Legislating Nurse-Patient Ratios: Will this Solve Burnout Once & For All?

Authored by: Peggy Pilon, BSN, MS, RN  VP of Clinical Success 

Nurse burnout continues to be a hot topic today in hospitals all over the U.S. In 2019, only 15.6% of nurses reported feeling burnt out. However, over the past three years, 95% of nurses have reported burnout. It is well documented that 30% of all U.S. nurses quit their jobs in 2021, and 27% of those nurses who quit reported burnout as their main reason for leaving. As of 2023, the annual rate of nurse turnover is 27.1%. It is estimated that by 2024 we will need another 1 million nurses globally. In addition, it is projected that we will need 13 million nurses by 2030. So it is imperative that we deal with nurse burnout quickly and effectively. 

Is the Cure to Burnout Legislating Nurse-Patient Staffing Ratios?

One of the important aspects in providing healthcare is the nurse-patient ratio. This ratio determines the number of patients a nurse can effectively care for during his or her shift. Over the years, there has been a growing debate about the need to legislate nurse-patient ratios in order to enhance patient safety, improve the working conditions, and prevent burnout for nurses. Let’s explore the current laws surrounding nurse-patient staffing ratios, the pros and cons of legislating these ratios, and the ramifications to patient care.

Current Laws Surrounding Nurse-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.” In addition, according to the American Nurses Association, there are currently 14 states with regulations regarding nurse staffing: California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington.  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). Outside of California, Massachusetts also has a law regulating nurse-to-patient ratios; however, it only applies to intensive care units.

Will More States Follow California’s Lead?

Nearly a decade later, California is still the only state to have enacted a nurse-staff ratio law. But nursing unions in other states are pressing their lawmakers to follow suit. Six more states which include: Florida, Iowa, Minnesota, New Jersey, New York, and Texas and the District of Columbia are now considering enacting nurse ratio laws of their own.

The Pros of Legislating Nurse-to-Patient Ratios:

  • Improved Patient Safety: One of the primary benefits of legislating nurse-to-patient ratios is the potential for improved patient safety. Research suggests that adequate staffing levels are associated with reduced mortality rates, decreased medication errors, and improved patient outcomes. Registered nurses constitute an around-the-clock surveillance system in hospitals for early detection and prompt intervention when patients’ conditions deteriorate. The effectiveness of nurse surveillance is influenced by the number of registered nurses available to assess patients on an ongoing basis. By ensuring a sufficient number of nurses are available to attend to patients, legislated ratios can minimize the risk of adverse events and enhance overall patient safety.
  • Enhanced Quality of Care: Legislated nurse-to-patient ratios have the potential to improve the quality of care provided to patients. Patient mortality and the number of preventable mistakes, which include patient falls, pressure ulcers, central line infections, and healthcare-associated infections, are all proven to decrease after minimum nurse-to-patient ratios are instigated.When nurses are not overwhelmed with excessive patient assignments, they have more time to dedicate to each patient, allowing for increased attention, monitoring, and individualized care. This can result in better patient satisfaction, improved patient experiences, and positive health outcomes.
  • Reduced Nurse Burnout: By implementing legislated nurse-to-patient ratios, nurses can experience reduced burnout rates. Reasonable workloads allow nurses to maintain a better work-life balance, reduce stress, and provide care without compromising their own physical and mental well-being.
  • Attraction and Retention of Nurses: Legislated nurse-patient ratios can play a crucial role in attracting and retaining qualified nurses. Adequate staffing levels can create a positive work environment that promotes job satisfaction, leading to increased nurse retention rates. 

The Cons of Legislating Nurse-to-Patient Ratios:

  • Inflexibility: Some argue that legislated nurse-patient ratios may lack flexibility in addressing the unique needs of different healthcare settings. The staffing needs of a specialized unit, such as intensive care or emergency departments, may differ significantly from those of a general medical-surgical unit. Rigid ratios may fail to accommodate these variations, potentially resulting in inefficiencies or inadequate staffing in certain areas. There can also be instances, especially in Critical Care, where the patient is unstable and requires care from two RNs. In that case, the staffing mandate often does not allow for an additional RN to support the patient.
  • Financial Burden: Implementing legislated nurse-patient ratios can impose a financial burden on healthcare institutions. Hiring additional nursing staff to meet mandated ratios can strain already limited resources, particularly for smaller hospitals or those facing budget constraints. Critics argue that the costs associated with compliance could lead to reduced access to care, cutbacks in other areas, or increased healthcare costs for patients.
  • Potential for Exacerbating Staffing Shortages: Legislating nurse-patient ratios without considering the availability of an adequate nursing workforce can exacerbate existing staffing shortages. If there are not enough nurses to meet the mandated ratios, healthcare institutions will face difficulties in recruiting and retaining the required number of qualified professionals. This may result in compromised patient care and longer wait times for services. California has mandated nurse-patient ratios, yet they are experiencing the same nurse shortages as the rest of the country.
  • Unintended Consequences: Others suggest that legislating nurse-patient ratios may lead to unintended consequences. For example, hospitals may respond by cutting other healthcare personnel or services to redirect resources towards nursing staffing. This could negatively impact the overall multidisciplinary care team, and limit the availability of other healthcare professionals who play vital roles in patient care. Mandatory staffing ratios can be difficult to implement and enforce for both nurses and healthcare organizations. It can require significant changes in policies, processes, and culture. Mandate staffing levels can also create legal, financial, and ethical dilemmas. For example, how to define and measure nurse staffing, how to balance nurse supply and demand, how to fund and allocate resources, and how to protect nurse and patient rights.


Solving the issue of nurse burnout is complex and multifactorial. It is clear, regardless of what side of the debate of legislating nurse-patient ratios one is on, nurse staffing is a dynamic issue that requires ongoing research, innovation, and advocacy and will likely not be solved in the very near future. In the meantime, AI-driven technologies like CalmWave can help hospital leadership to recognize and mitigate nurse burnout. 

CalmWave™ is an operations-based artificial intelligence (AI) platform that captures, analyzes, and synthesizes real-time data from dozens of data sources (monitors, labs, orders, findings, etc.) to empower hospitals with the intelligence critical to improving patient outcomes, optimizing operations, and retaining staff. The AI technology from CalmWave™ presents objective solutions that reduce non-actionable alarms by providing proper alarm management insight to the caregiver, thereby decreasing alarm fatigue, excessive cognitive load, and burnout. The issues involving nurse burnout and nurse-patient staffing ratios are far from being solved, but CalmWave is here now…as an innovative, data-driven solution that can be implemented today to make a tangible impact in the nurse burnout crisis.