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DEPARTMENTS: Legal Issues and Risk Management

Nurse Staffing Legislation: An Overview

Miller, Lisa A. CNM, JD

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The Journal of Perinatal & Neonatal Nursing: January/March 2012 - Volume 26 - Issue 1 - p 10-12
doi: 10.1097/JPN.0b013e3182432cdc
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Hospital nurse staffing is an ongoing issue in healthcare, and recent developments suggest that it is increasingly becoming a legal issue. Although perinatal and neonatal care has not been the specific focus of studies on nurse-sensitive outcomes related to staffing, research showing correlation between lower staffing levels and higher adverse patient outcomes has garnered the public attention, and state legislatures across the United States are becoming increasingly involved in promulgating laws related to hospital nurse staffing. At the same time, hospital nursing vacancies average 13% and are predicted to reach as high as 29% by 2020. The vacancy rate coupled with rising acuity levels means that there will be fewer nurses caring for sicker patients.1

Acuity levels of hospitalized patients have increased significantly in all specialties.1 In the perinatal and neonatal settings, acuity levels are increasing, in part, due to advances in the reproductive sciences—higher numbers of patients with chronic illnesses are able to conceive, multiple gestations secondary to assisted reproduction are more frequent, and greater numbers of neonates need specialized care for a variety of reasons. In an effort to avoid what seems to be shaping up as the “perfect storm,” when it comes to nurse staffing and patient safety, many states are enacting nurse staffing legislation that mandates minimum nurse-patient ratios. This column provides an overview of the issue of legislating nurse staffing, the various approaches lawmakers are employing, and the implications for nurses in the perinatal and neonatal fields.


There are 2 primary drivers behind legislative efforts related to nurse staffing: (1) improvement of patient outcomes and (2) improvement of working conditions for nurses. Multiple studies funded by the Agency for Healthcare Research and Quality have linked both higher mortality rates and incidence of failure to rescue with lower staffing; and nursing opinion surveys reveal that nurses' dissatisfaction with their jobs is 2 to 3 times higher than other workers in the United States.1 Nurses cite both number of staff and skill mix as a top reason for job dissatisfaction and burnout, and although there is no formally recognized consensus on what constitutes safe staffing, most sources agree that it includes both the appropriate number of nurses and an appropriate skill mix such that patient care can be carried out effectively in a hazard-free environment.2 California was the first state to legislate nurse-patient ratios in an effort to improve both patient outcomes and working conditions for nurses. Minimum ratios for acute care hospitals took effect in California in 2004, and there are now data that suggest such ratios lower mortality and improve nursing retention (a marker for job satisfaction). Aiken and colleagues3 compared patient outcomes and job satisfaction across 3 states, California, Pennsylvania, and New Jersey. At the time of data collection, only California had been operating with mandated minimum staffing ratios (for a period of 2 years). Fewer patients per nurse were associated with both lower mortality and increased job satisfaction; these findings were also seen when nursing workloads in the nonlegislated states were consistent with nursing workloads mandated in California.3 These findings, along with the public's increasing concerns related to patient safety and the increase in formal nursing support for legislative responses to staffing will likely result in more states enacting legislation related to hospital nurse staffing. Nursing organizations seem to be in favor of legislation and are becoming more vocal in promoting legislation. The American Nurses Association “supports a legislative model in which nurses are empowered to create staffing plans specific to the unit and patient population and to which healthcare facilities are held accountable.”4 Although the American Nurses Association does not offer specific legislative wording, its statement clearly endorses a model that moves beyond simple minimum ratios.


Since California's initial legislative mandate, a number of other states have followed suit. As of March 2011, the District of Columbia along with 15 states* have either adopted state regulations or enacted legislation related to nurse staffing, using 1 or more methodologies.4 Three different approaches have been identified, which are as follows2:

  1. Mandated ratios (the California approach)
  2. Acuity-based nurse staffing plans
  3. Public disclosure of staffing by unit and shift

Individually, each approach has both identifiable benefits and risks. Mandated ratios set minimums but receive criticism because they fail to account for patient acuity and variations in staff mix and experience. Staffing plans based on acuity are endorsed by the American Nurses Association and viewed by most nurses as more comprehensive but may be difficult to enforce through regulatory bodies that look for standardization in guidelines. Finally, although public disclosure certainly improves transparency and enhances awareness, it may not be very effective in communities where consumer choice is limited, as consumers may have no alternative to the local hospital. And in communities where hospital competition is significant, public disclosure may simply result in hospitals “matching” staffing patterns with each other rather than basing staffing decisions on ratios or acuity.

