Congress is considering a federal bill that would set specific minimum nurse-to-patient ratios for every hospital unit.1 The move comes on the heels of new research supporting the benefits of minimum nurse-to-patient ratios on patient outcomes, including a lower mortality rate.2 However, not all organizations support standardized nurse-to-patient ratios.

“Mandated legislative proposals to nurse staffing limit innovations in team-based care models and increase stress on a health care system already facing an escalating shortage of educated nurses,” said Robyn Begley, DNP, RN, NEA-BC, FAAN, Chief Nursing Officer and senior vice president of workforce at the American Hospital Association (AHA). Dr Begley is also chief executive officer for the American Organization for Nursing Leadership.

The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act was reintroduced to Congress by US Sen Sherrod Brown (D-OH) and Rep Janice Schakowsky (D-IL) on May 12, 2021. The bill was initially introduced on May 8, 2019, in a previous session of Congress, but was not voted on.1 The federal act is similar to a California bill passed in 2004 that established nurse-to-patient ratios.

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Zenei Triunfo-Cortez, RN

The federal act also includes provisions for research on best practices for nurse staffing, whistleblower protections to protect the right of nurses to advocate for the safety of their patients, and education support for nurses through an expansion of the nurse retention grant and the nurse workforce loan repayment and scholarship program, according to a statement from Schakowsky.2

“We know from numerous scientific studies, and from the results of the landmark nurse-to-patient ratios state law in California, that mandatory, minimum nurse-to-patient ratios save patients’ lives and improve quality of care, while also reducing nurse burnout and keeping experienced nurses at the bedside,” said Zenei Triunfo-Cortez, RN, president of National Nurses United, which is a cosponsor of the bill.2

Minimum Nurse-to-Patient Ratio Improves Patient Outcomes

New findings further support the benefits of standardized nurse staffing ratios. Introduction of nurse-to-patient ratios for adult medical-surgical wards across 27 hospitals in Queensland, Australia, was linked to an estimated 145 patient lives saved in the first year, prevention of 255 readmissions, and 29,222 hospital days, and savings of between $55.2 to $83.4 million (AUD), according to study findings published in The Lancet.3,4

Reducing a nurse’s caseload by 1 patient was associated with significant reductions in mortality (odds ratio [OR], 0.93; 95% CI, 0.86-0.99; P =.045), readmissions (OR, 0.93; 95% CI, 0.89-0.97; P <.0001), and hospital length of stay (adjusted incident rate ratio, 0.97; 95% CI, 0.94-0.99; P =.035). An estimated 167 full-time equivalents were needed to meet ratio requirements

“Queensland Health is to be commended for its evidence-based policymaking that included the funding of a prospective independent evaluation of the outcomes of establishing minimum nurse-to-patient ratios in the state,” said study coauthors Matthew McHugh, PhD, JD, MPH, RN, CRNP, FAAN, and Linda H. Aiken, PhD, RN, FAAN, FRCN, from the University of Pennsylvania School of Nursing. The university was appointed to independently evaluate the new ratio system by Queensland Health.4  

The study authors believe their findings will be helpful to other jurisdictions considering similar laws around nurse staffing.

American Hospital Association Cautions Against the Nurse Staffing Ratios

Robyn Begley, DNP, RN, NEA-BC, FAAN

“Safe staffing is based on a complex set of variables such as hospital type, patient population, care delivery models, unit layout, patient acuity, and the education and experience of the nurse,” Dr Begley said in an interview. “Mandated nurse staffing ratios imply a ‘one size fits all’ approach to patient care. Nurse leaders and nurses are best qualified to determine appropriate staffing for the needs of their patients. Mandated nurse staffing ratios are a static and ineffective tool that do not ensure quality care, optimal patient experience, and staff well-being.”

“Safety for patients and the health care team is our top priority,” Dr Begley said on behalf of the AHA. “Hospitals and health systems across the country are working to advance patient safety, affordability, and enhance value by transforming health care delivery.”


1. H.R. 2581 — 116th Congress: Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2019.” 2019. June 4, 2021

2. Congresswoman Schakowsky, Senator Brown introduce nurse staffing standards legislation. News Release. May 12, 2021. Accessed June 7, 2021.

3. McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. Lancet. 2021;397(10288):1905-1913. doi:10.1016/S0140-6736(21)00768-6

4. University of Pennsylvania School of Nursing. Mandated nurse-to-patient ratio in Queensland is “saving lives.” Accessed June 4, 2021.