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Nurses, Not Policymakers, Should Determine Appropriate Staffing Levels

Analysis  |  By Carol Davis  
   July 18, 2023

Mandating nurse staffing ratios is 'short-sighted and counterproductive,' AONL contends.

Though a handful of state legislatures are considering mandating nurse-to-patient staffing ratios, government mandates are not the answer to nurse staffing, the American Organization of Nursing Leadership (AONL) has declared.

"Staffing is a complex decision based on the experience and clinical expertise of the nurse, care team, resources, and patient needs," AONL said in a prepared statement. "Organizational leaders, nurse managers, and direct care nurses, not policymakers, should collaboratively align staffing with patient needs."

In January 2004, California became the first and only state, so far, to establish minimum RN-to-patient ratios in every hospital unit. Other states prioritize patient safety through different nurse staffing ratio rules. Just last month, New York set higher staffing ratios to hospitals’ critical care and intensive care units. It did not set minimum staffing levels for all units.

But that is for a hospital or health system to determine, according to AONL.

"Mandated nurse staffing standards remove real-time clinical judgment and flexibility from nurses. Government-mandated ratios do not account for an individual patient or the healthcare team’s needs in an ever-changing environment, nor do they account for the variability among healthcare organizations," it says. "Mandated approaches to staffing do not consider these differences and requires organizations to staff nurses to the number of patients rather than a patient’s needs."

Mandated ratios are typically based on traditional nursing care models, AONL said, which are becoming outdated and more nursing practices embrace innovation, advanced capabilities in technology, and collaborative interprofessional care teams.

Further, the nursing shortage has reached a crisis stage, some nursing organizations say. About 100,000 RNs left the workforce during the COVID-19 pandemic in the past two years due to stress, burnout, and retirement, and nearly 900,000 intend to leave the nursing workforce by 2027, according to the National Council of State Boards of Nursing and National Forum of State Nursing Workforce Centers

"Mandated staffing does not create more nurses or guarantee improvements in safety, patient outcomes, or ensure a positive practice environment. Mandatory ratios compound the strain healthcare systems are already facing, potentially forcing hospitals who do not have enough nurses to meet the nurse-to-patient ratio, to turn patients away or delay care, threatening the patient’s ability to access care in their community," according to AONL.

AONL supports the American Nurses Association Nurse Staffing Task Force’s definition of appropriate staffing, which reads, "Appropriate staffing is a dynamic process that aligns the number of nurses, their workload, expertise, and resources with patient needs in order to achieve quality patient outcomes within a healthy work environment."

It also supports most of the task force’s systematic recommendations, including reforming the work environment, innovating models of care, improving regulatory efficiency, and valuing the unique contribution of nursing.

"As an independent profession, nurses are best suited to determine staffing," according to AONL. "Asking policymakers to mandate nurse staffing ratios for our patients relinquishes nurses’ professional autonomy; it is short-sighted and counterproductive."

“Nurses are best suited to determine staffing.”

Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.


A handful of state legislatures are considering mandating nurse-to-patient staffing ratios.

California is the only state to establish minimum RN-to-patient ratios in every hospital unit, though other states have differing ratio rules.

Health system leaders, nurse managers, and direct care nurses—not policymakers—should determine correct staffing, AONL says.

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