Policies to Achieve Hospital Nurse Staffing Adequacy

Safe nurse staffing is common sense. Patients have better outcomes, and healthcare workers suffer less burnout and are more likely to stay on the job. But too many healthcare executives place profits over patient care. Throughout the United States, clinicians and their unions have spent decades fighting for safe staffing through collective bargaining, community pressure, actions like informational picketing and strikes, and legislation.

The fight has been long and hard, and strategies have differed at times. To keep working together, and to keep our coalitions strong, we need to listen to each other and continue learning from our successes and setbacks. Here, we are fortunate to offer the perspective of a true pioneer in safe staffing research and policy, who shares the data and offers some ideas on the road forward. While some readers may not agree with everything in this article, we are confident that everyone will be informed by the research and recommendations. Together, we will continue to fight for and win staffing levels that ensure quality care for patients and good working conditions for clinicians.

–EDITORS

Nurses are the primary surveillance system for early detection of complications and the launch of rapid interventions to rescue patients. But nurse surveillance is compromised by inadequate nurse staffing when nurses are not able to directly observe, assess, and quickly act on patients’ conditions. This often results in life-threatening delays in clinical interventions, health disparities, and moral distress for nurses.¹

More than two decades ago—and again in 2014—research conducted by my colleagues and me established that each one patient added to a nurse’s workload is associated with a 7 percent increase in the risk of hospital mortality and failure to rescue patients.² Subsequent research has also found significant evidence that adequate nurse staffing is a key hospital resource that impacts nurse well-being and retention, patient mortality and complications, patient satisfaction, and favorable financial metrics driven by nurses, such as cost savings produced by shorter lengths of stay and reduced nurse turnover.³ And yet, variation in patient-to-nurse staffing ratios across hospitals is long-standing and remains common.⁴

The World Health Organization’s recommendations for addressing nursing and other healthcare shortages make it clear that relying on training new members of the workforce is insufficient; hospitals must significantly improve nurse retention.⁵ Among the top reasons that nurses leave jobs in healthcare are burnout and insufficient nurse staffing.⁶ Research consistently shows that high patient-to-nurse ratios are associated with high nurse burnout, increased job dissatisfaction, and greater intent to leave their current job.⁷

But nurses, nurse and patient advocacy groups (including nurses’ unions), and concerned citizens are not sitting by the sidelines. Across the country, they’ve been fighting for safe staffing legislation.

Establishing Safe Hospital Nurse Staffing Requirements

Legislative activity to mandate safe nurse staffing in US hospitals has been increasing, as has the evidence showing that these policies improve nurse retention and well-being as well as patient outcomes. Two states—California and Oregon—have implemented legislation mandating comprehensive hospital minimum nurse-to-patient ratios, and two states—Massachusetts and New York—have passed hospital-mandated nurse staffing for critical care only. Eight states have adopted mandated hospital nurse staffing committees, and 11 states require hospital staffing plans. Five states have mandated public reporting of hospital nurse staffing.⁸

Comprehensive Staffing Ratio Laws

California implemented a comprehensive safe staffing law in 2004. The legislation did not include specific ratios but directed the California Department of Health Services (now the California Department of Public Health) to establish minimum, specific, and numerical licensed-nurse-to-patient ratios by hospital unit type for acute-care, acute-psychiatric, and specialty hospitals.⁹ The ratios apply at all times, including during meals, breaks, and excused absences. Some rural hospitals were eligible for delayed implementation. Hospitals can use up to 50 percent licensed vocational nurses (LVNs) to meet the ratios. To float nursing staff between units, the law requires staff to receive orientation and have validated current competence.

The ratios outlined were intended to be a floor, not a ceiling, with hospitals required to increase nurse staffing based on patient acuity. The law was implemented in phases, with the final phase going into effect on January 1, 2008, tightening ratios for some unit types. Initially, for example, no nurse could care for more than 6 adult medical or surgical patients at one time; over an 18-month period, that number was reduced permanently to 5 patients per nurse. The table below shows a sample of unit ratios as of 2008.

