Safe Nurse Staffing Continues…..

Safe nurse staffing continues to be a priority issue for nurses and legislators.  In the first half of 2009, two additional states passed safe staffing laws: Nevada and Texas.  Enactment in Nevada required the legislature override the Governor's veto. This brings the total number of states with staffing laws to eleven.  Maine and the District of Columbia also passed staffing legislation in 2004, but are not reflected in the eleven states since each was changed and not implemented as originally intended. 

The approaches have varied and include “legislated” mandated ratios; hospital wide staffing committees responsible for unit specific plans and associated policy; and reporting and/or public disclosure.  Legislated ratios and staffing committees each address numbers of nurses however, the process to achieve safe staffing levels differs.  In 1999, California became the first and thus far only state to pass a staffing law establishing a minimum staffing ratio.   The law (AB394) mandated that the Department of Health Services work to create “regulations that establish minimum specific and numerical licensed nurse to patient ratios by licensed nurse classification by hospital unit.”  The law also stipulated that hospitals assign additional staff using the patient classification system previously identified in regulations. Finally in 2004, the actual staffing ratios were determined and the law went into effect. Just this year, the first study, “Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care” was released.  The study cited the many challenges associated with maintaining ratios at all times, yet ratios did not appear to affect nurse sensitive indicators such as decubitus ulcer, deep vein thrombosis and failure to rescue. What was notably changed is a decline in length of stay. Clearly, as recommended by the authors, further study is needed on the affects of the ratios on quality.

Three states: New Jersey, Rhode Island and Vermont chose a different tactic: reporting / public disclosure. New Jersey requires a general hospital or nursing facility to complete and post daily staffing information for each unit and each shift. This information is also to be provided to the Commissioner of Health and Senior Services monthly and the Commissioner in turn is to make it available to the public on a quarterly basis. Vermont’s law is similar in that it requires public access to information related to nurse staffing as part of the Bill of Rights for hospitals. Rhode Island requires every licensed hospital to annually submit a core-staffing plan to the department of health that must specify staff numbers and skill mix and the number of patients upon which staffing plan is based.

The remaining seven states (CT, IL, NV, OH, OR, TX, WA) have legislated staffing committees in which staff nurses are empowered to establish staffing plans specific to unit and shift needs in collaboration with management. As a condition of licensing, Nevada's new law requires that health care facilities (hospitals in counties with a population of 100,000 more and greater than 70 beds) establish a staffing committee comprised of 50 percent direct care nurses who will develop staffing plans. It is expected that plans will be flexible enough to accommodate for changes in patients, staff, unit design, and technology. The experience of this new law will be summarized in a written report submitted to the Director of the Legislative Counsel Bureau (even years) and the Legislative Committee on Healthcare (odd years). Similarly, Texas will establish a staffing committee to direct policy and devise a staffing plan for each unit, with one half of the membership required to be direct care nurses. Texas’ law also includes provisions for whistleblower protections and mandatory overtime.

Passing legislation is just the beginning. Nurses will now need to learn a new role, that of staffing committee member. Additional research is needed related to staffing levels, skill mix, and the effects on nurse sensitive indicators. And so safe nurse staffing continues……

Janet Haebler, MSN, RN