Nurse Staffing

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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 and lower rates of adverse patient outcomes. Learn more »

When health care employers fail to recognize the association between RN staffing and patient outcomes, laws and regulations become necessary.

A Federal regulation has been in place for some time, 42 Code of Federal Regulations (42CFR 482.23(b) which 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".  This nebulous language and the continued failure of Congress to enact a federal law, The Registered Nurse Staffing Act , has resulted in states taking action to ensure there is optimal nurse staffing appropriate to patients' needs.

State staffing laws tend to fall into one of three general approaches:

  • The first is to require hospitals to have a nurse driven staffing committee which create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff.
  • The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation.
  • A third approach is requiring facilities to disclose staffing levels to the public and /or a regulatory body.

The American Nurses Association (ANA) supports a legislative model in which nurses are empowered to create staffing plans specific to each unit. This approach aides in establishing staffing levels that are flexible and account for changes; including intensity of patient's needs, the number of admissions, discharges and transfers during a shift, level of experience of nursing staff, layout of the unit, and availability of resources (ancillary staff, technology etc.). Establishing minimum upwardly adjustable staffing levels is statute may also aide the committee in achieving safe and appropriate staffing plans.

States with Staffing Laws
14 states currently addressed nurse staffing in hospitals in law / regulations: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA.

  • 7 states require hospitals to have staffing committees responsible for plans (nurse-driven ratios) and staffing policy – CT, IL, NV, OH, OR, TX, WA.
  • CA is the only state that stipulates in law and regulations a required minimum nurse to patient ratios to be maintained at all times by unit. MA passed a law specific to ICU requiring a 1:1 or 1:2 nurse to patient ratio depending on stability of the patient.
  • MN requires a CNO or designee develop a core staffing plan with input from others. The requirements are similar to Joint Commission standards.
  • 5 states require some form of disclosure and / or public reporting – IL, NJ, NY, RI, VT

Other limited efforts......

  • NM (2012) charged specific stakeholder groups to recommended staffing standards to the legislature; the department of health is to collect information about the hospitals that adopt standards and report the cost of implementing an oversight program.
  • NC (2009) requested a study in the use of mandatory overtime as a staffing tool. No subsequent action taken.
  • DC and ME (2004) – passed legislation; later amended from original intent; staffing mandate removed.

Last updated 12/2015