California Statutory Minimum Nurse-to-Patient Staffing Ratios

Nurse staffing improved significantly in California hospitals after the legislation’s implementation. According to comparisons of hospital data from 1997 to 2016, patients received up to three hours more RN care per day than patients in hospitals in other states.¹⁰ Nurse staffing improved rapidly and significantly in safety net hospitals, with the implication that mandated nurse staffing ratios can improve health outcomes for underserved populations.¹¹ Despite what some feared, there is no evidence that hospitals closed or reduced services because of the staffing policy, and no evidence of erosion of nursing skill mix with hospitals replacing RNs with LVNs.¹²

Evidence of positive impacts of California’s nurse staffing legislation on nurses’ well-being is strong. As a direct result of the legislation, nurse job satisfaction improved and nurse burnout was reduced.¹³ However, the impact of the legislation on patient outcomes is sometimes said to be “mixed.” Large-scale studies with sufficient statistical power to find associations between the legislation and patient outcomes provide evidence that mortality and failure to rescue decreased in California following staffing improvements. But some studies of “nurse-sensitive indicators” at the unit level, such as pressure ulcers and falls, had null findings that could well be due to outcome measurement error and faulty research design.¹⁴

Oregon became the second US state to implement comprehensive nurse staffing legislation in 2024. The initial ratio was no more than 5 patients on adult medical and surgical units per nurse, tightening to 1:4 on June 1, 2026. To ease implementation, rural hospitals may receive a two-year variance from the law’s requirements if approved by the nurse staffing committee.¹⁵ As in California, this law sets a floor, not a ceiling. Hospital nurse staffing committees may create staffing plans with higher standards.

Oregon’s statutory ratios, or higher standards solidified by staffing committee–approved plans, are enforced at all times, including during meals and breaks; hospitals must pay nurses $200 for each missed break or meal when the nurse files a valid complaint within 60 days. Additional penalties may be levied on hospitals that fail to adhere to the ratios or the standards set forth in a unit’s staffing plan. The only time facilities can deviate from the legal ratios is when nurse staffing committees pursue an innovative care model by including other clinical staff; in those cases, the model must be approved by the staffing committee and then reappraised every two years.¹⁶ The table below shows a sample of unit ratios mandated in the legislation.

Oregon Statutory Minimum Nurse-to-Patient Staffing Ratios

*Medical surgical ratio began at 1:5 in June 2024 and drops to 1:4 in June 2026.

Targeted Ratio Staffing Laws

Massachusetts in 2014 (with implementation beginning in 2016) and New York in 2021 (with implementation in 2023) passed legislation setting minimum nurse staffing requirements only in intensive care (or critical care). These more targeted laws were enacted after comprehensive minimum nurse staffing ratio bills failed to pass.

In Massachusetts, the law mandated all hospital ICUs maintain a ratio of 1 nurse to 1 or 2 patients, depending on patient acuity. An outcomes evaluation compared ICUs in six academic medical centers impacted by the law with 114 academic medical centers outside of the state. The researchers concluded that the legislation was a failure because they found no differences in Massachusetts hospitals in ICU staffing over time compared to ICUs in other states and no changes in patient outcomes associated with the legislation. (Nurse outcomes were not studied.)¹⁷ However, the null findings were to be expected because there is not as much variation in ICU nurse staffing as in other types of units like medical and surgical, especially in the academic medical centers included in the study. If the legislation had a significant effect on nurse staffing in ICUs, it would have been more likely in community hospital ICUs, which were not studied. Additionally, the ICU quality outcomes evaluated—including incidence of hospital-acquired pressure ulcers and patient falls with injury—were not ideal nurse staffing-sensitive measures of improvement in ICU morbidity.¹⁸

The New York ICU staffing ratio rule, enacted by the New York State Department of Health in 2023 pursuant to the 2021 Safe Staffing for Hospital Care Act, requires—at all times—a minimum of 1 RN for every 2 ICU and critical care patients, increased as appropriate for the acuity level of the patient. Unlike in Massachusetts, there were baseline data collected on New York hospitals, documenting that ICU staffing ranged across all NY hospitals (not just academic medical centers) from 1.8 to 4.3 patients per nurse, with an average of 2.5 patients per nurse.¹⁹ Thus, implementing a required minimum staffing of 1 RN for every 2 ICU patients can potentially improve ICU staffing in some New York hospitals.

