Fact Sheet 2024

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Highlights

• Research has shown that reducing patient-to-nurse ratios in hospitals improves patient care outcomes, helps prevent burnout among nurses, and contributes to less turnover. 

• The combination of chronic understaffing, heavy workloads, and stressful work environments in hospitals and long-term care facilities contributes to greater risk of occupational hazards, nurse burnout, and attrition.

• Aside from advocating for legislation to establish safe staffing ratios, nurses and other healthcare professionals can achieve staffing protections and have a greater say in their workplaces through collective bargaining.

Introduction

Nurses play an integral role in the health care system. They provide acute care for patients and administer medicine and other daily essentials in our country’s hospitals, ambulatory healthcare facilities, long-term care facilities, and in many other places. But far too often, nurses are overworked and under-supported, while healthcare administrators seek to lower costs and boost profits.

In the face of aggressive cost-cutting, minimum staffing levels are necessary to ensure the safety of patients and nurses. Adequate nurse staffing is key to improving patient care and nurse retention, while inadequate staffing endangers patients and drives nurses from the profession. Unfortunately, staffing problems are only expected to get worse as baby boomers age and the demand for health care services grows, making staffing a growing concern for nurses and patients alike.

 Safe staffing measures improve patient care outcomes

Ample research has shown that the implementation of safe staffing measures, like reducing patient-to-nurse ratios, improves patient care outcomes. In 1999, California became the first state to pass a law setting a legal maximum patient-to-nurse staffing ratio in order to improve patient care. Since it was fully implemented in 2004, there have been measurably improved patient outcomes in California. This is in line with the broader academic consensus about the positive impact of lowering nurse workloads.

• A comprehensive study published in 2010 about the impact of the 1999 law compared hospitals in California to hospitals in New Jersey and Pennsylvania. Researchers found significantly better health outcomes in California, including lower surgical mortality rates, reduced inpatient deaths within 30 days of admission, and a lower likelihood of death from failing to properly respond to symptoms.[1]

• These conclusions are backed up by a 2018 meta-analysis of other research, which found that for every increase of one nurse, patients had a 14 percent decrease in risk for in-hospital mortality.[2] An earlier analysis produced similar results, showing in 2007 that an increase of one full-time registered nurse (RN) in a unit per day would result in nine percent fewer hospital-related deaths in the ICU, 16 percent fewer deaths for surgical patients and six percent fewer deaths for medical patients.[3]

• In long-term care facilities, patients with more direct time with RNs (30 to 40 minutes daily per patient) reported fewer pressure ulcers, acute care hospitalizations, urinary tract infections, urinary catheters, and less deterioration in their ability to perform daily living activities.[4]

• While increased nurse staffing greatly improves patient outcomes in hospitals with positive nurse working conditions, studies have shown that it has little to no effect in hospitals that otherwise have poor nurse working conditions. Good nursing work environments are characterized by positive working relationships between doctors and nurses, active nurse involvement in hospital decision making, management responding to nurses’ concerns about patient care, continuing education programs for nurses, and constant quality improvement for patient care programs.[5]

Inadequate staffing endangers patients and nurses alike

Inadequate nurse staffing and poor nurse working conditions are closely associated with poor patient outcomes. High patient-to-nurse ratios are correlated with an increase in medical errors, as well as cases of patient infections, bedsores, pneumonia, cardiac arrest, and accidental death.[6]

• A 2021 study found that in hospital medical surgical units in Illinois, for each patient added to a nurse’s average workload, the likelihood of the patient dying within 30 days of admission increased by 16 percent, and the likelihood that the patient stayed in the hospital for a day longer increased by five percent.[7] The same study estimated that if the hospitals were staffed at four patients to one nurse during the study period, “more than 1595 deaths would have been avoided.”[8]

• Both nurse work environments and patient-to-nurse ratios may be associated with survival rates. A 2016 study found that the likelihood of survival of patients recovering from an in-hospital cardiac arrest was 16 percent lower in hospitals with poor nursing work environments and five percent lower for each additional patient per nurse on medical-surgical units.[9]

• Even temporary exposure to high nursing workloads and limited staffing can have a negative impact on patients. In 2017, researchers found that “exposure to as little as one day of high workload/staffing ratios is associated with a substantially increased risk of death in critically ill patients.”[10]

• Heavy nurse workloads, evidenced by shift length, is significantly related to decreases in patient satisfaction. In hospitals with large proportions of nurses working shifts of 13 hours or longer, more patients reported that they were not likely to recommend the hospital to family and friends compared to patients in hospitals with shift lengths of 11 hours or less.[11]

Nurse understaffing contributes to greater risk of workplace injuries and illnesses

Understaffing and heavy workloads contribute to greater risk of occupational hazards and burnout among nurses and other healthcare staff.

