Nurse Staffing Ratios: Overview and FAQ

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Written by Alexa Davidson, MSN, RN Content Writer, IntelyCare
A nurse meets with a young girl lying in a hospital bed, and they share a smile.

Nurse staffing ratios are the maximum number of patients a nurse can be responsible for in a shift. Setting a nursing workload is complicated and depends on many variables in a dynamic healthcare setting. However, the general rules are simple: The more patients in a nursing workload, the higher the risk of patient harm. With appropriate staffing ratios, nurses are able to provide high-quality care.

How can facilities address nurse-to-patient ratios in a way that supports patients, nurses, and the budget? We answer commonly asked questions about nurse staffing ratios to guide decision-making.

What Is a Nurse-To-Patient Ratio?

Facilities use staffing ratios to inform the number of patients in a nurse’s assignment each shift. California, one of the only states with mandated staffing ratios, defines nurse-to-patient ratios as “the maximum number of patients that may be assigned to an RN during one shift.”

A nurse-to-patient ratio is measured by comparing the number of nurses to the number of patients in an assignment. For example, if one nurse is assigned four patients, the ratio is 1:4. It’s also possible for a patient to have more than one nurse — critical care units commonly have 2:1 assignments, for instance.

One caveat is patient census turnover — between admissions and discharges, a nurse-to-patient ratio of 1:4 could potentially allow the nurse to care for several more patients on a given shift. Workloads are considered acceptable as long as a point-in-time ratio doesn’t exceed the patient maximum.

How Are Nurse Staffing Ratios Regulated?

There is no federal regulation for nurse staffing ratios. Centers for Medicare and Medicaid Services (CMS) states that facilities participating in CMS programs must have adequate staff to provide nursing care to patients. This includes registered nurses, licensed practical or vocational nurses, and other personnel.

Individual states must define what “adequate staffing” means at their healthcare facilities. This can be regulated by:

  • mandated staffing ratios
  • public reporting
  • mandatory staffing committees

Staffing Ratio Mandates

California and Massachusetts are the only states with mandated nurse-to-patient ratios. In California, nurse-to-patient ratios are regulated in acute care, psychiatric, and specialty hospitals. Massachusetts regulation limits patient maximums to one or two patients in the Intensive Care Unit (ICU). Nurses must use an acuity tool to determine if a patient is stable enough to be in a 1:2 assignment.

Staffing Committees

In some states, healthcare facilities are required to utilize staffing committees to address nurse staffing ratios. A board of nurses and healthcare leaders collaborate to determine safe ratios for individual units. They must make a core staffing plan based on their findings.

States with mandatory staffing committees include:

  • Connecticut
  • Illinois
  • Minnesota (staffing plan is done by the Chief Nursing Officer)
  • Nevada
  • New York
  • Ohio
  • Oregon
  • Texas
  • Washington

Public Reporting

Some states also require public disclosure of nurse-to-patient ratios. This is meant to incentivize facilities to be accountable and take actionable steps to improve staffing ratios.

The states that require public reporting include:

  • Illinois
  • New Jersey
  • New York
  • Rhode Island
  • Vermont

Effects of Regulation

While staffing committees and public reporting allow facilities to exercise accountability, research doesn’t support objective improvements in quality of care. A study examining alternative approaches to nurse staffing concluded that mandated ratios are the only intervention with quantifiable results.

The study measures the time patients get with nurses in “hours per patient day” for each intervention. States with mandatory nurse-to-patient ratios saw an increase in hours per patient day. There was no difference in hours per patient day in states with mandatory public reporting or staffing committees.

What Are the Effects of Inadequate Staffing in Nursing?

For every patient added to a nurse’s workload, the risk of patient harm increases. This was proven in one study examining safe staffing at acute care hospitals in Illinois. Results from the study showed that for every additional patient added to a nurse’s workload:

  • the odds of a longer length of stay increases by 5%
  • patients’ 30-day mortality risk goes up by 16%

Mortality and increased length of stay are costly to healthcare facilities. It’s in a facility’s best interest to take measures to prevent the risk of patient harm, whether financially or morally motivated.

What Are Recommended Nurse Staffing Ratios?

Although nurse-to-patient ratios are not regulated nationwide, facilities may use general standards as a guide. Adjustments may be made based on the level of care a facility offers, such as tighter ratios at a trauma center vs. a lower acuity hospital.

Below are the recommended nurse-to-patient ratios by specialty proposed by National Nurses United (NNU), the largest nurses union and professional organization for registered nurses. The recommendations are supported by data from the successful implementation of mandatory nurse-to-patient ratio guidelines.

Nursing specialty Nurse-to-patient ratio
Operating room 1:1
Trauma patient in the Emergency Department 1:1
ICU patient in the Emergency Department 1:2
Intensive Care Unit 1:2
Coronary Care Unit 1:2
Neonatal Intensive Care Unit 1:2
Post-Anesthesia Care Unit 1:2
Labor and Delivery 1:2
Burn unit 1:2
Acute Respiratory Care 1:2
Emergency Department 1:3
Step Down Telemetry 1:3
Pediatrics 1:3
Postpartum Couplets 1:3
Combined L&D and Postpartum 1:3
Antepartum 1:3
Medical/Surgical 1:4
Intermediate Care Nursery 1:4
Psychiatric 1:4
Other Specialty Care 1:4
Rehabilitation Skilled Nursing Facility 1:5
Well Baby Nursery 1:6

How Can Facilities Improve Nurse-To-Patient Ratios?

Staffing shortages create a smaller pool of nurses and can lead to higher nurse-to-patient ratios. It’s important for healthcare leaders to take steps to correct short-staffing and reduce the burden on nurses. Here are some ways to improve nursing workloads at your facility:

Stabilize Your Nursing Workforce

Facilities can work toward a solution for short staffing by creating flexible staffing models that adapt to the patient census. This may include having nurses available in float pools, W-2 nursing workforce pools, and per diem status.

Reduce Nurse Turnover

Leaders should create a positive work environment that makes nurses want to stay. Establish retention strategies that make nurses feel valued and heard within the organization.

Advocate for Mandated Ratios at the State and Federal Levels

Evidence supports the need for mandated nurse-to-patient ratios to allow nurses to deliver the care they seek to provide. Year after year, nurses propose safe staffing ratios to legislators only to be turned down. Show your support by advocating for laws and regulations that ensure safe nurse-to-patient ratio guidelines.

Improve Patient Care Today

Addressing nurse staffing ratios at your facility is an important step to providing high-quality patient care. Better ratios improve patient outcomes, reduce costs, and improve nursing morale. Stay connected with IntelyCare for more free insights for improving quality of care and other resources for your facility.