One bill that failed to pass, the NY Safe Staffing for Quality Care Act (S. 1032/A. 2954), called for nurses to care for no more than 4 patients each on adult medical and surgical units. Published baseline research showed nurse staffing varied across adult medical and surgical units in NY hospitals from 4.3 to 10.5 patients per nurse, with an average of 6.3 patients each.²⁰ Half of nurses in NY hospitals suffered from high job-related burnout, close to 30 percent were dissatisfied with their jobs, and over 1 in 5 nurses said they intended to leave their jobs within the year.²¹ Based upon observed differences in hospital outcomes at all nurse staffing levels, researchers predicted that passage of the NY Safe Staffing for Quality Care Act would have significantly improved nurse well-being and intention to stay. They also estimated that 4,370 in-hospital deaths would have been avoided just among elderly Medicare patients admitted for common surgical and medical reasons during the two years of the study, and many more deaths would have been avoided if all patients who benefit from improved nurse staffing were counted. Additionally, a minimum savings of $720 million was estimated over two years because of shorter lengths of stay and fewer readmissions²²—funds that could have been reinvested in hiring the additional nurses needed to meet the proposed ratios. Despite this compelling research, New York did not pass the comprehensive hospital safe nurse staffing bill but defaulted to ratios in ICUs only.

Interestingly, legislation that mandates changes in care, as opposed to staffing ratios, has been more successful in getting passed. For example, in 2013, New York state passed a bill mandating that all hospitals implement a sepsis care bundle to prevent sepsis deaths. Researchers estimated that more deaths from sepsis would be avoided by adopting New York’s minimum nurse staffing bill than by the sepsis bill mandating an evidence-based care bundle.²³ Obviously, adherence to the sepsis bundle will not happen without adequate nurse staffing, so this is a good example for nurses to use when advocating for staffing legislation. Another example is the Health Care Workplace Violence Prevention Act that passed in the Pennsylvania House of Representatives in May 2025. Although nurses rightly celebrated, this bill’s effectiveness will be limited because a comprehensive nurse staffing bill that the state House passed in 2023 is still stalled in the state Senate.²⁴ Nurse understaffing is a root cause of violence in hospitals;²⁵ without solving that, it is unlikely that violence against nurses will be eliminated whether there is a law or not.

Pending Ratio Legislation

The Illinois Safe Patient Limits Act, which has not passed, calls for hospital nurses outside of ICUs to care for no more than 4 patients each.²⁶ Researchers documented large variation in nurse staffing in Illinois hospitals, from 4.2 patients on adult medical and surgical units for each nurse in some hospitals to as many as 7.6 patients per nurse in others. Using these staffing data by hospital linked with objective patient outcomes data for the same hospitals, researchers estimated that if all Illinois hospitals staffed at not more than 4 patients per nurse on medical and surgical units, about 1,595 deaths could have been avoided among Medicare beneficiaries during the study period. Additionally, over $117 million could be saved per year just among Medicare patients—and likely considerably more across all hospitalized patients.²⁷

In addition to ratios proposed for other hospital units, Pennsylvania’s pending Patient Safety Act restricts nurses on adult medical and surgical units to caring for no more than 4 patients at a time.²⁸ University of Pennsylvania researchers testified at legislative Health Committee hearings that the average medical-surgical hospital nurse in Pennsylvania provides care to 5.6 patients, and nurses’ workloads range across hospitals from 3.3 patients per nurse to as many as 11 patients per nurse. If all Pennsylvania hospitals were staffed in medical and surgical units at the proposed ratio of no more than 4 patients per nurse, an estimated 1,155 deaths annually could be avoided. Moreover, patient length of stay could be reduced by approximately 39,919 days, resulting in cost savings of over $93 million per year.²⁹ A previous study showed that if Pennsylvania hospitals staffed at levels mandated in California (5 patients per nurse), surgical mortality rates in Pennsylvania hospitals could be reduced by nearly 11 percent.³⁰