• According to the U.S. Bureau of Labor Statistics (BLS), in 2022, skilled nursing facilities and residential facilities were the workplaces with the highest rates of reported incidents of illness or injury resulting in either one or more days away from work, restricted job activity or job transfer. Hospitals had among the highest rates of these reported incidents as well that year.[12]

• According to the BLS, during the two-year period spanning 2021 and 2022, registered nurses experienced 221,600 reported incidents of illness or injury resulting in either one or more days away from work, restricted job activity, or job transfer. Nursing assistants experienced 302,770 incidents during that period.[13] These alarming figures represent reported incidents in the private sector only.

• But safe staffing policies can help reduce the risks faced by nurses and other healthcare professionals. A 2015 study of hospitals in California found 31.6% fewer RN injuries and 38.2% fewer licensed practical nurse (LPN) injuries than what would have been expected based on data from the other 49 states and the District of Columbia.[14]

Understaffing contributes to nurse fatigue, health issues, and job dissatisfaction

High patient-to-nurse ratios are strongly associated with emotional exhaustion, job dissatisfaction and fatigue. Nurse fatigue (sometimes called burnout) can be described by a number of symptoms, including irritability, insomnia, headaches, back pain, weight gain, and high blood pressure. Working long hours with inadequate staffing also increases nurses’ risk of developing conditions such as musculoskeletal disorders, hypertension, cardiovascular issues, type 2 diabetes, and depression, among other conditions.[15]

• Nurses’ cardiovascular health often suffers as a result of working long shifts and overtime. In a 2010 study, researchers showed a clear trend between frequent overtime work and incidents of heart disease, with workers who reported three to four hours of overtime per day being 60 percent more likely to have cardiovascular health disorders.[16]

• Nurse fatigue itself can hurt patient care outcomes. A 2012 study found that reducing the number of nurses with high levels of fatigue from the average of 30 percent to 10 percent could prevent 4,160 infections in Pennsylvania hospitals alone, saving approximately $41 million.[17]

• A 2002 study found that the addition of each patient over four patients per nurse carried a 23 percent risk of increased nurse burnout and a 15 percent decrease in job satisfaction. The same study found that each additional patient per nurse was associated with a seven percent increase in the likelihood of the patient dying within 30 days of admission.[18]

• A 2023 study involving both nurses and physicians at 60 Magnet hospitals across the U.S. found that nurse staffing was the primary issue that subjects identified as wanting management to improve. Additionally, the study revealed that “hospitals characterized as having too few nurses and unfavorable work environments had higher rates of clinician burnout, turnover, and unfavorable patient safety ratings.”[19]

  
  

[20]

 Chronic understaffing is exacerbating the nursing shortage

Before the COVID-19 pandemic (hereafter, the pandemic), the nurse staffing crisis had already been plaguing U.S. hospitals and other healthcare facilities for several years. The pandemic further contributed to burnout among nurses[21] and raised in relief the multi-pronged crises facing healthcare professionals, due in large part to understaffing issues, not only in hospitals across the country but around the world.[22] Without widespread safe staffing measures in place to reduce nurse burnout and turnover, the staffing crisis is likely to be compounded in the future.

• The BLS estimates that between 2023 and 2033, the employment of registered nurses will increase six percent – two percentage points greater than the average projected growth rate of all occupations. An average of 194,500 new nursing jobs each year are projected over this ten-year period.[23]

• According to the BLS, the number of advanced practice registered nurses (including nurse anesthetists, nurse practitioners, and nurse midwives) in the U.S. is projected to grow 40 percent between 2023 and 2033, which is significantly faster than average.[24]

• A 2023 survey of over 18,000 nurses revealed that subjects expressed grave concern about the nurse staffing shortage, and career satisfaction declined significantly since the survey was conducted two years prior. Additionally, the percentage of nurses who agreed with the statement that the current staffing shortage was worse than five years ago rose staggeringly, “from 37% in 2015 to 89% in 2023.”[25]

The costs of nurse turnover and temporary labor

• Chronic understaffing is among the reasons why many in the nursing profession seek part-time nursing jobs or travel nursing jobs. This phenomenon has especially been the case since the start of the pandemic, when many nurses chose to leave the profession altogether or retire earlier than originally planned.

