Nurse Staffing Laws Bringing Big Changes are On the Horizon

Sentara Halifax Regional Hospital, South Boston

by James C. Sherlock

In my lengthy series on Virginia’s nursing homes, I pointed out that many of them are understaffed with nurses, RNs in particular.

I also pointed to a nationwide nurse shortage, due in part to burnout, that the training pipelines are not poised to fill.

New York, Pennsylvania and Oregon are poised to mandate by law minimum staffing for hospitals and skilled nursing facilities to address both patient safety and burnout.

On June 28, the Pennsylvania House, in a bipartisan vote, passed a bill that declared:

(1) Health care services are becoming more complex, and it is increasingly difficult for patients to access integrated services.

(2) Competent, safe, therapeutic and effective patient care is jeopardized because of staffing changes implemented in response to market-driven managed care.
(3) To ensure effective protection of patients in acute care settings, it is essential that qualified direct care registered nurses be accessible and available to meet the individual needs of patients at all times.
(4) To ensure the health and welfare of Pennsylvania citizens, mandatory hospital direct care professional nursing practice standards and professional practice protections must be established to assure that hospital nursing care is provided in the exclusive interests of patients.
(5) Direct care registered nurses have a fiduciary duty to assigned patients and necessary duty and right of patient advocacy and collective patient advocacy to satisfy professional fiduciary obligations.
(6) The basic principles of staffing in hospital settings should be based on the individual patient’s care needs, severity of the condition, services needed and the complexity surrounding those services and the skill level of staff.
(7) Current unsafe hospital direct care registered nurse staffing practices have resulted in adverse patient outcomes.
(8) Mandating adoption of uniform, minimum, numerical and specific registered nurse-to-patient staffing ratios by licensed hospital facilities is required for competent, safe, therapeutic and effective professional nursing care, for retention and recruitment of qualified direct care registered nurses and to improve patient outcomes.
(9) Direct care registered nurses must be able to advocate for their patients without fear of retaliation from their employer.
(10) Whistleblower protections that encourage registered nurses and patients to notify government and private accreditation entities of suspected unsafe patient conditions, including protection against retaliation for refusing unsafe patient care assignments by competent registered nurse staff, will greatly enhance the health, welfare and safety of patients.

It defines a new category of nurse, a direct care nurse.

“Direct care registered nurse” or “direct care professional nurse.” A registered nurse who:
(1) Currently holds an unencumbered license issued by the State Board of Nursing to engage in professional nursing with documented clinical competence as defined in the act of May 22, 1951 (P.L.317, No.69), known as The Professional Nursing Law.
(2) Has accepted a direct, hands-on patient care
assignment to implement medical and nursing regimens and provide related clinical supervision of patient care while exercising independent professional judgment at all times in the interests of a patient.

It requires a “Patient classification and acuity tool” that, if implemented, would provide

(1) A method and process of determining, validating and monitoring individual patient or family care requirements over time in order to assist in determinations such as:
(i) Unit staffing.
(ii) Patient assignments.
(iii) Case mix analysis.
(iv) Budget planning and defense.
(v) Per patient cost of nursing services.
(vi) Variable billing.
(vii) Maintenance of quality assurance standards.
(2) The method under paragraph (1) utilizes a standardized set of criteria based on evidence-based practice that acts as a measurement tool used to predict registered nursing care requirements for individual patients based on the following:
(i) The severity of patient illness.
(ii) The need for specialized equipment and technology.
(iii) The intensity of required nursing interventions.
(iv) The complexity of clinical nursing judgment required to design, implement and evaluate the patient’s nursing care plan with consistent professional standards.
(v) The ability for self-care, including motor, sensory and cognitive deficits.
(vi) The need for advocacy intervention.
(vii) The licensure of the personnel required for care.
(viii) The patient care delivery model.
(ix) The unit’s geographic layout.
(x) Generally accepted standards of nursing
practice, as established by the American Nurses Association’s “Nursing: Scope and Standards of Practice, 3rd Edition,” as well as elements reflective of the unique nature of the acute care hospital’s patient population.
(3) The method under paragraph (1) determines the additional number of direct care registered nurses and other licensed and unlicensed nursing staff mix the hospital must assign, based on the independent professional judgment of the direct care registered nurse, to meet the individual patient needs at all times.

I frankly cannot picture how that “tool” would be implemented, but the General Assembly of Pennsylvania has been convinced it can be done over the several years this bill has been pending. It would be used in hospitals (including critical access and long-term acute care hospitals) and skilled nursing facilities.

The bill also defines units within hospitals requiring various levels intensity of care.

Support for the bill that makes it politically safer for the Senate to pass and the Governor to sign came on July 9th in an editorial by Kevin B. Mahoney, MBA, Chief Executive Officer of the University of Pennsylvania Health System, Pennsylvania’s largest.

He writes, inarguably, that

We should not be afraid to follow the evidence toward new approaches when the status quo is broken.

He sees the bill, along with higher payments to pay for it, as necessary to solve difficulties related to recruiting and retaining nurses.

Bottom line on the bill. The concepts behind the bill represent a major overhaul of the way nurses are employed in hospitals in order to provide improved patient safety. And certainly will require more nurses than the average hospital has on staff.

Not surprisingly, 90% of Pennsylvanians polled support the concept.

If passed and signed, one near term consequence would be that some hospitals will find they need to eliminate some services in order to fulfill the requirements with the staff nurses available.

There would need to be some regional orchestration of service availability sanctioned by the government in order to maintain availability while avoiding antitrust violations.

The bill won’t increase the numbers of physicians, nurses and medical technicians.  But it will allow regulators to challenge facilities that reach unsafe levels of staffing and restrict new patient acceptance into understaffed services at hospitals and to understaffed nursing homes.

Badly-managed nursing homes may have to close. So be it.

That in turn may require patient wait lists for both non-emergency procedures and for nursing home admission. Then we will see about 90% public support, but the supply/demand ratios are not instantly flexible.

Very quickly it will require:

  • higher insurance reimbursements in return for increased patient safety;
  • that are turned into higher nurse pay, to attract more applicants to nursing programs;
  • that pay instructor nurses more.

Virginia. Virginia should watch carefully the experiments in New York, Pennsylvania and Oregon. VDH should report on them to the General Assembly.

The Virginia General Assembly usefully could pass a law next session that would require the Health Commissioner to exercise her legal authority to restrict new patients for nursing homes that have been awarded CMS 1-star RN staffing grades for two quarters in a row.

Such facilities should not be permitted to accept new patients until, through some combination of hiring and patient load reduction, they achieve three-star (national average) staffing.

Such a law would not assign blame or assess direct financial penalties, but it would put patient safety first.