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Establishing Safe Nurse-to-Patient Ratios: A Way To Keep Nurses at Bedside

In the realm of healthcare, one critical concern that continues to plague the nursing profession is that of unsafe nursing ratios. According to the American Nursing Association, unsafe nursing ratios refer to situations where the number of patients assigned to a nurse exceeds safe and manageable levels, compromising patient care and increasing the risk of adverse outcomes (ANA, 2012). Unsafe staffing ratios have been influenced by the absence of federally mandated ratio laws, tighter hospital budgets, and the growing nursing shortage. This paper will outline the causes, adverse outcomes, and prevention strategies for low patient-nurse ratios.

Prevalence of Nursing Shortage

The nursing shortage is a common issue in the country and globally. ANA outlined that more than 500000 nurses will retire by the end of 2022, creating a massive nursing shortage. The shortage also comes due to an increased number of individuals diversifying to other professions. The estimated shortage in the country was 1.1 million by 2022, which has already created a crisis (Haddad et al., 2022). The number is also expected to increase by 2026 to more than 15 per cent. To address the nursing shortage, ANA proposes various specific approaches and interventions from the nursing profession. For instance, they propose enhancing recruitment efforts, strengthening educational programs, investing in retention programs, encouraging nurse specializations, and addressing workforce diversity. ANA’s recommendations provide a roadmap for the profession to navigate this critical challenge and maintain safe and high-quality patient care delivery. World Health Organization also outlined a deficit of more than one million nurses in the country by the end of 2020. Fewer individuals participate in the nursing career, which has lowered the numbers in most parts of the nation. The Bureau of Statistics also outlined that nursing careers will require more than 250 000 individuals between 2020 and 2030. It also outlines a vast opportunity for the employment rate in the nursing field to grow by nine per cent in the nursing career. Another report outlined that more than 1.2 million nurses will be needed to reduce the shortage by 2030. The nursing field receives a lower entry rate than other careers, affecting the ratio in many parts of the nation. The Bureau also projected an increase of 73 million deficits in the nursing field. The data on the shortage issue outlines the high prevalence of the issue.

Causes of Nursing Shortage

The ageing workforce

The estimated number of ageing nurses has increased, which makes the profession have a huge deficit. The ageing workforce affects their ability to offer effective services in the facilities. More than one million nurses in the nation are 50 years and above. They fear remaining in the workforce for long periods (Haddad et al., 2022). This has made the occupation a hot target for the new generation who need to fill the empty spaces. However, different faculties have received a lower registration rate, complicating the situation. Few students register for the nursing profession compared to other faculties. Hence the ageing population and the fewer individuals registering to take the course have led to an increase in the shortage and patient-nurse ratio.

Violence in Healthcare

Nursing groups are the most affected parties by workplace violence. The nurses experience physical and emotional abuse from different stakeholders in the healthcare setting. The nursing environment presents stressful situations like burnout and fatigue; hence additional violence may affect the professional outlook. For example, the emergency department risks facing violence from other stakeholders due to the pressure to handle different individuals at a given time. A study in Poland outlined that the nursing profession is vulnerable to insults. Verbal insults were the most recorded violence from different individuals in the facilities. According to WHO, “between 8 and 38% of nurses suffer from healthcare violence at some point in their career” (Kafle et al., 2022, p. 1). The common violence in the sector has discouraged many individuals from pursuing other courses and ignoring nursing. The environment is already an insulting condition due to stressed factors. Therefore, additional violence makes the profession unbearable for many individuals.


Burnout is prevalent in various industries, including nursing, with complex medication procedures and patient issues contributing to its occurrence (Shah et al., 2021). Nurses often face the challenge of managing complex patients, particularly with the presence of the baby boomer population, which adds to the complexity of their work. The increased workload and long shifts further contribute to nurse burnout, negatively impacting their work-life balance and overall morale. A significant percentage of nurses, approximately 80%, who considered leaving the profession cited burnout as the primary cause, as it leads to emotional disturbance and hinders their personal lives (Shah et al., 2021). This burnout phenomenon affects existing nurses’ morale and dissuades potential individuals from pursuing a nursing career.

Negative Outcome

The issue of inadequate staffing has led to a rise in nursing strikes, with a notable example occurring this year in New York City. More than 7,000 nurses participated in the protest, advocating for implementing enforceable safe staffing ratios. This demonstration highlights the growing dissatisfaction among nurses regarding staffing levels and the urgent need for measures that ensure optimal staffing to guarantee patient safety and quality care. The current inadequate staffing levels hurt patient safety. According to a study published in The New England Journal of Medicine, patient care is compromised when nurses face high workloads, increasing the risk of adverse events. The researchers analyzed nearly 200,000 patients from 43 nursing units and revealed a 6% rise in mortality rates compared to fully staffed ones (Blouin & Podjasek, 2019). Another negative impact of unsafe nurse-to-patient ratios is the exacerbation of nurse burnout, a leading cause of nurses leaving the bedside (Shah et al., 2021). In a study from 2018 surveying more than 50,000 registered nurses, inadequate staffing was found to be 30.0% of why nurses are leaving the profession and 42.6 % of why they have considered leaving (Shah et al., 2021).

