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Introduced by   Senator Lyons of Chittenden District and Senator Flanagan of Chittenden District

Referred to Committee on


Subject:  Health; nurses; staffing ratios

Statement of purpose:  This bill proposes to ensure that there is sufficient nurse staffing in health care facilities in order to promote optimal health care outcomes.


It is hereby enacted by the General Assembly of the State of Vermont:

Sec. 1.  18 V.S.A. chapter 43 is amended to read:


Subchapter 1.  General Provisions

* * *

Subchapter 2.  Nurse Staffing Standards


(a)  The purpose of this subchapter is to assure that the delivery of health care services to patients in health care facilities located within Vermont is adequate and safe, and that health care facilities retain sufficient registered nursing staff so as to promote optimal health care outcomes. 

(b)  Inadequate hospital staffing results in dangerous medical errors and patient infections.  Registered nurses constitute the highest percentage of direct health care staff in acute care facilities and have a central role in health care delivery.  To ensure the adequate protection and care for patients in health care facilities, it is essential that qualified registered nurses be accessible and available to meet the nursing needs of patients. 

(c)  The basic principles of staffing in health care facilities should be focused on patient health care needs and based on consideration of patient acuity levels and services that need to be provided to ensure optimal outcomes.

(d)  The general assembly recognizes the findings and recommendations contained in the 2001 report, Blue Ribbon Nursing, A Call to Action:  Addressing Vermont’s Nursing Shortage, especially the high stress workplace environment caused by an increase in the number of patients assigned to nurses coupled with a decrease in the amount of time nurses have to participate in direct patient care.

(e)  Establishing staffing standards for registered nurses in health care facilities ensures that these facilities throughout the state provide a safe workplace environment, and guarantees the public safety and the delivery of quality health care services.


As used in this subchapter, the following words and phrases shall be defined as follows:

(1)  “Acuity-based patient classification system” means a standard set of criteria based on scientific data that acts as a measurement instrument which: predicts registered nursing care requirements for individual patients based on severity of patient illness, need for specialized equipment and technology, intensity of nursing interventions required, and the complexity of clinical judgment needed to design, implement, and evaluate the patient’s nursing care plan consistent with professional standards of care; details the amount of registered nursing care needed, both in number of direct-care registered nurses and skill mix of nursing personnel required on a daily basis for each patient in a nursing department or unit; and is stated in terms that can be used readily and understood by direct-care registered nurses.  The acuity system criteria shall take into consideration the patient care services provided not only by registered nurses but also by licensed practical nurses and other health care personnel.

(2)  “Assessment tool” means a measurement system which compares the registered nurse staffing level in each nursing department or unit against actual patient nursing care requirements in order to review the accuracy of an acuity system.

(3)  “Department” means the Vermont department of health.

(4)  “Direct-care registered nurse” means a registered nurse who has accepted direct responsibility and accountability to carry out medical regimens, nursing, or other bedside care for patients.

(5)  “Facility” means a hospital licensed in Vermont, any licensed private or state-owned and operated general acute care program hospital, psychiatric facility, specialty hospital, or an acute care within a state-operated facility.

(6)  “Nursing care” means care that falls within the scope of practice as prescribed by state law or otherwise encompassed within recognized professional standards of nursing practice, including assessment, nursing diagnosis, planning, intervention, evaluation, and patient advocacy.

(7)  “Ratio” means the actual number of patients to be assigned to each direct care registered nurse.


The department of health shall have the power and duty to:

(1)  adopt rules necessary to carry out the purposes and provisions of this subchapter, including defining terms and prescribing the process for establishing a standardized acuity-based patient classification system;

(2)  assure that the provisions of this subchapter and all rules adopted under it are enforced, and adopt, within one year of the effective date of this subchapter, rules providing for an accessible and confidential system to report any failure to comply with requirements of this subchapter and public access to information regarding reports of inspections, results, deficiencies, and corrections under this subchapter; and

(3)  develop within one year of the effective date of this subchapter a standardized acuity-based patient classification system as defined in section 1921 of this subchapter to be used by all facilities for the purpose of increasing the number of direct-care registered nurses to meet patient needs.