Alternative Staffing Policies

In the United States, there are two other types of legislated nurse staffing policies besides ratios that aim to improve nurse staffing adequacy in hospitals: mandated committees and public reporting. Mandated hospital nurse staffing committees, usually required to comprise at least 50 percent direct care nurses, decide on nurse staffing levels and skill mix. This is the most common form of hospital nurse staffing legislation in the United States and is currently implemented in eight states (Connecticut, Illinois, Nevada, New York, Ohio, Oregon, Texas, and Washington).³¹ Mandated hospital nurse staffing committee legislation is often considered a compromise in highly contentious debates between hospital stakeholders over mandated minimum nurse staffing ratios. However, research suggests that nurse staffing committees alone do not improve nurse staffing.³² And there is no evidence that nurse staffing committees significantly improve nurse well-being and retention or patient outcomes.³³

Five states (Illinois, New Jersey, New York, Rhode Island, and Vermont) have mandated public reporting of hospital nurse staffing, and another three states (Massachusetts, Minnesota, and Washington) have voluntary public reporting. Research suggests that mandatory reporting is, by itself, not an effective policy to significantly improve nurse staffing or nurse well-being.³⁴ There is little evidence that consumers in states with mandatory public reporting of hospital nurse staffing are accessing or acting upon the information, which is not standardized and may be difficult to locate and interpret.³⁵ The most consumer-friendly healthcare website in the United States, Care Compare (available at go.aft.org/1fe), was established by the Centers for Medicare and Medicaid Services (CMS); it provides information that enables consumers to compare quality outcomes across hospitals, but it includes no information on hospital nurse staffing. Adding hospital nurse staffing through administrative action by CMS could be a useful goal for advocates, as such information would be widely available to the media for inclusion in their frequent stories about nurse shortages.

Continuing Legislative Advocacy

Evidence is building that minimum safe nurse staffing policies are in the public interest, and more US states (and international jurisdictions) have policies under consideration. Advocates for such legislation should heed the following five lessons from previous policy experiences. First, the role of regulation in the United States is largely to protect the public rather than to foster optimal quality. Pending legislative efforts, such as the push for 1 nurse for every 4 patients, may be striving for “optimal” staffing policies rather than those that research indicates are safe. For example, patient care clearly improved in California with a minimum requirement of no more than 5 patients per nurse on medical-surgical units. Politically, proposing ratios of 1 nurse for every 4 patients may be overreaching, especially if baseline data show that most hospitals in a state do not currently meet a 1:4 ratio, thus requiring almost all hospitals to add additional nurses, as was the case in New York for the staffing bill that failed.³⁶ Second, many bills are too complicated with too many requirements; simpler is better. Any detail that cannot be defended by evidence risks undermining support for the entire bill. As there is currently no research evidence to justify different ratios on many different specialty units, specifying ratios for every type of unit is a risk to passage of proposed legislation. Third, many bills try to punish hospitals through complex fines, are difficult and expensive for the state to implement, and have not been shown effective in gaining compliance. Fourth, nurses are not speaking with one voice to support ratio legislation. Nurse executives and leaders, in particular, often testify in state hearings against nurse staffing legislation, confusing elected officials and undermining the chances for positive votes. A high priority should be developing consensus among nurses on proposed staffing legislation before bills are introduced, including considering new provisions that might exempt hospitals that show consistent evidence of meeting minimum ratios. Fifth, policies limited to ratios in ICUs have limited benefits, as staffing is already best there, and these policies derail more comprehensive approaches.

“New” Nurse Staffing Models

Despite US and global evidence showing that policies establishing minimum safe nurse staffing requirements in hospitals are effective in retaining nurses and in improving patient safety and quality of care, powerful stakeholders remain opposed to ratio policies. Their alternative approaches are implementing “new” nurse staffing models to solve difficulties recruiting enough nurses by trying to reorganize care to require fewer RNs.

Justification for new nurse staffing models is premised on a scenario of a nonexistent nursing shortage in the United States. The number of US graduates from nursing programs has been steadily increasing for years,³⁷ resulting in the nation adding about a million net new RNs to its national supply in the decade preceding COVID-19. Even if 60,000 nurses a year reach retirement age, the nearly 200,000 new US graduates annually could more than replace retiring nurses.³⁸ Additionally, the United States remains at the top of the international nurse recruitment pyramid,³⁹ offering another option for recruitment of RNs if necessary—although current US immigration policy is uncertain.