• The 2023 survey of over 18,000 nurses found that 30 percent of respondents said they would likely leave their career due to the pandemic. This figure rose seven percentage points since the last survey completed two years prior.[26]

• Nurse turnover is costly for hospitals. According to a 2022 report by the Society for Human Resource Management, the average cost-per-hire of an employee is $4,683.[27]

• A 2013 study found that nurse turnover was a significant factor in patient outcomes in nursing homes, linking nursing homes with high turnover of certified nursing assistants (CNAs) to “significantly higher” chances of patient conditions including pressure ulcers and urinary tract infections.[28]

• In addition to enforcing mandatory overtime, employers often use supplemental nurses to temporarily fill gaps in nurse staffing. These temporary nurses are more likely to be concentrated in hospitals with poor staffing ratios and inadequate resources.

• The pandemic caused a sharp rise in the number of supplemental or travel nurses in hospitals across the country; from 2019 to 2020, the number of travel nurses grew 35 percent.[29] In general, the number of these types of nurses employed in hospitals varies depending on the hospital size and geographic location. A 2024 study by the U.S. Government Accountability Office found that among the hospitals studied, the increase in the number of supplemental nurses from 2019 to 2022 ranged from two to 28 percent.[30]

• Temporary nurses are often compensated triple or even quadruple the rate of a regular full-time RN, further adding to cost and contributing to resentment among permanent nurses.[31]

• As the percentage of temporary nurses employed goes up, the quality of patient care tends to go down. A 2005 study found that hospitals with temporary nurse staffing under five percent reported fewer hospital-acquired infections and fewer patient falls than hospitals with temporary nurse staffing at five to 15 percent. The percentage of nurse work-related injuries was also significantly higher in hospitals where temporary nurses made up more than 15 percent of the total nursing staff.[32]

Safe staffing may be an effective way to retain experienced nurses and lure back those who left the field

• Soon after patient-to-nurse ratio regulations went into effect in January 2004, the California Board of Nursing reported being inundated with RN applicants from other states. That year, applications for nursing licenses increased by more than 60 percent.  By 2008, vacancies for registered nurses at California hospitals plummeted by 69 percent.[33]

• Many researchers have found that factors such as mandatory overtime are inversely associated with nurses’ intention to stay in their jobs.[34] Almost 18 percent of new registered nurses leave their first nursing job within the first year, and one in three nurses leave their first job within two years.[35]

• While wage levels are an important part of determining how satisfied a nurse is with their job, it takes more than good pay to keep nurses in their jobs in the long-run. In fact, researchers have found that the most impactful way to decrease nurse fatigue and increase retention is to improve the work environment and maintain reasonable patient-to-nurse staffing ratios.[36]

• In the 2010 study of California’s staffing law, both nurses and nurse managers agreed that the ratio legislation achieved its goals of improving recruitment and retention of nurses, reducing nurse workloads, and improving the quality of care.[37]

Safe staffing measures do not burden hospitals

The majority of available research shows that safe staffing practices are cost-effective for hospitals. High turnover rates and the overreliance on temporary nurse staffing increase the average cost per discharge (cost of inpatient care, including administration) and overall operating costs. Safe staffing policies improve nurse performance and patient-mortality rates and reduce turnover rates, staffing costs, and liability.

[38]

• The 2021 study of hospital medical surgical units in Illinois found that a staffing ratio of four patients to one nurse would have saved a total of $117 million per year across the hospitals in the study due to reduced lengths of stay.[39]

• Though nursing is often the largest line-item cost for hospitals, a 2013 study found that higher levels of nurse staffing contributed towards positive financial performance for hospitals in competitive markets as improved productivity, reductions in secondary infections and a reduction in the average length of patient stays lead to cost savings and productivity in the long-term.[40]

• A 2009 study found that adding an additional 133,000 RNs to the hospital workforce across the U.S. would produce medical savings estimated at $6.1 billion in reduced patient care costs. This does not include the additional value of increased productivity when nurses help patients recover more quickly, an estimated $231 million savings per year.[41]

• Safe staffing ratios also reduce the additional costs of supplemental nurses and staffing agencies, as nurse retention tends to go up with safe staffing.[42] Temporary nurses are more expensive for hospitals to hire and, as previously stated, do not provide the same quality of care when compared to staff nurses.

The role of other healthcare professionals

While much of the debate and research surrounding the issue of hospital staffing focuses on RNs, many other types of professionals and support staff work in important and understaffed patient care roles as well.

• Social workers can play a critical role in ensuring patients have the resources they need to continue receiving healthcare in a timely, cost-effective manner after they are discharged from the hospital. Studies have shown that increased support services from social workers in hospitals can lead to lower total hospital costs and increased physician follow up after discharge.[43]

• Physical and occupational therapists play a similar role in ensuring patient care transitions are as smooth and successful as possible. Especially in the treatment of older adults, research shows that physical therapists should be relied on more in order to “assess and address post hospitalization physical and functional deficits.”[44] Such changes can again play a role in reducing readmissions, improving patient care outcomes and reducing overall medical costs.

