Evaluating nurse-to-patient ratio legislation to improve patient safety and care quality: A mixed-methods policy study

Background: Insufficient nurse staffing is a global issue, especially in lower-resource settings. High workloads are linked to increased infection rates, readmissions, and adverse clinical events. Jordanian hospitals face chronic understaffing, nurse migration, and limited regulatory oversight. Objective: This study aimed to assess the impact of implementing standardized nurse-to-patient ratios on patient outcomes and care quality in Jordanian hospitals, and to evaluate the feasibility of national legislation based on international models. Methods: A mixed-methods design was employed. Quantitative analysis included administrative data from four acute care hospitals between 2021 and 2024, focusing on patient safety indicators such as infection rates, readmissions, and hospital stays. Semi-structured interviews were used to gather qualitative data from 22 administrative and clinical stakeholders. American Nurses Association values and the Centers for Disease Control and Prevention's Policy Analysis Framework were used in the study to direct evaluation. Results: Units with staffing ratios of five or fewer patients per nurse had significantly better outcomes, including 55 % lower infection rates and nearly half the number of readmissions compared to poorly staffed units. Interview participants highlighted systemic barriers to safe staffing, including limited budgets, migration-driven shortages, and rigid hierarchical cultures. However, there was broad consensus in support of regulated staffing standards adapted to patient acuity and care setting. Conclusion: The study suggests that standardizing nurse-to-patient ratios in Jordan can significantly enhance patient safety and care quality, but requires phased legislation, dynamic acuity adjustments, and workforce development investment for successful implementation.