(a)  Each facility shall incorporate and maintain the following minimum direct-care registered nurse-to-patient ratios:

(1)  Intensive Care Unit                                       1:2

(2)  Critical Care Unit                                          1:2

(3)  Neonatal Intensive Care                                1:2

(4)  Burn Unit                                                      1:2

(5)  Step-down/Intermediate Care                       1:3

(6)  Operating Room

(A)  Under Anesthesia                                    1:1

(B)  Postanesthesia                                         1:2

(7)  Postanesthesia Care Unit

(A)  Under Anesthesia                                    1:1

(B)  Postanesthesia                                         1:2

(8)  Emergency Department                                 1:3

(A)  Emergency Critical Care             1:2

(B)  Emergency Trauma                                 1:1

(C)  The triage, radio, or other specialty registered nurse shall not be counted as part of the numbers for the staffing requirements of this subdivision.

(9)  Perinatal Care

(A)  Antepartum                                             1:3

(B)  Active Labor                                           1:1

(C)  Immediate Postpartum                            1:2

(D)  Postpartum                                             1:6

(E)  Intermediate Care Nursery                      1:4

(F)  Well-Baby Nursery                                 1:6

(10)  Pediatrics                                                   1:3

(11)  Psychiatric                                      1:4

(12)  Medical and Surgical                                  1:4

(13)  Telemetry                                                   1:3

(14)  Observational/Outpatient Treatment            1:4

(15)  Transitional Care                                        1:5

(16)  Rehabilitation Unit                           1:5

(17)  Specialty Care Unit                         1:4

(18)  Any unit not otherwise listed above shall be considered a specialty care unit.

(b)  The ratios in subsection (a) of this section shall constitute the minimum number of direct-care registered nurses.  Additional direct-care registered nurses shall be added and the ratio adjusted to ensure direct-care registered nurse staffing in accordance with an approved acuity-based patient classification system.  Nothing herein shall be deemed to preclude any facility from increasing the number of direct-care registered nurses, nor shall the requirements set forth be deemed to supersede or replace any requirements otherwise mandated by law, rule, or collective bargaining contract, so long as the facility meets the minimum requirements outlined.


(a)  As a condition of licensing, each facility annually shall submit to the department a prospective staffing plan together with a written certification that the staffing plan is sufficient to provide adequate and appropriate delivery of health care services to patients for the ensuing year, and does all of the following:

(1)  Meets the minimum direct-care registered nurse-to-patient ratio requirements of section 1923 of this subchapter;

(2)  Meets any additional requirements of other laws or regulations;

(3)  Employs the acuity-based patient classification system for addressing fluctuations in patient acuity levels requiring increased registered nurse staffing levels above the minimums set forth in section 1923 of this subchapter;

(4)  Provides for orientation of registered nursing staff to assigned clinical practice areas, including temporary assignments, sufficient to provide competent nursing care;

(5)  Includes other unit or department activity such as discharges, transfers, admissions, and administrative and support tasks that are expected to be done by direct-care registered nurses in addition to direct nursing care;

(6)  Submits the assessment tool used to validate the acuity system relied upon in the plan; and

(7)  Is produced in consultation with a majority of the direct-care nurses in each department or unit or, where applicable, with the recognized or certified collective bargaining representative of direct-care registered nurses.

As a condition of licensing, each facility annually shall submit to the department an audit of the preceding year’s staffing plan as dictated in this subsection.  The audit shall compare the staffing plan with measurements of actual staffing as well as measurements of actual acuity for all units within the facility.  

(b)  As a condition of licensing, a facility required to have a staffing plan under this subchapter shall:

(1)  Prominently post within each unit the daily written nurse staffing plan to reflect the registered nurse‑to‑patient ratio as a means of consumer information and protection.

(2)  Upon request, make copies of the staffing plan filed with the department available to the public.

(3)  Provide each patient and family member with a toll-free hotline number at the department, which may be used to report inadequate registered nurse staffing.  Such complaint shall cause investigation by the department within 24 hours to determine whether any violation of law or regulation by the facility has occurred.

