Nursing Staff Ratios: What are the Rules? What can you do?

-written by Marina OMeara, RN

There are still nurses working in the field who can remember nurse patient ratios of 40:1, 40 patients to one nurse on night shifts. Those were the days before IV teams, Respiratory Therapists and unit dose medications. All medications had to be hand poured from large bottles. Intravenous drips (IVs) of which there could be up to 2 dozen per shift to manage, had to be eye to drop counted, since digital drop counters did not exist. Oxygen tanks had to be unchained, “cracked” and gauges screwed on before rolling the lumbering tanks down the hall, rather than just inserting a gauge into wall piped Oxygen flow. If there was no time to document the record on the 40 patients during the shift, the nurse may have been required to stay several hours after the shift to perform the charting, but without pay.


The hospital could require a nurse to work back-to-back 24 hours in a row shifts or risk losing his or her job. The hospital could require the nurse to work rotating shifts, which was working a variety of day, evening and night schedules, all in one week.

They were not the “good ole days”.

Today there are both federal and State laws related to an expectation that healthcare facilities have adequate staff to meet the patient need. The federal law [42 CFR 482.23b] only applies to facilities that participate in Medicare plans and even then the language only requires that the ratio be adequate without any specific requirement.

STATE LAWS: These tend to: a) mandate a specific ratio, b) require disclosure of the ratio to the public, or c) require that a plan be in effect. In Oregon State the law [ORS 441.160-192 and OAR 333-510-0045] requires that the facility have a staffing plan and post a notice in the facility related to the law. There needs to be at least one RN and one other direct care nursing staff when a patient is present in a facility. The Oregon Health Authority may conduct a random audit of 7% of the facilities within the State to determine if the plans are meeting the law.

STAFFING PLANS: Oregon law requires that the decision-making power for determining nurse-patient ratios be based on staffing plans assigned by a committee with an equal number of nurse managers and of direct care nursing staff. Direct care staff can select their own members, not the facility management. The committee needs to indicate how it will monitor its plans and make modifications if needed. The committee needs to appropriately reflect competency of staff and the nursing needs and acuity of the patients. The committee needs to determine the minimum number of nursing personnel needed to meet the patient needs.

MANDATED OVERTIME PROHIBITED: Oregon law indicates that a nurse cannot be mandated, that is cannot be required, to work overtime beyond the agreed upon scheduled shift. A nurse may volunteer to perform extra hours. The exception is one hour overtime may be mandated in emergency situations such as inclement weather or an epidemic impacting nurse availability. The facility may request a waiver – a right to overrule the law, if it submits in writing a variance request stating the reason for seeking it, that the committee has reviewed it and then publicly posts the variance request.

UNDERSTAFFED: If a nurse believes that the workload assigned exceeds safe limits, the nurse can request to see the staffing plan to learn what the facility has determined is a safe nurse-patient ratio. If the ratio of patients to nurse is higher than that in the plan, the nurse can make a polite statement to the nurse manager about the concern. Members of the facility staffing committee are also a resource for dialogue.

REPORTING CONCERNS: Oregon law requires that the nurse report concerns about safe staffing to the facility first to give the facility an opportunity to respond and to provide correction if necessary. Thereafter a report can be submitted to the Oregon Health Authority. The person submitting the concern can request protection of their identity. A note from yourself to yourself, time-stamped in within your personal email can document that you raised the concern and what the response was, if any.

EDUCATION: A nurse can self-educate about staffing ratios by contacting the Oregon Nurse Staffing Collaborative (ONSC) at . They meet once a month and each quarter they interface with the Oregon Health Authority manager responsible for the law’s oversight. Resources are available at ONSC with fact sheets, frequently asked questions, sample notice postings and staffing guidelines.