Argumentative Essay (APA 7): Should Safe Nurse Staffing Ratios Be Mandated by Law?

Introduction

If one extra patient on a nurse's workload can change whether a hospital patient survives, who should decide how many patients each nurse is given? In the United States, that decision usually rests with hospitals, which weigh it against budget pressures. A review of state laws found that some states take no action, others require only staffing committees, a handful mandate ratios for a single unit, and only California and Oregon have comprehensive ratio laws covering multiple hospital units (Krishnamurthy et al., 2024). Studies of New York hospitals and of Queensland, Australia, where ratios were legislated, link heavier nurse workloads to higher patient mortality and lighter workloads to safer care (Lasater et al., 2021; McHugh et al., 2021). That evidence suggests the question is too important to leave to local budgets. US states should legislate minimum nurse-to-patient ratios in acute-care hospitals, because heavier nurse workloads are linked to higher patient mortality, because losing experienced nurses harms patient safety and cannot be fixed by substituting cheaper staff, and because the strongest evidence from legislated ratios shows safer care at a cost that savings can offset.

Workload and Patient Mortality

The most direct reason is patient survival. In a study of 116 New York State hospitals and 417,861 Medicare patients, Lasater et al. (2021) found that each additional patient assigned to a nurse was associated with higher odds of in-hospital death (adjusted OR = 1.13 for both medical and surgical patients). Using their models, the authors estimated that staffing every hospital at the proposed 4:1 ratio, rather than the observed average of about 6:1, would have averted roughly 4,370 deaths over two years. A study in England points the same way. Using rosters from 53 adult wards in one NHS Trust (66,923 admissions), Zaranko et al. (2023) found that one extra 12-hour registered nurse shift was associated with about 9.6% lower odds of patient death (OR = 0.90, 95% CI [0.82, 1.00]). Both studies are observational, and the New York figures are model-based projections, so they show association rather than proven cause. Yet findings from two different health systems, in different countries, that agree in direction make coincidence an unlikely explanation. A plausible mechanism is that nurses with fewer patients have more time to notice early signs of deterioration and act on them. On this evidence, a nurse's patient load is a safety variable, not merely a staffing preference.

Workforce Stability

Safe staffing also depends on keeping experienced nurses in post. In a systematic review of 20 studies, Jun et al. (2021) found that nurse burnout was consistently inversely associated with patient safety, quality of care, nurses' organizational commitment, nurse productivity and patient satisfaction, and they argued that burnout should be treated as an organizational problem, not only an individual one. The England study adds that substitution is not a ready fix: the mortality benefit appeared only for registered nurses employed directly by the hospital, while healthcare support workers and agency staff showed no significant association (Zaranko et al., 2023). The studies cited here do not measure directly whether ratio laws reduce burnout, so that link remains an inference. It is a reasonable one, since workload is the very thing ratios control. If it holds, a legislated minimum protects patients twice: it limits unsafe workloads now and supports the stable, directly employed nursing workforce on which the evidence shows safety depends. It also removes a disadvantage for hospitals that staff generously, because every hospital must meet the same floor.

Evidence From Legislated Ratios

The most persuasive evidence comes from a place that actually legislated ratios. In 2016, Queensland, Australia, introduced minimum ratios in selected hospitals. McHugh et al. (2021) compared 27 intervention hospitals with 28 comparison hospitals before the change and two years afterward, using records for more than 230,000 patients at baseline and more than 257,000 afterward. Among hospitals with reliable staffing data, the share exceeding 4.5 patients per nurse fell from 83% to 58%. Over the same period, 30-day mortality fell significantly in hospitals with ratios (adjusted OR = 0.89, 95% CI [0.84, 0.95]) but did not change significantly in comparison hospitals, and length of stay fell further in hospitals with ratios. The authors also reported that costs avoided through fewer readmissions and shorter stays were more than double the cost of the additional nurses. A systematic review of 23 economic studies reached a cautious but supportive conclusion: Griffiths et al. (2023) found that six studies linked more nurses to better outcomes at lower or unchanged net cost, and judged that adding registered nurses to general medical and surgical wards could be highly cost-effective. Because the Queensland study followed hospitals over time against a comparison group, it supports a causal effect more strongly than the earlier observational work.

The Counterargument

Critics raise two objections. The first is cost: hiring more nurses is expensive, particularly where nurses are in short supply. The second is that ratios may not deliver the promised benefits. Krishnamurthy et al. (2024) reviewed US state legislation and reported that California's ratio mandates, in place for over a decade, have produced mixed evaluation results: some studies found better mortality, failure-to-rescue and nurse-reported quality, while others found no significant reduction in falls, pressure ulcers or restraint use. They also noted that laws vary widely between states and that no staffing law has addressed underlying drivers of lean staffing, such as reimbursement models. These are serious points, and they show that ratios are not automatically effective. They do not outweigh the wider evidence, though. The mixed California results concern a different set of outcomes from the mortality gains seen in Queensland (McHugh et al., 2021), and the cost evidence, while encouraging, comes mostly from observational studies with moderate or high risk of bias (Griffiths et al., 2023). The sensible reading is an argument for carefully designed legislation, with acuity adjustment and outcome monitoring built in, not for leaving staffing entirely to local discretion. As for shortages, a legislated minimum will not create nurses on its own, so ratios should be phased in alongside investment in the workforce.

Conclusion

The recent evidence supports legislating minimum nurse-to-patient ratios in US acute-care hospitals. Heavier patient loads are linked to higher mortality in New York and in England, the nursing workforce that safe care depends on is hard to replace with cheaper staff, and the best available evidence from a legislated system shows safer care at a net saving. California's mixed results do not argue against ratios themselves; they argue for designing them carefully and measuring what they achieve. The argument is also an ethical one. The American Nurses Association's Code of Ethics for Nurses commits nurses to protecting patients' health and safety (Provision 3) and to working to establish, maintain and improve an ethical work environment (Provision 6) (American Nurses Association, 2025). Nurses cannot fully meet those commitments when workloads are set by budgets alone, so safe staffing should be treated as a standard of care that is set in law and monitored, not as a budget line that shrinks when money is tight.

References

• American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/provisions
• Griffiths, P., Saville, C., Ball, J., Dall'Ora, C., Meredith, P., Turner, L., & Jones, J. (2023). Costs and cost-effectiveness of improved nurse staffing levels and skill mix in acute hospitals: A systematic review. International Journal of Nursing Studies, 147, Article 104601. https://doi.org/10.1016/j.ijnurstu.2023.104601
• Jun, J., Ojemeni, M. M., Kalamani, R., Tong, J., & Crecelius, M. L. (2021). Relationship between nurse burnout, patient and organizational outcomes: Systematic review. International Journal of Nursing Studies, 119, Article 103933. https://doi.org/10.1016/j.ijnurstu.2021.103933
• Krishnamurthy, N., Mukherjee, N., Cohen, B., Mazor, M., & Appel, J. M. (2024). Hospital nurse staffing legislation: Mixed approaches in some states, while others have no requirements. Health Affairs. https://doi.org/10.1377/hlthaff.2023.01521
• Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Anusiewicz, C. V., Martin, B., Reneau, K., Alexander, M., & McHugh, M. D. (2021). Is hospital nurse staffing legislation in the public's interest? An observational study in New York State. Medical Care, 59(5), 444–450.
• McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). 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(10288), 1905–1913. https://doi.org/10.1016/S0140-6736(21)00768-6
• Zaranko, B., Sanford, N. J., Kelly, E., Rafferty, A. M., Bird, J., Mercuri, L., Sigsworth, J., Wells, M., & Propper, C. (2023). Nurse staffing and inpatient mortality in the English National Health Service: A retrospective longitudinal study. BMJ Quality & Safety, 32(5), 254–263. https://doi.org/10.1136/bmjqs-2022-015291