(c)  No facility may directly assign any other personnel to perform undelegatable licensed nurse functions in lieu of care delivered by a licensed registered nurse.  Additionally, other personnel are prohibited from performing tasks which require the clinical assessment, judgment, and skill of a licensed registered nurse.  Such functions shall include:

(1)  Nursing activities which require nursing assessment and judgment;

(2)  Physical, psychological, and social assessments which require nursing judgment, intervention, referral, or follow-up;

(3)  Formulation of the plan of nursing care and evaluation of the patient’s response to the care provided;

(4)  Administration of medications; and

(5)  Health teaching and health counseling.

(d)  A full-time registered nurse executive leader shall be employed by each facility to be responsible for the following:

(1)  overall execution of the resources to ensure sufficient registered nurse staffing is provided by said facility;

(2)  overall quality assurance of nursing care is provided by the facility; and

(3)  overall occupational health and safety of nursing staff employed by said facility.

(e)  For the purpose of compliance with the minimum registered nurse staffing requirements set forth in this act, no registered nurse shall be assigned or be included in the count of assigned registered nurse staff in a nursing department or unit or a clinical area within the facility unless that registered nurse has an appropriate orientation in that clinical area sufficient to provide competent nursing care to the patients in that area, and has demonstrated current competence in providing care in that area.

(f)  As a condition of licensure, each facility shall adopt, disseminate to direct-care nurses, and comply with a written policy that meets the requirements under this section, detailing the circumstances under which a direct-care registered nurse may refuse a work assignment.

(1)  At a minimum, the work assignment policy shall permit a direct-care nurse to refuse any assignment for which:

(A)  the nurse is not prepared by education, training, or experience to safely fulfill the assignment without compromising or jeopardizing patient safety, the nurse’s ability to meet foreseeable patient needs, or the nurse’s license; or

(B)  the assignment otherwise would violate requirements under this subchapter.

(2)  At a minimum, the work assignment policy shall contain procedures for the following:

(A)  Reasonable requirements for prior notice to the nurse’s supervisor regarding the nurse’s request and supporting reasons for being relieved of the assignment or continued duty.

(B)  Where feasible, an opportunity for the supervisor to review the specific conditions supporting the nurse’s request, and to decide whether to remedy the conditions, to relieve the nurse of the assignment, or to deny the nurse’s request to be relieved of the assignment or continued duty.

(C)  A process will be in place that permits the nurse to exercise the right to refuse the assignment or continued duty status when the supervisor denies the request to be relieved if:

(i)  The supervisor rejects the request without proposing a remedy or the proposed remedy would be inadequate or untimely;

(ii)  The complaint and investigation process with a regulatory agency would be untimely to address the concern; and

(iii)  The employee believes in good faith that the assignment meets conditions justifying refusal.

(D)  A nurse who refuses an assignment pursuant to a work assignment policy established in this section shall not be deemed, by reason thereof, to have engaged in negligent or incompetent action, patient abandonment, or otherwise to have violated applicable nursing law.

§ 1925.  SANCTIONS

(a)  Any facility that fails to anticipate, design, maintain, or adhere to a daily written nurse staffing plan in accordance with the provisions of this section, or any rule or regulation promulgated hereunder, shall be subject to:

(1)  revocation of said facility’s license or registration, or a fine of not more than $25,000.00, or both,

(2)  a civil penalty of not more than $25,000.00, for each such violation.

(b)  Each day each such violation occurs or continues shall be deemed a separate offense.  These penalties shall be in addition to any other penalties that may be prescribed by law.  The department shall have jurisdiction to coordinate enforcement-related activities.  The civil penalty may be assessed in any action brought on behalf of the state or on behalf of any patient or resident aggrieved hereunder in any court of competent jurisdiction.  A facility shall be subject to fine when found to falsify or cause to falsify documentation required by this act.

(c)  Fines relative to the violations under this section shall be collected and distributed to a foundation developed for the purpose of advancing the nursing profession and enhancing patient safety.

Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont