By Brianna Zink
Approaching the final stretch of 2023, the Unites States has seen at least 13 healthcare worker strikes and narrowly avoided many more. Each of these strikes have at least one component in common – safe staffing. Many states are considering legislation around safe staffing for nurses, and some are evaluating the implementation of mandated nurse-to-patient ratios – with Oregon most recently passing a new bill specifying nurse-to-patient ratios for different inpatient hospital settings and includes CNAs.
In 1999, California became the first state (and would remain the only state for more than two decades) to mandate nurse to patient ratios in their hospitals. Now, 24 years later, it is shocking that a simple ratio is still the primary measurement of focus to ensure patients receive quality care and that nurses have safe working conditions. It’s also the primary measurement of focus to prevent nurse burnout or exhaustion. It doesn’t reflect the incredibly complex and ever-changing work that nurses do but rather seems like a simple checkbox to give the appearance of accomplishment. We hear constantly about the nursing shortage that is apparent now and poised to get worse – but does a ratio really address this shortage? If it does not, what will be the next step, or will it be too late?
Mandated nurse-patient ratios, while arguably better than having no protective measures in place at all, do not consider the full picture and do not allow for flexibility or future innovations. If you compare just about any aspect of life today to early the early 2000’s, when California began implementing this groundbreaking change, very little seems the same. At that time, the only way to access the internet was through dial-up, most Americans did not own a cellphone, airport security did not require you to take off your shoes, and I personally spent too much of my free time trying to download songs on Napster. The advancements in technology since that time have changed how we function in our day-to-day lives, often allowing us to accomplish much more and do things we wouldn’t have imagined 20+ years ago.
This begs the question, how has nurse staffing and patient assignments remained so stagnant? Healthcare is incredibly personal - each patient comes from a unique scenario and has unique needs and concerns. A mandated ratio does nothing to consider these uniqueness’s. Even if these proposed mandates provide considerations for changes (as Oregon does), they still set the stage for the standard and could prove to be an obstacle for change, keeping these processes stagnant for many years to come. This could hinder future innovations around how nurses provide care, inhibit changes to the now-standard primary nursing model, and does not always guarantee that a nurses’ assignment will be fair, safe, or equitable.
I had many shifts where the number of patients I was assigned was under the ratios typically proposed, yet I could not keep up with the work. I know I’m not alone in this scenario. I would go home at the end of the shift (most likely leaving later than scheduled) and spend hours questioning what I may have missed in the frenzy of the day. “Did I chart that? Oh no! I never reassessed 102’s pain after the pain meds…” etc. This additional stress spilling into nurses’ lives beyond their shift contributes to burnout. Alternatively, I had days where I had a higher number of patients assigned and felt that I had ample time to stay and chat with patients and their family members or had extra time to just sit and take a load off. If the goal is really to improve the nurse and patient experience and ensure safe working conditions, we need to utilize all the data available to understand the work being done by nurses as well as consider the skill mix of the supporting teammates.
Over recent years, many advancements and changes have been introduced impacting how nurses provide care. Several health systems across the globe are implementing virtual nursing programs. These programs leverage various elements of technology and allow a nurse to provide aspects of nursing care to a patient that does not require hands-on tasks. This often includes answering call lights and delegating the patients’ needs, providing patient education, performing portions of the admission assessment, documenting medication reconciliation, and more. Many hospitals have found that virtual nursing has improved the patient experience and helped with staffing shortages as more nurses are open to working a virtual shift which in turn decreases the workload for the nurses at the bedside. I hope that many more advancements will come that will have impacts on how nurses provide care but worry that mandated ratios will be an obstacle for these changes.
Nurses are the backbone of patient care in a hospital setting. They typically spend the most time with the patient, they are responsible for carrying out the plan of care, and they are the patient’s last line of defense against medication or treatment errors. Therefore, the fact that patient outcomes will suffer when nurses’ workloads are more than they can handle is obvious. Winning the battle to ensure protective staffing measures are in place is vital for healthcare workers and patients alike. There are over 1 million nurses in the United States with active licenses that are not working, and some hope that mandated ratios will encourage many of those nurses to return to the profession. While some may, I don’t anticipate that number being impactful enough to address the nursing shortage and I don’t think this is a big enough change. I do not believe ratios are the right metric, but rather the easy metric.
Brianna Zink is the Infor Healthcare Senior Director for Product Strategy. Visit: