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Safe Staffing Victories on the State Level

Nurses are an increasingly potent force in shaping federal and state policies that promote patient safety and quality health services.  Ensuring the delivery of safe, effective, evidence-based health care requires nurses to become informed and involved in efforts to promote safe staffing and other quality care initiatives.

As part of its Safe Staffing Saves Lives Campaign (www.safestaffingsaveslives.org), the ANA is actively working with State Nurses Associations to promote legislation that holds hospitals and other health care settings accountable for establishing safe staffing plans.  The ANA is refining federal legislation – introduced in the 110th Congress (2007-2008) as the Registered Nurse Safe Staffing Act of 2007 (S.73/H.R.4138) – which is consistent with the ANA’s Principles on Nurse Staffing. The core concept: requiring hospitals, in consultation with direct-care nurses, to develop staffing plans based on patient acuity, nursing expertise, skill mix, and unit-level geography and circumstances.  

To date, 15 states and the District of Columbia have passed some form of legislation and/or regulation addressing safe nurse staffing. Among the staffing approaches are: (1) nurse staffing plans based on patient, nurse and unit-level needs; (2) mandated nurse-to-patient ratios; or (3) a combination of nurse staffing plans and mandated nurse-to-patient ratios.

Seven states have enacted legislation requiring hospitals to create hospital-wide staffing plans, with unit-specific needs identified. Plans are created through a committee comprised of at least 50% direct care RNs:

• Texas (2009)
• Nevada (2009)
• Connecticut (2008)
• Ohio (2008)
• Washington (2008)
• Illinois (2008)
• Oregon (2002, amended 2005)

Texas is the latest state to pass a law requiring hospital-wide nurse staffing plans.  The new Texas law requires that a governing body of a hospital adopt, implement and enforce a written nurse staffing policy to ensure an adequate number and skill mix of nurses available to meet patients needs by unit and shift. Staffing policies will be created by a staffing committee. The comprehensive approach also provides whistleblower protections and prohibits mandatory overtime. This legislation replaced 2002 regulations.

Though less explicit in the law, Rhode Island (2005) supports staffing plan development, specifying needed staff 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. The plan is to be submitted to the department of health annually. 

Four states have taken the approach of public reporting /disclosure of staffing levels:
 

• New York (2009) passed a law requiring health care facilities to make available to the public information on nurse staffing and patient outcomes as specified in rules and regulations.
• Vermont (2006) enacted legislation which adds a provision to the Bill of Rights for Hospital Patients requiring public access to information related to nurse staffing ratios.
• New Jersey (2005) 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.
• California (1999) enacted legislation requiring specific nurse-to-patient ratios. The law calls 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.

Legislation enacted in Maine (2004) removed established staffing systems consisting of required minimum nurse to patient staffing ratios, adjustable to accommodate for change in patient needs (acuity). The amended legislation directed the Maine Quality Forum Advisory Council to make recommendations related to minimum staffing ratios to the legislature. In its 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. The Forum concluded the best approach would be through standardization of staffing plans and acuity tools. Therefore, minimum ratios are not expected to be implemented in the foreseeable future. 

In 2004, the District of Columbia also waived a nurse staffing ratio law originally enacted in 2002 because of a nursing shortage.

In 2009, Minnesota took a different approach to addressing safe nurse staffing levels, adopting a legal provision under which health care facilities must consider staffing levels and their impact upon an adverse event when conducting root cause analysis of the event.  

Also in 2009, the North Carolina legislature determined that it would study the use of mandatory overtime as a tool to ensure safe nurse staffing.