Texas Laws Governing

Hospital Nurse Staffing

TEXAS LAWS GOVERNING HOSPITAL NURSE STAFFING

T he importance of nursing to patient care in Texas

hospitals cannot be overstated. Texas hospitals and
their almost 136,000 nurses are committed to ensuring
that all patient needs are met and the highest outcomes
achieved.
rather than having the budget inform the staffing plan.
• Guide the hospital in assigning nurses hospital-wide.
• Set minimum staffing levels for patient care units, which
are determined by the nursing assessment in accordance
with evidence-based safe nursing standards.
Texas law requires the boards of trustees of hospitals to enact
a written nurse staffing plan developed with input from direct • Take into account: patient characteristics and the number
care nurses that is updated at least annually. This plan ensures of patients, including discharges, admissions, and transfers;
compliance with state law and regulations and provides the the intensity and variability of patient care in the unit; the
flexibility needed for each hospital to respond to patient and scope of services; the context and setting of the care and
community need. the availability of technology; and the characteristics of the
nursing staff and other support staff.
This document explains the requirements included in hospi-
tals’ nurse staffing plans. • Include built-in flexibility with a method for adjusting the
plan shift-to-shift for each patient care unit.
In general, Texas hospitals must ensure that:
• Include a contingency plan for when patient care needs
• Nurses have current licensure.
exceed staff resources.
• There are enough RNs and LVNs to care for patients.
• Describe how on-call time will be used.
• There is supervisory and staff personnel for each depart-
• Reflect current standards by accrediting bodies, profes-
ment or nursing unit to provide the immediate availability of
sional organizations and government entities.
an RN to provide care for any patient.
• Include a mechanism for evaluating the effectiveness of
• An RN is on duty in each building of a licensed hospital
the staffing plan based on patient needs, nursing sensitive
that contains at least one nursing unit where patients are
quality indicators, nurse satisfaction measures collected by
present.
the hospital and evidence-based nurse staffing standards. At
• There is a nursing plan of care for each patient which least one of these outcomes must be correlated to the
addresses the patient’s needs. adequacy of staffing:
• They have a standing nurse staffing committee comprised ɦɦ Nurse-sensitive patient outcomes selected by the
of direct care nurses selected by their peers. nurse staffing committee, such as, patient falls, adverse
drug events or length of stay.
Nurse Staffing Plan ɦɦ Operational outcomes, such as work-related injury,
violence towards nurses, overtime rates or turnover.
The nurse staffing plan and related
policies must: ɦɦ Substantiated patient complaints related to staffing
levels.
• Consider the recommendations of
the hospital’s nurse staffing committee. • Incorporate a process to solicit concerns about the nurse
staffing plan that:
• Be based on the needs of each patient care unit, shifting
based on the needs of patients. ɦɦ Prohibits retaliation for reporting concerns.
• Take into account the skills and ability of the nurses and ɦɦ Requires nurses to timely report concerns through
patient safety. appropriate channels at the hospital.
• Encourage input from the nursing staff with protection ɦɦ Orients nurses on how and to whom to report
from retaliation. concerns.
The nurse staffing plan also must: ɦɦ Encourages nurses to provide input about staffing
concerns to the nurse staffing committee and provides
• Be retained for at least two years. for review, assessment, and response by the nurse
• Be a component in setting the nurse staffing budget, staffing committee.