Team nursing is the most common “new” nursing care delivery model—although it is not new at all, as it was the usual method of nursing care delivery in hospitals before 1980.⁴⁰ Team nursing uses fewer RNs to manage a team of licensed practical nurses (LPNs) and nursing assistants. Many rigorous studies have documented that replacing RNs with lower-qualified personnel results in poor patient outcomes and poor RN retention, and it does not save money.⁴¹ Team nursing is not synonymous with interdisciplinary teams that comprise clinicians from different professions. Team nursing has one group of professionals—RNs—who are the target of reductions. A recent evaluation of the outcomes of team nursing estimates that reducing RNs to supervising lower-wage workers poses serious risks of increased preventable deaths and other patient complications; additionally, it will not save money because of expected increases in length of stay, readmissions, expensive complications like hospital-acquired infections, and increasing RN turnover.⁴²

Another new model is virtual nursing, in which nurses direct and monitor patient care remotely or in conjunction with in-person care. No evidence yet exists that this will reduce expensive nurse turnover or enable the employment of fewer RNs. There is a possibility that virtual nurses may be able to improve quality of care under some circumstances,⁴³ but the motivation in moving to virtual nursing is not quality improvement but reduction in labor costs. Technology is another example of improving quality of care under certain circumstances, but almost all technology introduced into hospitals has so far been nurse-intensive, expanding the scope of practice of RNs rather than substituting for RNs.

Practically speaking, the best evidence-based solution for delivering hospital care with fewer RNs is to divert more patients from hospital admissions through better preventive care or better and more accessible community-based healthcare alternatives. The best example of success is same-day surgery for which patients are not admitted. However, retaining good outcomes for patients diverted from inpatient care will require more access to nursing care in the community than is presently available.

The best solution for staffing today’s hospitals is adequate evidence-based ratios of inpatient RN staffing. Policies mandating minimum nurse staffing standards are successful in improving not only patient outcomes and quality of care but also nurse well-being and retention. RNs are high-value labor for hospitals. The United States has a robust supply of RNs, so the problem is not a shortage of nurses; rather, too few hospitals are providing expert clinicians with the resources and organizational engagement needed to sustain excellent care and promote institutional loyalty and commitment.   

Linda H. Aiken, PhD, RN, FAAN, FRCN, is an internationally recognized expert on human resources in health, workforce shortages, nursing outcomes research, and health policy evaluations. She is a professor in and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, a senior fellow at the Leonard Davis Institute of Health Economics, and an elected member of the National Academy of Medicine.

Endnotes

1. M. Carthon et al., “Better Nurse Staffing Is Associated with Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests,” Medical Care 59, no. 2 (February 2021): 169–76; and A. Booth et al., “Institute-Wide Moral Distress Among Nurses,” Journal of Nursing Administration 54, no. 11 (November 2024): 597–604.

2. L. Aiken et al., “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” JAMA 288, no. 16 (2002): 1987–93; and L. Aiken et al., “Nurse Staffing and Education and Hospital Mortality in Nine European Countries: A Retrospective Observational Study,” The Lancet 383 (2014): 1824–30.

3. A. Schlak et al., “Leveraging the Work Environment to Minimize the Negative Impact of Nurse Burnout on Patient Outcomes,” International Journal of Environmental Research and Public Health 18, no. 2 (2021): 610; J. Needleman et al., “Nurse-Staffing Levels and the Quality of Care in Hospitals,” New England Journal of Medicine 346, no. 22 (2002): 1715–22; K. Lasater et al., “Is Hospital Nurse Staffing Legislation in the Public’s Interest? An Observational Study in New York State,” Medical Care 59, no. 5 (2021): 444–50; and M. McHugh et al., “Effects of Nurse-to-Patient Ratio Legislation on Nurse Staffing and Patient Mortality, Readmissions, and Length of Stay: A Prospective Study in a Panel of Hospitals,” The Lancet 397, no. 10288 (May 22, 2021): 1905–13.

4. L. Aiken et al., “A Repeated Cross-Sectional Study of Nurses Immediately Before and During the COVID-19 Pandemic: Implications for Action,” Nursing Outlook 71, no. 1 (December 8, 2022): 101903.

