Nurse Staffing Plans and Ratios

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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 meet patients needs safely.

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/phone.cfm

Enacted to date

Thirteen states, plus the District of Columbia* have enacted legislation and / or adopted regulations to address nurse staffing: CA, CT, FL, IL, ME*, NV, NJ, OH, OR, RI, TX, VT, and WA.
NV's 2003 legislation did not impose staffing requirements, rather called for a study on staffing. *DC and ME modified legislation from its original intent. Approaches can be reviewed in the following text.

Description for those states requiring safe staffing

Staffing Plans

OH (2008) is the latest state to enact safe nurse staffing legislation, following the Governor's signature on June 12th. Resultant revised Code will provide 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.

Effective October (2008), CT nurse staffing legislation will require 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 WA with near unanimous votes in early March (2008), with the Governor signing into law soon after. Highlights include:

  • Each hospital, by September 2008, 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.

IL (2007) passed the "Patient Acuity Staffing Plan", which provides 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.

In 2005, OR enacted legislation 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.

RI 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.

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.

Staffing 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 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.

In 2006, FL passed legislation addressing minimum staffing requirements for nursing homes. The rules to be developed were to call for 2.7 hours of direct care/ resident / day as of January, 2007; with at least one certified nursing assistant per 20 residents and a minimum of one licensed nurse for 1.0 hour of direct care/ resident / day and never below one nurse for 40 residents. That same year, FL was also successful in enacting law requiring a registered nurse presence in the operating room during the entire surgical procedure.

Public Reporting of Nurse Staffing

In 2006, legislation was enacted in VT which adds a provision to the Bill of Rights for Hospital Patients requiring public access to information related to nurse staffing ratios.

In 2005, NJ enacted legislation 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.

In 2003, IL passed legislation instituting a Hospital Report Card, which in addition to reporting patient outcomes would report on nurse staffing plans, orientation & training.

Waived/Modified

In 2004, ME enacted legislation 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, DC waived enactment of staffing ratios, previously legislated in 2002 due to the nursing shortage.

Study Only

NV passed legislation in 2003 that required the Legislative Committee on Health to appoint a subcommittee to conduct an interim study on nurse staffing.

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Staffing Legislation Introduced 2008
(AZ, CT, FL, HI, IA, MN, MO, NJ, NM, NY, OH, VA, WV)

Staffing Plans

IA (SB2296) 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. The staffing plan must be submitted to the regulatory agency semiannually. There are provisions for the facility to deviate from the plan during an emergency. Protections from retaliation are afforded nurses who report staffing violations. MN (SB2742/HB3042) requires licensed hospitals to implement a staffing plan establishing the maximum number of patients that may be assigned to a direct care nurse. A “Staffing for Patient Safety” committee would review assignments taking into account such factors as anticipated admissions, discharges, transfers, skill mix, national specialty standards for staffing and nursing-sensitive quality outcomes. Shift to shift adjustments in the staffing plan would include consideration of patient acuity. OH (HB346) requires a hospital to convene a hospital-wide nursing care committee to establish staffing guidelines. WV (HB2487) “Ensuring Patient Safety Act” calls for staffing plans with minimum ratios and use of patient acuity to adjust with the added provision prohibiting mandatory overtime. As a condition of licensure CT (HB5902) and OH (HB346) also seeks a staffing committee approach to creating a staffing plan for each unit within a hospital and to work in collaboration with management in identifying associated employment practices (such as temporary / traveling nurses) and in evaluating of the plan.

Staffing Ratios

AZ (HB2041) has proposed legislation establishing guidelines for patient protections and nurses rights in hospitals that would require prescribed nurse-to-patient ratios as well as implementation of a patient classification system. FL (SB1338), the “Safe Staffing for Quality Care Act” extends prescribed minimum ratios beyond acute care hospitals and emergency care, to ambulatory, outpatient surgery, and psychiatric facilities. Similarly, NJ (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. HI (SB2781), too, specifies the maximum number of patients for which a RN can deliver care by unit. Although NY has several staffing bills introduced (such as for select mental health settings AB1439; nursing homes AB3791& AB8220); nurse staffing centers AB5525), it is AB6119/SB1551, the “Safe Staffing for Quality Care Act that requires acute care facilities to submit a staffing plan to the Department of Health on an annual basis, implement minimum ratios; authorizes nurses to refuse an assignment that is deemed to exceed their abilities or in which the required staffing level has not been met; requires public disclosure and imposes penalties for violations. MO (HB2450) establishes a minimum of direct care nurse-to-patient ratio by type of unit with provisions to adjust based upon a patient acuity system. Every hospital would be expected to create a nursing advisory board that would develop the acuity system, re-evaluate the nurse-to-patient ratios every three years, develop an assessment tool for the hospital to use for documentation of the staffing plan, and report to the Department of Health & Senior Services noncompliance with the staffing plan. Associated penalties are defined.

Public Reporting

FL (HB851/SB1186), Patient’s Right to Know Act would require health care facilities to publish and disseminate nurse staffing levels and turnover rates, in addition to violations of regulations and complaints filed with regulatory agencies. Facilities would also need to be able to provide staffing schedules and methods used to determine staffing levels upon request. Legislation in MO (HB2183) requires daily compilation and posting of staffing information in patient care areas of every unit of the hospital, while NM (HB455) would require staffing levels be disclosed as part of a comprehensive hospital transparency information system.

Nursing Homes

Both CT (SB385) and VA (HB1046) are pursuing legislation that would improve staffing levels in nursing homes. VA’s bill would require the Board of Health to establish the staffing standards.
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Last updated 6/17/08

Disclaimer: Every effort has been made to include all legislation enacted, but omissions are possible.