DNP 820 Module 5 The Regulatory Process and a Public Comment Example

Commenting on a Staffing Rule: The Federal Regulatory Process and a Nurse Leader's Public Comment on Nursing Home Staffing Standards

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Doctor of Nursing Practice Program, Aspen University

DNP 820: Health Policy and Advocacy

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Month Day, Year

Commenting on a Staffing Rule: The Federal Regulatory Process and a Nurse Leader's Public Comment on Nursing Home Staffing Standards

Many of the rules that shape nursing practice are made not by legislatures but by agencies. Federal agencies implement laws through regulations, and the public, including nurses, has a formal opportunity to influence those regulations before they take effect. This paper explains the federal rulemaking process, presents the core of a public comment on a proposed rule to set minimum staffing standards in nursing homes, and reflects on what the rule's later history teaches doctoral nurses about regulatory advocacy.

How Federal Rules Are Made

Under the Administrative Procedure Act, most federal regulations follow notice-and-comment rulemaking. An agency publishes a proposed rule in the Federal Register, explaining what it proposes, why, the evidence it relied on and its estimated costs and benefits. The public then has a comment period, often 60 days, to submit comments electronically. The agency must consider significant comments and respond to them when it publishes the final rule, explaining what it changed and why. Final rules can be challenged in court, for example on the ground that the agency exceeded its legal authority or failed to consider important evidence, and Congress can override them through legislation. Comments matter because they create the record on which the final rule, and any legal challenge, is judged.

Agencies also publish regulatory agendas listing rules they plan to propose, which gives organized groups, including nursing associations, a chance to prepare evidence before a proposal appears.

The Proposed Rule

In September 2023, the Centers for Medicare & Medicaid Services proposed a staffing floor for nursing homes that participate in Medicare and Medicaid. The proposal would require at least 3.48 total nurse staffing hours per resident per day, including at least 0.55 hours from registered nurses and 2.45 hours from nurse aides, and round-the-clock registered nurse presence every day of the week, with exemptions for facilities in workforce shortage areas that met certain conditions (Centers for Medicare & Medicaid Services [CMS], 2023). The agency cited evidence linking higher staffing, especially registered nurse staffing, to better resident outcomes.

The Evidence Behind It

Research has long associated nursing home staffing with quality. A review of the evidence on appropriate staffing levels concluded that higher registered nurse and total nurse staffing are associated with better quality of care, including fewer pressure ulcers, less use of restraints and antipsychotics, fewer hospitalizations and fewer deficiencies, and it recommended minimum total staffing above the level later proposed, along with a registered nurse on duty around the clock (Harrington et al., 2020). Critics of the proposal argued that the workforce did not exist to meet the standard, that the cost would force some facilities, especially rural ones, to close or limit admissions, and that a uniform standard ignored differences in resident acuity.

The Comment

The comment was written by a doctoral-prepared nurse leader in a regional health system that operates three nursing homes. It supported the proposal's registered nurse requirement, noting that in the system's own facilities, nights without a registered nurse on site had preceded several avoidable transfers to the emergency department, and cited the research linking registered nurse presence to fewer hospitalizations. It supported a total staffing floor but asked the agency to phase it in over a longer period for rural facilities, tied to funding for training nurse aides, because the system's rural home had eleven vacant aide positions despite wage increases. It asked the agency to adjust the standard for resident acuity using data facilities already report, so that facilities caring for more complex residents would be expected to staff above the minimum. And it recommended public reporting of daily staffing by shift, so that families and regulators could see whether standards were met.

The comment followed practices that increase influence: it identified the commenter's expertise, addressed specific provisions by section, supported claims with published evidence and local data, and proposed concrete alternatives rather than simply opposing or supporting the rule.

Before submitting, the nurse leader shared a draft with the system's nursing home administrators, directors of nursing and finance staff, whose corrections to the vacancy and cost figures made the comment more credible. The final comment was about four pages, far shorter than many industry submissions, but specific enough that agency staff could act on each recommendation.

What Happened Next

The agency finalized the rule in 2024, keeping the total staffing and around-the-clock registered nurse requirements with phased implementation. The rule was then challenged in court, and in July 2025 Congress enacted a law that barred the Department of Health and Human Services from implementing or enforcing key provisions until September 30, 2034. In December 2025, the agency issued an interim final rule repealing those provisions, citing the change in law (CMS, 2025).

Lessons for Doctoral Nurses

The rule's history offers three lessons. First, comments shape the record; the evidence nurses submitted became part of the justification for the final rule, and future efforts will draw on it. Second, a regulation that lacks the resources to implement it, in this case a sufficient workforce and funding, is vulnerable, however strong its evidence. Advocacy for standards should be paired with advocacy for the workforce and payment needed to meet them. Third, regulation is only one venue. States can set their own staffing standards, and some have, so nurses can pursue the same goals through state legislation and Medicaid payment policy while federal action is paused.

Keeping the comment and its evidence on file allows it to be reused when the issue returns.

Conclusion

The notice-and-comment process gives nurses a direct voice in the rules that govern care. A comment on the proposed nursing home staffing standards could support the evidence for registered nurse presence while proposing phasing, acuity adjustment and public reporting to address legitimate concerns. The rule's later repeal shows that regulatory success depends on political and resource conditions as well as evidence, which is why doctoral nurses need to advocate across agencies, legislatures and states, and to keep doing so after a rule is final.

References

Centers for Medicare & Medicaid Services. (2023, September 6). Medicare and Medicaid programs; Minimum staffing standards for long-term care facilities and Medicaid institutional payment transparency reporting (Proposed rule). Federal Register. https://www.federalregister.gov/documents/2023/09/06/2023-18781/medicare-and-medicaid-programs-minimum-staffing-standards-for-long-term-care-facilities-and-medicaid

Centers for Medicare & Medicaid Services. (2025, December 3). Medicare and Medicaid programs; Repeal of minimum staffing standards for long-term care facilities (Interim final rule with comment period). Federal Register. https://www.federalregister.gov/documents/2025/12/03/2025-21792/medicare-and-medicaid-programs-repeal-of-minimum-staffing-standards-for-long-term-care-facilities

Harrington, C., Dellefield, M. E., Halifax, E., Fleming, M. L., & Bakerjian, D. (2020). Appropriate nurse staffing levels for U.S. nursing homes. Health Services Insights, 13, Article 1178632920934785. https://doi.org/10.1177/1178632920934785