Nurse Staffing Plans and Ratios
ANA launched a web site dedicated to the issue of safe staffing in 2008. This site educates nurses about ANA's history of advocacy on the issue, provides updates on the newest information and developments, and gives nurses tools to get involved. Join ANA's Safe Staffing Campaign!
Background
Identifying and maintaining the appropriate number and mix of nursing staff is critical to the delivery of quality patient care. Numerous studies reveal an association between higher levels of experienced RN staffing land lower rates of adverse patient outcomes.
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". With such nebulous language and the continued 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. In a survey of almost 220,000 RNs from 13,000 nursing units in over 550 hospitals and a response rate of 70%, nurses reported to ANA that: 54% of nurses in adult medical units and emergency rooms do not have sufficient time with patients; overtime has increased during the past year with 43% of all RNs working extra hours because the unit is short staffed or busy; and that inadequate staffing affected unit admissions, transfers and discharges more than 20% of the time.
The benefits of increased RN staffing has been demonstrated. Each additional patient care RN employed (at 7.8 hours per patient day) will generate over $60,000 annually in reduced medical costs and improved national productivity.(1) This is only a partial estimate of the economic value of nursing omitting intangible benefits of reduced pain and suffering of patients and family members; the risk of patient re-hospitalization; benefits to the hospital such as improved reputation, reduced malpractice claims and payouts, and reduced compliance-related costs; and improved work environment that results in reduced turnover and risk of injury.
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 appropriate nurse staffing through legislative or regulatory means.
Three general approaches to assure sufficient nurse staffing have been utilized at the state level. The first is to require and hold hospitals accountable for implementation of nurse staffing plans, with input from direct care nurses, to assure safe nurse to patient ratios are based on patient need and other influencing criteria. The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. A third approach is that of requiring facilities to disclose staffing levels to the public and /or a regulatory body.
The prescriptive approach of legislating mandated fixed ratios does not accommodate for changes in patients' needs, available technology, and the preparation and experience of staff. What may be established through legislation today as an appropriate minimum nurse to patient ratio may be obsolete by the next shift or two years from now. Disclosure of staffing plans without evaluation and recourse for those that represent inadequate levels for safe, quality care are futile.
The American Nurses Association (ANA) supports a legislative model in which nurses are empowered to create valid and reliable staffing plans specific to the unit and patient population and to which healthcare facilities are held accountable.
ANA's Principles for Nurse Staffing* provide recommendations on appropriate staffing and require nurses to be an integral part of the nurse staffing plan development and decision-making process. Unlike legislated mandated fixed ratios, this approach is not a "one size fits all". Instead hospitals have the flexibility of tailoring nurse staffing to the specific needs of patients based on factors including how sick the patient is, the experience and training of the nursing staff, technology, and support services available to the nurses.
States continue to seek 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. And as part of the comprehensive safe staffing effort, some states include whistleblower protections for nurses wishing to report unsafe staffing.
*Utilization Guide for the ANA Principles for Nurse Staffing (2005) may be ordered at http://nursingworld.org/books/phone.cfm
(1) Dall, Yaozhu, Seifert, Maddox & Hogan. (2009) "The Economic Value of Nursing" Medical Care: Vol 47:1.
Enacted to date
Fourteen states, plus the District of Columbia* enacted legislation and/or adopted regulations to address nurse staffing: CA, CT, IL, ME*, MN, NV, NJ, NY, OH, OR, RI, TX, VT,and WA.
*DC and ME - legislation changed from original intent removing a staffing mandate, resulting in 12 states with staffing laws.
Description of Staffing Approaches Enacted/Adopted
Staffing Plans
June 2009, the TX Governor signed into law nurse staffing protections similar to other state approaches, requiring that a governing body of a hospital adopt, implement and enforce a written nurse staffing policy to ensure adequate number and skil mix of nurses available to met patients needs by unit and shift, utilizing a staffing committee. A comprehensive approach, there are also provisions for whistleblower protections and mandatory overtime prohibition. This legislation replaced 2002 regulations.
NV 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.
OH is
the latest state to enact safe nurse staffing legislation, following the Governor's signature on June 12th 2008. 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
NY is added to the states having enacted disclosure legislation (2009). The new law requires Health care facilities will be required to make available to the public information on nurse staffing and patient outcomes as specified by the Commissioner in rules and regulations; the least of which will include the number of RNs, LPNs, and unlicensed personnel providing direct care and the ratio of patients per care giver, expressed in actual numbers, in terms of total hours of nursing care per patient, and including adjustment for case mix and acuity and broken down in terms of the total patient care staff, each unit and shift. Other reportable information relates to incidence of adverse outcomes such as medication errors, patient injury, decubitus ulcers, nosocomial infections, including urinary tract infections.
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.
Another approach to staffing......
In 2009, MN (HB1760) included a provision the law in which health care facilities must consider staffing levels and their impact upon an adverse event when conducting root cause analysis.
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.
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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
TX (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. (Passed both Houses; awaits Governor's signature)
FL (HB463) has two staffing bills; this one also requires a staffing committee with nurse involvement in the creation of a staffing plan and policies for adjustment.
NH (LSR562) also seeks the creation of staffing plans.
PA (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.
MA (SB876) provides a comprehensive approach using staffing committees
Staffing Ratios
AZ (HB2186) is 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.
CA (SB360) would amend the staffing ratio law of 1999 to ensure nurses are not included in the staffing ratio count until orientation has concluded.
FL (HB 241), the "Safe Staffing for Quality Care Act" is similar to the AZ bill in that it also prescribes nurse to patient ratios (med-surg, 1:4) and includes mandatory overtime prohibitions
IL (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.
MI (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.
MN (SB441) has provisions similar to MI’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.
MO (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.
NV (AB121/BDR492) requires a staffing plan and committee with minimum nurse to patient ratios described in legislation (signed into law 6/09)
NY (AB2264 and AB731) introduced the "Safe Staffing for Quality Care Act", which also prescribes nurse to patient ratios as well as 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.
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.
OR (SB564) legislates nurse to patient ratios by unit - specialty.
PA (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.
WV (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.
CT (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.
Public Reporting
CA (AB57) The State Department of Public Health would adopt regulations that would require University of CA hospitals create written staffing plans and which would also establish a procedure for collection and review.
MO (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.
NY (SB565) is another approach to staffing by requiring the establishment of standards, filing of reports and posting of daily levels for the public to view. (passed)
Last updated 9/23/09
Disclaimer: Every effort has been made to include all legislation enacted, but omissions are possible.