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RATIOS: The Anatomy of a Good Bill

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Below are essential “DOs” and “Don’ts” for any RN association considering the sponsorship or promotion of RN safe staffing legislation.

It is well known that adequate registered nurse (RN) staffing in acute care settings increases patient safety, and reduces healthcare costs.  Numerous research studies demonstrate the positive effects of improved RN staffing for patients and hospitals, including reductions in the risk of patient mortality, medical errors, hospital-acquired infections, and length of stay; and, increases in RN retention, productivity, and hospital cost savings.  However, despite this mounting evidence, hospitals across the nation continue to staunchly resist organized efforts to improve RN staffing in order to reduce labor costs.  This resistance puts patients at risk, and has forced RNs to seek legislative solutions at both state and federal levels.

Numerical RN-to-patient ratios are the cornerstone of safe RN staffing as they constitute a maximum number of patients assigned to one RN at any one time, and set a universal floor for RN staffing standards to which all hospitals are required to adhere.  With the numerical RN-to-patient ratios in place, hospitals cannot manipulate RN staffing based on variable factors or at any time require an RN to accept patient assignments in numbers that exceed the ratios set forth in the law.  It should also be noted that staffing based on patient acuity should only be used to improve staffing based on numerical ratios.  While patient acuity is a driving factor for safe RN staffing, it does not replace the foundation of minimum staffing standards set by ratios.

Beginning in the early 1990s, the California Nurses Association (CNA) waged a successful 12-year campaign to secure safe nurse staffing ratios.  To date, California remains the only state in the nation to have the protections of numerical nurse-to-patient ratios, paving the way for RNs in other states to work with their respective state and federal leaders to enact safe staffing laws that will protect patients.  To aid in that effort, this document provides guidance on what should or should not be included in optimal safe staffing legislation. 



Legislative Models

DO use S. 739 (Boxer, D-California) or California’s nurse staffing law, A.B. 394, as your legislative template.

S. 739, federal ratios legislation sponsored by Sen. Barbara Boxer of California, builds upon the success of California’s historic law, A.B. 394, which established minimum, specific, numerical RN-to-patient ratios by hospital unit.

S. 739 provides a comprehensive legislative model that is rooted in ratios, and that provides language that should be considered for inclusion into any RN staffing legislation.


Numerical RN-to-Patient Ratios

DO require numerical RN-to-patient ratios in your legislation.

DO include explicit language in your RN staffing legislation that RN-to-patient ratios are in effect in each unit “at all times.”

The addition of this language to an RN staffing bill is essential to protect against any interpretation that RN-to-patient ratios may be suspended by the hospital during periods when the hospital claims it will not have enough RNs to meet the ratio mandate, e.g. coverage during meals, breaks, in-service training, or other RN absences from the unit. No excuses allowed. Ratios are to be followed every second of every shift, every day.





DON’T establish nurse staffing standards based on factors such as variability in the number of admissions, discharges, or transfers for a unit.  These types of factors are vague, can be manipulated by the hospital, and diverge from minimum staffing standards based on numerical RN-to-patient ratios.

DON’T allow averaging of the number of patients and the total number of RNs on the unit during any one shift, nor over any period of time. 

Hospitals will always try to find ways to undermine RN-to-patient ratios in order to save money.  Using averages of patient census and staffing is one way that hospitals will avoid compliance with ratios and safe RN staffing based on the immediate needs of the patient.

DON’T allow hospitals to comply with mandatory ratios and safe RN staffing standards through the use of mandatory overtime.

DON’T include other types of healthcare workers in the RN-to-patient ratio.

The severity of illness and the complexity of clinical judgment, knowledge, and interventions/actions demanded by today's acute-care patients warrant the demand for an RN staffing ratio in acute-care facilities.  Generally, only registered nurses (RNs) are authorized by their respective practice acts to perform patient assessment to formulate a diagnosis; plan and implement care; perform effective clinical supervision functions; evaluate care and patient/family education; and advocate in the interest of the patient.  Other ancillary staff members, including LVNs, LPNs, certified nursing assistants, aides, and other assistive personnel, do not have the legal authority to perform these RN functions. Accept no substitutes. 

As stated above, minimum, numerical RN-to-patient ratios, specific to each hospital unit, is the central component to safe nurse staffing standards. Numerical ratios can be adjusted downward to give RNs fewer assignments based on patient acuity, but can never be raised beyond the maximum allowed patients per RN. Using concrete numbers assures for uniform staffing standards in all hospitals and units so that patients can be guaranteed the same protections no matter where they are admitted.


Patient Acuity

DO improve upon the minimum, numerical RN-to-patient ratios by taking patient acuity into account.

Remember, numerical RN-to-patient ratios establish the minimum staffing standard on a unit and must be achieved first. Once minimum ratios are already established, RN staffing legislation should include provisions that allow for an increase in the number of RN staff needed on a unit based on patient acuity, using a documented system such as a patient classification system.


DON’T base RN staffing standards solely on patient acuity.

Patient acuity should be used to increase RN staffing beyond minimum ratio standards, but should not be the sole determinant of safe staffing. In the absence of numerical RN-to-patient ratios, hospitals have no minimum staffing standards to uphold.


Orientation and Competency Validation

DO require RNs to demonstrate competence and assure RNs receive orientation prior to assignment on a nursing unit or clinical area.

This will assure that, in order to meet ratio requirements, hospitals do not assign RNs to units in which they are not able to provide competent care to patients.  Orientation and competency validation requirements should also explicitly apply to temporary RNs utilized by the hospital.


Whistle-blower and Patient Protections

DO include explicit whistle-blower protections for RNs to allow them to fulfill their duty and right to advocate in the best interest of the patient.

RNs must have legal protections allowing them to exercise their right to act as the patient’s advocate by initiating action to improve healthcare or to change decisions or activities which, in the professional judgment of the RN, are against the interests and wishes of the patients.  As such, nurse staffing legislation should include explicit language protecting whistle-blowers and prohibiting hospitals form discriminating or retaliating against employees who refuse an unsafe staffing assignment, object to the hospital’s staffing plan, or expose hospital violations of staffing laws.


Fines and Enforcement

DO ensure hospitals face appropriate consequences by establishing fines for failing to comply with RN-to-patient ratios and safe RN staffing standards.

Hospitals must be held accountable to meet the letter of the law and to keep patients safe.  Financial penalties for violations of ratios and safe staffing standards should be included in any safe staffing laws.