Nurse Staffing Ratios FAQs

  • What is meant by a nursing ratio?

    A nursing ratio refers to the number of patients one nurse is assigned to care for during the work shift. So, a ratio of 1:4 would mean the nurse has four patients that she or he is responsible for during a typical eight or 12-hour shift. A nursing ratio also usually specifies the type of nurse. For example, the nurse could be a registered nurse (RN) or a licensed nurse. “Licensed nurses” could be either RNs or licensed practical nurses (LPNs).

  • Are ratios an effective way to decide nurse staffing levels in hospitals?

    No. We value the expertise of New Jersey nurses and other healthcare professionals in our hospitals and believe they are best positioned to ensure safe and efficient staffing levels, rather than using rigid ratios set by government.

    When ratios are mandated, the flexibility of making patient assignments based on the “real time” need of the patients is taken away from nursing supervisors and managers. Nor does a ratio recognize the education and experience level of the nurses on a given shift. A rigid “one-size-fits-all” ratio simply cannot ensure the optimal level of patient care on a very dynamic patient unit, especially for medical/surgical units.

  • What is a medical/surgical unit?

    Unlike specialty units like intensive care, medical-surgical units have a wide variety of patients – some just returned from surgery, some recently transferred from the intensive care unit, some ready for discharge – and all with different needs that can quickly change. Rigid ratios are not the right fit for this type of patient unit. Guidelines that suggest, rather than mandate, staffing numbers are acceptable and are, in fact, used in many hospitals.

  • How does a hospital decide how many patients each nurse should care for?

    A number of issues are considered when patient assignments are made, starting with the condition of the patients and what their needs may be for that shift of care. Other variables that are taken into consideration include the complexity of treatments the patients are receiving; the competency and experience of the nursing staff; the support of other members of the care team such as nurse aides, technicians, therapists, social workers and others; the time and day of the shift (days versus nights, weekdays versus weekends); and the technology used on the nursing unit. Nursing supervisors and managers usually work with their team to decide the best patient assignments for an upcoming shift based on what has been happening on the previous shift and what is expected to happen on the upcoming shift. This not only provides a “real-time” response to staffing based on patient needs, but also ensures that the hospital’s staffing is efficient.

  • Have ratios been used in New Jersey before?

    Broad rigid ratios across all patient units have not been used in our state. However, ratios already exist for certain specialty units under New Jersey hospital licensure rules. For example, in an intensive care unit, one RN must not have more than three patients. Regulations specify ratios in areas where patient needs are fairly uniform in nature with few variables, such as the delivery room, operating room and post-surgery recovery area. New Jersey hospitals also are required to report staffing levels to the N.J. Department of Health, which posts this information on its website.

  • Have any states tried ratios?

    California is the only state that has enacted rigid ratios across all units of the hospital. California’s ratio law was passed in 1999 and was enacted in 2004. Last fall, Massachusetts put a question on the ballot to let voters decide whether they wanted mandated nurse ratios. The measure failed dramatically, with 70 percent of the voters saying no to rigid ratios.

  • What have been some of the results in California?

    Research into the impact of California’s ratio law has revealed mixed results. Some studies have shown a relationship between ratios and improved patient outcomes, while others could find no correlation. Additional factors such as the education level of nurses and other innovations in the nursing environment, such as the use of staffing committees comprised of nurses, also were found to have positive impacts on healthcare quality. In addition, no research has clearly defined the “magic number” that would be a universally effective nurse-to-patient ratio.

  • What would the impact be on healthcare costs if New Jersey were to adopt rigid staffing ratios?

    Mandating rigid ratios across all of the state’s acute care hospitals would add an estimated $181.4 million annually in healthcare costs in New Jersey. At a time when consumers, taxpayers, employers and healthcare providers are concerned about the affordability of healthcare, ratios would greatly add to healthcare costs.

  • Could there be any unintended consequences of rigid nursing ratios?

    There are many potential consequences of a rigid nurse ratio law. For healthcare consumers, the greatest concern may be the added costs at a time when everyone is worried about the costs of healthcare on their pocketbooks. Hospitals and other healthcare providers have been under pressure to provide “value” in healthcare – that is, high quality care at the lowest possible cost to consumers. New Jersey hospitals have worked hard to deliver high-value healthcare, and those efforts have been successful in slowing the healthcare cost increases while improving healthcare quality. A ratio would make that effort much more difficult.

    Many other workers in the healthcare field also worry about job losses if hospitals are required to keep more nurses on the unit at all times, especially given that pressure to maintain overall healthcare costs. All members of the healthcare team are important, and hospitals rely on an array of caregivers including therapists, technicians, nurse aides, social workers and others to meet patient needs.

    In addition, healthcare is changing. More care is moving outside the hospital into post-acute care settings like nursing homes and community-based settings with the support of home health. Ratios are an outdated model that could hinder innovation in healthcare delivery.