Nurse-to-Patient Ratios

ANA Applauds Federal Legislation to Mandate Safe Nurse-to-Patient Ratios

Sen. Inouye introduces bill to protect patients, hold hospitals accountable for RN staffing.

Washington, D.C. — The American Nurses Association (ANA) today applauded the introduction of the Registered Nurse Safe Staffing Act of 2003, federal legislation that aims to ensure that patients receive safe, quality nursing care in hospitals and other health care institutions. The legislation mandates the development of staffing systems that require the input of direct-care registered nurses (RNs) and provides whistle-blower protections for RNs who speak out about patient care issues.

The bill, S.991, was introduced by Sen. Daniel Inouye (D-HI) yesterday. Today marks the start of National Nurses Week, which is celebrated May 6-12 each year.

ANA, which worked closely with Sen. Inouye's office on the bill, lobbied for this legislation to protect patients and registered nurses, given the absence of enforceable standards for nurse staffing in hospitals and the widespread practice of healthcare facilities stretching their nursing staff with unsafe patient loads, mandatory overtime, "floating" to specialty units without training and orientation and other practices that undermine the delivery of safe, quality care.

"Inappropriate nurse staffing is the number one concern of nurses today," said ANA President Barbara Blakeney, MS, APRN, BC, ANP. "More than a decade of research has shown that RNs make the quality difference in patient care and that when RN care is insufficient, patient safety is compromised and the risk of death is increased."

"We applaud Sen. Inouye for his leadership on this issue and for his commitment to protecting patients and nurses from practices that are dangerous," said Blakeney. "Furthermore, this legislation is needed to improve the work environment for nurses, to enhance retention of practicing nurses and recruitment into the profession."

In July 2002, the Department of Health and Human Services released data confirming that a nursing shortage already exists in the United States and that it is expected to grow. According to the HHS study, in 2000, there was a shortage of 110,000 nurses (6 percent).

Without changes in the system, the HHS study predicts that shortage will grow to 12 percent by the year 2010, 20 percent by 2015 and 29 percent by 2020.

The RN Safe Staffing Act amends the conditions of participation in the Medicare program and establishes a requirement for minimum staffing ratios. Rather than establishing a specific numeric ratio, the act requires the establishment of a staffing system that "ensures a number of registered nurses on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care."

Specifically, the staffing system must:

  • Be created with input from direct-care RNs.
  • Be based on the number of patients and level and intensity of care to be provided, with consideration given to admissions, discharges and transfers that nurses must handle each shift.
  • Account for architecture and geography of the environment and available technology.
  • Reflect the level of preparation and experience of those providing care.
  • Reflect staffing levels recommended by specialty nursing organizations.
  • Provide that a RN not be assigned to work in a particular unit without first having established the ability to provide professional care in such a unit.

In addition, the act requires public reporting of staffing information. Hospitals must post daily for each shift the number of licensed and unlicensed staff providing direct patient care, specifically noting the number of RNs.

In addition, the act provides whistle-blower protections for RNs and others who may file a complaint regarding staffing. The RN Safe Staffing Act incorporates ANA's Principles of Nurse Staffing. Rather than recommending specific numeric ratios, ANA developed the principles in 1999 as a tool for nurses to better gauge appropriate staffing.

The principles not only take into account the number of patients, but also look at other important staffing considerations, such as the experience level of nurses on the unit, the severity of patients' conditions and the availability of support services and resources.

"ANA has long been supportive of establishing nurse-to-patient ratios," said Blakeney. "However, ANA has not supported the approach of legislating specific numeric ratios, because that approach fails to take into consideration the multiple variables that affect nurse staffing at the unit level. Staffing systems can only be effective if the direct care nurses who work on a specific unit have input into the system. This legislation provides a comprehensive solution to the complex and urgent problem of insufficient nurse staffing."