Mandated Nursing to Patient Ratio. Research Paper.

Policy Problem

The problem that is under discussion is the possible effect of a mandated nurse to patient ratio systems in the healthcare sector and how such steps can contribute to dealing with preventable medical errors that have always proved to be a problem from time to time in the medical industry (Greenwald et al., 2006). Hospitals and other medical units have made it an objective to reduce the number of cases of patients succumbing to medical errors that could otherwise have to be avoided. Mistakes that are said to be preventable are those errors that occur as a result of lack of paying attention from the nurses or due to their negligences, and the prevention can be achieved through the introduction of mandated nurse to patient ratio.

The paper looks at the historical development of the problem or how the issue came to exist or become an issue in the healthcare sector as well as the extent of the effects that have resulted since it ensued. Mandatory nurse to patient ratio implementation requires funding from different sources and the paper also looks at such sources of funds that are used to ensure the objective of mandated nurse to patient ratio process is achieved. Another aspect that is considered regarding the need for a mandatory nurse to patient ratio is the background of the issue on the grounds of the social factors that are influencing it, the economic factors as well as the legal and political factors. The issue statement regarding mandating nurse to patient ratio is also addressed as well as the policy alternatives that are in place to cover for possible inefficiencies in the system, and the various stakeholders in the entire subject.

Brief History

The safety of an individual during their stay in the hospital depends on the manner in which they are offered nursing care in those different hospitals, and that explains why federal regulations require that hospitals have licensed nurses. According to the Federal regulation 42 CFR 482.223 (b), every hospital needs to have licensed nurses as a sign of competence, and that includes the practical nurses as well as other medical personnel. The staff ratio debate in the health care regarding mandating nurse to patient ratios originated in California where different nursing unions in the state colluded to encourage or push the state legislature to implement an improved nursing policy.  The policy was aimed to lead to restructuring the ratio of nurses to patients in a manner that was considered to be able to result in the achievement of efficiency in service delivery in the healthcare units within the United States. Mandated nurse to patient ratios originated from the need to have a competent care in the hospitals and different medical facilities in the country since without such competence in the practices and activities of the nurses or physicians, the lives of patients who visit the facilities would be at risk (Frolich et al., 2007).

The necessity to have a mandated nurse to patient ratio was fueled by the belief that if nurses were given a responsibility to attend to a fewer number of patients and that if the nurses can have a direct patient care, the outcomes of medical interventions would improve remarkably (Donaldson et al., 2005). Fewer patients per nurse enable the nurses to have a reduced focus of activity that would make them more useful in the work they do, and the effectiveness would lead to the achievement of better health care standards. Patients have a differing level of severity and complexity and the hospitals cannot control such externals, but can only plan their nurse staffing and the mechanisms of the functioning of the nursing arrangements to address such cases. This need to have hospitals become better prepared to attend to the different requirements of the patients has tremendously contributed to the necessity of the mandated nurse to patient ratios in hospitals and medical units.

The need to have a mandated nurse to patient ratios has also been caused by the increasing need to guarantee a resolution to the safety concerns of the patients and to increase the percentage of successful medical interventions in the healthcare sector (Bolton et al., 2007). There is also need to reduce the amount of workload that is assigned to different nurses and medical practitioners and in the process make them more efficient in the various duties and responsibilities that they have to attend. The implementation of the mandated nurse to patient ratios would enable the creation of safer care in the healthcare sector that would lead to the satisfaction of both the patients and the nurses (Graf et al., 2003). The implementation of the mandated nurse to patient ratio (MNPR) is favored or advocated for due to the associated flexibility that it guarantees in the definition of the minimum staffing requirements based on the expertise of the nurses and the nature of the complexity of their health care needs.


The funding of the mandated nursing to patient ratio in the states where it has been implemented such as California is provided by both the federal and the state governments. To this end,  funds are used to hire the extra capacity of nurses that may be required to ensure the process is a success (Gordon, Buchanan & Bretherton, 2008). Additional support can also be offered by the respective hospitals if the management of the hospitals feels the need for a further increase of capacity in the staffing of the nurses in their departments.


