Legislative Summary

HB 2041

"Arizona Hospital Patient Protection Act of 2008"

Legislative Purpose

ESTABLISHING MANDATORY HOSPITAL DIRECT CARE NURSING PRACTICE STANDARDS AND PROFESSIONAL PRACTICE PROTECTIONS TO ASSURE THAT NURSING CARE IS PROVIDED IN THE EXCLUSIVE INTERESTS OF PATIENTS - MANDATING ADOPTION, BY LICENSED HOSPITAL FACILITIES, OF SAFE STAFFING BY INDIVIDUAL PATIENT ACUITY STANDARDS OF WHICH THE DIRECT CARE REGISTERED NURSE-TO-PATIENT STAFFING RATIOS IS THE MINIMUM, NECESSARY FOR THE PROVISION OF COMPETENT, SAFE AND THERAPEUTIC NURSING CARE AND FOR RETENTION AND RECRUITMENT OF QUALIFIED DIRECT CARE REGISTERED NURSES-

RECOGNIZING PROFESSIONAL DIRECT CARE REGISTERED NURSE DUTY AND RIGHT OF PATIENT ADVOCACY-

PROVIDING EFFECTIVE PROTECTION AGAINST RETALIATION FOR REPORTING UNSAFE PATIENT CARE CONDITIONS AND FOR REFUSING OBJECTING TO UNSAFE PATIENT CARE ASSIGNMENTS.

Legislative Findings

• Health care services are becoming more complex and it is increasingly difficult for patients to access integrated services.

• Safe, therapeutic and competent patient care is jeopardized because of staffing changes implemented in response to managed care.

• To ensure the adequate protection of patients in acute care settings, it is essential that qualified registered nurses be accessible and available to meet the individual needs of the patient.

• The basic principles of staffing in the acute care setting should be based on the patient's care needs. The severity of condition, services needed, and the complexity surrounding those services.

• Restrictions/prohibitions on the use of certain technologies.

• Current unsafe hospital registered nurse staffing practices has resulted in adverse patient outcome.

• Direct care registered nurses must be able to advocate for their patients without fear of retaliation from their employer.

• Whistle blower protections that encourage registered nurses to notify government and private accreditation entities of suspected unsafe patient conditions; including protection against retaliation for refusal of unsafe patient care assignments by competent registered nurse staff will greatly enhance the health, welfare and safety of patients.

• Direct care RNs have an irrevocable duty and right to advocate on behalf of their patient's interest and this duty & right shall not be encumbered by cost-saving schemes.

Uniform Statewide Standards

1. Minimum, Specific, and Numerical Direct Care Registered Nurse-to-Patient Staffing Ratios by Clinical Unit for Acute Care Hospitals

(a) Unit-specific direct care registered nurse-patient ratios for all shifts at all times *Additional direct care registered nurses and other licensed and unlicensed nursing personnel shall be assigned through the implementation of a patient classification system (PCS).

(b) The direct care registered nurse-to-patient ratios are;

Intensive/Critical Care 1:2; Neonatal Intensive Care 1:2; Operating Room 1:1; Conscious sedation 1:1; Post-anesthesia Recovery 1:2; Labor and Delivery 1:1; Ante partum 1:3; New Born Nursery 1:2; Postpartum couplets 1:3; Postpartum women only 1:4; Pediatrics 1:3; Emergency Room 1:4; ICU patients in the ER 1:2; Trauma patients in the ER 1:1; Step Down & Telemetry 1:3; Medical/Surgical 1:4; Other Specialty Care 1:4; Psychiatric 1:4; Rehabilitation Unit & Skilled Nursing Facility 1:5

(c) Restrictions on Use of Unlicensed Assistive Personnel (UAP)

*Prohibits the use of a UAP lieu of a direct care RN

*UAPs shall not perform RN functions under the direct care RN supervision

2. Direct Care Registered Nurse Patient Advocacy - Professional Duty and Right of Patient Advocacy

• Professional Obligation: an RN has the professional obligation and therefore the right to act as the patient's advocate.

• Acceptance of Patient Care Assignments: the RN is always responsible for providing safe, therapeutic, and competent nursing care to assigned patients.

• Acceptance of Orders: the direct care RN shall assess each medical order before implementation to determine if the order is: (a) in the best interests of the patient; and (b) initiated by a person legally authorized.

• Free Speech — Whistle Blowing — Patient Protection: all direct care registered nurses responsible for patient care in a hospital facility shall enjoy the right of free speech, such as reporting unsafe practices or violations of statutes and/or regulations, without fear of retaliation; and shall be protected in the exercise of that right both during working hours and during off-duty hours.

• Collective Patient Advocacy: engaging in acts of collective patient advocacy shall constitute an exercise of the direct care RN duty and right of patient advocacy.

3. Direct Care Registered Nurse Planning and Implementation of Hospital Patient Care (The Nursing Process Model of Care)

Essential Functions of a Direct Care RNs: A direct care RNs, employing scientific knowledge and experience in the physical, social and biological sciences, and exercising independent judgment in applying the nursing process, shall directly provide: (a) Continuous and ongoing patient assessments of the patient's condition based upon the independent professional judgment of the direct care RN; (b)The planning, implementation and evaluation of nursing care provided to each patient, including the implementation of advocacy intervention based on the direct care RN independent professional judgment.

• Determining Nursing Care Needs: the nursing care needs of individual patients shall be determined by a direct care RN through the process of ongoing patient assessments, nursing diagnosis, formulation and adjustment of nursing care plans.

• Independent Judgment: Competent performance of the essential functions of a direct care RN requires the exercise of independent judgment in the exclusive interests of the patient. The exercise of such independent judgment, unencumbered by the commercial or revenue generation priorities of a hospital and/or employing entity of a direct care RN, is essential to safe hospital patient nursing care.

4. Restrictions of the use of Technology: Prohibits the

1) override of the RN independent professional judgment, 2) interference with the RN duty and right to advocate in the exclusive interest of patients, and 3) skill degrading.

5. Direct Care RNs are Professional Employees

The exercise of independent professional judgment in assigning and clinical supervision of nursing personnel by a direct care registered nurse shall not disqualify the direct care registered nurse as a professional employee.

6. Enforcement

• Fines for Violating Employee Whistle Blowing Rights; Acute care hospital ($25,000 for each act of violation) and any person ($20,000 for each act of violation) that violates employee rights under this Act shall be subject to civil penalties.

• Ratios Violation Fines; any acute care hospital that violates any provision dealing with direct care RN-to-patient ratios shall be subject to civil penalties. ($25,000 for each act of violation and an additional $10,000 per shift until the hospital complies with the ratios law).