., 2018):
• Infections
• Pneumonia
• Decubitus ulcers
• Cardiac arrest
• Accidental death
• Increase in failure to rescue found in post op patients (Huston, 2021) 
 Challenges to Implementation:

The Nursing Shortage

• The nursing shortage directly impacts the implementation of standard ratios
• 80,000 RNs are expected to exit the workforce as of 2020
• Roughly 187,000 RNs are expected to retire 
SIGNIFICAN • 198,000 are expected to move into Advanced Practice
CE TO A More Complex and Chronically Ill Patient Population
NURSING (Huston,2021)
• People ages >85 are expected to increase from 6.3 million to 13 million by 2035
• 40% diagnosed with Diabetes
• 25% diagnosed with Cancer
• 43% with Heart Disease

Cost burden associated with implementation of mandated ratios

• Hiring additional full-time RNs, wage increases and operational costs 
• Massachusetts Health Policy Commission - $676 million to $949 million
(Heath,2019)
PROPOSAL OF RESOLUTION

• Several Approaches to safe ratios:

• Nurse-run staffing committees creating staffing plans 
• Associated with decreased length of patient stay and adverse events (McClendon, 2018)
• Ohio's legislation for staffing committee duties:
• Evaluation of staffing plans
• Follow guidelines and recommendations by accredited organizations
• Patient acuity, each units changing needs 
• Establishment of hospital policy for finding additional RNs when needed
• Staffing Matrixes that represent individual unit needs
• Public Reporting of Nurse Staffing Patterns
PROPOSAL OF RESOLUTION
• Incentivizing Nursing as a Career to address the Nursing Shortage
• Tuition reimbursement programs
• Require a minimum employment period after tuition is paid
• Wage increases
• Incentive pay for additional shift to compete with Travel RN wages
• Yearly Bonuses/ Sign on bonuses 
• Competitive Benefits Packages
• Rising Cost of Health Insurance – U.S. Workers are spending more out of
pocket on healthcare every year (Health Insurance: Premiums and Increases,
2018)
• Retirement 
 CONCLUSION
• Mandated Ratios is a Complex Nursing and Political Issue
• Requires a multifaceted approach to implement
• Legislation alone may not be the answer to improving patient safety and
decreasing nurse burnout
• Cost Burden a major factor
• Nurse Staffing Plans, Committees, Public Reporting of Staff, and
Incentivizing Nursing with legislative measures a better approach to safe
ratios
REFERENCES
Chen, Y. C., Guo, Y. L., Chin, W. S., Cheng, N. Y., Ho, J. J., & Shiao, J. S. (2019). Patient-Nurse Ratio is Related to Nurses' Intention to Leave Their Job through
Mediating Factors of Burnout and Job Dissatisfaction. International journal of environmental research and public health, 16(23), 4801.
https://doi.org/10.3390/ijerph16234801
de Cordova, P. B., Pogorzelska-Maziarz, M., Eckenhoff, M. E., & McHugh, M. D. (2019). Public Reporting of Nurse Staffing in the United States. Journal of nursing
regulation, 10(3), 14–20. https://doi.org/10.1016/S2155-8256(19)30143-7
Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., Lehwaldt, D., McKee, G., Munyombwe, T., & Astin, F. (2018). The effect of nurse-to-patient ratios
on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European journal of cardiovascular nursing, 17(1), 6–22.
https://doi.org/10.1177/1474515117721561
Gutsan, E., Patton, J., Willis, W.K., & Coustasse-Hencke A. (2018, April). “Burnout syndrome and nurse-to-patient ratio in the workplace.” Presented at the 54th Annual
MBAA Conference, Chicago, IL.
Heath, S. (2019, June 28). Nurse staffing ratios tied to high costs, Patient Safety Savings. PatientEngagementHIT. Retrieved August 3, 2022, from
https://patientengagementhit.com/news/nurse-staffing-ratios-tied-to-high-costs-patient-safety-savings
Health Insurance: Premiums and Increases. National Conference of State Legislatures . (2018, December 4). Retrieved August 3, 2022, from
https://www.ncsl.org/research/health/health-insurance-premiums.aspx
Huston, Carol. (2020). Professional issues in nursing: Challenges and opportunities (5th ed.). WOLTERS KLUWER MEDICAL.
Legislative Services Commission. (2008, September 12). Section 3727.52: Duties of Nursing Care Committee. Section 3727.52 - Ohio Revised Code | Ohio Laws.
Retrieved August 3, 2022, from https://codes.ohio.gov/ohio-revised-code/section-3727.52
McClendon, S. (2018, February 22). Ana applauds nurse staffing legislation. American Nurses Association. Retrieved August 3, 2022, from
https://www.nursingworld.org/news/news-releases/2018/ana-applauds-nurse-staffing-legislation/
Press, A. N. (2021, January 19). The patient-to-staff ratios won by California Nurses Save Lives. We need more of them. Jacobin. Retrieved August 3, 2022, from
https://jacobin.com/2021/01/nurses-covid-19-pandemic-safe-staffing-legislation-california
Smith-Kimble, C. (2022, May 11). How much do travel nurses make? NurseJournal. Retrieved August 3, 2022, from https://nursejournal.org/careers/travel-nurse/salary/
Volpe, K. D. (2021, June 19). Nurse-to-patient staffing standards bill has mixed support. Clinical Advisor. Retrieved August 3, 2022, from
https://www.clinicaladvisor.com/home/topics/practice-management-information-center/nurse-to-patient-staffing-standards-bill-reintroduced-congress/