• It is estimated that at least one third of patients are malnourished when they arrive at American hospitals. While hospitals place responsibility for patient nutrition on dieticians, many institutions lack an adequate number of staff dieticians to adequately address all patient needs and existing dieticians’ recommendations are often not implemented properly. To boost the quality of care and improve the chances for patient recovery, investments need to be made into professional dietician services.[45]

• All of these professionals are supported every day by LPNs, CNAs, and other staff without whom hospitals would not function. The term “skill mix” in clinical settings is used to characterize the number and educational experience of nurses. While scientific studies have not come to a consensus about whether there is a significant relationship between the number of LPNs or CNAs and patient outcomes, studies have confirmed that a “richer” skill mix of RNs, or a skill mix consisting of a higher proportion of RNs, leads to better patient outcomes and fewer hospital costs.[46]

Solutions to improve nurse working conditions

While nurse fatigue and the nursing shortage is lamented across the country, the push to boost hospital profit margins and reduce costs has left some nurses feeling left out of the conversation. For more than three decades, registered nurses and other healthcare professionals have been joining together through their unions and professional associations to advocate for safe staffing standards and mechanisms. These mechanisms can take various forms, including negotiating staffing ratios or nurse staffing committees in collective bargaining agreements, and enacting safe staffing legislation at the state and federal level.

 

[47]

 Union success stories where safe staffing was a central issue

Nurses who are union members use their power at the bargaining table to push for improved staffing standards. The following cases are examples of union success stories just within the past year in which safe staffing was a central issue.

2024

• Nurses at the Kapi’olani Medical Center for Women and Children, members of the Hawai’i Nurses’ Association, an affiliate of the Office and Professional Employees International Union (OPEIU), voted overwhelmingly to ratify their collective bargaining agreement that includes a major win for both the nurses and their patients – “the state’s first contractually enforceable staffing ratios.”[48]

• RNs and other healthcare professionals who are members of the United Health Professionals of New Mexico, an affiliate of the American Federation of Teachers (AFT), successfully negotiated for the creation of a labor-management committee that, among other things, will address safe staffing ratios and job protections.[49]

• Nurses who are members of Health Professionals and Allied Employees (HPAE), an affiliate of AFT, at the Palisades Medical Center in New Jersey ratified a contract that establishes patient-to-nurse ratios for the first time at this hospital.[50] HPAE nurses at Englewood Hospital and Medical Center and Cooper University Health Care ratified new contracts that include enforceable staffing ratios.[51]

• Increased staffing levels were a central organizing issue of the Patient Care Associates (PCAs) and Psychiatric Care Technicians (PCTs) at the Ohio State University’s Wexner Medical Center, who voted to join the International Association of Machinists and Aerospace Workers (IAMAW). The organizing efforts of these healthcare workers were supported by the 4,000 RNs at Wexner who are already represented by the Ohio Nurses Association, an affiliate of AFT.[52]

2023

• Nurses at Robert Wood Johnson University Hospital in New Brunswick, New Jersey who are members of the United Steelworkers (USW) secured guidelines and enforcement mechanisms for safe staffing levels.[53]

• Nurses at Oregon Health and Science University who are members of the Oregon Nurses Association, an AFT affiliate, ratified their contract that stipulates minimum staffing standards in accordance with a 2023 Oregon state law for hospital staffing (see next section), as well as a strengthened nurse staffing committee.[54]

Legislation for safe staffing at the state level

• California is still the only state with a law mandating maximum patient-to-nurse ratios in all hospital units at all times.

• In 2023, the state of Oregon enacted minimum nurse staffing ratios for several hospital units, including “emergency departments, intensive care units, labor and delivery units, operating rooms, and others.”[55] The law also established two new staffing committees – one for service staff and another for professional and technical hospital workers, as well as complaint-driven enforcement mechanisms and legitimate rest and meal breaks. Lastly, the law also established staffing ratios for CNAs.[56]

• In 2021, New York passed a law establishing patient-to-nurse ratios in acute care facilities and residential health care facilities. Ratios were also established for unlicensed direct care staff.[57]

• Massachusetts passed a law in 2014 requiring a maximum of two patients for every nurse in intensive care units.[58]

• Seven states (CT, IL, NV, OH, OR, TX, WA) require hospitals to have committees responsible for developing staffing policies unique to their hospitals, one state (MN) requires hospitals’ chief nursing officers or their designee design a staffing plan in consultation with other hospital staff, and five states (IL, NJ, NY, RI, VT) require public disclosure and/or reporting of hospital staffing policies.[59]

