By Gary Evans, Medical Writer

While nurse-patient ratios are primarily seen as a patient safety issue, studies have found that better staffing levels can reduce occupational injuries and the emotional toll of burnout.

A measure that would have mandated nurse-patient staffing ratios in Massachusetts was recently voted down, leaving California as the only state with a law.

There are ongoing efforts in other states to pass such measures; for example, the New York State Nurses Association is lobbying for a staffing law to give all patients “access to quality care.”1

Passed in 2004, the law in California requires nurse-patient ratios from 1:1 to 1:5 depending on the unit, level of patient acuity, and other factors.

“We have seen from nursing documentation nurses [caring for] up to eight or nine patients at one time,” says Donna Kelly-Williams, RN, president of the Massachusetts Nurses Association. “The patient is not aware that they are sharing their nurse with that many other patients.”

The nursing union led the fight for the Massachusetts staff ratio law, which was solidly defeated in a referendum in November 2018. However, the issue is now out in the public, and more patients are aware of the risks of low staffing levels, she says.

“Nurses do a really good job as they are caring for their patients not to frighten them,” Kelly-Williams says. “They don’t want to concern their patients with the fact that they may have too many other patients to give them the best care.”

In a statement after the vote, Kelly-Williams urged patients to save the distributed educational materials about nurse-patient ratios and “not be afraid to speak up for your loved ones in the hospital.”2

Nurse Safety in California

Although patient safety often is emphasized in such efforts, nurses in California appear to have greatly benefited from the law. This effect was quantified in a study that found nursing injuries were reduced by roughly one-third in comparing data before and after the law was enacted.

“The California law was associated with 55.5 fewer occupational injuries and illnesses per 10,000 RNs per year, a value 31.6% lower than the expected rate without the law,” researchers reported.3 “The most probable reduction for LPNs was 33.6%. Analyses of confidence intervals suggest that these reductions were unlikely to be due to chance.”

Other studies support the premise that staffing ratios protect nurses, says Gerard Brogan, RN, director of nursing practice at the California Nurses Association.

Findings include a study that showed that nurses in poorly staffed units were more likely to suffer needlesticks.4

Also, the stress associated with an increased patient load has been linked to burnout in one analysis of the literature on the subject. “The nurse-patient ratio is a direct determinate of the effects of psychological, mental, [and] emotional health and nurse productivity in the workplace, which also determines the patients’ overall health,” researchers concluded.5

Nurses with higher patient care duties also are at greater risk for musculoskeletal disorders.6 Ergonomic research overall shows a direct relationship between staffing levels and these injuries, which often occur in the neck, back, and shoulder.

“We can trace the causal chain of nurse-patient ratios to the amount of patient handling, to biomechanical-exposure intensity, to back injury,” says Laura Punnett, ScD, co-director of the Center for the Promotion of Health in the New England Workplace at the University of Massachusetts in Lowell.

In addition, Brogan cites the anecdotal evidence gleaned from interacting with the thousands of nurses he teaches each year, particularly after he shares his personal story of injuries due to lifting patients.

“It was seen by nurses, like many things, as just part of the job,” he says. “We have been challenging that paradigm for the last 20 years. The main effective measure to prevent injuries is to have an adequate amount of staff.”

Inadequate staffing levels also may heighten the risk of violence, Brogan adds. “I have a lot of experience as a psych nurse, and the less staff you have, the more dangerous it is,” he says.

Patient Safety Data

Although it is certainly intuitive to conclude that more nursing hands on deck increases patient safety, opponents of staff ratio mandates have argued there is a lack of evidence for this assumption. For example, authors of the aforementioned study3 that found reduced injury rates for nurses wrote, “the evidence that legally mandated ratios improve patient outcomes — the stated purpose of the law — is very limited.”

A study published before the vote in Massachusetts found that a previously adopted state staffing law requiring at least one nurse for two patients in ICUs has had “little impact” on patient outcomes.7

On the other hand, a study comparing California with two other states found lower staff ratios were associated with significantly lower patient mortality. “When nurses’ workloads were in line with California-mandated ratios in all three states, nurses’ burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care,” the authors concluded.8

Additionally, a study in the New England Journal of Medicine concluded that “staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients’ needs for nursing care.”9

Proponents of the failed effort in Massachusetts made these arguments, saying more nurses mean more nursing care for hospitalized patients, Kelly-Williams says.

“The bottom line is when you are in the hospital, you are there because you need nursing care,” she says. “If your nurse is not able to do all the things that they need to do, that’s when we start to see problems for patients.”

One of the arguments against the staffing law in Massachusetts was that there were not enough nurses in the state for hospitals to comply.

“We have the nurses, but we also have nurses who are not willing to work under the current conditions,” Kelly-Williams says. “But, just as in California, if you build it, they will come. After their regulation, they had nurses flocking back to the bedside.”

Gold Rush

Indeed, there has been something of a nursing gold rush in California after the staff ratio law was adopted. The law has resulted in better nurse retention and recruiting, Brogan says. There was an influx of 110,000 nurses in the first four years after the law was passed, he says.

