Legislation Would Put Nurses — Not State Law — in Charge of Staffing Levels

Lilo H. Stainton | November 21, 2019 | Health Care
Measure calls for hospitals to establish nurse-led staffing committees that would set specific nurse-to-patient ratios
Credit: Twenty20
Munoz legislation calls for nurse-led staffing committees that would set specific nurse-to-patient ratios

A new legislative proposal would essentially put nurses in charge of nursing staffing-level decisions at hospitals in New Jersey — and possibly other health care facilities — and could help resolve a debate about patient care and workforce needs that dates back at least 16 years.

Introduced last week by Assemblywoman Nancy Munoz (R-Union), a licensed nurse herself, the bill calls for hospitals to establish nurse-led staffing committees that would set specific nurse-to-patient ratios for the facility as part of the hospital’s licensing conditions. Among other things, these committees would consider the experience of the nurses on staff, impact of technology and physical layout of the facility, in addition to patient needs.

Munoz said the measure is based on bipartisan federal legislation. Similar plans have been adopted in seven states including Connecticut. Hospital officials and some nursing groups seemed encouraged by this approach, but not all nurses are on board — at least in the bill’s current state.

Credit: NJTV News
Assemblywoman Nancy Munoz (R-Union)

“Ensuring nurses have input on staffing decisions makes nurses more effective and improves patients’ care, that’s the bottom line,” Munoz said. (While the current legislation deals specifically with hospitals, Munoz’s staff said she hopes to amend it to include nursing homes and other health-care facilities.)

Staffing levels have long been a top concern for frontline nurses and other caregivers nationwide, who claim hospital officials regularly fail to hire enough people to provide bedside care, endangering patients and overworking the caregivers on duty. In New Jersey, the Health Professionals and Allied Employees — the state’s largest health care union — has led the charge to pass a bill that would codify specific nurse-to-patient ratios in state law.

(A similar campaign exists for staff levels at nursing homes. A bill to establish staffing ratios for certified nursing assistants passed the Senate last summer and was OK’d by an Assembly panel in June but faces several more votes before it could be signed into law by the governor.)

But hospital officials and many nurses in management positions raise concerns about this approach, insisting a state mandate would be overly rigid, hampering a facility’s flexibility to effectively respond to patient needs and other conditions. They also worry about the cost of such a mandate, which would likely force hospitals to hire far more staff from an already limited labor pool; there are currently about 150,000 registered nurses in the Garden State, a labor pool that studies suggest won’t be able to meet the growing demand.

This divide has left the staffing-ratio bill favored by HPAE essentially on ice; first proposed in 2003, the measure has been re-introduced in every legislative session since, but only enjoyed one hearing in 2015. In that session, members of the Assembly health committee approved the proposal — with eight votes in favor and four opposed — but it hasn’t moved since. (California is the only state with statutory nurse-to-patient ratios; a 2016 effort to enact this by ballot measure in Massachusetts failed.)

Who decides where nurses work?

Munoz, an advanced-practice nurse with graduate training, is among those who voted against the staffing-level bill in the 2015 committee hearing. (Assemblyman Herb Conaway Jr., a doctor who chairs the committee, voted “yes.”) Munoz said hospitals may need to beef up their nursing staff, but where they are deployed is a decision best made by those doing the work in each specific facility.

“Nurses have a profound effect on the quality of care patients receive, and they know better than politicians in Trenton how to maximize the care they are providing,” Munoz said. “A one-size-fits-all approach could be a fatal conceit if mandated by the state. The nurses tending to patients know the unique and ever-changing needs of the people they care for.”

Currently, nurse-staffing levels in New Jersey are governed by state regulations that set minimum ratios for certain critical-care units, including the emergency room, intensive care, operating room and labor and delivery units. Hospitals must file with the state quarterly staffing plans that reflect the condition of the patients they treat; the state Department of Health investigates staffing-related complaints and can require changes if they find problems.

Munoz’s bill (A-5954) notes that studies have shown adequate nursing staff levels have a direct connection to good patient outcomes, including reducing errors and medical complications. With sufficient staff, nurses and other caregivers are also less likely to be injured and are more likely to be satisfied with their work, research shows. The measure has been referred to the Assembly health committee, but no hearing is scheduled; there is currently no Senate version.

The bill calls for the DOH to revise the licensing requirements for acute-care hospitals to ensure that each facility establishes a nurse staffing-level committee, either by creating a new body with at least 55% of the members registered nurses or by adding RNs to an existing committee. (Administrator participation would be limited to less than 45% of the group.) Nurses on the panel would be selected based on collective-bargaining agreements, if they exist, or nominated by their peers.

HPAE did not dismiss the proposal outright, but said significant changes would be required to make it truly effective. As drafted, it would fail to ensure rank-and-file nurses are properly represented, and the legislation currently contains no real enforcement mechanism, said HPAE president Debbie White, a nurse herself.

‘An exercise in futility’?

“A majority of the members in any hospital staffing committee must be bedside nurses and other frontline caregivers. Their voices must be heard and respected on any staffing committee,” she said. “Many HPAE nurses already participate in staffing committees at their hospitals.  Yet without the authority to implement and enforce the committee recommendations, the entire process becomes an exercise in futility.”

Under the bill, the committees would be tasked with developing and overseeing the implementation of an annual nurse-staffing plan, based on patient needs, numbers and outcomes, specialized care requirements, staff training and technological and logistical considerations — like the length of the hallways and the layout of patient rooms on a floor, factors that can have a significant impact on caregivers’ daily work.

“You could be running all over the place,” said Judith Schmidt, a nurse and CEO of the New Jersey State Nurses Association, which represents RNs in staff and managerial positions; NJSNA has not formally endorsed the Munoz bill, but Schmidt said they are likely to support this approach. “It’s not just a numbers issue,” she said, noting that the set-ratio bill favored by HPAE doesn’t provide enough flexibility to address the needs of each facility.

“We’re proponents of safe staffing,” Schmidt said, but the decisions should be made by nurses, not lawmakers in Trenton. “Who better to develop staffing patterns than the people who work in that environment?”

Under the bill, the committees would also need to consider the availability of support personnel, impact on hospital finances, national recommendations for staffing levels and strategies to ensure nurses can take meal, rest and bathroom breaks. While this is already required by law, many caregivers complain that they don’t have enough time for these basic needs. There would be an exemption for “unforeseeable emergencies” like natural disasters or medical catastrophes that could lead to an influx of patients.

Munoz’s proposal is also attractive to the New Jersey Hospital Association, which represents hospitals and other health-care facilities, although the group has not yet reviewed the plan in detail.

Keeping staffing decisions local

“We agree with the assemblywoman that a one-size-fits-all approach is not a smart way to staff for quality patient outcomes and high-value care,” said NJHA communications director Kerry McKean Kelly.  “We also believe in empowering nurses to practice to the full level of their professional expertise and engaging them in discussions about their workplace environment, rather than having staffing decisions dictated by legislators in Trenton.”

The legislation would require committees to review this plan every six months and present the final draft to the hospital’s CEO; that executive would need to provide a written explanation and alternative options if he or she did not accept the proposal.

Under the bill, hospitals would also be required to file the plan with the state DOH. That department and each hospital panel would need to develop processes to accept and respond to complaints; the state could also investigate ongoing complaints not resolved by the committee and could fine facilities $1,000 per day for not complying with its staffing plan.