Nurse Staffing Plans and Ratios
Background
Federal regulations require 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" (42CFR 482.23(b). With such nebulous language and no national nurse staffing law, states are taking steps to ensure that staffing is appropriate to meet patients’ needs.
Nursing budget cuts and higher incidence of sicker patients have compelled nurses to seek legislative remedies to protect patients by holding hospitals accountable for providing sufficient nurse staffing.
State nurse staffing legislation generally reflects three approaches.
1) Nurse Staffing Plans – Direct care nurses contribute to development of hospital-wide plans, by unit and shift, that set nurse staffing levels based on patient acuity and needs at any given time, available support staff and other factors.
2) Nurse-to-Patient Ratios – A specific, legally mandated minimum ratio, varying based on the type of unit.
3) Disclosure of Staffing Levels - Hospitals must publicly report nurse staffing levels so staffing plans can be reviewed by hospital staff, patients, the public or a regulatory body.
ANA's Preferred Approach
ANA supports legislation that holds hospitals accountable for the development and implementation of nurse staffing plans tailored to each hospital unit and characteristics of the patient population.
These plans are based upon ANA's Principles for Nurse Staffing* which provides recommendations on appropriate staffing and includes nurses as an integral part of the plan development and decision-making process. Unlike a more rigid ratio required by law, ANA's preferred approach allows hospitals flexibility to tailor nurse staffing to factors such as patient needs, staff experience and skills, and available support staff and technology.
ANA advocates this approach because we recognize that neither nurses nor patients should be treated as mere numbers.
*Order the Utilization Guide for the ANA Principles for Nurse Staffing (2005)
Enacted to Date
Disclaimer: Every effort has been made to include all legislation enacted, but omissions are possible.
15 states, plus the District of Columbia, have passed legislation and/or regulations addressing nurse staffing:
CA, CT, IL, MN, NV, NJ, NY, NC, OH, OR, RI, TX, VT, and WA. (DC and ME waived or modified mandatory safe staffing provisions after original enactment.)
7 states have enacted laws that reflect ANA's preferred approach.
Nurse Staffing Plans (7)
Texas (2009) - The governing body of a hospital must adopt, implement and enforce a written nurse staffing policy. The policy, created by a staffing committee, would ensure a sufficient number and skill mix of nurses available to meet patients’ needs by unit and shift. The law also provides whistleblower protections and prohibits mandatory overtime.
Nevada (2009) -- Health care facilities with at least 70 beds and in counties with a population of at least 100,000 must establish a staffing committee comprised of 50% direct care nurses to develop flexible staffing plans with management. Written reports must be submitted to legislative panels annually.
Ohio (2008) -- A hospital committee must create a nurse staffing plan, based on documented outcomes, guiding assignments of nurses. Plans must reflect nurse and patient factors to determine minimum staffing levels, as well as current practice standards set by accrediting and government agencies. The committee must evaluate the plan annually based upon patient outcomes, prevailing standards of care, and cost of care.
Connecticut (2008) -- A hospital committee with at least 50% direct care RNs must assist in the development of a nurse staffing plan. The plan must reflect the minimum professional skill mix for each patient care unit; temporary and traveling nurse employment practices; and administrative staffing for each patient care unit.
Washington (2008) – A hospital committee with at least 50% direct care nurses must develop, oversee and evaluate a nurse staffing plan for each unit and shift of the hospital based on patient care needs, skill and experience mix of RNs and other nursing personnel, layout of the unit, and national standards/recommendations on nurse staffing. Staffing information must be posted in a public area.
Illinois (2007) -- A hospital committee with at least 50% direct care nurses must contribute to the development of hospital-wide nurse staffing plan. The plan must reflect the complexity of care and clinical judgment required, staff skill mix, and the need for specialized equipment. Hospitals must identify an acuity model for adjusting the staffing plan for each inpatient care unit.
Oregon (2005, strengthening landmark patient protection originally enacted in 2002). A hospital committee with equal numbers of managers and direct care RNs must develop and implement a nurse staffing plan that includes the number, qualifications and categories of nursing staff needed for all units.
Nurse-to-Patient Ratios (1)
California (1999) – Hospitals must employ specific nurse-to-patient ratios in every patient care unit, with the ratio varying depending on the type of unit. The ratios represent a minimum requirement that may be adjusted based on patient acuity, creating a higher ratio of nurses to patients. The law builds on a patient classification system intended to set nurse staffing levels based on nursing care requirements of individual patients.
Disclosure of Staffing Levels (5)
New York (2009) requires health care facilities to make available to the public certain information on nurse staffing and patient outcomes.
Vermont (2006) includes a provision in its Bill of Rights for Hospital Patients requiring public access to information related to nurse staffing ratios.
New Jersey (2005) requires hospitals and nursing facilities to complete and post staffing information for public view daily for each unit and shift, and to provide the information to the state for compilation and release to the public quarterly.
Rhode Island (2005) – Hospitals must submit annually a staffing plan to the state, outlining the number of registered nurses, licensed practical nurses, and/or certified nursing assistants who ordinarily will be assigned for each patient care unit and shift, and the average number of patients upon which the staffing is based.
Illinois (2003) institutes a Hospital Report Card, which, in addition to reporting patient outcomes, reports on nurse staffing plans.
Staffing Level’s Effect on Adverse Outcomes (1)
Minnesota (2009) requires health care facilities to evaluate staffing levels and their impact upon a negative patient outcome when conducting root cause analysis of the adverse event.
Study Mandatory Overtime and Effects on Staffing (1)
North Carolina (2009) established a commission to analyze the use of mandatory nurse overtime as a staffing tool, and its impact on medication errors, patient care and safety, nurses’ health and safety and other factors. The commission will evaluate current nurse-to-patient ratios, and examine whether requiring minimum ratios would improve patient safety and quality of care. It also will consider the effects of banning mandatory overtime on current nursing shortages.
Staffing Legislation Waived or Modified (2)
Maine (2004) removed established staffing systems consisting of required minimum nurse-to-patient ratios with an amendment directing a state council to make recommendations on staffing ratios to the legislature. The council did not recommend setting minimum staffing ratios; instead, it advised collecting data on 15 nursing performance measures.
Washington, D.C. (2004) waived a nurse staffing ratio law enacted in 2002 because of a nursing shortage.