For nearly 25 years, California has been the only state to mandate minimum staffing levels for hospital nurses. But more than a dozen states have regulations that give nurses a stronger role in setting staffing ratios, including the state of Washington. Legislation is pending in other states, and a federal bill could set staffing levels nationwide.
“Nurses are less willing than ever to work in chronically understaffed hospitals,” Linda H. Aiken, RN, FAAN, FRCN, told Medscape Medical News. Aiken, who is professor of nursing and sociology and founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia, noted a general trend among hospitals nationwide to set minimum safe nurse staffing standards.
Reforms at the national level, however, have lagged. A federal bill setting minimum nurse-to-patient ratios in hospitals, first introduced in Congress in 2019 and subsequently reintroduced several times, has failed to gain traction in Congress.
National Nurses United (NNU), federal labor unions, and state nursing associations support the legislation. But the American Hospital Association, the American Organization for Nursing Leadership, and state hospital associations oppose the bill, citing concerns about the national nursing shortage, among other issues.
The bill, which currently is in a Senate committee, would require hospitals to adopt a staffing plan that complies with specified minimum nurse-to-patient ratios by unit. Hospitals would have to post a notice of the ratios in each unit, maintain records of whether ratios were met, and prohibit other staff members from performing nurse functions unless authorized. Facilities that violate the staffing standards would face civil monetary penalties from the US Department of Health and Human Services, which could also publish the names of noncomplying hospitals.
With a divided Congress and opposition from the healthcare industry, Jean Ross, RN, BSN, one of NNU’s four presidents, told Medscape she is not confident that the bill will pass this year. “But it’s an accomplishment that we have it on the table now,” she said. “It took 10 years of hard work to get the mandate to pass in California, so it may take time. We are going to keep the momentum going.”
Giving Nurses a Stronger Voice
Laws in some states, such as Washington, allow nurses to help set staffing levels. The Washington law requires hospital administrators and nurses to agree on the number of staff assigned in each patient care unit and ensures that workers receive rest and meal breaks.
The Washington State Hospital Association (WSHA) strongly opposed an earlier version of the bill. The organization was “deeply concerned” about its negative effects on patient access. But the WSHA, the prime bill sponsor, union representatives, and legislators devised a compromise bill that passed through the Senate.
The new bill removed mandated nurse-to-patient ratios and set requirements for hospital staffing committees, Chelene Whiteaker, WSHA senior vice president of government affairs, told Medscape.
A hospital staffing committee, comprised equally of nursing staff and hospital administrators, would set staffing levels. The committees were already in place in Washington, but the new bill strengthens them and requires hospitals to meet nurse-to-patient ratios most of the month, she said. State health and labor officials can investigate any hospital that doesn’t comply, and if the facility continues to violate the staffing levels, they could request a corrective action plan or impose penalties.
Aiken doesn’t favor such compromises. She pointed to research showing that nurse staffing committees do not improve staffing. “The new legislation just delays further any serious intervention to reduce unsafe staffing levels and makes the case stronger for federal intervention.”
California’s staffing law took effect in 2004, and California remains the only state to require a nurse-to-patient ratio in every hospital unit. Ten years later, Massachusetts established a more narrowly focused staffing mandate for all intensive care units in the state.
The American Nurses Association reports that more than a dozen states have regulations about staffing ratios. Many, like Washington, have committees in which direct-care nurses make up half the members. The chief nursing officer in each Minnesota hospital, for example, develops a staffing plan; other states require that staffing levels be disclosed to public or regulatory bodies.
Nursing Shortage?
Some who are opposed to mandated ratios say they worsen the nationwide nursing shortage, which was exacerbated during the pandemic. NNU blames unsafe staffing as the reason nurses have left the field.
Paul Banach, RN, an ICU nurse who has worked with CT Nurses United in Connecticut, said that staffing committees are ineffective because state regulatory agencies aren’t enforcing their measures and that they need to be strengthened. Connecticut’s staffing ratio bill is making its way through the legislature.
Legislatures in Oregon and Maine also are considering nurse staffing bills.
State laws are helpful, but a federal law would have more impact, Ross said. “We need to have safe staffing for all patients in this country and safe working conditions for all nurses.”
Hospitals also benefit from staffing measures, she said. Ross cited studies that show that better staffing helps prevent medical errors, patient complications, and nurse burnout while saving money and lives and increasing nurse retention.
“Right now there is a lot of emphasis on increasing the number of nurses to ‘fix’ the nursing shortage. But if we don’t fix the ‘leaky bucket’ at the other end, staffing problems will continue.”
Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.
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