The necessity of the mandated nurse to patient ratio has been influenced by different factors in the society across the nation and those factors justify the introduction of the system in one way or the other. Some of the factors that led to the influence of the implementation of the ratio system include different social factors, economic factors, and political as well as legal factors that also had to be considered in the process. The social, economic, political, and the legal aspects that affect the implementation of the mandated nurse to patient ratios must be deemed to ensure the implementation process is a success.

The social aspects or factors that influence the need to have a mandated nurse to patient ratio and must, therefore, be considered include the increasing need to have patient safety among members of different societies that seek medical interventions from time to time (Donaldson et al., 2005). It is believed that the health condition of members of various communities within the country will improve if the ratio of patients attended to by a given number of nurses is reduced to an acceptable level that leaves the nurses with a manageable level of activities handle. A fixed ratio of nurses to patients would lead to improved patient safety, patient safety being one of the primary considerations for the justification of the need to have ratios of nurses per patient (Donaldson et al., 2005).

In consideration of the social factors, it is also believed that introduction of mandated nurse to patient ratio is intended to increase the job satisfaction of the nurses since with an enhanced job satisfaction; the nurses would be better motivated to improve their efficiency in attending to different patients (Bolton et al., 2007). According to a survey carried out in Pennsylvania hospitals on many nurses, it was concluded that the job satisfaction level of nurses would be improved if there was a small ratio of patients to nurses in the hospitals or health care facilities. The survey established that if one more patient increased the ratio of patients to nurses, the rate of job dissatisfaction by the nurses would increase from 15 % to 23 %.

The economic impacts have also justified the implementation of the MNPRin the healthcare sector that the lack of it has on the medical practitioners such as the nurses and nurses and other physicians in the medical profession.  The nursing profession is so demanding that most of the current practicing nurses have always considered or are expected to consider part-time nursing or to have a career change altogether (Bolton et al., 2007). A survey carried out in 2011 established that about forty-five percent of the nurses that took part in the research study had a plan to move to a new career in the next few years to meet their financial needs with a similar investment in effort and time.  One-third among those who were considered to have job changes were considering moving to alternative professional specializations other than in the nursing sectors because they argued that work and pay were not corresponding.

To have success in the implementation of the mandated nurse to patient ratio, there may be needed to make sure legislative foundation, and in that regard, the Congress needs to come up with an Act that would guide the registration of the nurses. The Registered Nurse Staffin Act, H.R. 2083/S.1132 may need to be enacted to aid the process since it is legislation that does not lie on the side of any political party and as such would most likely receive a massive support (Rep, 2015). The bill will put an obligation on the hospitals, and medical facilities that take part in ensuring medical safety of different patients and that requirement would lead to an improved capacity in such hospitals (Croskerry, 2009).

Research carried out by the American Association of Colleges of Nursing established that the average cost per hire of nurses is estimated to be around $ 2,820, while other research studies have also revealed that the overall turnover cost per RN is around sixty-five thousand  (Donaldson et al., 2005). Hospitals are also estimated to lose about three-hundred thousand without the implementation of the mandated nurse to patient ratio for every percentage increase in the turnover number of the nurses (Bolton et al., 2007). Hospitals may need to attend to the various rising inefficiency from nurses turnover by supplementing nurses, which is still expensive to the extent of costing between two-hundred and fifty thousand and four hundred thousand dollars annually.

Thus, the only sure way to attend to the associated economic needs of the nurses as well as make them more efficient and effective is to have a mandated nurse to patient ratios in the health care sector (Donaldson et al., 2005).The process of implementation of the mandated nurse to patient ratios is a politically initiated process as the union of nurses pushed for the introduction of the rates system in the management of hospitals, and the process is supported through legislative proceedings. Even though only a few states such as California have the mandated nurse to patient ratios implemented, 17 other states have introduced legislations that would support such implementation, for example, Bill A660 in New Jersey (Bolton et al., 2007).

