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Nurses are pushing to limit the number of patients that can be assigned to a single person — a move that advocates say will make care safer and improve working conditions.
The American Nurses Association, which officially threw its support behind minimum nurse-to-patient ratio mandates in 2022, tracked nurse staffing bills in 21 states this year, many involving ratios. Federal ratio legislation was also introduced.
Hospitals charge that mandatory minimum ratios are a bad way to address chronic understaffing because they cause reduced services and higher prices.
Powerful industry opposition has led some states to pass weak alternatives, such as requiring hospitals to publicly report their ratios or establish internal committees containing nurses to create staffing plans.
Journalists have to dig into the fine points to discern how a particular piece of legislation will affect patients.
“These policies are typically presented in monolithic terms, but the detail of policy design really matters,” said Matthew McHugh, Ph.D., director of the University of Pennsylvania nursing school’s Center for Health Outcomes & Policy Research.
Here are some reporting tips, compiled with input from McHugh and other experts.
Learn the history. The first U.S. law to mandate nurse staffing ratios for hospitals passed in California in 1999 and took effect in 2004. After that, hospitals largely blocked efforts to expand ratio laws in other states. An exception was Massachusetts, which approved minimum ratios for intensive care.
The pandemic deepened nurses’ moral distress, spurring them and their unions to step up lobbying as well as add minimum ratios to collective bargaining agreements. In 2021, New York passed minimum ratios for intensive care and critical care, although the state’s lawmakers rejected standards for other types of hospital units.
Finally in August, nurses in Oregon declared a big victory when their state adopted sweeping minimum ratios for registered nurses and certified nursing assistants [see graphic]. Passage entailed significant concessions to hospitals, including removing workforce expenses from the state’s health care cost growth cap. Still, union leaders said they hope other states will copy the standards.
Report policy details. Does the legislation establish specific ratios, and for which units? Do ratios apply during rest and meal breaks? What types of nurses are included? Is overtime limited? Are remote or virtual nurses allowed? What’s the implementation timeline? What are the penalties for non-compliance?
Ask about other state policies. Ratio laws can’t fix everything. Does the state participate in the Nurse Licensure Compact? Do nurses have whistleblower protections? How about loan forgiveness? Are there incentives for nurses to work in underserved areas?
Interview frontline nurses. “It’s not just the numbers,” said Diana Mason, Ph.D., a professor at The George Washington University School of Nursing’s Center for Health Policy and Media Engagement. Along with talking to patients and their families about how care differs between well-staffed and understaffed facilities, she suggests asking nurses what difference having an additional colleague on duty makes in their ability to provide care, especially spotting and responding to emerging complications.
Unions can connect reporters with their members, who can be quoted by name without fear of retaliation. Nurse managers, on the other hand, are unlikely to speak out about unsafe staffing.
Cite the copious research. Numerous studies over multiple decades have linked higher nurse staffing levels to safer care and better outcomes, including lower mortality.
In an unusual large-scale experiment, Queensland, Australia, implemented minimum nurse ratios in its public hospitals in two phases in order to assess their impact. Hospitals in the first phase experienced greater reductions in mortality, readmissions and length of stay than hospitals where staffing policies initially remained unchanged.
U.S. minimum ratio laws have consistently been linked to improved staffing and greater nurse satisfaction, although observational studies have not always detected associations with better patient outcomes.
Point out misleading or contradictory claims. Hospitals assert that mandatory minimum ratios remove nurses’ flexibility to deliver care based on patient acuity, but ratios establish a floor, not a ceiling. California’s rules, for example, provide for additional nurses to be assigned if patients have complex medical needs. Likewise, hospitals charge that ratio laws increase costs, but some analyses suggest that additional staffing largely pays for itself.
Cover alternative approaches. According to the American Nurses Association, nine states require internal staffing committee laws and five require public reporting. One analysis found that these measures have had little impact.
With staffing committee laws, “We suspect that is because none required hospital leadership to accept the committee’s recommendations,” said a co-author of the analysis, Patricia Pittman, Ph.D., director of George Washington University’s Fitzhugh Mullan Institute for Health Workforce Equity (Pittman’s evidence review on hospital staffing and outcomes, which she wrote for Washington state, is worth reading).
Incidentally, news organizations may shoulder some blame for failing to spotlight public reporting programs, which rely on patient awareness in order to drive business to hospitals with higher ratios. The analysis noted that when New Jersey’s reporting program was launched, “the media hardly acknowledged its existence.”
Recently, states have tried to toughen enforcement, with mixed results. In April, Washington boosted hospitals’ accountability for following their staffing plans. Yet a month later, Minnesota lawmakers torpedoed staffing committee legislation with strong public reporting and compliance measures after Mayo Clinic threatened to cancel its future development projects in the state.
