Medical Care blog

Comments from the scientific community regarding Medical Care.

Thursday, January 7, 2016

Nursing Ratios & Work Environments: A Few Questions & Answers

by Alexa Ortiz MSN

Hospitalized patients rely on their nurses 24 hours per day, 365 days per year.  Nurses are the primary caregivers and the first line of observation if a patient’s condition is starting to worsen.  A recent article in Medical Care discusses how decreasing nurse-to-patient ratios in medical-surgical units as well as improving work environments is associated with increased patient survival following an in-hospital cardiac arrest (IHCA) [1].  The authors found that hospitalized patients receiving care in poor nursing work environments had a 16% lower likelihood of survival [1].  Moreover, for each extra patient a medical-surgical nurse took on, their patient’s odds of surviving an IHCA decreased by 5% [1].  However, reading this article did raise some questions about nurse staffing ratios and what signifies a good working environment.  After doing some initial searching, here is what I learned.


What signifies an improved working environment for nurses?

McHugh and colleagues partially answer this question within the previously mentioned article [1].  The  authors state that one avenue for achieving an improved working environment is for hospitals to obtain Magnet status through the American Nurses Credentialing Center (ANCC) [1].  After reviewing the ANCC site, it can be concluded that Magnet status is a high quality credential to receive.  Achieving Magnet status is a performance driven recognition based on goals outlined by the ANCC, such as creating a setting that supports professional practice, encouraging excellence in nursing care, and dissemination of best nursing practices [2].   


Would lowering nurse-to-patient ratios singlehandedly have an impact on patient outcomes?    

It’s easy to think more nurses with fewer patients = higher quality of patient care; however, this might not always be the case.  A 2011 article in Medical Care found that patient outcomes dramatically improved when low nurse-to-patient staffing ratios were accompanied by good working environments [3].  On the other hand, low nurse-to-patient staffing ratios had no impact on patient outcomes when combined with poor working environments [3].

What are the current laws surrounding nurse-to-patient staffing ratios?

The federal regulation 42 CFR 482.23 – Condition of Participation: Nursing Services states, “The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed” [4, 5].  In addition, according to the American Nurses Association, there are currently 14 states with laws/regulations regarding nurse staffing: California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington [5].  Of those, California is the only one that has a law outlining the minimum nurse-to-patient ratio based on the type of care unit (i.e., intensive care unit, medical surgical, step-down) [5, 6].  Outside of California, Massachusetts also has a law regulating nurse-to-patient ratios; however, it only applies to the intensive care unit [5, 7].


What are the pros and cons for laws/regulations mandating specific nurse-to-patient ratios?

A number of the pros and cons were based on the experiences and lessons learned after California’s implementation of nurse staffing legislation.  A few of the key points were as follows [8]:


Pros: Mandating specific nurse-to-patient staffing ratios allowed nurses in California to spend more time with their patients.  In addition, procedural errors declined and patient outcomes improved since nurses were finally able to slow down and not rush patient care.


Cons: More Nurses = Higher Costs.  Since hospitals in California were not able to meet the mandated nurse staffing ratios, they were required to hire more nurses. Consequently, the healthcare system’s overall costs continued to rise.  Patients may also end up experiencing longer wait times with nurse staffing regulations.  A large influx of patients might not receive immediate treatment since the hospital is required to keep nurse-to-patient ratios at a certain level.   


What are the key takeaway points regarding nurse staffing and working environment?

Laws and regulations guiding nurse-to-patient ratios are beneficial, but they come at a price.  Nurses may be able to spend more time with their patients, but healthcare costs may continue to rise.  Furthermore, a lower nurse-to-patient ratio doesn’t automatically mean an improvement in patient outcomes.  Changes to nurse staffing ratios must also be accompanied by improved working conditions for patient outcomes to be positively impacted.


Alexa Ortiz is a Registered Nurse and Health IT Scientist at RTI International.  The views expressed are those of the author and do not necessarily reflect those of RTI International.



[1] Mchugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., . . . Aiken, L. H., American Heart Association’s Get With The Guidelines-Resuscitation Investigators (2016). Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Medical Care, 54(1), 74-80. doi:10.1097/MLR.0000000000000456


[2] ANCC Magnet Recognition Program®. American Nurses Credentialing Center. Retrieved from:


[3] Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and nurse education on patient deaths and hospitals with different nurse work environments. Medical Care, 49(12), 1047-1053. doi:10.1097/MLR.0b013e3182330b6e


[4] 42 CFR 482.23 – Condition of Participation: Nursing Services. U.S Government Publishing Office.  Retrieved from:


[5] Nurse Staffing.  American Nurses Association. Retrieved from


[6] Nurse-to-Patient Staffing Ratio Regulations. California Department of Public Health.  Retrieved from


[7] HPC Regulation 958 CMR 8.00 to Implement the ICU Nurse Staffing Law.  Administration and Finance. Retrieved from:


[8] Health Experts Debate the Merits of Nurse-Staffing Ratio Law. Retrieved from:

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