RN to Patient Staffing Ratio — Here’s What the Federal Government Says

Nurse-to-patient staffing ratios are an area of concern for many nurses. Taking on too many patients at once not only causes high levels of stress, but it also increases the chance of mistakes or errors in patient care.

However, if a hospital is understaffed or too many health care workers are out sick while there’s an influx of sick patients (like, for instance, during the COVID-19 pandemic), bridging the staffing gap can be difficult. 

Hospitals need to ensure they have the proper number of registered nurses at all times, especially if there’s a risk of them becoming understaffed. Here’s what the federal government says about RN-to-patient staffing ratios.

What Is Considered Safe RN-to-Patient Ratios?

Having the proper number of RNs to patients is necessary for the proper care of others, and nurses are also trying to make it a legal standard. 

In 2019, Congress introduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act. The bill advocates for an amendment to the Public Health Service Act that would make a standard nurse-to-patient ratio required in hospitals and health care facilities. 

Key components of this bill include:

  • Mandated RN-to-patient ratios that are specific to unit types
  • An acuity system for bedside nurses to decide the level of care for patients
  • Strong whistleblower protection for nurses who report understaffing and unsafe assignments
  • A prohibition of substituting direct patient care from an RN with telehealth or other related technology
  • A required committee to oversee and regulate staffing requirements

Although exact ratios are often disputed, below are some of the RN-to-patient ratios that the National Nurses United recommends for safe staffing:

  • Medical/Surgical: 1:4
  • Emergency Room: 1:3
  • Intensive Care: 1:1
  • Psychiatric: 1:4
  • Rehabilitation: 1:4
  • Labor and Delivery: 1:2
  • Pediatrics: 1:3

Why Are RN-to-Patient Ratios Important?

Nurses know that fewer patient assignments means they can spend more time caring for each patient. They can pay attention to smaller, more subtle details while building a rapport and learning more information about their patients. 

They also won’t feel as overworked and stressed by having to tend to more patients, making them more well rested and attentive, and that can lead to preventing errors. When a hospital is understaffed, patients have a greater risk of infection, medical error, or even death. 

Having an improper RN-to-patient ratio negatively affects both nurses and their patients. This has a trickle effect that makes the hospital’s overall care quality go down alongside its reputation. 

Below are various reasons why RN-to patient ratios are so important and how being understaffing can affect a hospital:

  • Increased risk for medical errors and accidents such as falls
  • Higher nurse stress leading to a risk for burnout
  • Unsafe workloads
  • Less time per patient for direct patient care
  • Patients who feel unattended or ignored
  • Greater risk of misinformation spreading
  • Higher nurse turnover

Nurse-to-Patient Ratio Controversies

Legally having a hospital or facility staffed with more nurses seems like something everyone can agree on. After all, more nurses means the more attention a patient can get, leading to a higher quality of care. 

However, executing recommended nurse-to-patient ratios is not an easy task. Because of budget and staffing restrictions, hospitals argue that they might have to turn patients away if they don’t have the staff to accommodate them.

It’s an ongoing debate, with both views demanding further investigation. Here are the cases both for and against nursing ratios.

The Case for Nursing Ratios

Nurses are the vital part of the labor force within every hospital. Yet when cutting budgets, administrators see them as expendable. 

Many nurses report feeling overworked and undervalued when there aren’t many nurses on staff. Worse, they also feel as though they’re not giving patients the best care they can give. 

Understaffing creates a cycle that leads to many nurses leaving their hospital or quitting in their beginning years as they feel burnt out.

Nursing ratios would make sure that nurses feel supported and that all their patients can have the proper amount of attention and care. There would be less burnout and lower staffing turnover if nurses always knew how many patients were in their care and developed a routine as to how much time and care was needed.

The Case Against Nursing Ratios

Those who argue against nurse staffing ratios see them as a flawed approach that doesn’t actually improve patient care. Many people, including health care professionals, are outspoken against these laws and policies, because they say that enacting them may result in patients waiting longer to get care or having to be turned away. 

Additionally, many hospitals fear that the ratios would force them to turn away people who need emergency attention. They also worry that these ratios would put a strain on their budgets and put many hospitals out of business, because they wouldn’t be able to generate enough profit if their patient numbers were reduced.

Enforcing RN-to-Patient Staffing Ratios

Another question facing proponents for staffing ratios is how the federal government can enforce staffing laws in private entities. 

However, while there’s currently no national policy for hospitals to have set staffing ratios, many states already have laws in place mandating staff regulations.

These laws have three approaches as to how they enforce staffing ratios. The first requires hospitals to have nurse-driven staffing oversight committees. The second type of legislation mandates specific ratios. The third type mandates that the facilities disclose their specific staffing levels to the public.

Currently, 14 states have one of these three types of laws to address nursing staff regulations: California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington. 

Seven of these states require hospitals to have staff committees that overlook nursing staffs and implement policies. Those seven states are Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington.

California is currently the only state with a law that requires a set nurse-to-patient ratio based on a unit’s speciality. Massachusetts passed a similar law, but their legislation only requires set nurse-to-patient ratios in ICUs, depending on the stability of the patient. 

Other states outside of the listed 14 are currently trying to pass legislation to have staffing regulations in their hospitals.

The argument for and against mandated nurse-to-patient ratios is ongoing in many states and on the federal level. However, some states have already taken the leap, and it may be only a matter of time before more states follow.