Health Policy Monitor
Skip Navigation

Legislating Nurse Staffing Ratios in Pennsylvania

Partner Institute: 
Department of Behavioral Science and Health Education, Rollins School of Public Health, Emory University
Survey no: 
(13) 2009
Elena Conis, Emory University
Health Policy Issues: 
Quality Improvement, HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no
Featured in half-yearly report: Health Policy Developments 13


Pennsylvania legislators are debating the relative merits of a bill that would require hospitals to meet state-specified, unit-specific, nurse-to-patient ratios. Eight other states are currently considering laws that would set minimum nurse-to-patient ratios in hospitals in order to improve quality of care and reduce health care costs. The laws are modeled after a 1999 California law, which has so far increased by 100,000 the number of registered nurses working in that state.

Purpose of health policy or idea

Health officials and legislators in Pennsylvania have taken several steps in recent years to address a growing nursing workforce shortage in the state. Experts argue that the shortage is affecting the quality of care throughout the state and contributing to rapidly rising healthcare costs. The Pennsylvania Hospital Patient Protection Act of 2009, introduced by Democratic state Senator Daylin Leach in late February, proposes to improve quality of care by requiring hospitals to meet state-mandated, hospital-unit specific, nurse-to-patient ratios at all times. The Act would also provide whistle-blower protection to nurses who speak out against unsafe practices or work assignments.

A similar bill, HB 147, was introduced in the House this session by Democratic Representative Tim Solobay. Late in March, yet another nurse staffing ratio bill was introduced, by Republican Representative Bill Adolph. Adolph's bill (HB 1033) would require hospitals and other healthcare facilities to establish their own nurse-to-patient ratios, but also includes a whistle-blower protection provision.  

A number of studies over the last decade have linked nursing shortages with increases in adverse patient outcomes. A study published in JAMA in 2002, for example, found that surgery patients faced a 31% increased risk of mortality in hospitals with high nurse-to-patient ratios. A 2007 report by the Agency for Healthcare Research and Quality linked increases in nurse staffing with decreases in failure to rescue and decreased hospital stays. When Leach announced his bill in March, he cited a 2005 study published in the American Journal of Public Health, which concluded that keeping nurse-to-patient ratios at 1 to 4 could save up to 72,000 patient lives a year. He also cited evidence from California, which increased its registered nurses (RN) workforce by 100,000 following adoption of the 1999 law, in part by attracting registered nurses from other states.

Main points

Main objectives

The current bill has three overarching objectives. The first is to reduce medical errors that several studies have attributed to nursing shortages. The second is to reduce hospital infections that result from unsafe working conditions, which can result in understaffed hospitals. The third is to cut back on expenses incurred by hospitals in recruiting and filling nursing vacancies; nursing shortages, experts say, lead to unsafe and stressful working conditions that force many nurses out of the field. Supporters of the bill predict that ratios will not only improve quality of care, but will also improve nurse job satisfaction and  therefore increase nurse retention. Leach and other supporters also argue that the ratios will improve overall safety and therefore save patient lives.

Type of incentives

Neither Leach's bill nor the other two bills mentioned above technically incentivize hospitals to adopt minimum ratios.

Groups affected

Hospitals, Nurses, Patients

 Search help

Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low high very high
Transferability strongly system-dependent neutral system-neutral

State-mandated nurse-to-patient ratios are by now not innovative, but their popularity has recently surged as states, inspired by California's perceived success, struggle to respond quickly to severe nursing shortages.

Political and economic background

The state of Pennsylvania currently faces a growing gap between the number of registered nurses (RNs) working in health care and the demand for such nurses. The state is predicated to be short by 16,000 nurses by 2010, and is estimated to be facing a nursing position vacancy rate of 41% by the year 2020, according to the Health Resources and Services Administration.

The nursing shortage is compounded by a stubbornly low rate of new students entering the field, a lack of educators, and an aging nursing workforce, a large proportion of which is slated to retire in about a decade. Most of the state's nurses are over 35, many are over 50, and nearly one in four of the state's registered nurses choose to work in fields other than health care. Nursing needs, meanwhile, have increased as the population ages, and as increasingly older patients with greater medical needs place greater demands on existing nursing staff.

