In legislatures across the country, advocates for nurse and hospital associations are clashing over proposed nurse staffing bills, many of which require nurse-to-patient ratios.

Since the beginning of the year, at least 18 states have introduced or advanced nurse staffing bills, according to data from the American Nurses Association. And in March, Congress reintroduced federal legislation to set minimum nurse-to-patient ratios nationwide.

But the proposals are being met with resistance and lobbying from hospital associations, who argue the laws would impede their ability to provide patient care.

For lawmakers like Minnesota Rep. Sandra Feist, the COVID-19 pandemic put frontline providers’ concerns front and center. Feist, a Democrat who introduced the “Keeping Nurses at the Bedside Act” in March, was motivated to act by hearing first-hand accounts from nurses. She told Healthcare Dive by email that nurses reported that staffing levels were “the main cause” driving Minnesota nurses to “leave the bedside in record numbers.” 

Those concerns echo nationwide, as hospital nurse turnover remained elevated in 2022 at almost 23%. Since 2020, staffing shortages have created bottlenecks for care and strained relations between labor and management, becoming a source of friction driving historic nursing strikes across the country.

Mary Turner, president of the Minnesota Nurses Association and an advocate for safe staffing legislation, told Healthcare Dive that her organization surveyed bedside nurses who exited the profession over the past year, and 80% would return to the bedside “if staffing improved.”

Uneven adoption

Across the country, at least 16 states have successfully passed laws or regulations related to nurse staffing levels, which require nurse-to-patient ratios, staffing committees with nursing representation or disclosure of staffing policies.

Last week, Oregon legislators passed a bill that would require staffing committees and set minimum nurse-to-patient ratios in acute settings including emergency departments, intensive care units, labor and delivery units and operating rooms. Hospitals that violate the law could face up to $5,000 in penalties per offense. The bill now heads to the desk of Gov. Tina Kotek, a Democrat, for signing.

And in April, Washington passed a safe staffing law that requires nurse staffing committees and mandates reporting of staffing plans.

But other states have pushed back on nurse staffing mandates.

In Connecticut, the legislature rejected original language in one bill that mandated nurse-to-patient ratios, citing prohibitive costs to hospitals. Instead, Gov. Ned Lamont signed a law offering nurses more input in creating staffing plans.

In Minnesota, Feist’s legislation, which required staffing committees to consist of 35% direct care nurses, passed both the House and Senate but fell apart at the final hour after pushback from the state’s largest private employer, academic medical system the Mayo ClinicThe nonprofit threatened to send billions of dollars of investments out of state if the hospital was required to abide by the law. 

Nurse representation on staffing committees was dropped. Instead, Gov. Tim Walz, a Democrat, signed the revised Nurse and Patient Safety Act into law three weeks later. The law includes provisions addressing workplace violence, health professional education loan forgiveness and creates a study on staffing and retention.

Nurses’ unions argue staffing ratios enhance patient care — using quantitative metrics, like readmittance and mortality rates, as well as patient experience reports to bolster their claims— while hospital associations say the set standards limit flexibility and are out of date with current care models.

Staffing ratios “do not consider advanced capabilities in technology or interprofessional team-care models. These newer models incorporate nurses at various levels of licensure, but also respiratory therapists, occupational therapists, speech-language pathologists, physical therapists and case managers,” said Robyn Begley, chief nursing officer of hospital lobby the American Hospital Association.

Opponents point to the nationwide staffing shortage, arguing that staffing laws might exacerbate the problem. Begley said mandated staffing laws could “increase stress on a health care system already facing an escalating shortage of educated nurses” and do “not create more nurses.” 

Advocates, including MNA’s Turner and Anne Tan Piazza, executive director at the Oregon Nurses Association, argue that there isn’t a shortage of nurses — there’s a shortage of nurses willing to work in unsafe conditions.

Paradoxically, requiring more nurses on staff could, in their view, help alleviate the staffing shortage.

Linda Aiken, professor of nursing at the University of Pennsylvania and founding director of the Center for Health Outcomes and Policy Research, who has studied staffing ratios for three decades, agrees. She said the first nurse ratio law passed in California in 2004. At the time, she recalled, there were similar concerns over staffing shortages.

“The number of hours of nursing care started going up immediately, which means more nurses came back in the field,” Aiken said. “Today, patients in California get three more hours of [registered nurse] care on average than patients in other states because of that legislation.”

Aiken added that patient care — regardless of the restrictions imposed on California providers — has improved. She pointed to peer-reviewed research demonstrating elevated care for poor and minority patients as well as those at safety net hospitals. Plus, she said, no hospitals closed.

Yet in states like Maine, Michigan, Missouri, Pennsylvania and New Jersey, nurses and hospitals remain at odds, waiting on the outcome of staffing bills as they move through state legislatures.

Despite the setbacks some localities have encountered, nurse staffing advocates are focused on passing legislation they view as vital to protecting patients and nurses.

“We have to work damn hard to get change. And it sometimes can take a decade,” Turner said. “Are we going to see it in the next year or two? Maybe not. But we’re starting the process.”

Editor’s note: This story has been updated to reflect additional language concerning the passage of a Connecticut staffing law.