Nurse Staffing Plans and Ratios
Background
42 Code of Federal Regulations (42CFR 482.23(b) requires hospitals certified to participate in Medicare to "have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed". Clearly with such nebulous language and failure of Congress to enact a quality nursing care staffing act to date, it is left to the states to ensure that staffing is appropriate to patients needs.
Massive reductions in nursing budgets have resulted in fewer nurses working longer hours, while caring for sicker patients. Nurses therefore, have requested the assistance of elected officials on the state and federal level to protect patients by holding hospitals accountable for the provision of adequate nurse staffing through legislative or regulatory means. Although approaches are varied, three general approaches to assure sufficient nurse staffing have been proposed. The first is to require and hold hospitals accountable for implementation of nurse staffing plans, with input from practicing nurses, to assure safe nurse to patient ratios are based on patient need and other criteria. The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. The third approach is a combination of nurse staffing plans and legislated nurse to patient ratios. Enhancing these approaches includes a provision for making staffing information available to the public.
The American Nurses Association (ANA) and State Nurses Associations are promoting legislation to hold hospitals accountable for the development and implementation of valid and reliable nurse staffing plans. These plans are based upon ANA's Principles for Nurse Staffing* which provide recommendations on appropriate staffing and require nurses to be an integral part of the nurse staffing plan development and decision-making process. This is not a "one size fits all" approach to staffing but instead provides hospitals with the flexibility of tailoring nurse staffing to the specific needs of patients based on factors including how sick the patient is, the experience of the nursing staff, technology, and support services available to the nurses. This flexibility does not negate the accountability of hospitals to ensure safe and effective nurse staffing. States are looking at enforcement measures ranging from termination or suspension of a facility’s license to public disclosure of violations to fees, penalties and private right of action suits.
*Utilization Guide for the ANA Principles for Nurse Staffing (2005) may be ordered at http://nursingworld.org/books/phome.cfm
Enacted to date
Fourteen states, plus the District of Columbia have passed legislation and/or regulations attempting to address nurse staffing. In two cases, the laws or regulations were waived or modified: DC and ME. States in which the legislation was enacted/adopted as proposed include: CA, CT, FL, IL, NV, NJ, OH, OR, RI, TX, VT, and WA.
Description of Staffing Approaches Enacted/Adopted
Staffing Plans
Nevada enacted staffing legislation, overriding the Governor's veto June 1, 2009. As a condition of licensing, the law requires that health care facilities (hospitals in counties with a population of 100,000 more and greater than 70 beds) establish a staffing committee comprised of 50% direct care nurses who will develop staffing plans with management. A written report will be submitted to the Director of the Legislative Counsel Bureau (even years) and the Legislative Committee on Healthcare (odd years), providing details of the plan and execution. It is expected that plans will be flexible enough to accommodate for changes in patients, staff, unit design, technology etc.
Ohio enacted safe nurse staffing legislation in 2008. The law provides for a hospital-wide nursing care committee to create an evidenced-based written nursing services staffing plan, guiding assignments of nurses throughout the hospital. In addition to reflecting the current standards by accrediting organizations and government entities, the plan is to consider multiple nurse and inpatient factors to yield minimum staffing levels with care delivered by competent staff. Details are not provided in the bill. Annually, the committee is to evaluate the plan based upon patient outcomes, prevailing standards of care, cost for delivery, followed by recommendations. Copies of the plan are to be available to all staff with a notice to the public in each hospital alerting them to the availability of a copy upon request.
Connecticut's safe nurse staffing legislation (2008) requires each hospital establish a hospital wide staffing committee (or an existing committee) responsible for assisting in the development of a nurse staffing plan. Committee membership shall consist of at least 50% direct care RNs. The plan shall include the minimum professional skill mix for each patient care unit in the hospital; identify the hospital's employment practices concerning the use of temporary and traveling nurses; set forth the level of administrative staffing for each patient care unit that ensures direct care staff are not utilized for administrative functions; establish a process review of the staffing plan; and includes a mechanism for obtaining input from direct care staff and other members of the patient care team in the development of the staffing plan.
The Safe Nurse Staffing Act passed in Washington with near unanimous votes in 2008. Highlights include:
- Each hospital must establish a nurse staffing committee composed at least half direct care nurses. This committee will develop, oversee and evaluate a nurse staffing plan for each unit and shift of the hospital based on patient care needs, appropriate skill mix of registered nurses and other nursing personnel, layout of the unit, and national standards/recommendations on nurse staffing.
- If the staffing plan developed by the staffing committee is not adopted by the hospital, the CEO must provide a written explanation of the reasons why to the committee.
- The staffing information must be posted in a public area and must include the nurse staffing plan and the nurse staffing schedule, as well as the clinical staffing relevant to that unit. It must be updated at least once every shift and made available to patients and visitors upon request.