Pennsylvania's situation is not unique. The Agency for Healthcare Research and Quality reports that on average, 13% of nursing positions in U.S. hospitals are currently vacant. One study estimates that the proportion of vacancies nationwide will more than double by the year 2020.  

States have taken a variety of legislative approaches to address nursing shortages in recent years. Many of these laws and initiatives have allocated funding to increase both the number of students entering nursing programs as well as the number of faculty available to train them. Maryland's Nurse Support Program, for example, provides scholarship funding for graduate nursing students and faculty. Kansas has implemented an initiative to improve nurse faculty salaries and facilities, among other aims. Illinois, Colorado and Nebraska have passed laws to forgive  and help repay loans for nursing students, including those who commit to teach after graduation. In September 2008, Pennsylvania's governor announced a more than $1.5 million program, in the form of a public-private partnership, which will direct funds to nursing schools to hire additional faculty and train additional students.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no

Origins of health policy idea

The implementation of nurse-to-patient ratio mandates, is a fairly new approach to a persistent problem. In 1999, California passed the first state law mandating minimum nurse to patient ratios in hospital wards (also see Medlin, Carol. "Rules on Nursing Ratios". HealthPolicyMonitor, August 2003). The state's Department of Health Services determined the precise ratios, which were released in 2002 and went into effect in 2004. The regulations mandate specific ratios for a number of contexts, including one nurse for every four patients in emergency wards, one for every two patients in maternity wards, and one for every five patients in medical-surgical units.

In the last two years, a number of states have considered laws modeled in part on California's; many of these are currently under consideration. Last year, Massachusetts lawmakers considered and rejected a law that included a provision that would have set minimum nurse to patient ratios in that state. This year, at least eight other states, including Arizona, Florida, New Jersey and Texas, are now considering bills that would set staffing ratios in those states.

Initiators of idea/main actors

  • Government
  • Providers

Approach of idea

The approach of the idea is described as:
renewed: The approach is modeled after that already taken in California and now being considered by other states.

Stakeholder positions

Nationwide, nurses, according to a report by the NCSL, are split on the issue of state mandated ratios. Some state nursing associations have argued that ratios should be set by hospitals, not the state; others, meanwhile, have argued that state laws are necessary to protect nurses from potentially dangerous decisions made by hospital managers looking to cut costs. Still others have argued that merely setting ratios does not address the overall shortage of nurses and students entering nursing programs throughout the U.S. In Pennsylvania, professional nurses are similarly split, with the Pennsylvania Association of Staff Nurses and Allied Professionals and the SEIU Nurse Alliance supporting Leach's bill, and the American Nursing Association and Pennsylvania State Nurses Association supporting Adolph's HB 1033.

Actors and positions

Description of actors and their positions
State Sen. Daylin Leachvery supportivevery supportive strongly opposed
State Rep. Tim Solobayvery supportivevery supportive strongly opposed
State Rep. Bill Adolphvery supportiveopposed strongly opposed
Pennsylvania Association of Staff Nurses and Allied Professionalsvery supportivevery supportive strongly opposed
American Nursing Associationvery supportiveopposed strongly opposed
Pennsylvania State Nurses Associationvery supportiveopposed strongly opposed
SEIU Nurse Alliancevery supportivevery supportive strongly opposed
Hospitalsvery supportiveopposed strongly opposed

Influences in policy making and legislation

Senator Leach has spearheaded the effort to institute nurse staffing ratios in Pennsylvania. Leach modeled his bill after California's mandate, and authored it in conjunction with the executive director of the Pennsylvania Association of Staff Nurses and Allied Professionals, Bill Cruice. Leach and Cruise have argued that the legislation proposed by Adolph (similar legislation has been adopted in about a dozen other states) does not go far enough to protect nurses or ensure improvements in quality of care. Representative Adolph, meanwhile, has the backing of other nursing professional organizations in the state. At this point, it is unclear whose legislation, if anyone's, will be adopted.