5. World Health Organization: European Region, Health and Care Workforce in Europe: Time to Act (Copenhagen: 2022), fnopi.it/wp-content/uploads/2023/05/9789289058339-eng_compressed-1.pdf.

6. K. Muir et al., “Top Factors in Nurses Ending Health Care Employment Between 2018 and 2021,” JAMA Network Open 7, no. 4 (April 9, 2024): e244121; L. Li et al., “Nurse Burnout and Patient Safety, Satisfaction, and Quality of Care: A Systematic Review and Meta-Analysis,” JAMA Network Open 7, no. 11 (November 4, 2024): e2443059; and K. Leep-Lazar, C. Ma, and A. Stimpfel, “Factors Associated with Intent to Leave the Nursing Profession in the United States: An Integrative Review,” Research in Nursing and Health 48, no. 4 (August 2025): 429–40.

7. S. Shin, J.-H. Park, and S.-H. Bae, “Nurse Staffing and Nurse Outcomes: A Systematic Review and Meta-Analysis,” Nursing Outlook 66, no. 3 (May–June 2018): 273–82; and Aiken et al., “A Repeated Cross-Sectional Study of Nurses.”

8. N. Krishnamurthy et al., “Hospital Nurse Staffing Legislation: Mixed Approaches in Some States, While Others Have No Requirements,” Health Affairs 43, no. 8 (August 2024): 1172–79.

9. J. Coffman, J. Seago, and J. Spetz, “Minimum Nurse-to-Patient Ratios in Acute Care Hospitals in California,” Health Affairs 21, no. 5 (September/October 2002): 53–64.

10. A. Dierkes et al., “The Impact of California’s Staffing Mandate and the Economic Recession on Registered Nurse Staffing Levels: A Longitudinal Analysis,” Nursing Outlook 70, no. 2 (March–April, 2022): 219–27; and Penn Nursing, “CHOPR Researchers Study Hospital Patient-to-Nurse Ratio Legislation,” University of Pennsylvania, March 18, 2021, nursing.upenn.edu/live/news/1899-chopr-researchers-study-hospital-patient-to-nurse.

11. M. McHugh et al., “Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California,” Milbank Quarterly 90, no. 1 (March 2012): 160–86.

12. M. McHugh et al., “Contradicting Fears, California’s Nurse-to-Patient Mandate Did Not Reduce the Skill Level of the Nursing Workforce in Hospitals,” Health Affairs (Millwood) 30, no. 7 (July 2011): 1299–1306.

13. L. Aiken et al., “Implications of the California Nurse Staffing Mandate for Other States,” Health Services Research 45, no. 4 (August 2010): 904–21; J. Spetz, “Nurse Satisfaction and the Implementation of Minimum Nurse Staffing Regulations,” Policy, Politics, & Nursing Practice 9, no. 1 (2008): 15–21; and K. Muir et al., “Lower Burnout Among Hospital Nurses in California Attributed to Better Nurse Staffing Ratios,” Policy, Politics, & Nursing Practice 26, no. 3 (August 2025): 219–26.

14. Aiken, “Implications of the California Nurse Staffing Mandate”; and B. Mark et al., “California’s Minimum Nurse Staffing legislation: Results from a Natural Experiment,” Health Services Research 48, no. 2 (April 2013): 435–54.

15. Oregon Nurses Association, “Safe Staffing Law,” oregonrn.org/page/SafeStaffingLaw.

16. Oregon Nurses Association, “Safe Staffing Law.”

17. A. Law et al., “Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations,” Critical Care Medicine 46, no. 10 (October 2018): 1563–69.

18. Law et al., “Patient Outcomes.”

19. Lasater et al., “Is Hospital Nurse Staffing Legislation in the Public’s Interest?”

20. Lasater et al., “Is Hospital Nurse Staffing Legislation in the Public’s Interest?”

21. K. Lasater et al., “Chronic Hospital Nurse Understaffing Meets COVID-19: An Observational Study,” BMJ Quality & Safety 30, no. 8 (August 18, 2020): 639–47.

22. Lasater et al., “Is Hospital Nurse Staffing Legislation in the Public’s Interest?”

23. K. Lasater et al., “Evaluation of Hospital Nurse-to-Patient Staffing Ratios and Sepsis Bundles on Patient Outcomes,” American Journal of Infection Control 49, no. 7 (2021): 868–73.