Issue Statement

The American Organization of Nurse Executives (AONE) recognizes the need to have a sufficient and adequate level of staffing in the nursing department to ensure the quality of patient care has been delivered efficiently in all the hospitals across the nation. The number of patients that a single nurse can attend to depends on different factors for the nurses to provide safe services. Such factors include the competence of the care, as well as the quality,  ability of the nurses regarding expertise level or the extent of seriousness of the condition of the patient.


The interested parties in the healthcare sector that have raised concern in the ratio of nurses to patients in hospitals include the nurses, patients, physicians of different specializations and nursing unions that have raised concerns on various occasions. Nursing organizations have always issued concerns regarding the few nurses that are expected to attend to an always increasing number of patients, a problem that has been noted even by researchers assigned by government bodies. The members of the public are also concerned with the ability of the nurses to deliver their designated duties efficiently, and as a result, they are also counted as major stakeholders.

Policy Alternatives and Comparison of the Alternatives

The choice to deal with the staffing issues has been fronted by the American Association (ANA) which prefers the endorsement of staffing systems. It would need RNS to have in place a direct care for the admitted patients and be included in making the central staffing decisions to ensure that the system is a reflection of the desired level of service delivery to the patients. Comparing this alternative to the mandated nurse to patient ratio, the MNPR is seen to be better since it guarantees job satisfaction of the nurses as well as ensure that the safety of the patients in the health care systems is also guaranteed.


Mandatory nurse to patient ratios is considered to continue being a widely controversial aspect in hospital and health care management among the major stakeholders in the sector and policies are developed from time to time to address the rising issues. The implementation of this staff rating in hospitals was initiated in 1999 by the state legislature in California after pressure from a coalition of nurses that demanded that the functionality of the nurses and their effectiveness be improved through an introduction of a mandated nurse to patient ratio. Nursing organizations have always issued concerns regarding the few nurses that are expected to attend to an always increasing number of patients, a problem that has been noted even by researchers assigned by government bodies. The federal, as well as state governments, have also indicated the nature of the work that involves attending to patients and the complaints that have been raised and the necessary steps and policy developments that would facilitate mandating of the nurse to patient ratios have been developed in different states.



Bolton, L. B., Aydin, C. E., Donaldson, N., Brown, D. S., Sandhu, M., Fridman, M., & Aronow, H. U. (2007). Mandated nurse staffing ratios in California: a comparison of staffing and nursing-sensitive outcomes pre-and postregulation. Policy, Politics, & Nursing Practice8(4), 238-250.

Croskerry, P. (2009). Patient safety in emergency medicine. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Donaldson, N., Bolton, L. B., Aydin, C., Brown, D., Elashoff, J. D., & Sandhu, M. (2005). Impact of California’s licensed nurse-patient ratios on unit-level nurse staffing and patient outcomes. Policy, Politics, & Nursing Practice6(3), 198-210.

Frolich, A., Talavera, J. A., Broadhead, P., & Dudley, R. A. (2007). A behavioral model of clinician responses to incentives to improve quality. Health Policy, 80, 179-193.

Gordon, S., Buchanan, J., & Bretherton, T. (2008). Safety in numbers: Nurse-to-patient ratios and the future of health care. Cornell University Press.

Graf, C. M., Millar, S., Feilteau, C., Coakley, P. J., & Erickson, J. I. (2003). Patients’ needs for nursing care: beyond staffing ratios. Journal of Nursing Administration, 33, 76-81

Greenwald, L., Cromwell, J., Adamache, W., Bernard, S., Drozd, E., Root, E. et al. (2006). Specialty versus community hospitals: referrals, quality, and community benefits. Health Affairs, 25, 106-118.

Rep, M. M. M. W. (2015). Health Disparities. MMWR Morb Mortal Wkly Rep64(33), 889-96.

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