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RATIOS: National Nursing Shortage Reform and Patient Advocacy Act - S. 992 (Boxer)

Nurses rally for safe staffing ratios.

National Nursing Shortage Reform and Patient Advocacy Act - S. 992 (Boxer)

This 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. Registered nurses shall also have the obligation to act in the exclusive interest of their patients, and the right to be patient advocates. 

pdf icon Read the full text of S. 992, introduced by Senator Barbara Boxer, May 12, 2011

pdf icon Read accompanying House Bill H.R. 2187 introduced by Rep. Jan Schakowsky - IL, June 2011

 Legislative Purpose

To address the nationwide shortage of hospital direct-care registered nurses; provide minimum safe patient protection standards — such as safe staffing ratios — for short-term and long-term acute-care hospitals in the United States; protect direct care registered nurse as patient advocate, create registered nurse education grants, and living stipends to recruit and retain direct-care registered nurses.

To create a hospital nursing service environment that will immediately attract new RNs and provide the foundation for ultimate restoration of the hospital direct RN workforce; and

To establish clearly defined, legally protected and enforceable duties and rights to direct-care registered nurses as advocates exclusively for the interests of patients.
Whistleblower protections that encourage patients, RNs and other healthcare workers to notify government and private accreditation entities of suspected unsafe patient conditions that will greatly enhance the health, welfare, and safety of patients.

The essential principles of staffing in the acute-care hospital settings must be based on patient’s individual acuity and needs; severity of conditions; services needed; and complexity surrounding those services.

Uniform National Professional Standards

1. Direct-Care Registered Nurse Patient Advocacy — Professional Duty of Patient Advocacy

  • Professional Obligation and Right; an RN has the professional obligation and therefore the right to act as the patient’s advocate.
  • Acceptance of Patient Care Assignments; the RN is always responsible for providing competent, safe, therapeutic, and effective nursing care to assigned patients.
  • Free Speech — Whistleblowing — Patient Protection; all direct-care RNs responsible for patient care in a hospital facility shall enjoy the right of free speech.

2. Minimum, Specific, and Numerical Direct-Care Registered Nurse-to-Patient Staffing Ratios by Clinical Unit for Acute-Care Hospitals

(a) Unit-specific direct-care RN-to-patient ratios for all shifts at all times.

A patient classification system (PCS) to determine additional staff, based on a National Acuity Tool developed by CMS.

(b) The Direct-Care RN-to-Patient Ratios

Intensive/Critical Care 1:2
Neo-natal Intensive Care 1:2
Operating Room 1:1
Post-anesthesia Recovery 1:2
Labor and Delivery 1:2
Ante partum 1:3
Well baby nursery 1:6
Postpartum couplets 1:3
Pediatrics 1:3
Emergency Room 1:3
ICU patients in the ER 1:2
Trauma patients in the ER 1:1
Step Down & Telemetry 1:3
Medical/Surgical 1:4
Other Specialty Care 1:4
Psychiatric 1:4
Rehabilitation Unit & SNF 1:5
Acute respiratory units 1:2
Burn units 1:2
Intermediate care nursery 1:4
Combined labor and delivery, and postpartum 1:3

(c) Direct-care LV/PN ratios study and its effect on patient care in hospitals.

3. Registered Nurse Workforce Initiative

Purpose: achieve immediate short-term mitigation and remedy of the nationwide nursing shortage.

(a) Basic Educational Assistance Benefit & Living Stipend

Creation of an education assistance entitlement program for eligible associate and baccalaureate degree applicants.

(b) Preceptorship and Mentorship Demonstration Project

To provide additional support to nurses entering the workforce

4. Enforcement

  • Action by the Secretary; Administrative action. The Secretary shall receive, investigate, and attempt to resolve complaints of violations.
  • Fines for Violating Employee and Patient Rights; acute-care hospital that violates employee or patient rights under this Act shall be subject to civil penalties - $25,000.00
  • Fines for Violating Employee and Patient Rights; any individual employed by a hospital that violates employee or patient rights under this act shall be subject to civil penalties - $20,000.00
  • Fines for violating ratios - $25,000.00

5. Prohibition Against Averaging of Ratios

6. Prohibition Against Imposition of Mandatory Overtime Requirements

7. Protection for the Refusal of Unsafe Patient Assignments


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