“Those were primarily nurses within California coming back into the profession,” he says. “Now nurses across the country are coming to work in California. Staff ratios are the Holy Grail for every nurse. And they always cite that as why they are coming to work here.”

That enthusiasm translates to greater nurse retention as well. A 2016 report10 on hospital turnover rates for RNs showed an annual rate of 3.2% in California. That compared favorably to the RN turnover rates in states without staff laws, such as New York (8.7%), Florida (16.2%), and Texas (21.9%). The cost of replacing a single RN is estimated at $50,000.11

“When you are losing nurses, that is a lot of wasted resources that could go to patient care,” Kelly-Williams says. “Those like myself, who have been in nursing for more than 40 years, stay at one place for their entire career. A lot of nurses today have more flexibility, and a lot of them are ‘chasing’ safe staffing. We have lost nurses in Massachusetts to California because of the safe limits.”

Some young nurses are leaving the profession entirely because of the stresses of working short-staffed, she says.

“After passing all those competencies and being licensed as a nurse — to be put on a unit where you are given too many patients,” she says. “The response of administrators — who should be there to get you the resources you need — is ‘Do the best you can.’”

This situation goes beyond stress and aggravation, as nurses may “feel quite guilty that some harm may come to a patient if they have a prolonged hospitalization,” she says. “All because the nurse wasn’t able get in there and do the things we know need to be done to ensure a safe recovery.”

With other states considering similar laws, the defeat of the staffing initiative in Massachusetts should serve as a cautionary tale for what powers may align to defeat such measures.

Although proponents of the effort argued the cost of required staff ratios would be offset by better patient outcomes and nurse retention, the opposition successfully argued the law would hurt hospitals and possibly shutter some. Hospital groups and the state association primarily led the fight to defeat the staffing initiative, with one health system arguing it would have to care for 21% fewer patients and hire 220 additional nurses to comply with the law.

“We would risk being fined $25,000 per violation, per day — forcing some units to close, and crippling our community hospitals,” Baystate Health posted on its website.12

The Massachusetts Health Policy Commission released a report13 before the vote that concluded mandated nurse staffing ratios would cost an additional $676 million to $949 million annually.

Surprisingly, even the state chapter of the American Nurses Association came out against the proposal, saying it would undermine “the flexibility and decision-making authority of nurses and [put] rigid mandates above patient safety, clinical nurse input, [and] nurse manager’s discretion.”14 Moreover, the Massachusetts College of Emergency Physicians and Massachusetts Emergency Nurses Association issued a joint statement against the bill, saying mandated staffing ratios were unworkable in the ED.15

Given this level of opposition, the measure failed. But Kelly-Williams says the struggle in her state goes on.

“As devastating as the [outcome was] the day of the vote, I have to tell you there has been a resurgence of nurses looking for all opportunities to keep this in the forefront,” she says.


  1. New York State Nurses Association. Healthcare advocates from across the state have a message for legislators: Now is the time to pass safe staffing for nurses and caregivers. Jan. 9, 2019. Available at:
  2. Massachusetts Nurses Association. Statement from Donna Kelly-Williams on Question 1 Election Results. Nov. 7, 2018. Available at:
  3. Leigh JP, Markis CA, Losif AM. California’s nurse-to-patient ratio law and occupational injury. Int Arch Occup Environ Health 2015;88(4):477–484.
  4. Clarke SP, Sloane DM, Aiken LH, et al. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health 2002;92(7):1115-1119.
  5. Gutsan E, Patton J, Willis WK, et al. Burnout syndrome and nurse-to-patient ratio in the workplace. Marshall Digital Scholar 2018. Available at:
  6. Lipscomb J, Trinkoff A, Brady B, et al. Health Care System Changes and Reported Musculoskeletal Disorders Among Registered Nurses. Am J Public Health 2004 August; 94(8):1431–1435.
  7. Law A, Stevens JP, Hohmann S, et al. Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations. Crit Care Med 2018;46(10)1563–1569.
  8. Needleman J, Buerhaus P, Pankratz S, et al. Nurse Staffing and Inpatient Hospital Mortality. N Engl J Med 2011;364:1037-1045.
  9. Aiken LH, Sloane DM, Cimiotti JP. Implications of the California Nurse Staffing Mandate for Other States. Health Services Research 2010; DOI: 10.1111/j.1475-6773.2010.01114.
  10. Texas Center for Nursing Resource Studies. Hospital Nurse Staffing Study 2016. Available at:
  11. Nursing Solutions, Inc. 2018 National Health Care Retention & RN Staffing Report. Available at:
  12. Baystate Health. 2018 Nurse Staffing Ballot Initiative: Get the Facts. Available at:
  13. Massachusetts Health Policy Commission. Mandated Nurse-to-Patient Staffing Ratios in Massachusetts: Analysis of Potential Cost. Oct. 3, 2018. Available at:
  14. Massachusetts Health and Hospital Association. ANA Opposes Ballot Question that Takes Decision Making from RNs. 2018. Available at:
  15. Mandated Nurse Staffing Ratios in Emergency Departments: Unworkable & Harmful to the Community. September 2018. Available at: