implications of manadated nurse-patient ratios

What are mandated nurse-to-patient ratios?

Mandated nurse-to-patient ratios are the minimum number of nurses required by law to provide care to patients in different healthcare settings. Such minimum nurse staffing requirements were first implemented in California in 2004 (Aiken et al., 2010) following enactment of supporting legislation in 1999 (Aiken, Clarke, Sloane, Sochalski & Silber, 2002). Subsequently, various other states have established regulations or are in the process of enacting legislation to govern minimum-staffing levels for nurses (Aiken et al., 2010).

What led to setting up of such minimum nurse-to-patient ratios?

Mandated nurse-to-patient ratios arose from two premises. Firstly, it was suggested that such minimum staffing ratios would enhance patient outcomes by ensuring that healthcare facilities recruit adequate nurses thus ensuring quality care in their establishments (Aiken et al., 2002). This followed the link between a high nurse staffing and better patient outcomes in aspects such as chronic obstructive pulmonary disease, stroke, diabetes and coronary heart disease in previous studies (Griffiths, Murrells, Maben Jones & Ashworth, 2010).

Secondly, it was suggested that mandated nurse-to- patient ratios would enhance nurse outcomes. In this respect, it was advanced that the ratios would ensure appropriate staffing of various units thus reducing nurse burnout and job dissatisfaction (Aiken et al., 2002). Such positive nurse outcomes would then promote retention of nursing staff thus helping to address the increasing shortage of nurse in many places (Aiken et al., 2002).

What are the recommended ratios?

The patient-to nurse ratios required by California legislation differ by specialty. The requirements for each specialty are as indicated in table 1:

Specialty Patient-to-nurse ratio
Medical-surgical 5:1
Pediatric 4:1
Intensive care units 2:1
Telemetry 5:1
Oncology 5:1
Psychiatric 6:1
Labor/delivery 3:1

Source: Aiken et al. (2010, p. 910)

Have the ratios been effective in enhancing patient and nurse outcomes?

Mandated nurse-to-patient ratios have improved patient and nurse outcomes where they have been implemented. For instance, in a study by Aiken and colleagues (2010), comparison of hospitals in a state that had implemented such ratios (California) and two other states that had not implemented such ratios (Pennsylvania and New Jersey) found positive results following the implementation of the ratios. In California, nurses in the medical and surgical units served fewer patients compared to those in similar units in the other two states thus leading to better patient outcomes such as reduction in patient mortality (Aiken et al., 2010).

Although some studies have not revealed significant changes in some patient outcomes (e.g. patient falls and length of hospital stay) following implementation of staffing ratios (e.g. Donaldson, Bolton, Aydin, Brown, Elashoff & Sandhu, 2005; Donaldson & Shapiro, 2010), such studies have shown clear benefits in nursing outcomes. However, other studies have reported positive outcomes in patient-related aspects (California Healthcare Foundation, 2009; McHugh, Carthon, Sloane, Wu, Kelly & Aiken, 2012). Such findings indicate an overall positive outcome of implementation of mandated nurse-to-patient ratios.

Issues of concern on implementing mandated nurse-to-patient ratios.

Various concerns have been raised with minimum nurse staffing ratios. Two of these are that such requirements would force hospitals without appropriate staffing to lower their patient intake to meet the conditions, thus adversely affecting access to care. Secondly, it was opined that such requirements could lead to hospitals reducing the proportion registered nurses in total nurses to reduce their costs (Mchugh et al., 2012).

Studies have however shown that mandated nurse staffing ratios, results into a higher patient exposure to care by registered nurses rather than reducing such time (McHugh et al., 2012; Donaldson et al., 2005). Although, following the introduction of the nurse staffing requirements, hospitals in California have operated at lower financial margins, such effects have not been linked directly to the implementation but rather other aspects such as changing funding from sources such as Medicare (California Healthcare Foundation, 2009).

Final thoughts on mandated nurse-to-patient ratios.

Mandated nurse-to-patient ratios offer a way to improve nurse staffing and patient outcomes. Such ratios could especially help to increase the quality of care in initially low-staffed health facilities. However, it is vital for the ratios to be based on evidence to avoid very high ratios that affect the hospitals’ capability to provide care to a higher amount of patients.


Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987 – 1993.

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A, Spetz, J. & Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45(4), 904 – 921, doi: 10.1111/j.1475-6773.2010.01114.x

California Healthcare Foundation (2009). Assessing the impact of California’s nurse staffing ratios on hospitals and patient care. Issue Brief. Retrieved from

Donaldson, N., Bolton, L. B., Aydin, C., Brown, D., Elashoff, J. D., & Sandhu, M. (2005). Impact of California’s licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. Policy Politics Nursing Practice, 6(3), 198 – 210, doi:10.1177/1527154405280107

Donaldson, N. & Shapiro, S. (2010). Impact of California mandated acute care hospital nurse staffing ratios: A literature synthesis. Policy Politics Nursing Practice, 11(3), 184 – 201, doi: 10.1177/1527154410392240.

Griffiths, P., Murrels, T, Maben, J, Jones, S & Ashworth, M. (2010). Nurse staffing and quality of care in UK general practice: Cross-sectional study using routinely collected data. British Journal of General Practice, 60(570), 36-48, doi:10.3399/bjgp10X482086

McHugh, M. D, Carthon, B. M., Sloane, D. M., Wu, E., Kelly, L. & Aiken, L. H. (2012). Impact of nurse staffing mandates on safety-net hospitals: Lessons from California The Milbank Quarterly, 90(1), 160

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