1. Artz, Michelle

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While the very public battle over California's mandated nurse-to-patient ratios continues to be featured prominently in the news, other states are working on their own solutions to the staffing crisis. Nineteen states have introduced staffing legislation in 2005, and to date nine states, including California, have enacted staffing measures (California [regulations and legislation], Maine, Florida, Kentucky, Nevada [regulations], Oregon, Texas [regulations], and Virginia).


Whether by legislating nurse-to-patient ratios, holding hospitals accountable for developing and implementing nurse staffing plans, mandating public reporting of RN staffing levels, or a combination of the three approaches, states across the country are moving to find their own ways to address nursing workforce and patient safety concerns.


Perhaps most notably, Oregon and Texas have both enacted comprehensive staffing laws-with little of the fanfare generated by California, and far less controversy. Both states' laws follow the staffing system approach favored by the ANA and reflected in federal staffing legislation (S 71, HR 1372). This approach is based on the ANA's Principles for Nurse Staffing and ensures that nurse-to-patient ratios are established, not by legislators, but in direct coordination with nurses themselves and are based on unit-by-unit circumstances and needs. Oregon's legislation, enacted in 2001, and Texas's regulations, adopted in 2002, both require the development and implementation of a nurse staffing plan and hold hospitals accountable for compliance. Interestingly, both Oregon and Texas were able to work with the hospital association in their respective states to move staffing legislation forward.



In 2001, the Oregon Nurses Association (ONA) proposed HB 2800 in the Oregon state legislature. The ONA's compelling case for the relationship between adequate nurse staffing in hospitals and good patient outcomes led to bipartisan support and passage of the bill.


The Oregon staffing law requires hospitals to develop and implement RN staffing plans based on individual and aggregate patient needs, imposes civil penalties for hospitals that violate the new law, establishes random hospital audits by the Oregon Health Division, includes whistleblower protections, and specifies mandatory overtime protections.


In 2005, the ONA successfully passed refinements to the original staffing law that give nurses an even greater voice in developing staffing plans and further decrease the number of hours a nurse may be required to work. Under the law, a nurse could not be required to work more than 12 consecutive hours in a 24-hour period, with exceptions for emergencies or disasters.


Signed into law on July 28, the new provisions require the formation of a formal committee or committees with equal representation of direct care RNs and administrative staff. Direct care nurses will select their own representatives, and national, evidence-based specialty standards are to be used in developing the staffing plan. Specialty standards apply to units such as labor and delivery, emergency, ICU-cardiac care, surgery, and neonatal ICU. In addition, the staffing plan will include a formal process for evaluating and initiating limitations on admission or diversion of patients to another acute care facility when, in the judgment of the direct care RN, there is an inability to meet patient needs or a risk of harm to new and existing patients.



At the request of the Texas Nurses Association, regulations were adopted in 2002 that require Texas hospitals to adopt, implement, and enforce a written staffing plan (under the administrative authority of a chief nursing officer and in accordance with an advisory committee comprised of nurse members). This plan must be consistent with standards established by the Texas nurse licensing boards and based on the nursing profession's code of ethics. Patient outcomes related to nursing care are evaluated to determine the plan's adequacy.


It will take several years to assess the full impact of these and other staffing measures in place in the states, but a preliminary study published in the August 2005 edition of Policy, Politics and Nursing Practice titled "Nurses' Work Environment Perceptions When Employed in States With and Without Mandatory Staffing Ratios and or Mandatory Staffing Plans" showed evidence that "mandatory staffing plan legislation may be linked with the most positive nurse work environment perceptions when compared with implementation of mandatory staffing ratios or no workforce regulation."


This early evidence validates the belief held by many proponents of staffing systems: that this approach treats nurses as professionals rather than numbers and empowers them at last to have a decision-making role in the care they provide.