Illinois passed the "Patient Acuity Staffing Plan" in 2007, providing flexibility for each hospital to meet the ever-changing patient care needs linked to nurse staffing with required input of direct care registered nurses. The legislation requires a nursing care committee comprised of 50% direct care staff nurses who will contribute to the development, recommendation, and review of the written hospital-wide staffing plan. The plan will take into account the complexity of care and clinical judgment required, staff skill mix, the need for specialized equipment and staffing technology as well as every hospital will identify an acuity model for adjusting the staffing plan for each inpatient care unit.
Oregon enacted legislation in 2005 strengthening landmark patient protection that became law in 2002. The bill requires hospitals to develop and implement a written hospital-wide staffing plan for nursing services. The staffing plan shall include the number, qualifications and categories of nursing staff needed for all units and be developed by a committee composed of an equal number of hospital managers and direct care registered nurses. The bill also requires that staffing plans be consistent with nationally recognized evidence-based specialty standards and guidelines. Current law provides civil penalties for hospitals which violate the law and random audits of hospitals by the Oregon Health Division.
Rhode Island enacted legislation in 2005 requiring every licensed hospital to annually submit a core-staffing plan to the department of health in January of each year. The plan must specify for each patient care unit and each shift, the number of registered nurses, licensed practical nurses, and/or certified nursing assistants who shall ordinarily be assigned to provide direct patient care and the average number of patients upon which such staffing levels are based.
Texas adopted regulations in 2002 that require hospitals to (under the administrative authority of a chief nursing officer and in accordance with an advisory committee comprised of nurse members) adopt, implement and enforce a written staffing plan. This plan must be consistent with standards established by the Texas nurse licensing boards and based upon the nursing profession's code of ethics. Patient outcomes related to nursing care will be evaluated to determine the adequacy of the staffing plan.
Staffing Ratios
Another legislative approach to address nurse staffing is to mandate specific nurse to patient ratios. In 1999, California enacted legislation calling for regulations to be adopted that would define the same unit specific nurse to patient ratios to be utilized in all nursing units in all California hospitals. Currently, a few states now require specific ratios in specialty areas such as intensive care and labor and delivery units, but none require ratios in every patient care unit in every hospital as required in the California regulations. California Governor Arnold Schwarzenegger suspended the law scheduled to take effect January 1, 2005 that would have required one nurse for every five patients in medical-surgical units, a change from the current ratio of one nurse for every six patients. A judge ruled that the governor’s administration overstepped its authority and barred the administration from delaying the implementation of the staffing ratios. The mandated ratios represent minimum requirements that may be adjusted based upon patient acuity. California hospitals have been required to utilize a patient classification system, described in regulations by the California Department of Health Services, since 1986. The system is intended to set nursing staffing levels that identify the nursing care requirements of individual patients, and indicate to the hospital the amount of nursing staff needed to provide the identified care by patient, by unit and by shift. The California staffing ratio legislation, first enacted in 1999 with subsequent amendments is enhanced by the continuation of the mandated use of a patient classification system.
Public Reporting of Nurse Staffing
Vermont enacted legislation in 2006 that adds a provision to the Bill of Rights for Hospital Patients requiring public access to information related to nurse staffing ratios.
New Jersey enacted legislation in 2005 requiring a general hospital or nursing facility to complete and post daily staffing information for each unit and each shift. This information will also be provided to the Commissioner of Health and Senior Services monthly and the Commissioner shall in turn make it available to the public on a quarterly basis.
Illinois passed legislation in 2003 instituting a Hospital Report Card, which in addition to reporting patient outcomes would report on nurse staffing plans, orientation & training.
Waived/Modified
Maine enacted legislation in 2004 that removed established staffing systems consisting of required minimum nurse to patient staffing ratios, adjustable to accommodate for change in patient needs (acuity). The new legislation directed the Maine Quality Forum Advisory Council to make recommendations related to minimum staffing ratios to the legislature and in their December 3, 2004 report, the Forum stated that there is no reliable scientific evidence that mandated registered nurse to patient staffing ratios are a guarantor of quality and safety of in-patient care. Rather the Forum recommended the collection of 15 nurse-sensitive indicators in hospital settings. They concluded the best approach would be though standardization of staffing plans and acuity tools and therefore, minimum ratios are not expected to be implemented in the foreseeable future.
Also in 2004, the District of Columbia waived enactment of staffing ratios, previously adopted in 2002, due to the nursing shortage.
Staffing Legislation Introduced 2009/Still Active from 2008
(AZ, CA, CT, FL, IL, MA, MI, MN, MO, NV, NH, NJ, NY, OR, PA, TX, WV)
Staffing Committees/Plans
Texas (HB591/SB476)—Establishes a staffing committee to direct policy and devise a staffing plan for each unit, with one half of the membership required to be direct care nurses. Included are provisions for prohibiting mandatory overtime and whistleblower protections. (Signed into law in June 2009)
Florida (HB463)—This bill also requires a staffing committee with nurse involvement in the creation of a staffing plan and policies for adjustment.
