When healthcare employers fail to recognize the association between RN staffing and patient outcomes, laws and regulations become necessary, the American Nursing Association argues.

An existing federal regulation (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.” “This nebulous language and the continued failure of Congress to enact a federal law — ‘The Registered Nurse Staffing Act’ — has left it to the states to ensure that staffing is appropriate to meet patients’ needs safely,” the ANA states on its website. (http://bit.ly/1vmQMzI)

According to the ANA, state staffing laws tend to fall into one of three general approaches:

• Require hospitals to have a nurse-driven staffing committee which creates staffing plans that reflect the needs of the patient population and match the skills and experience of the staff.

• Mandate specific nurse-to-patient ratios in legislation or regulation.

• Require facilities to disclose staffing levels to the public and/or a regulatory body.

The ANA supports a legislative model in which nurses are empowered to create staffing plans specific to each unit. “This approach aides in establishing staffing levels that are flexible and account for changes; including intensity of patient’s needs, the number of admissions, discharges and transfers during a shift, level of experience of nursing staff, layout of the unit, and availability of resources (ancillary staff, technology etc.),” the ANA states.

The ANA summarizes the situation as follows:

• Thirteen states currently have addressed nurse staffing in hospitals in law or regulations: CA, CT, IL, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA. Of these, seven require hospitals to have staffing committees responsible for plans and staffing policy: CT, IL, NV, OH, OR, TX, WA. In addition, five states require some form of disclosure and/or public reporting of staffing levels: IL, NJ, NY, RI, VT.

• California is the only state that stipulates in law and regulations a required minimum nurse-to-patient ratio to be maintained at all times by unit.

• Massachusetts passed a law specific to the ICU requiring a 1:1 or 1:2 nurse-to-patient ratio depending on stability of the patient.

• Minnesota requires that a chief nursing officer or designee develop a core staffing plan with input from others. The requirements are similar to Joint Commission standards.

• New Mexico charged specific stakeholder groups to recommended staffing standards to the legislature in 2012. The department of health is to collect information about the hospitals that adopt standards and report the cost of implementing an oversight program.

• North Carolina requested a study on the use of mandatory overtime as a staffing tool in 2009, but no subsequent action taken.

• Washington, D.C. and Maine passed legislation in 2004, but the staffing mandate was later removed in both states.