Nurse Staffing Plans and Ratios
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 patients needs.
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/phome.cfm
Enacted to date
Nine states, plus the District of Columbia have passed legislation and / or regulations attempting to address nurse staffing; two of which have been waived or modified: DC and ME. States in which the legislation was enacted / adopted as proposed includes: CA, FL, IL, NJ, OR, RI, TX, VT, witha brief description to follow. NV is not included in the total, although in 2003 legislation passed requiring the Legislative Committee on Health to appoint a subcommittee to conduct an interim study on staffing.
Staffing Plans
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 annual ly 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
This is to acknowledge thatNV passed legislation in 2003 that required the Legislative Committee on Health to appoint a subcommittee to conduct an interim study on nurse staffing.
2007 Activities
Staffing Plans
CT,FL, MI, ME, and MO, introduced legislation which would require hospitals to compile direct care staffing schedules and patterns and methods for determining and adjusting levels, with disclosure to the public. NV legislation would require hospitals and ambulatory surgical centers to establish staffing plans, collect staffing statistics and disclose information to the public. CO introduced similar legislation, providing a staffing committee with oversight, requiring hospitals to staff according to the plan, prohibiting employers from retaliating or intimidating staff who either participate on the staffing committee or who report staffing deficiencies, and provides for civil penalties or licensure revocation for any hospital which fails to fulfill its’ staffing obligations. WA, too introduced legislation requiring staffing plans to be generated by a staffing advisory committee, with reports by the hospital to the department of health semiannually to include information about actual staffing and correlation to nursing quality indicators. The legislation also calls for staffing plans along with actual staffing to be posted and visible to the public on each patient care unit; and like CO, prohibits the hospital from retaliation against employees who report unsafe staffing.
Staffing Ratios
IL, KY, MI, MO, NY, NJ and WV introduced staffing ratio legislation in 2007. The MI, MO, NJ, NY, WV and DC legislation (carried over from 2006) all set minimum ratios for each type of care unit, requiring use of patient classification / patient acuity system before adjusting the legislated minimum ratios; NJ also specified the presence of a float pool. NY introduced several staffing bills with the most comprehensive requiring creation of a staffing plan with ratios for different types of patient units, monitored by a staffing committee, in which RNs are members, disclosure of the staffing plan is required, with a provision for refusal of an assignment if the nurse deems they lack the necessary education / skill for carrying it out. A hospital in NY neglecting to meet the staffing plan requirements could lose its operating certificate. MI and MO’s bills are similar to NY. Additionally, MO and NJ extend staffing requirements to ambulatory care / surgery centers. KY proposed legislation requiring staffing ratios for long term care facilities with greater than 75 beds. The ratios define "nurse" and nurse aide to resident ratios as well as stipulating the presence of an RN on the premises in the supervisory role for the day and evening shifts and nurse administrator requirements. RI Introduced staffing ratio legislation specific to nursing homes, requesting the department of health to establish nurse to resident ratios, while the legislation sets ratios for CNAs to residents per shift.
Public Reporting
WV is promoting the posting of staffing on resident care units in nursing homes through their proposed legislation, similar to what is currently a federal requirement.
NY also introduced legislation that would require nursing homes to report staffing levels in hours per resident to the Department of Health, (DOH) along with a number of other characteristics such as quality which the DOH would be responsible for disclosing to the public.
Other
FL, NY, PA, and SC introducedlegislation requiring an RN be present in the operating room in the role of circulating nurse for each surgery through its duration, while GA introduced legislation requiring a "nurse", not qualified as an RN, but with appropriate training to be available at all times as a circulating nurse in each operating room suite. FL was successful in 2006.
PA introduced legislation stipulating staffing requirements for any facility providing dialysis and/or care for patients with end-stage renal disease.
Last updated 9/15/07
Disclaimer: Every effort has been made to include all legislation enacted, but omissions are possible.