Nurse-to-Patient Ratios: A State-by-State Guide

For FacilitiesJanuary 14, 2021

Nurse-to-patient ratios are a key metric in determining the quality and consistency of care a facility is able to provide; they also play a pivotal role in creating work environments that are healthy and safe for nurses as well. This ratio refers to how many patients each nurse is responsible for during a shift. For critical care facilities, the ratio will be lower, as patients require more constant monitoring and care. For long-term facilities, the ratio may be higher as patient needs may be more focused on health management.

Ratios for Nurse-Patient Types

Whether it’s in an acute care hospital or a long-term care facility, optimal care depends on proper nurse staffing. If nurses are overextended, the quality of care suffers —  and lives may even be at risk. For decades, medical professionals have conducted studies and reviewed statistics in an attempt to quantify the ideal number of patients that nurses should be responsible for in various care settings.

According to Federal public health regulation 42CFR 482.23(b), in order to participate in Medicare, hospitals are required to “have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed.” The regulation also addresses supervisory staffing with the direction that “There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.”

In conjunction with these regulations, the Federal government has also issued proposed recommendations for nurse-to-patient staffing ratios. These recommendations have been championed by the American Nurses Association (ANA) and nurse advocates around the country. The following chart offers an overview of the suggested nurse staffing ratios.

Proposed Federal Nurse-to-Patient Ratios

Type of Care and Proposed RN-to-Patient Ratio (Based on patient acuity, with most critical receiving 1:1 care.)

Intensive/Critical Care 1:2
Neonatal Intensive Care 1:2
Operating Room 1:1
Post-anesthesia 1:2
Labor and Delivery 1:2
Antepartum 1:3
Labor & Delivery and Postpartum 1:3
Well Baby Nursery 1:6
Postpartum Couplets 1:3
Intermediate Care Nursery 1:4
Pediatrics 1:3
Emergency Room 1:3
Trauma Patient (ER) 1:1
ICU Patient (ER) 1:2
Step Down 1:3
Telemetry 1:3
Medical/Surgical 1:4
Coronary Care 1:2
Acute Respiratory Care 1:2
Burn Unit 1:2
Specialty Care Units 1:4
Psychiatric 1:4
Rehabilitation 1:5
Skilled Nursing Facility 1:5

State-Specific Nurse Staffing Regulations

While these regulations and recommendations offer guidance, they stop short of dictating state-specific policy. Each state is responsible for setting its own standard for nurse-to-patient staffing ratios. Response from states has varied, with California being the only state to officially establish comprehensive laws and regulations that dictate minimum nurse-to-patient ratio minimums. On a smaller scale, Massachusetts has taken steps toward formalizing its requirements by passing a law that stipulates safe staffing practices for Intensive Care Units (ICU) in the state. 

It’s important to note that even though California and Massachusetts are the only states to pass laws governing safe staffing policies, 12 other states have introduced statewide regulations that address nurse staffing in hospitals. These additional states include Connecticut, Illinois, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington. 

Of those states, Connecticut, Illinois, Nevada, Ohio, Oregon, Texas, and Washington require hospitals to form staffing committees to develop plans and policies to direct the implementation of optimal staffing practices. 

Beyond these states, New Mexico and North Carolina have also started the assessment process by requesting studies that will gather and report information that can be used to develop future staffing mandates and policies. Additionally, Illinois, New Jersey, New York, Rhode Island, and Vermont have all initiated programs to increase public reporting on the impact of strategic staffing.

While other states may be considering statewide regulations, none have released official statements or passed laws specifically aimed at regulating nurse staffing, which leaves nurse-to-patient ratios in the hands of individual medical facilities.

Benefits of Nurse Staffing Ratios

Even without strictly enforced regulations in place, healthcare facilities may implement their own “safe staffing” policies that establish optimal nurse-to-patient ratios for their teams. By taking this step, facility leaders can elevate their care level with benefits that impact patients and nurses alike. These benefits include: 

  • Fewer medication errors
  • Lower patient mortality
  • Shorter hospital stays
  • Lower patient care costs associated with readmission
  • Less nurse fatigue and burnout
  • Increased patient satisfaction 
  • Higher HCAHPS patient care survey scores

Nurse Staffing Ratios for Long-Term Care Facilities

While they are not strictly regulated, the nurse-to-patient staffing ratios of long-term care (LTC) facilities are just as important as those in acute care facilities. In a typical nursing home or assisted living setting, nurses care for patients or residents across broad age ranges with extremely diverse medical needs. 

With this in mind, the Federal government established regulations for long-term care facilities by passing The Nursing Home Reform Law of 1987. While there have been no updates in almost four decades, the measure dictates that long-term care facilities comply with the following requirements:

  • A Registered Nurse (RN) must be present for eight consecutive hours, seven days a week
  • Licensed nurses must be on-site 24 hours a day
  • Sufficient nursing staff to meet the needs of the facility residents

While these Federal regulations provide an official baseline for staffing standards, several states have gone a step further and introduced statutes and regulations to govern nurse staffing in nursing homes. In 2008, a University of California San Francisco study reviewed state-specific requirements for Sufficient, Licensed, and Direct Care staff levels in nursing homes, and the results showed direction that varies widely from state to state. 

Even with these standards and recommendations, a 2018 Kaiser Health News study uncovered multiple discrepancies between state standards and some facilities’ staffing records. With that information in mind, most healthcare professionals agree that the broad requirements don’t go far enough to ensure that patients and residents receive the best care possible. Just as with acute care facilities, long-term care facilities can improve care and nurse satisfaction by implementing strategic nurse-to-patient ratios based on the specific needs of the facility and its residents. 

Use Gale to ensure you always have safe nurse staffing.

If you are a healthcare facility executive or manager looking for a simple, effective way to ensure your nurse-to-patient ratios are consistently met, Gale Healthcare offers a powerful tool. When you partner with Gale, you can use the Gale app to broadcast your open shifts to qualified nurses and nurse aides in your area When our nurses accept those shifts in the app, you gain the confidence of knowing your shifts will be filled by credentialed, qualified professionals who are ready to give your patients and residents the care they deserve. Learn more about Gale by scheduling a demo today!

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The days of stressing over unfilled shifts are over. Gale enhances your ability to manage staff, fill open shifts, and ensure your facility provides quality care on a consistent basis.

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