Legislative outcome


Actors and influence

Description of actors and their influence

State Sen. Daylin Leachvery strongstrong none
State Rep. Tim Solobayvery strongstrong none
State Rep. Bill Adolphvery strongstrong none
Pennsylvania Association of Staff Nurses and Allied Professionalsvery strongstrong none
American Nursing Associationvery strongstrong none
Pennsylvania State Nurses Associationvery strongstrong none
SEIU Nurse Alliancevery strongstrong none
Hospitalsvery strongvery strong none
State Sen. Daylin Leach, State Rep. Tim Solobay, Pennsylvania Association of Staff Nurses and Allied Professionals, SEIU Nurse AllianceState Rep. Bill Adolph, American Nursing Association, Pennsylvania State Nurses AssociationHospitals

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

As the proposal is in the legislative stage, and as the bills are likely to undergo change before possible adoption, it is too early to comment on who, other than nurses and hospitals, generally speaking, will be engaged in and affected by adoption and implementation.

Monitoring and evaluation

Under Leach's bill, each healthcare facility required to abide by the state mandated ratios would also be required to keep "daily statistics, by nursing  department and unit, of mortality, morbidity, infection, accident, injury and medical errors." By law, the records would have to be kept for seven years and made available on request to state officials and the public. The law does not otherwise specify a required plan for evaluation.

Expected outcome

Several studies have shown higher rates of pneumonia, heart attack, urinary tract infection and other conditions occur in hospitals and wards with lower numbers of nurses on staff. However, the evidence most relevant to states, like Pennsylvania, that are currently considering enforced staffing ratios, is that coming out of California, which began implementing its ratios five years ago. Senator Leach and others have pointed out that California's law has been successful at drawing RN's to jobs in the state, and has thereby been successful at increasing the overall number of registered nurses working in that state. The growth in number of hospital-employed RN's has been one of the most widely touted outcomes of the California law.

Evidence on whether the ratios have improved quality of care, however, is less clear. In February 2009, the California HealthCare Foundation (CHCF) released a study suggesting that the state's minimum nurse-to-patient ratio had one positive outcome, namely, the increase in employment of registered nurses in California hospitals, with a resultant increase in "skill mix" in state hospitals. The CHCF study also found that despite concerns, the ratios have not significantly affected hospital finances relative to other demands-although hospital administrators did report having to reduce services and cut costs in order to implement the staffing changes. Perhaps most importantly, however, the CHCF study found that there is no evidence to suggest that the ratios have altered the average length of hospital stay nor changed the frequency or number of many "nursing-sensitive" adverse events, including pneumonia and failure to rescue. In some hospitals, emergency department waiting times increased following implementation of ratios; hospital administrators responded that it was particularly challenging to meet ratios at all times, including through nurse meal times and scheduled work breaks.  

Some of California ratios were phased in gradually; the five-to-one ratio of nurses to patients in medical-surgical units, for example, was initially six to one. Additional effects of the ratios may-or may not-become more evident with time. The authors of the CHCF study concluded that more detailed investigation is necessary to properly assess the full impact of state-mandated nurse-to-patient ratios.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low high very high

The success of California's law may have been due in part to its unique nature at the time; certainly, as more states adopt mandatory ratios (if they do), they may increasingly exacerbate shortages in states without ratios. Evidence suggests that low nurse-to-patient ratios are key to improving patient and worker safety, but state-mandated ratios alone are likely to be insufficient to fully address a national shortage of nurses, rising healthcare costs, and quality of care concerns.


Sources of Information

American Association of Colleges of Nursing. "State Legislative Initiatives to Address the Nursing Shortage (October, 2006)" and "Nursing Shortage Fact Sheet."

Geever, Matthew. Improving the Quality of Care: The Continuing Debate Over Nurse-Patient Ratios. State Health Notes, National Conference of State Legislatures, March 16, 2009.

Pennsylvania Worforce Investment Board. "The Registered Nurse Workforce in Pennsylvania." Summer 2005.

Spetz, Joanna et al. "Assessing the Impact of California's Nurse Staffing Ratios on Hospital and Patient Care." California HealthCare Foundation, February, 2009.

Stanton, Mark. Hospital Nurse Staffing and Quality of Care. Research in Action, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Issue 14.

Author/s and/or contributors to this survey

Elena Conis, Emory University

Suggested citation for this online article

Conis, Elena. "Legislating Nurse Staffing Ratios in Pennsylvania". Health Policy Monitor, April 2009. Available at