Although it is still the minority of states that have formal legislative or regulatory mandates, nurse staffing legislation has also been the subject of federal legal initiatives. In May 2011, Senator Barbara Boxer introduced S.992,5 which seeks to amend the Public Health Service Act to include minimum nurse-patient staffing ratios; and a complimentary bill, HR.2187,6 was introduced by Representative Jan Schakowsky the following month. Both bills have been referred to committee and will likely die in committee (as previous attempts have also failed), but the fact that such bills continue to be introduced at a federal level seem to indicate that the issue of nurse staffing will be an ongoing public health topic. Nurses associations, hospital associations, and consumer groups in states without current legislation would do well to initiate discussion and educate each other and the public regarding nurse staffing.


Nurses are patient safety advocates and have a duty to evaluate staffing as an integral component of safety. Legislative initiatives involving nurse staffing are likely to continue, and many nurses already work in states with laws or regulations on staffing in place. A proactive approach to staffing issues may prevent (or remedy) ineffective legislation but requires nurses who are educated on different staffing approaches and engaged in the legislative process. In particular, nurses working in specialty areas, such as perinatal and neonatal nursing, must be ready to provide input and cite evidence in support of safe staffing legislation. In addition to basics, such as understanding ratios versus acuity versus disclosure approaches, familiarity with updated specialty-specific guidelines is crucial. In 2010, the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) published Guidelines for Professional Registered Nurse Staffing for Perinatal Units (AWHONN guidelines). According to AWHONN, the guidelines are meant “to provide a basis for planning adequate registered nurse staffing that result in safe and effective perinatal nursing care.”7 Specifically noting that models of staffing used by medical-surgical units are “not applicable to perinatal care,” the AWHONN guidelines address variables unique to perinatal care and reflect the current complexity of obstetric and neonatal patient populations.7 Nurse managers and executives can use the AWHONN guidelines as a foundation for safe staffing initiatives, nurses can use them to increase public awareness in their communities and with their legislators, and nurse researchers can use the AWHONN guidelines to evaluate perinatal outcomes related to various staffing models.

Improvement in patient outcomes and nursing retention through enhanced work environments are the twin goals of safe staffing legislation. The challenges in safe staffing that are unique to perinatal care must be addressed for staffing legislation to be effective in the maternal-child setting. Nurses and nurse executives who are familiar with both the variety of legislative approaches and the updated AWHONN guidelines will be in the best position to positively impact public health and safety.

—Lisa A. Miller, CNM, JD


Perinatal Risk Management and Education Services

Portland, Oregon


1. Agency for Healthcare Research and Quality. Hospital nurse staffing and quality of care. Res Action. 2004;(14). Accessed November 15, 2011.
2. Mulrooney G. A case for improved quality of care through more accurate staffing. Safe staffing legislation, an API Healthcare White Paper. Accessed November 15, 2011.
3. Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California nurse staffing mandate for other states. Health Serv Res. 2010;45(4):904–921.
4. American Nurses Association. Nurse staffing plans & ratios. Accessed Nov-ember 15, 2011.
5. National Nursing Shortage Reform and Patient Advocacy Act, S 992, 112th Cong, 1st Sess (2011). Accessed November 15, 2011.
6. Nurse Staffing Standards for Patient Safety and Quality Care Act of 2011. HR 2187, 112th Cong, 1st Sess (2011). Accessed November 15, 2011.
7. Association of Women's Health, Obstetric & Neonatal Nurses. Guidelines for professional registered nurse staffing for perinatal units executive summary. J Obstet Gynecol Neonatal Nurs. 2011;40(1):131–134.

* California, Connecticut, Illinois, Maine, Minnesota, Nevada, New Jersey, New York, North Carolina, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington.
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