Finding enough qualified RNs will remain tough: The U.S. Department of Health and Human Services projects the current shortage of a few hundred thousand RNs could hit 750,000 by 2020 as aging baby boomers need more care and the nursing work force gets older.

But in Washington and states from New Jersey to Oregon, nurses' unions are ramping up battles for new laws or contracts setting minimum nurse-patient ratios.

Local unions have been fighting for — and increasingly winning — contracts that limit patient loads or that put nurses on committees that set staffing guidelines. It's a key issue this year in contract talks for nurses in at least 12 New Jersey hospitals.

Last October, nurses at University Hospital in Newark, N.J., won a contract setting ratios of one nurse per two patients in ICU and seven in medical/surgical or general, units.

Two years ago, nurses at Englewood Hospital and Medical Center in northern New Jersey got a contract with similar ratios — enforceable through arbitration.

RN Stephanie Orrico says Englewood is mostly meeting the rules. Before, it wasn't uncommon for medical/surgical nurses to have patient ratios of up to 1-to-15, she says.

"You tell me what kind of care those patients were getting," Orrico says.

Several unions have held lengthy strikes over staffing ratios, including one that began Nov. 14, 2002, at Northern Michigan Hospital in Petoskey, Mich. Some nurses have temporarily taken jobs as far away as Hawaii rather than cross the picket line, which has endured for two winters.

"It's difficult for a lot of people to believe that nurses would make that sacrifice for their patients," says Sharon Norton of Teamsters Local 406. "They know not only is the patients' safety in jeopardy, their licenses are on the line, and they're not willing to take it anymore."

Many nursing groups are looking to California as a model for nurse ratios.

In January, it enacted the nation's first hard-and-fast ratios, ward by ward. An RN may care for six patients at most, and only four in the ER and two in critical care units.

Six other states — Florida, Kentucky, Nevada, Oregon, Texas and Virginia — have enacted staffing regulations but not ratios, and 18 states introduced some staffing legislation last year, according to the American Nurses Association.

The California Nurses Association says its survey of nurses at 111 of the 450 acute care hospitals found 68 percent were complying or had improved staffing by late January.

"While some significant problems remain, the progress made to date is very encouraging," says the union's president, RN Deborah Burger.