The Case against Mandatory Nurse Staffing Ratios

Mackenzie Bean (Twitter) – Wednesday, January 18th, 2023

Washington state lawmakers have introduced a bill that would limit the number of patients a nurse can legally care for in hospitals, reigniting a long-standing debate over the benefits and consequences of mandated staffing ratios.

California became the first state to legally mandate minimum nurse staffing ratios in 1999, according to NPR affiliate WHYY. In 2014, Massachusetts enacted staffing limits for nursing in intensive care units.

Since then, nurses have become increasingly vocal about the need for lower staffing ratios, commonly raising the issue during protests or contract negotiations. In March 2022, nurses also called on The Joint Commission to require safe staffing ratios as a condition of accreditation for healthcare facilities.

Nurses contend staffing ratios have, in many cases, increased to unsustainably high levels that jeopardize care quality and contribute to clinician burnout. They argue mandated nurse-patient ratios would promote patient safety and prevent more nurses from leaving the field amid an already severe nursing shortage.

The Washington State Hospital Association said it “strongly opposes” the staffing ratios bill, a common stance from hospital groups in the U.S. They argue such ratios would exacerbate the nursing shortage, limit healthcare access and deny nurses the flexibility and independence to determine staffing needs.

“Ratios are a static and ineffective tool that cannot guarantee a safe healthcare environment,” Mary Ann Fuchs, DNP, RN, former president of the American Organization for Nursing Leadership, an affiliate of the American Hospital Association, said in a 2021 blog post. “Care is team-based and a lack of flexibility to provide staffing based on the acuity of individual patient needs jeopardized safe patient care.”

This one-size-fits-all approach would not meaningfully improve care quality and rests on the false notion that nurses are solely responsible for patient safety, according to the District of Columbia Hospital Association. Some hospital associations have expressed concern that the ratios may lead to longer wait times, reduced services or an increased dependence on temporary nurses to maintain ratios.

Nurse staffing ratios would also drive up hospitals’ operating costs and “threaten financially struggling hospitals,” the Illinois Health and Hospital Association said in a 2019 fact sheet opposing such legislation. A 2019 report from the Massachusetts Health Policy Commission found mandated nurse staffing ratios would cost an estimated $676 million to $949 million annually in the state, which has about half the population and number of hospitals as Illinois.

The American Nurses Association advocates for a legislative model that includes nurse-driven staffing committees “because this approach encourages flexible staffing levels,” the group said. The committees are tasked with creating unit-specific staffing plans based on patients’ acuity, along with staff members’ skills and experience.