2005 Legislation: Staffing Plans and Ratios (updated 12/05)
Background : Staffing Plans and Ratios
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 and federal level to protect patients by holding hospitals accountable for the provision of adequate nurse staffing through legislative or regulatory means. 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.
Nurse Staffing Plans
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.
In addition to state legislation, ANA has developed federal legislation, S 71, The Registered Nurse Safe Staffing Act. It was introduced by Senator Inouye (D-HI), and its companion bill, HR 1372 was introduced by Representative Lois Capps (D-CA) and Robert Simmons (R-CT. The bills require hospitals to develop and implement staffing plans as a condition of participation in Medicare.
In 2005, OR legislation was enacted that strengthens landmark patient protection legislation 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. In addition to pushing for the enactment of this legislation, the Oregon Nurses Association has published a guide and developed a training program on how to solve inadequate hospital nurse staffing.
RI enacted legislation requires 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.
NJ enacted legislation requires 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 will be available to the public on an annual basis.
In 2004, no legislation addressing nurse staffing plans was enacted.
In 2003, NV enacted legislation that would require the Legislative Committee on Health Care to appoint a subcommittee to conduct an interim study on nurse staffing.
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. Last year a FL bill also passed that specified the establishment of a minimum staffing standards and quality requirements for a subacute pediatric transition care center to be operated as a 2-year pilot program.
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 to Patient Ratios
Another legislative approach to address nurse staffing is to mandate specific nurse to patient ratio legislation. 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 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.
No nurse to patient ratio legislation was enacted in 2005.
Nurse Staffing Plans and Nurse to Patient Ratios
No legislation was enacted in 2005.
In 2004, ME enacted legislation that removed language requiring minimum nurse to patient staffing ratios that would be increased as patient needs demand as determined by an established patient staffing system. Instead, the bill directed the Maine Quality Forum Advisory Council to make recommendations to the legislature by January 2005 related to minimum staffing ratios. 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. The Forum instead recommends the collection of 15 nurse-sensitive indicators to access the quality of care in ME in patient hospital settings. They concluded that effectiveness for hospitals and the Division of Licensing and Certification could be achieved by the standardization of staffing plans and acuity tools. Minimum ratios will not be implemented in Maine at this time.
Return to ANA 2005 State Legislative Trends Report
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