• Additionally, 18 states (AK, CA, CT, IL, ME, MD, MA, MN, MO, NH, NJ, NY, OR, PA, RI, TX, WA, WV) have laws that prohibit or severely restrict hospitals from assigning mandatory overtime to nurses.[60]

• While nurses, patient advocates, and other organizations have organized in other states to pass safe staffing legislation similar to California’s, they have encountered well-funded opposition campaigns, anchored by state hospital associations. Most recently, the Massachusetts Health and Hospital Association spent $25.18 million to defeat the high profile 2018 ballot initiative campaign.[61]

Legislation for safe staffing at the federal level

Multiple attempts have been made to pass legislation to ensure safe staffing levels in every hospital in the U.S., though none have been successful so far. However, in 2024, the first federally-imposed rules for minimum nurse staffing requirements in long-term care facilities were put into effect.

• In 2024, the Centers for Medicare & Medicaid Services established minimum nurse staffing requirements for long-term care facilities, including 24/7 RN on-site requirements and the input of RNs and unlicensed direct care staff in facility assessments.[62]

• In 2023, Senator Sherrod Brown (D-OH) and Rep. Jan Schakowsky (D-IL) reintroduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act. This legislation and previous iterations have been endorsed by the AFL-CIO, American Federation of Government Employees (AFGE), AFT, and USW, among other labor unions and nurses’ organizations.

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[1] Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., Spetz, J., Smith, H. L. (2010). Implications of the California nurse staffing mandate for other states. Health services research 45(4), 904–21. doi: 10.1111/j.1475-6773.2010.01114.x

[2] Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6–22. https://doi.org/10.1177/1474515117721561.

[3] Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S., & Wilt, T. J. (2007). The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Medical care, 45(12), 1195–1204. https://doi.org/10.1097/MLR.0b013e3181468ca3.

[4] Hughes, Rhonda G. (Ed.). (2008) Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21328752/.

[5] See, for example, Rosenbaum, K.; Lasater, K.; McHugh, M.; Lake, E. (2024). Hospital Performance on Hospital Consumer Assessment of Healthcare Providers and System Ratings: Associations With Nursing Factors. Medical Care 62(5): 288-295. doi:10.1097/MLR.0000000000001966; and Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical care, 49(12), 1047–1053. doi:10.1097/MLR.0b013e3182330b6e

[6] See, for example: Spence Laschinger, H. K., & Leiter, M. P. (2006). The impact of nursing work environments on patient safety outcomes: the mediating role of burnout/engagement. The Journal of Nursing Administration, 36(5), 259–267. https://doi.org/10.1097/00005110-200605000-00019; Cimiotti, J.P., Haas, J., Saiman, L. and Larson, E.L. (2006) Impact of Staffing on Bloodstream Infections in the Neonatal Intensive Care Unit. Archives of Pediatrics and Adolescent Medicine, 160, 832-836. https://doi.org/10.1001/archpedi.160.8.832; “MRSA ‘linked to nurse shortages’.” (May 6, 2005). BBC News. Retrieved from http://news.bbc.co.uk/1/hi/health/4522141.stm; Page, A. (Ed.). (2004). Keeping Patients Safe: Transforming the Work Environment of Nurses. Institute of Medicine, National Academy of Sciences. Retrieved from https://pubmed.ncbi.nlm.nih.gov/25009849/; “Strategies for Addressing the Evolving Nursing Crisis.” The Joint Commission Journal on Quality and Safety, 29(1), 41-50; and Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. The New England journal of medicine, 346(22), 1715–1722. https://doi.org/10.1056/NEJMsa012247.

[7] Lasater K.B., Aiken, L.H., Sloane, D., et al. Patient outcomes and cost savings associated with hospital safe

nurse staffing legislation: an observational study. BMJ Open (2021), 11. doi:10.1136/bmjopen-2021-052899.

[8] Ibid.

[9] McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., Merchant, R. M., Aiken, L. H., & American Heart Association’s Get With The Guidelines-Resuscitation Investigators (2016). Better Nurse Staffing and Nurse Work Environments Associated With Increased Survival of In-Hospital Cardiac Arrest Patients. Medical care, 54(1), 74–80. https://doi.org/10.1097/MLR.0000000000000456.

[10] Lee, A., Cheung, Y., Joynt, G. M., Leung, C., Wong, W. T., & Gomersall, C. D. (2017). Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Annals of intensive care, 7(1), 46. https://doi.org/10.1186/s13613-017-0269-2.

[11] Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff (Millwood). (2012 Nov) 31(11), 2501-9. doi: 10.1377/hlthaff.2011.1377.

