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, promote 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 developed federal legislation, S 991,introduced by Senator Inouye (D-HI), and its companion bill, HR 3656, introduced by Representative Lois Capps (D-CA), that requires hospitals to develop and implement staffing plans as a condition of participation in Medicare. ANA has also worked with Representative Maurice Hinchey (D-NY) to introduce HR 4374 that requires Medicare providers to publicly disclose nurse staffing and patient quality outcomes measurements.
In 2004, FL, HI, IL, MA, RI and WA introduced legislation that would require health care facilities to develop nurse staffing plans. The bills contain a variety of components such as requiring: nurse administrators to adopt and implement a staffing plan with input from direct care registered nurses; the numbers of nursing staff responsible for patient care to be posted daily; the adequacy of the staffing plan be evaluated through the collection of patient quality outcomes; ANA’s Principles for Nurse Staffing to serve as a basis for development of a staffing plan; and civil penalties to be used for enforcement purposes.
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. In 2004, California state regulators found that more than half the hospitals they reviewed were in violation of the ratios, most commonly in emergency rooms, medical-surgical units and telemetry units. Governor 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.
Legislation was introduced this year in HI, IA, MO and TN that would require specific nurse to patient ratios in hospitals and/or other health care facilities. These broad-based bills assign a numeric nurse to patient ratio for specific patient care units such as pediatric recovery rooms, trauma, and psychiatric units. CT legislation calls for the Commissioner of Public Health to adopt regulations establishing minimum nurse-to-patient ratios. Strict enforcement is another hallmark of these bills with violations leading to any combination of the following: loss of hospital license, fines, termination of Medicaid reimbursement, private right of action and civil penalties.
Nurse Staffing Plans and Nurse to Patient Ratios
In 2004, ME enacted legislation requiring minimum nurse to patient staffing ratios as outlined in law that will be increased as patient needs demand as determined by an established patient staffing system. The Department of Human Services will adopt rules for establishing patient staffing systems. Legislation was introduced in IL, MA, MI, NY, PA, RI and TN requiring a combination of minimum nurse to patient ratios that would be augmented by hospital based staffing systems.