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 supports federal legislation – specifically the Registered Nurse Safe Staffing Act of 2007 (S.73/H.R.4138) – which is consistent with the ANA’s Principles on Nurse Staffing: i.e., 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, thirteen states and the District of Columbia have passed legislation and/or regulations that specify one of three staffing approaches: (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.
Five states have enacted legislation requiring hospitals create hospital-wide staffing plans, with unit specific needs identified; accomplished through a committee structure in which at least 50% of the membership are direct care RNs: Connecticut (2008)
Ohio (2008)
Washington (2008)
Illinois (2008)
and Oregon (2002, amended 2005)
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. Texas (2002) adopted regulations requiring 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. The 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 are to be evaluated to determine the adequacy of the staffing plan.
Three states have taken the approach of reporting / disclosure of staffing levels. 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, while 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 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.
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 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.