In January 2004, after a 12 year campaign by the California Nurses Association, California became the first – and to date only – state to implement mandatory nurse-to-patient ratios. The California Nurses Association later merged with the United American Nurses and Massachusetts Nurses Association to form the National Nurses United (“NNU”) in 2009.

Since its formation, the NNU and its affiliate state agencies have been aggressively pushing staffing ratios through the collective bargaining process and have held or threatened to hold strikes in California, Massachusetts, Minnesota and Washington D.C. – to name a few – over staffing related issues. The unions have also been vocal supporters of proposed federal and state legislation to impose mandatory staffing ratios. Currently, NNU affiliates in Washington D.C., Michigan, and Minnesota are actively pushing staffing legislation in their respective jurisdictions.

Last month in the District of Columbia, 200 NNU nurses wearing red scrubs chanted “patients over profit” at a press conference held by D.C. Council members to introduce the Patient Protection Act, a measure that would establish mandatory minimum nurse-to-patient ratios modeled after California’s landmark legislation. In addition, the Patient Protection Act would ban mandatory overtime. The legislation has the early support of nine D.C. Council members, a number sufficient to pass the Patient Protection Act.

Similar legislation is being considered in Michigan, where the NNU/Michigan Nurses Association joined lawmakers on March 4, 2013, to support the Michigan Safe Patient Care Act, which also would impose mandatory minimum nurse-to-patient staffing ratios similar to those in California. In addition, the proposed legislation would ban mandatory overtime except in emergency situations. More than one-third of Michigan House lawmakers co-sponsored the Safe Patient Care Act.

The NNU/Minnesota Nurses Association is taking a slightly different approach in Minnesota. In February, the union held a rally in support of the Standards of Care Act, legislation aimed to require that hospitals staff to levels recommended by professional nursing specialty organizations, such as the Association of Women’s Health, Obstetric and Neonatal Nurses, and the American Association of Critical Care Nurses. In the absence of such recommended standards, the governor would appoint a working group to develop staffing-level standards. In addition, the Minnesota Standards of Care Act would require all hospitals to establish safe patient assignment committees, made up of at least 60 percent registered nurses who provide direct patient care. The committees would be required to complete a patient safety assessment; implement and evaluate staffing standards; develop a procedure for making shift-to-shift adjustments to increase staffing based on patient acuity and nursing intensity; and identify incidents in which the hospital fails to meet the applicable standards. On February 21, 2013, the Standards of Care Act passed the assigned House Committee and is proceeding through the legislative process.

While it not clear which state may next follow California by adopting mandatory nurse-to-patient ratios, it is clear that the NNU and its affiliates will continue to advance the staffing issue by pushing for it at the collective bargaining table, instituting or threatening picketing and strikes, and supporting and sponsoring legislation at both the federal and state levels.