Legislating Proper Nurse Staffing

In an effort to address what she conceives as a nationwide shortage of hospital direct-care registered nurses and provide minimum safe patient protection standards, Sen. Barbara Boxer (D-CA) in April introduced a bill for the National Nursing Shortage Reform and Patient Advocacy Act.

The bill (S. 739) calls for safe staffing ratios for short-term and long-term acute-care hospitals in the U.S. and creates registered nurse education grants, and living stipends to recruit and retain direct-care registered nurses.

“This legislation will help save lives by improving the quality of care in our nation’s hospitals,” Sen. Boxer told ADVANCE. “We must support the nurses who work tirelessly every day to provide the best possible care to their patients.”

According to Boxer’s office, in simplest terms, the bill establishes requirements for acute-care facilities to provide registered nurse staff based on the acuity of patients provided that minimum nurse-to-patient ratios for each unit are met at all times.

The bill also says RNs have the obligation to act in the exclusive interest of their patients, and the right to be patient advocates, including by: (1) initiating action to improve healthcare or to change decisions or activities that are against the interests and wishes of the patient; and (2) giving the patient an opportunity to make an informed decision about healthcare before it is provided.

Furthermore, the bill authorizes a nurse to refuse to accept an assignment if it would violate minimum ratios under this Act, or if the nurse is not prepared by education, training or experience to fulfill the assignment without compromising the safety of any patient or jeopardizing the nurse’s license.

“I am proud to introduce legislation that will help save the lives of countless patients by improving the quality of care in our nation’s hospitals,” Boxer said.

The bill is supported by the California Nurses Association/National Nurses United and the American Federation of State, County and Municipal Employees.


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National Support

According to Deborah Burger, one of the presidents of National Nurses United, which sponsors the bill, the organization supports this bill whole-heartedly.

“We have experience with the ratios in California and know that they have positive outcomes for patients and they tend to get out of the hospital faster and healthier without ratios,” she says. “It has been proven to save money in the long run, because patients have the chance to get the education they need before they leave the hospital.”

According to the federal Health Resources and Services Administration, nurses work an average of 6.6 hours of mandatory overtime per week. By 2030, the U.S. will face a shortage of 540,000 nurses due to demographic factors such as the aging of the baby boomers and the 27 million Americans gaining access to health insurance through the Affordable Care Act.

In a letter to Sen. Boxer, William Samuel, director of the AFL-CIO, showed support for the bill on behalf of the organization.

“Your legislation provides crucial relief in addressing the nation’s nursing shortage – a growing problem that is compromising the ability of our healthcare system to deliver safe, high-quality patient care,” he wrote. “As you are aware, the nursing shortage is serious and getting worse. We look forward to working with you to pass this important legislation.”

The legislation builds on the success of California’s historic law that set minimum nurse-to-patient ratios and extends those minimum standards to hospitals that participate in Medicare and Medicaid.

The bill requires nurse-patient ratios of:

  • 1:1 on trauma and perioperative units
  • 1:2 in critical care
  • 1:3 in emergency departments
  • 1:4 on med/surg units
  • 1:5 on rehabilitation units
  • 1:6 in well-baby nursery units

Is There a Shortage?

Edward Holzwarth, BSN, RN, argues that there is not a shortage of nurses, but what exists is a shortage of nurses with two to three years of recent acute care experience.

“They need to address the real problem not the feel good easy approach that will have no effect on the mythical nursing shortage,” Holzwarth said.

“Making more classes to produce more nurses who in turn will not be able to get a job is definitely not the answer. The change that needs to be made is to make it profitable to get new nurses the acute care experience they need to meet the hospitals requirements and do that for nurses who are already here and have their licenses.”

Donna-Lee Moore-Stout BSN, RN, CCRN, RCES, Providence Health and Services, believes institutions are not hiring ADNs, even with experience, in some parts of the nation.

“New grads are having difficulty getting jobs in the larger metropolitan areas, but the smaller communities are still in need of nurses,” she said. “As more nurses achieve higher education, they seem to leave the bedside.

“On the other hand, in my institution, there are a number of master’s-prepared new graduate nurses who are still at the bedside, and they aren’t happy about it,” Moore-Stout continued. “The amount of debt that they have incurred to be able to be employed as a bedside nurse is shocking. One should not forget that the profession of nursing offers a great deal of opportunity beyond the hospital.”

Beverly Burton Twigg, RN, staff nurse at the Dallas VA Hospital, believes the lack of experienced hospital leadership combined with the lack of experienced nurses results in unsafe practices in facilities. “Why would any nurse choose to do direct patient care when there are so many other opportunities?” she asked rhetorically. “A common theme among nurses in the 45-plus group is that hospitals do not want or respect experience, compassion and skill of experienced nurses.”


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Burger argues that there absolutely is a shortage because hospitals are not staffing properly right now.

“Nurses are having to work extra shifts, work overtime, work through their lunches and breaks, in order to cover the care that the patients need,” she said. “The nurses are providing the care but not getting the proper relief they need. There is a shortage, but the hospitals are choosing to address it by using lesser-skilled technical people and not providing the care.”

According to Boxer, the bill would:

  • establish minimum nurse-to-patient ratios that will save lives, improve the quality of care and help to address the nursing shortage by creating a work environment that encourages nurses to remain in the hospital workforce;
  • provide whistleblower protections to protect the right of nurses to advocate for the safety of patients and report violations of minimum standards of care; and
  • invest in nursing mentorship demonstration programs to better prepare nurses for work in a hospital setting.


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House Bill Introduced

On May 9, 2013, Rep. Jan Schakowsky (D-IL) introduced on the floor of the U.S. House of Representatives companion legislation to the Nurse Staffing Standards for Patient Safety and Quality Care Act (H.R. 1907). This bill complements the version introduced by Sen. Boxer.

Both bills are modeled on a California law that studies have documented has saved patient lives, improved the quality of care in multiple other ways, and reduced nurse burnout keeping the most experienced RNs at the patient bedside.

“Rep. Schakowsky, Sen. Boxer, and the co-sponsors have earned the thanks of patients and nurses throughout the country for standing up for the one staffing reform that has the greatest immediate impact on protecting patients and saving lives,” said Deborah Burger, a California RN and co-president of NNU which is the lead sponsor of both bills. “In California we have seen the results. The law works, and all Americans deserve the security that real safe staffing laws provide.”

According to the bill, two years after enactment (four years for rural hospitals) hospitals will be expected to develop and implement nurse staffing plans that must meet newly-established minimum direct care registered nurse-to-patient ratios, adjust staffing levels based on acuity of patients and other factors, and ensure quality care and patient safety.

“This bill will help save the lives of patients by improving nursing care in our nation’s hospitals,” Schakowsky said. “I’m so proud to support the nurses who work every day to provide the best possible care to their patients. It’s time that hospitals develop nurse staffing plans that meets safe nurse-to-patient ratios to ensure quality care and patient safety.”

Keith Loria is a freelance writer.

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