Updated: May 10, 2013

Earlier this year we reported on the aggressive efforts of nursing unions to push nurse-to-patient staffing ratios through collective bargaining and by exerting political pressure on state legislatures. To date, California is the only state to pass legislation mandating that a certain number of nurses be staffed for every patient. But as we reported, the National Nurses United (NNU) and affiliated state unions were pushing similar legislative proposals in the District of Columbia, Michigan, New Jersey and Minnesota.

Since our last report, similar bills have been proposed in Florida, Texas, New York, and Iowa, as well as one reintroduced in the U.S. Senate that would apply nationwide.

The common purpose of these laws is to ensure a fixed number of nurses per patient, though there is some variation in the ratios and how they would be established.

Federal Bill

The federal legislation – the National Nursing Shortage Reform and Patient Advocacy Act (S. 739) – would, in addition to establishing minimum direct care registered nurse-to-patient ratios, require hospitals to implement nurse-to-patient staffing plans, and provide whistleblower protections for nurses who refuse to accept an assignment if they believe doing so would violate the requirements of the nurse staffing law or if they do not have the qualifications or experience necessary to perform the assignment. Specifically, the bill would:

• Establish minimum direct care registered nurse-to-patient ratios for particular hospital units, subject to exemptions in emergency situations;
• Prohibit hospitals from averaging the number of patients and nurses during any one shift or imposing mandatory overtime in order to meet the minimum ratios;
• Require hospitals to develop, maintain, and make available to the public a nurse staffing plan developed in conjunction with direct care registered nurses working at the hospital and, where applicable, with the collective bargaining representative of the nurses;
• Require hospitals to maintain records of the actual direct care registered nurse-to-patient ratio in each unit for each shift, and to make these available to the public for no less than 2 years;
• Make hospitals that take adverse action against a nurse for refusing an assignment under these conditions, or for filing a complaint about such assignments, liable for reinstatement, lost wages, other damages and attorneys’ fees;
• Subject hospitals found in violation of the law to civil monetary penalties of up to $25,000 for each knowing violation, or to greater, unspecified monetary penalties if the Secretary of Health and Human Services determines the hospital has a pattern or practice of such violation; and
• Subject individual employees of the hospital found in willful violation of the law to civil monetary penalties of up to $20,000 for each such violation.

If enacted, the federal bill would not preempt more stringent state nurse-to-patient ratio requirements.

While expansive, the National Nursing Shortage Reform and Patient Advocacy Act’s chance of passage this term is slim. Smaller-scale state bills have a greater chance of advancing.

State Bills

On May 14, 2013, the DC Council is scheduled to consider the DC Patient Protection Act. The nurse-to-patient ratios that would be established by this bill are modeled after those established in California. The proposed legislation in Minnesota, on the other hand, would base staffing level requirements on the recommendations of nursing specialty organizations. Many of the proposed state bills would also ban mandatory overtime for nurses, except in emergency situations.

Several of the state measures introduced earlier this year, including the Florida Hospital Patient Protection Act and Texas House Bill 2880, would impose a number of specific staffing ratio requirements, including a minimum nurse-to-patient ratio of 1:1 for active labor patients and 1:2 ratio for critical care patients. New York’s Safe Staffing for Quality Care Act’s requirement for critical care patients would be more stringent, requiring at least one nurse per patient, while the proposed bill in Iowa would allow a more relaxed 2:1 ratio in critical care and labor and delivery units.

Nursing unions and other proponents of the staffing laws argue such laws are necessary for adequate nursing care. Titles of several of the proposed bills, including the Patient Protection Act in the District of Columbia and the Michigan Safe Patient Care Act, prominently emphasize patient safety. But hospital administrators fiercely oppose mandatory staffing laws. They argue that such laws strip them of autonomy in making basic staffing decisions, create undue financial burdens, and impose arbitrary staffing requirements bereft of data establishing appropriate staffing levels. They further argue that federal laws imposing penalties for negative patient outcomes have spurred hospitals to create minimum staffing levels on their own initiative. The American Nurses Association (ANA), which advocates on behalf all nurses – union and non-union – opposes legislatively mandated, “one size fits all” fixed ratios, instead favoring staffing decisions made through a cooperative effort between nurses and hospital administrators that consider the level of patient sickness, the nursing staff’s training and experience, technology, and support services.

It remains to be seen whether these proposed laws will gain the political traction necessary to be the first passed into law since California’s in 2004. The growing number of states in which fixed nurse-to-patient ratio laws have been proposed suggests this battle between nursing unions and hospital administrators will continue to open on new fronts, including picket lines and in federal and state legislatures.

Update: On May 9, 2013, Rep. Jan Schakowsky (D-IL) introduced the Nurse Staffing Standards for Patient Safety and Quality Care Act (H.R. 1907) in the House of Representatives. This bill is substantively similar to the National Nursing Shortage Reform and Patient Advocacy Act.

Photo credit: AlexRaths