[12] Table SNR02. Highest incidence rates of nonfatal occupational injury and illness cases with days away from work, restricted work activity, or job transfer, 2022. U.S. Bureau of Labor Statistics, Injuries, Illnesses, and Fatalities. Retrieved from https://www.bls.gov/iif/nonfatal-injuries-and-illnesses-tables.htm.

[13] Table R9. Number of nonfatal occupational injuries and illnesses involving days away from work, restricted activity, or job transfer (DART), days away from work (DAFW), and days of restricted work activity, or job transfer (DJTR) by occupation and selected natures of injury or illness, private industry, 2021-2022. U.S. Bureau of Labor Statistics, Injuries, Illnesses, and Fatalities.

[14] Leigh, J. P., Markis, C. A., Iosif, A. M., & Romano, P. S. (2015). California's nurse-to-patient ratio law and occupational injury. International archives of occupational and environmental health, 88(4), 477–484. https://doi.org/10.1007/s00420-014-0977-y.

[15] Salvagioni, D.A.J., Melanda, F.N., Mesas, A.E., González, A.D., Gabani, F.L., et al. (2017) Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PLOS ONE 12(10). https://doi.org/10.1371/journal.pone.0185781.

[16] Virtanen, M., Ferrie, J. E., Singh-Manoux, A., Shipley, M. J., Vahtera, J., Marmot, M. G., & Kivimäki, M. (2010). Overtime work and incident coronary heart disease: the Whitehall II prospective cohort study. European heart journal, 31(14), 1737–1744. https://doi.org/10.1093/eurheartj/ehq124.

[17] Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care-associated infection. American journal of infection control, 40(6), 486–490. doi:10.1016/j.ajic.2012.02.029

[18] Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association. 288(16), 1987–1993. https://doi.org/10.1001/jama.288.16.1987.

[19] Aiken, L. H., Lasater, K. B., Sloane, D. M., Pogue, C. A., Fitzpatrick Rosenbaum, K. E., Muir, K. J., McHugh, M. D., & US Clinician Wellbeing Study Consortium (2023). Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety. JAMA health forum, 4(7). https://doi.org/10.1001/jamahealthforum.2023.1809.

[20] Robbins, A. (May 28, 2015). We need more nurses. The New York Times. Retrieved from https://www.nytimes.com/2015/05/28/opinion/we-need-more-nurses.html.

[21] See, for example, Martin B., Kaminski-Ozturk N., O'Hara C., Smiley R. (2023). Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses. Journal of Nursing Regulation 14(1), 4-12. doi: 10.1016/S2155-8256(23)00063-7; Lasater, K.B., Aiken, L.H., Sloane, D.M., et al. (2021) Chronic hospital nurse understaffing meets COVID-19: an observational study. BMJ Quality & Safety 30, 639-647; Al Sabei, S. D., Al‐Rawajfah, O., AbuAlRub, R., Labrague, L. J., & Burney, I. A. (2022). Nurses’ job burnout and its association with work environment, empowerment and psychological stress during COVID‐19 pandemic. International Journal of Nursing Practice, 28(5); Galanis, P., Vraka, I., Fragkou, D., Bilali, A., & Kaitelidou, D. (2021). Nurses’ burnout and associated risk factors during the COVID‐19 pandemic: A systematic review and meta‐analysis. Journal of advanced nursing, 77(8), 3286-3302; and Lopez, V., Anderson, J., West, S., & Cleary, M. (2022). Does the COVID-19 pandemic further impact nursing shortages?, Issues in Mental Health Nursing, 43(3), 293-295, doi: 10.1080/01612840.2021.1977875.

[22] International Council of Nurses. (2021). International Council of Nurses Policy Brief. The global nursing shortage and nursing retention. Retrieved from https://www.icn.ch/sites/default/files/inline-files/ICN%20Policy%20Brief_Nurse%20Shortage%20and%20Retention_0.pdf.

[23] U.S. Bureau of Labor Statistics. (August 29, 2024). Registered nurses, job outlook. Occupational Outlook Handbook. Bureau of Labor Statistics. Retrieved from https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6.

[24] U.S. Bureau of Labor Statistics. (August 29, 2024). Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners, job outlook. Occupational Outlook Handbook. Bureau of Labor Statistics. Retrieved from https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm#tab-6.

[25] AMN Healthcare. (2023). 2023 Survey of Registered Nurses. Retrieved from https://www.amnhealthcare.com/amn-insights/nursing/surveys/2023/.

[26] Ibid.

[27] SHRM Benchmarking: Talent Access Report. (2022). Society for Human Resource Management. Retrieved from https://www.shrm.org/content/dam/en/shrm/research/benchmarking/Talent%20Access%20Report-TOTAL.pdf..