2 TEXAS HOSPITAL ASSOCIATION / TEXAS NURSES ASSOCIATION

 TEXAS LAWS GOVERNING HOSPITAL NURSE STAFFING

ɦɦ Includes a process for providing feedback during the time providing direct patient care who are selected by their
committee meeting on how concerns are addressed. peers.
ɦɦ Uses the nurse safe harbor peer review process under • At least one RN from either infection control, quality
section 303.005 of the Occupations Code. assessment and performance improvement or risk manage-
ment.
• Include policies and procedures requiring orientation
(including the orientation of nonemployee nurses), • Representatives of the types of nursing services at the
documented competency in accordance with hospital hospital.
policy and nursing assignments congruent with competency.
• The CNO. The CNO is a voting member of the committee.
Committee members must be compensated for their time
Nurse Staffing Committee when attending committee meetings and relieved of patient
Any reports, records, or information care duties.
compiled by the nurse staffing committee
The nurse staffing committee must:
are confidential, not subject to disclosure under the Public
Information Act, and subject to the same confidentiality and • Develop and recommend the nurse staffing plan.
disclosure requirements as a record originating from a
medical peer review committee. • Solicit, evaluate and respond to staffing concerns ex-
pressed to the committee.
The nurse staffing committee must meet quarterly and
include: • Identify the nurse-sensitive outcome measures the
committee will use to evaluate the effectiveness of the
• At least 60 percent RNs who spend at least half of their official nurse services staffing plan.

TEXAS HOSPITAL ASSOCIATION / TEXAS NURSES ASSOCIATION 3

 TEXAS LAWS GOVERNING HOSPITAL NURSE STAFFING

Texas law requires the boards of trustees of hospitals to

enact a written nurse staffing plan developed with input
from direct care nurses that is updated at least annually.

• Evaluate and document in the minutes, at least twice per year, • Adopt policies on mandatory overtime where:
the effectiveness of the official nurse services staffing plan,
ɦɦ A hospital may not require a nurse to work mandatory
variations between the plan and the actual staffing and whether
overtime and a nurse may refuse to work mandatory over-
the plan meets patient needs, nursing sensitive quality indica-
time, except in the case of a disaster or declaration of
tors, nurse satisfaction measures collected by the hospital and
emergency in the county or contiguous county, an emergen-
evidence-based nurse staffing standards, as set out by the nurse
cy or unforeseen event that increases the need for health
staffing plan.
care personnel to provide safe care in a hospital or the nurse
• Submit, at least twice per year, a report to the board on nurse is actively engaged in an ongoing medical or surgical proce-
staffing and patient care outcomes, including the committee’s dure and the continued presence of the nurse is necessary
evaluation of the effectiveness of the official nurse staffing plan for the health and safety of the patient.
and aggregate variations between the staffing plan and actual
ɧɧ Scheduling a nurse for a procedure that may last
staffing.
beyond the nurse’s shift does not qualify as mandatory
overtime. For example, two nurses in the cardiovascu-
Hospital Obligations lar lab are scheduled to work from 7:00 a.m. until 4:00
p.m., and a procedure that began at 3:30 p.m. is not
Hospitals must: completed at 4:00 p.m. The two nurses assisting with
• Annually report to the Texas Department of the procedure are told they must stay until the proce-
State Health Services whether the hospital has dure is finished and the patient is transferred to
a nurse staffing policy, whether the committee has the required recovery. This scenario is not considered mandatory
membership composition, whether the nurse staffing commit- overtime. However, illegal mandatory overtime would
tee has evaluated the hospital’s nurse staffing plan and has occur if two cases were added to the schedule after
reported the results of the evaluation to the hospital’s govern- 4:00 p.m., and the nurses were directed to stay until
ing body and what nurse-sensitive outcome measures the those cases were completed.
committee adopted to evaluate the nurse staffing plan. ɦɦ If a hospital determines that an exception to the prohibi-
• Make official nurse staffing plan levels and current staffing tion on mandatory overtime exists, the hospital must, to the
levels available to nurses on each patient care unit at the extent possible, make a good faith effort to meet the staffing
beginning of each shift. need through voluntary overtime, and document that effort.

• Report variations between planned staffing levels and actual ɦɦ A hospital may not use on-call time as a substitute for
staffing levels to the nurse staffing committee (which are mandatory overtime.
confidential).

Texas Hospital Association / 1108 Lavaca, Suite 700, Austin, TX, 78701-2180 / www.tha.org

Texas Nurses Association / 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759 / www.texasnurses.org

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