24. A. Fox, “New Efforts Try to Balance Nurse Staffing Ratios with Access to Care,” Healthcare IT News, May 7, 2024, healthcareitnews.com/news/new-efforts-try-balance-nurse-staffing-ratios-access-care.

25. S. Kafle et al., “Workplace Violence Against Nurses: A Narrative Review,” Journal of Clinical and Translational Research 8, no. 5 (September 13, 2022): 421–24.

26. Illinois General Assembly, “Bill Status of HB2604,” ilga.gov/legislation/BillStatus.asp?DocTypeID=HB&DocNum=2604&GAID=15&SessionID=108&LegID=118738.

27. K. Lasater et al., “Patient Outcomes and Cost Savings Associated with Hospital Safe Nurse Staffing Legislation: An Observational Study,” BMJ Open 11, no. 12 (2021): e052899.

28. Pennsylvania General Assembly, “House Bill 106: 2023–2024 Regular Session,” palegis.us/legislation/bills/2023/hb106.

29. L. Aiken, “Testimony: Pennsylvania House Health Committee Public Hearing: Patient Safety Act HB106,” Pennsylvania House of Representatives, May 2, 2023, legis.state.pa.us/WU01/LI/TR/Transcripts/2023_0056_0006_TSTMNY.pdf.

30. Aiken et al., “Implications of the California Nurse Staffing Mandate.”

31. American Nurses Association, “Advocating for Safe Staffing,” American Nurses Enterprise, nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-advocacy.

32. X. Han, P. Pittman, and B. Barnow, “Alternative Approaches to Ensuring Adequate Nurse Staffing: The Effect of State Legislation on Hospital Nurse Staffing,” Medical Care 59, no. 10 Suppl. 5 (October 2021): S463–S470.

33. M. Bartmess et al., “Original Research: A Real ‘Voice’ or ‘Lip Service’? Experiences of Staff Nurses Who Have Served on Staffing Committees,” American Journal of Nursing 124, no. 2 (February 2024): 20–31.

34. P. de Cordova et al., “Does Public Reporting of Staffing Ratios and Nursing Home Compare Ratings Matter?,” Journal of the American Medical Directors Association 22, no. 11 (November 2021): 2373–77.

35. P. de Cordova et al., “Public Reporting of Nurse Staffing in the United States,” Journal of Nursing Regulation 10, no. 3 (2019): 14–20.

36. Lasater et al., “Is Hospital Nurse Staffing Legislation in the Public’s Interest?”

37. National Academies of Sciences, Engineering, and Medicine, National Academy of Medicine, and Committee on the Future of Nursing 2020–2030, “Chapter 3: The Nursing Workforce,” in The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, ed. J. Flaubert et al. (Washington, DC: National Academies Press, May 11, 2021), ncbi.nlm.nih.gov/books/NBK573922; and National Council of State Boards of Nursing, “NCLEX Pass Rates,” August 9, 2025, ncsbn.org/exams/exam-statistics-and-publications/nclex-pass-rates.page.

38. Aiken et al., “A Repeated Cross-Sectional Study of Nurses.”

39. D. Pillai, M. Rae, and S. Artiga, “The Growing Role of Foreign-Educated Nurses in U.S. Hospitals and Implications of Visa Restrictions,” KFF, July 10, 2024, kff.org/policy-watch/the-growing-role-of-foreign-educated-nurses-in-u-s-hospitals-and-implications-of-visa-restrictions.

40. K. Lasater et al., “Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care,” Medical Care 62, no. 7 (2024): 434–40.

41. L. Aiken et al., “Nursing Skill Mix in European Hospitals: Cross-Sectional Study of the Association with Mortality, Patient Ratings, and Quality of Care,” BMJ Quality & Safety 26, no. 7 (2016): 559–68.

42. Lasater et al., “Alternative Models of Nurse Staffing.”

43. B. Liu, Y. Xu, and B. Staats, “Bridging the Nursing Gap: How Virtual Nurse Adoption Impacts Patient Outcomes,” SSRN, April 10, 2025, papers.ssrn.com/sol3/papers.cfm?abstract_id=5213142.

[Illustrations by Alex Nabaum]