[28] Trinkoff, A.M., Han, K., Storr, C.L., Lerner, N., Johantgen, M., Gartrell, K. (December 2013). Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes. JONA: The Journal of Nursing Administration 43(12):p 630-636. doi: 10.1097/NNA.0000000000000004.

[29] Yang, Y. T., & Mason, D. J. (2022, January 28). COVID-19’s impact on nursing shortages, the rise of travel nurses, and price gouging. Health Affairs Forefront. Retrieved from https://www.healthaffairs.org/do/10.1377/forefront.20220125.695159/.

[30] United States Government Accountability Office. (August 2024). Expanded use of supplemental nurses during the COVID-19 pandemic. GAO-24-106447. Retrieved from https://www.gao.gov/assets/gao-24-106447.pdf.

[31] Yang & Mason (2022), above, n. 29.

[32] C.J. Jones. (2005). The Costs of Nurse Turnover, pt 2: Application of the Nursing Turnover Costs Calculation Methodology. Journal of Nursing Administration 35(1), 41-9.

[33] Robertson, K. (January 13, 2008). Nurses (still) wanted. Sacramento Business Journal. Retrieved from http://www.bizjournals.com/sacramento/stories/2008/01/14/focus1.html.

[34] Bae, S. H. (2024). Nurse Staffing, Work Hours, Mandatory Overtime, and Turnover in Acute Care Hospitals Affect Nurse Job Satisfaction, Intent to Leave, and Burnout: A Cross-Sectional Study. International Journal of Public Health, 69:1607068. doi: 10.3389/ijph.2024.1607068.

[35] Kovner, C. T., Brewer, C. S., Fatehi, F., & Jun, J. (2014). What Does Nurse Turnover Rate Mean and What Is the Rate? Policy, Politics, & Nursing Practice, 15(3–4), 64–71. Accessed at https://doi.org/10.1177/1527154414547953

[36] McHugh, M. D., & Ma, C. (2014). Wage, Work Environment, and Staffing: Effects on Nurse Outcomes. Policy, Politics, & Nursing Practice, 15(3–4), 72–80. https://doi.org/10.1177/1527154414546868

[37] Aiken, L., et. al. (2010). [above, n.1].

[38] Sapatkin, D. (July 30, 2012). Penn Study Examines Link Between Nurse Burnout, Care. Philadelphia Inquirer. Retrieved from https://www.philly.com/philly/health/20120730_Penn_study_examines_link_between_nurse_burnout__care.html.

[39] Lasater K.B., Aiken, L.H., Sloane, D., et al. (2021). [above, n. 7].

[40] Everhart, D., Neff, D., Al-Amin, M., Nogle, J., & Weech-Maldonado, R. (2013). The effects of nurse staffing on hospital financial performance: competitive versus less competitive markets. Health Care Management Review 38(2), 146-55. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4543286/

[41] Minnesota Nursing Association. (2010). Fact Sheet: RN-to-Patient Staffing Ratios. Retrieved from http://mnnurses.files.wordpress.com/2010/03/staffing-ratios-fact-sheet.pdf.

[42] National Nurses United. (2011). The Evidence is In: RN-to-Patient Ratios Save Lives. Retrieved from http://www.nationalnursesunited.org/issues/entry/ratios.

[43] Barber, R., Kogan, A., Riffenburgh, A., & Enguidanos, S. (2015). A role for social workers in improving care setting transitions: A case study. Social Work Health Care 54(3): 177–192. doi:10.1080/00981389.2015.1005273.

[44] Falvey, J. R., Burke, R. E., Malone, D., Ridgeway, K. J., McManus, B. M., & Stevens-Lapsley, J. E. (2016). Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Physical therapy 96(8), 1125-34. Retrieved from https://doi.org/10.2522/ptj.20150526.

[45] Tappenden, K.A., Quatrara, B., Parkhurst, M.L., Malone, A.M., Fanjiang, G., Ziegler, T.R. (2013). Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. Journal of parenteral and enteral nutrition 37(4),482-97. doi: 10.1177/0148607113484066.

[46] See, for example, Griffiths, P., Ball, J., Drennan, J., James, L., Jones, J., Recio-Saucedo, A., & Simon, M. (2014). The association between patient safety outcomes and nurse / healthcare assistant skill mix and staffing levels & factors that may influence staffing requirements. University of Southampton. Retrieved from https://eprints.soton.ac.uk/367526/1/Safe%2520nurse%2520staffing%2520of%2520adult%2520wards%2520in%2520acute%2520hospitals%2520evidence%2520review%25201.pdf; and Missed Care Study Group (2018). Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Quality & Safety. https://doi.org/10.1136/bmjqs-2018-008043.

