Market forces have not resolved the issues of patient safety and quality of care related to nurse staffing. 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 level to protect patients by holding hospitals accountable for the provision of adequate nurse staffing through legislative or regulatory means.

Nurse Staffing Plans
In 2001, the American Nurses Association (ANA) and State Nurses Associations, proposed state legislation to hold hospitals accountable for the development and implementation of a valid and reliable nurse staffing plans. These plans are based upon ANA's Principles for Nurse Staffing which provide recommendations on appropriate staffing. 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.

Seventeen states considered legislation this year pertaining to nurse staffing. Only an omnibus FL bill passed that specified the establishment of minimum staffing standards and quality requirements for a subacute pediatric transitional care center to be operated as a 2-year pilot program. 2002 regulations adopted in TX 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.

2001 legislation enacted in OR requires hospitals to develop and implement nurse staffing plans and establish internal review processes. Random audits of hospitals for compliance are mandatory and failure to comply will result in civil penalties or revocation of licensure. In 1998, legislation was passed by KY and VA to set appropriate staffing methodology and in 1995, regulations were developed in CA calling for institutions to develop valid staffing systems and in NV regulations were adopted a few years later.

Nurse Ratios
Another legislative approach to address nurse staffing is to mandate specific nurse to patient ratios. In 1999, legislation was enacted in CA 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 proposed in the California regulations. After difficulties and delays in the development of the ratios and disagreement on what the ratios should be, Governor Davis proposed specific ratios early this year. These proposed ratios will now be subjected to a public comment period.

Legislation was considered this year in FL, IA, KY, MO, NJ and RI that would require nurse to patient ratios in hospitals and/or other health care facilities. Ratios for nurses in operating rooms will be carried over in VA, while a nurse to radiological technologists ratio was considered but died in CT. Legislation to address nurse to pupil ratios in schools was considered in MN, MS, NY, OH, PA, SC and WV.