With states finding it difficult to pass nurse-patient staffing ratio mandates like the one in California, staffing disclosure laws in the name of transparency have emerged as something of a compromise, says Pamela B. de Cordova, PhD, RN-BC, professor of nursing at Rutgers University in New Jersey.

“The rationale behind it is to let patients and consumers hold hospitals accountable for poor nurse staffing,” says de Cordova, lead author of a study1 on the issue. “There is a fear of more stringent mandates, so this can be viewed as a compromise.”

While insufficient nurse staffing is frequently described as a patient safety issue, it also has been linked to increased occupational injuries and healthcare worker burnout.2-4

Transparency through public reporting is a widely accepted approach to improve quality, and eight states have mandated some form of a staffing disclosure provision. New Jersey is one of the five states where staffing disclosures are required by the state health department, although facilities have some flexibility in how they provide the data. To assess impact, de Cordova and colleagues looked at trends at hospitals in New Jersey since the state implemented the law in 2008, finding moderate improvements in staffing in many key areas.

“Public reporting improved nurse staffing, but the level of that improvement is not really that big,” she says. “But there was an improvement in 10 out of 13 specialties. The ballpark figures range from a 4% improvement in the emergency department all the way to an 11% increase in neonatal step-down units. Intensive care stayed the same, with a ratio of two patients per nurse over the seven-year study period.”

The study has sparked a state debate, as healthcare unions are lobbying for going beyond public reporting and mandating a nurse-patient ratio.

In an op-ed piece reacting to de Cordova’s study, a union official concluded, “In addition to requiring hospitals to publicly disclose staffing levels, we still need to enact safe staffing legislation to guarantee that minimum staffing levels and nurse-to-patient ratios are set throughout the state — to protect our nurses and ensure patient safety.”5

Taking neither a pro-hospital nor a pro-labor approach, de Cordova says her primary goal in looking at the data was to raise patient awareness.

“I want to get patients more engaged in this process, because public disclosure is a policy that has been used nationally to improve quality,” she says. “It shows there was some improvement, and patients should know this information exists. I’ve gotten a little bit of backlash after putting this forward — but it’s good. It really shows nurse staffing is an important point in improving quality in hospitals.”

A common concern with reporting of quality measures is that the facilities that most accurately report their data may end up looking worse than those who somehow game the system.

“Public reporting has been criticized for that,” she says. “Hospital administrators know that now their numbers are going to be publicly available. They want to be competitive with other hospitals that are geographically close to them. There is always the concern of gaming.”

Although the study concluded the hospitals reported accurately, the issue is complicated by provisions in the New Jersey law that allow local flexibility in reporting data.

“There is a standard template for what hospitals need to report, but how those numbers are actually calculated varies,” she says. “Is there a charge nurse who doesn’t have a patient assignment calculated in? Is there a nurse on orientation [counted] who is really just working with another nurse and is not assigned a patient? These factors can inflate the numbers to look like there are better ratios than there really are.”

ANA Seeks CMS Action

Still, some groups prefer the disclosure approach over mandated ratios that are seen as inflexible. The American Nurses Association (ANA), for example, is lobbying the Centers for Medicare & Medicaid Services (CMS) to make staffing ratios a reportable quality indicator nationally.

The ANA submitted comments to CMS in 2018 advocating for inclusion of nurse staffing measures for public reporting through the Hospital Inpatient Quality Reporting Program. CMS declined at that time, but the issue is not going away, with the ANA arguing that insufficient healthcare staffing results in costly delays of patient discharge.

“ANA strongly believes that these [staffing disclosure] measures contribute … to improved patient outcomes, empower patients and their families and caregivers, increase transparency with respect to care decisions, and do not present an additional or significant reporting burden for providers,” according to an ANA statement.6


  1. de Cordova PB, Rogowski J, Riman KA, et al. Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis. Policy Polit Nurs Pract. 2019 Mar 28:1527154419832112. doi: 10.1177/1527154419832112. [Epub ahead of print.]
  2. Leigh JP, Markis CA, Losif AM, et al. California’s nurse-to-patient ratio law and occupational injury. Int Arch Occup Environ Health 2015;88(4):477–484.
  3. Gutsan E, Patton J, Willis WK, et al. Burnout syndrome and nurse-to-patient ratio in the workplace. Presented at the 54th Annual MBAA Conference, Chicago, April 2018. Available at: https://bit.ly/2S2iL9b.
  4. Lipscomb J, Trinkoff A, Brady B, Geiger-Brown J. Health care system changes and reported musculoskeletal disorders among registered nurses. Am J Public Health. 2004;94(8):1431–1435.
  5. Placa, D. Has nurse staffing in New Jersey really improved? Opinion. Northjersey.com. April 13, 2019. Available at: https://njersy.co/2GFrurj.
  6. American Nurses Association. Comment to the Centers for Medicare & Medicaid Services. June 25, 2018. Available at: https://bit.ly/2GvZ4ik.