Proposed nurse staffing legislation in Illinois — HB3871 Safe Patient Limits Act— would significantly improve nurse staffing in hospitals and likely prevent thousands of deaths, according to a cross-sectional analysis of data from acute care hospitals in the state. The findings, published in BMJ Open, suggest that the cost of improving nurse staffing could be offset by cost savings achieved by the impact of better nurse staffing on shorter length of hospital stays.

The Safe Patient Limits Act currently pending action in the Illinois Legislature sets a minimum nurse staffing requirement of no more than 4 patients per nurse for all hospitals in the state.

The Illinois Health and Hospital Association (IHA) said it does not support one-size-fits-all, mandated nurse staffing ratios such as those in the legislature, especially when severe shortages of nurses and healthcare professionals would make it difficult to comply with mandated ratios without risking a reduction in healthcare services, according to Amy Barry of the IHA.

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Study Design

Karen Lasater, PhD, RN, and colleagues from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing conducted independent research using data from 87 hospitals on 210,493 patients hospitalized in 2018 who were receiving Medicare. Staffing estimates were derived from an average of 16 direct care medical-surgical nurse respondents per hospital in 2020. Primary outcomes were 30-day mortality and length of stay.

Patient-to-Nurse Ratios Vary Widely

The researchers found large differences in patient-to-nurse ratios on medical-surgical units by hospital ranging from 4.2 to 7.6 patients per nurse (mean, 5.4; SD=0.7).

Hospitals with fewer patients per nurse had lower 30-day mortality rates than those with higher patients per nurse. Each additional patient added to a nurse’s workload was associated with a 16% higher risk of patient mortality. Also, each additional patient added to a nurse’s workload increases the odds of staying in the hospital 1 day longer by 5%. The reduced length of stay afforded by improved nurse staffing was predicted to collectively save the state of Illinois over $117 per year, according to the researchers.

“If the study hospitals had been staffing medical-surgical nurses at the proposed ratio during the 1-year study period, we projected that 1595 deaths would have been avoided just among Medicare patients,” the study authors noted. They added that improved patient-to-nurse ratios may reduce nurse burnout and turnover that result from chronic understaffing.

Nurses Report Unsafe Workloads

Half of the nurses (51%) reported that their patient assignment during their last shift was unsafe and 67% of those assigned 6 or more patients assessed that their workload was unsafe.

Limitations of the study include the cross-sectional design, which precludes causal statements about the relationship between nurse staffing and patient outcomes, Dr Lasater and colleagues noted. The data is based on patients 65 years and older and, thus, does not consider the benefit of improved staffing on patients of all ages. Also, the patient data was collected in 2018 while the nurse staffing data were collected in 2020; however, the authors believe that these estimates would likely be similar in the same year. Finally, the data are derived from medium- and large-size hospitals in Illinois and small hospitals are underrepresented in the findings.

The authors concluded that few Illinois hospitals currently meet the minimum staffing levels included in the Safe Patient Limits Act. “The pending legislation would improve nurse staffing in Illinois hospitals, and likely save lives and avoid longer and more costly hospital stays,” said Dr Lasater, who is an assistant professor and Penn researcher.

IHA Supports Alternative Strategies

As an alternative to nurse staffing ratios, the IHA recently supported the Nurse Staffing Improvement Act (Senate Bill 2153), “which was backed by multiple nursing organizations and approved in a bipartisan manner by the Illinois General Assembly,” according to Barry. This legislation was signed into law in August 2021.

This bill increased the input and voice of nurses into decisions about staffing levels at individual hospitals, Barry explained. “Each hospital’s clinical team is in the best position to make staffing decisions for their particular hospital based on the unique circumstances at that hospital at any given point. This includes patient census, acuity of the patients in the hospital, surgery and procedure schedules, skill set of the staff on the floor and the overall needs of the community and their patients on any given day. Patients’ needs are specific, individual, and must be assessed by medical professionals to determine the appropriate clinical care team for that patient,” Barry said.


1. Lasater KB, Aiken LH, Sloane D, French R, Martin B, Alexander M, McHugh MD. Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study. BMJ Open. 2021;11(12):e052899. doi:10.1136/bmjopen-2021-052899

2. University of Pennsylvania School of Nursing. Illinois nurse staffing legislation predicted to reduce hospital deaths and improve care. December 8, 2021. Accessed December 28, 2021.