Proposed Strategy

The nursing profession recommends federal nurse staffing standards to reduce nurses leaving the bedside is associated with unsafe nurse-to-patient ratios.

State and Federal Legislation

In California, the implementation of Assembly Bill (AB) 394 has positively impacted staffing, nurse and patient satisfaction, and reduced hospital stays. AB 394, passed in 1999, introduced mandatory nurse-to-patient ratios in the state. These ratios vary based on the unit type and level of care provided. The introduction of AB 394 has led to several improvements. Firstly, it ensures that hospitals have adequate staffing levels, which contributes to improved patient safety and outcomes. With specific minimum nurse-to-patient ratios in place, hospitals are better equipped to meet the needs of their patients. Moreover, AB 394 has positively influenced nurse satisfaction. By mandating appropriate staffing levels, nurses can better provide quality care and experience less workload burden. This, in turn, enhances their job satisfaction and overall well-being. The implementation of AB 394 has also resulted in reduced hospital stays. When hospitals have sufficient nursing staff, patients receive timely and comprehensive care, leading to faster recovery and shorter hospital stays. This not only benefits patients but also helps to alleviate the strain on healthcare facilities.

Further, California’s success with AB 394 has inspired other states to adopt similar measures. States like New Jersey, New York, Oregon, Ohio, Washington, Texas, and Connecticut have implemented alternative forms of legislation, such as staffing committees or public reporting of staffing, to promote safe nursing ratios and improve patient care. At the federal level, progress is also being made to address safe nursing ratios. In May 2021, the Nurse Staffing Standards for Patient Safety and Quality Care Act was introduced to the United States Senate. This legislation proposes that hospitals establish staffing plans adhering to minimum nurse-to-patient ratios for each unit. It also accentuates the significance of publicly displaying information about nurse-to-patient ratios and maintaining records. By advocating for reform in the work environment, innovating care delivery models, establishing staffing standards, enhancing regulatory efficiency, and valuing the unique contribution of nurses, healthcare organizations and policymakers can further promote safe nursing ratios, ultimately enhancing patient care and nurse well-being.

Safe Nurse-to-Patient Ratios and Nurse Satisfaction

Implementation of safe staffing policies leads to an increase in the presence of registered nurses at the patient’s bedside. Various regions worldwide, such as California, have observed improved nurse-to-patient ratios following the enactment of legislation mandating nurse-to-patient ratios. Positive effects on nurse outcomes, such as decreased burnout, increased job satisfaction, and reduced intention to leave the profession, have been noted. (Van dan Heed et, al (2020). The patient-to-nurse ratio is linked to nurses’ workload, burnout, and job satisfaction in healthcare settings.

One study by Chen et al. (2019) examined the correlation between patient-nurse ratios, job burnout, and nurse dissatisfaction. The researchers found that an increased patient-nurse ratio decreased nurses’ intention to leave their job. This effect was primarily mediated by personal burnout, client-related burnout, and job dissatisfaction. These findings emphasize the significance of appropriate nurse-to-patient ratios in retaining nurses within the profession and highlight the need for policymakers and researchers to determine suitable standards for these ratios, periodically assess nurses’ intention to leave, and consider the impact of personal and client-related burnout and job dissatisfaction (Chen et al., 2019).

Another study by Shah et al. (2021) found that states with legislation regulating nurses to patient ratios had lower rates of nurse burnout. The strategy would work since legislation is very effective in handling different issues. The states which have implemented the law have rescued the profession, thus increasing the number of individuals taking the profession. The legislation will also prevent violence and burnout, thus motivating other individuals to pursue the course. The proper professional balance will reduce burnout and long shifts, thus making it reliable like other professions. Reduced shifts will make it easy for nurses to associate with their families and balance their mental and emotional well-being. Hence implementing this strategy will be very effective in solving the problem.


The nursing shortage is the reduced number of nurses compared to the available patients. Different factors have led to a reduced patient-nurse ratio, for example, an ageing workforce. Many nurses in the country are aged 50 and above, creating a massive deficit in the profession. The shortage is prevalent and projected to reach 73 million by 2030. Also, rampant violence has discouraged many individuals from taking the career since it is linked to emotional and physical distress, affecting job satisfaction and quality service delivery. Mandating nurse-to-patient ratios throughout the Unites States would improve nurse work environment quality. The legislation would reduce the shortage since it would address critical factors like burnout. Decreasing the nurse’s workload reduces the rates of dissatisfaction, burnout, and desire to leave the bedside. The legislation will also improve the profession’s general outlook, attracting many individuals to the career.


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Chen, Y. C., Guo, Y. L., Chin, W. S., Cheng, N. Y., Ho, J. J., & Shiao, J. S. (2019). Patient Nurse Ratio is Related to Nurses’ Intention to Leave Their Job through Mediating Burnout and Job Dissatisfaction Factors. International journal of environmental research and public health, 16(23), 4801.

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