New Hampshire (LSR562)— Seeks the creation of staffing plans.
Pennsylvania (HB1033)— A comprehensive bill using a committee approach to developing staffing plans; includes a provision for evaluation of the plan using nurse sensitive indicators and protections for nurses reporting unsafe staffing.
Massachusetts (SB876)—Provides a comprehensive approach using staffing committees
Staffing Ratios
Arizona (HB2186)— A comprehensive bill with prescribed minimum nurse to patient ratios by specialty. For medical-surgical units a 1:4 ratio would be required. The bill includes mandatory overtime prohibitions.
California (SB360)—Seeks to amend the staffing ratio law of 1999 to ensure nurses are not included in the staffing ratio count until orientation has concluded.
Connecticut (SB454)—Applies to nursing homes and would establish nurse to resident ratios, calculated based upon an average of staffing levels over the course of a year. Inlcudes other provisions.
Florida (HB 241)—The "Safe Staffing for Quality Care Act" is similar to the Arizona bill in that it also prescribes nurse to patient ratios (med-surg, 1:4) and includes mandatory overtime prohibitions
Illinois (HB485/SB224)—Creates the Nursing Care and Quality Improvement Act which sets forth the minimum direct care registered nurse-to-patient ratios required in a unit of a hospital during each shift in that unit. Provides for development and reevaluation requirements for the staffing plan. Prohibits a hospital from discharging, discriminating against, or retaliating against a nurse in any manner with respect to any aspect of employment based on the nurse's refusal of a work assignment under certain conditions or a nurse or any individual, who, in good faith, reports a violation of the Act, and sets penalties for violations.
Michigan (HB4008)—Requires hospitals to develop a written staffing plan and an acuity assessment tool to make adjustments to the plan as needed, all developed by a staffing committee of at least 1/2 shall be direct care RNs. Within three years of enactment, it is expected that staffing will meet the minimum nurse-to-patient ratios as described in the legislation.
Minnesota (SB441)—Includes provisions similar to Michigan's bill plus a provision for daily posting of staffing levels and a request for a study of ways to identify nursing care in order to reimburse for nursing services through the hospital cost report to more adequately reflect nurses’ contributions to quality patient outcomes.
Missouri (HB725)—As a part of each hospital's quality assurance and quality improvement program, every hospital shall create a nursing advisory board to establish a standardized acuity-based patient classification system for each individual direct-care unit in the hospital. The department of health and senior services shall establish, monitor, and manage each advisory board. The advisory board shall consist of eight members who are direct patient care registered nurses and appointed by the department from a list of ten bedside nurses furnished by the hospital. The advisory committee will be responsible for monitoring and evaluating the staffing plan, which includes a minimum nurse to patient ratio.
Nevada (AB121/BDR492)—Requires a staffing plan and committee with minimum nurse to patient ratios described in legislation (signed into law in June 2009)
New York (AB2264 and AB731)— The "Safe Staffing for Quality Care Act" prescribes nurse to patient ratios. NY (AB5370/(SB1780)—Establishes the "Safe Staffing for Hospital Care Act"; establishes minimum staffing levels for various healthcare workers in different health care facilities; requires submission of staffing plans; prohibits most mandatory overtime.
New Jersey (AB1531/SB1233)—Expands upon existing statute and establishes minimum RN staffing standards for hospitals and ambulatory surgery facilities and State developmental centers and psychiatric facilities. This would dictate specific ratios for different units as with the CA model previously enacted.
Oregon (SB564)—Legislates nurse to patient ratios by unit - specialty.
Pennsylvania (HB147/SB689)—Establishes the "Health Care Facilities Act" which creates provisions for staffing plans, minimum ratios, an acuity system and recordkeeping, for work assignment policies and for public disclosure of staffing requirements tied to facility licensure.
West Virginia (HB2949) Establishes the Ensuring Patient safety Act, the purpose of which is to establish minimum direct care regsitered nurse to patient ratios using an acuity based patient classification system.
Public Reporting
California (AB57)—Requires the State Department of Public Health to adopt regulations that would require University of CA hospitals create written staffing plans and which would also establish a procedure for collection and review.
Missouri (SB229/ HB651)—Requires hospitals to compile and post daily staffing information in patient care areas of each unit of the hospital. (HB849) also requires daily posting of staffing information on each unit.
New York (SB565)—Presents another approach to staffing by requiring the establishment of standards, filing of reports and posting of daily levels for the public to view.
Last updated 6/3/09
Disclaimer: Every effort has been made to include all legislation enacted, but omissions are possible.