[47] Price, C. (May 24, 2018). Nurses seek safe staffing at UVM Medical Center. Vermont Digger. Retrieved from https://vtdigger.org/2018/05/24/cristina-price-nurses-seek-safe staffing-uvm-medical-center/.

[48] Office and Professional Employees International Union. (October 3, 2024). Kapi’olani Nurses Vote Overwhelmingly to Ratify Historic New Contract. Retrieved from https://www.opeiu.org/Home/NewsandMedia/TabId/2838/ArtMID/4815/ArticleID/2848/Kapi%e2%80%99olani-Nurses-Vote-Overwhelmingly-to-Ratify-Historic-New-Contract.aspx.

[49] Ly, S. (October 13, 2024). United Health Professionals of New Mexico Ratify Contract Agreement. American Federation of Teachers. Retrieved from https://www.aft.org/press-release/united-health-professionals-new-mexico-ratify-contract-agreement.

[50] HPAE (June 13, 2024). HPAE Local 5030 Members Ratify Contract with HMH to Institute First Staffing Ratios in Hospital’s History. Retrieved from https://www.hpae.org/2024/06/hpae-local-5030-members-ratify-contract-with-hmh-to-institute-first-staffing-ratios-in-hospitals-history/.

[51] HPAE (June 6, 2024). Cooper, Englewood Nurses ratify enforceable safe staffing ratios, and economic gains. Retrieved from https://www.hpae.org/2024/06/cooper-englewood-nurses-ratify-enforceable-safe-staffing-ratios-and-economic-gains/

[52] IAM Healthcare. (January 3, 2024). Nearly 1,000 Health Care Workers at Ohio State University’s Wexner Medical Center Vote to Join IAM Union. Retrieved from https://iamhealthcarepros.org/organizing/nearly-1000-health-care-workers-at-ohio-state-universitys-wexner-medical-center-vote-to-join-iam-union/.

[53] Engel, C. (December 15, 2023). United Steelworkers. USW Nurses at Robert Wood Johnson Ratify Contract Securing Industry-Setting Staffing Standards. Retrieved from https://m.usw.org/news/media-center/releases/2023/usw-nurses-at-robert-wood-johnson-ratify-contract-securing-industry-setting-staffing-standards.

[54] Oregon Nurses Association. (October 5, 2023). AURN Tentative Agreement Ratified: New Contract Goes into Effect November 6th! Retrieved from https://www.oregonrn.org/blogpost/2050183/494312/AURN-Tentative-Agreement-Ratified-New-Contract-Goes-into-Effect-November-6th.

[55] Oregon Nurses Association. Safe Staffing Saves Lives: Amended Bill Overview. Retrieved from https://www.oregonrn.org/page/SafeStaffing-AmendedBill.

[56] Ibid.

[57] New York S3691 Enacts the “safe staffing for quality care act.” Trackbill. Retrieved from https://trackbill.com/bill/new-york-senate-bill-3691-enacts-the-safe-staffing-for-quality-care-act/387457/.

[58] Massachusetts Nurses Association. News and Information on the New Law for Safe Patient Limits in ICUs. Retrieved from https://www.massnurses.org/legislation-politics/safe-patient-limits/safe-patient-limits-in-icus/#bill.

[59] Roberts, A. (October 3, 2023). Nurse-Patient Ratios: These States Have These Controversial Policies in Place. Nurse Journal. Retrieved from https://nursejournal.org/articles/nurse-patient-ratios/. See also de Cordova, P. B., Rogowski, J., Riman, K. A., & McHugh, M. D. (2019). Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis. Policy, Politics, & Nursing Practice. https://doi.org/10.1177/1527154419832112

[60] Ohio Nurses Association. (June 7, 2018). Ohio Nurses Association Applauds Passage of House Bill 456 - Prohibit Requiring Nurses to Work Overtime. Retrieved from https://www.prnewswire.com/news-releases/ohio-nurses-association-applauds-passage-of-house-bill-456--prohibit-requiring-nurses-to-work-overtime-300662044.html.

[61] Ballotpedia. (2018). Massachusetts Question 1, Nurse-Patient Assignment Limits Initiative. Retrieved from https://ballotpedia.org/Massachusetts_Question_1,_Nurse-Patient_Assignment_Limits_Initiative_(2018).

[62] Federal Register. (May 10, 2024). Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting. Retrieved from https://www.federalregister.gov/documents/2024/05/10/2024-08273/medicare-and-medicaid-programs-minimum-staffing-standards-for-long-term-care-facilities-and-medicaid.