Healthcare policy issues and nursing strategies

Nursing

Policy Issue Analysis: The National Nursing Shortage

The healthcare industry is afflicted by a wide array of internal problems, policy issues and systemic flaws. Included among them are the prohibitively high costs of medical treatment, the inaccessibility of healthcare coverage for many system users and the frequency of preventable occurrences like medical error or health system negligence. One of the root problems in the healthcare system, a mounting crisis which impacts all of these and other areas of the industry, is the shortage of registered nurses and of healthcare workers in general.

Problem Identification:

In the face of rising demands for healthcare providers, the industry is experiencing records gaps in its ability to treat patients in the system. And projection suggest that this condition will only worsen, with ratios of nurses to patients becoming less and less optimal all the time. This is particularly problematic given the population trends that threaten to throw our economy into even further chaos in the coming years. As the population of retirees grows to include the enormous Baby Boomer generation, the nation's productivity and, by consequence, its healthcare system, will be fully reliant on the far smaller succeeding Generations X and Y. This means that gaps between healthcare providers and the patient population are likely to grow without some significant shift in the current trends in the field. According to the text by Cullen et al. (2010), "in 2008, American Health Care Association's report of vacancies in long-term facilities and American Hospital Association's report of hospital vacancies combined relayed an even larger shortage of 8.1%. By 2025, the shortage in RNs is projected to grow to an estimated 260,000 FTEs, twice as high as any U.S. nursing shortage since the 1960's." (Cullen et al. 2010) This alarming trend provides a rationale for the present research, which concerns the way that these ratios impact such matters as job performance for healthcare professionals, health outcomes for patients and efficiency for healthcare facilities on the whole.

These national figures are bolstered by similar patterns at the state and local level. In Texas, we are currently experiencing a staffing shortage that, according to Roberson (2010), is likely to reaching a shortfall on 71,000 nurses by 2020. At present, Roberson reports, rates of 5% vacancy have shrunk to 2% thanks to the recession and efforts at recruiting new nursing school students. However, this, the text reports, is a temporary improvement in trends that will rise by the projected date above. Accordingly, similar patterns have been seen in the locality of Houston. Here, according to Perin (2008), "the area is already struggling with an ongoing nursing shortage of 4,000 to 5,000 full-time RNs, and the HWS study shows that the vast majority of the RN pipeline locally will be inexperienced new graduates, indicating hospitals will have a growing problem hiring experienced nurses." (Perin 2008)

Background:

Social Factors:

At the root of the nursing shortage is a number of convergent sociological trends, including those relating to immigration, demographic shifts and population aging patterns. Accordingly, Cullen et al. indicate that myriad social factors may be identified as having in some aspect contributed to the initiation of the shortage and to what projections state will be a resurgence and far greater severity of gaps in staffing in the next decade. Cullen et al. report that "research suggests that the current shortage is the product of several trends including: steep population growth in several states, a diminishing pipeline of new students to nursing, a decline in RN earnings relative to other career options, an aging nursing workforce, and an aging population that will require intense health care services." (Cullen et al. 2010) These all point to a strong imperative for policy action and identify several areas where regulatory oversight might prevent projected trends. Critical among such trends, Cullen indicates that a survey conducted in 2006 projected that 55% of nurses surveyed intended to retire between the years of 2011 and 2015, with job dissatisfaction frequently cited as a major cause for this anticipated decision.

Economic Factors:

The text by Leavitt et al. (2012), underscores the economic correlation to nurse-to-patient ratios, indicating the direct correlation between fewer nurses and less desirable health outcomes is accompanied by a number of peripheral economic costs. Leavitt et al. note, "for example, inadequate nurse staffing could be linked to increases in rates of infection, morbidity, and morality -- outcomes that can increase institutional costs and jeopardize an institution's reputation and future business." (Leavitt et al. 2012) Another often overlooked cost is the lost productivity of a labor force with lesser healthcare outcomes and, as a result, greater susceptibility to illness, sustained ailment or mistreated injury. Lost work time and lower productivity are the results.

And importantly, the low level of worker morale and the high level of consequent turnover in nursing cost the system a significant sum in training, position vacancies and payment of overtime for compensatory work by retained nurses. According to the Texas Center for Nursing Workforce Studies (TCNWS)(2006), "in 2004, the New York State Education Department calculated that the statewide cost of RN turnover per year would be over $1 billion when the annual turnover rate is 15%.6 Nationally, the total cost of turnover, at a nurse turnover rate of 20% in U.S. hospitals, is estimated to be $12.3 billion." (TCNWS 2006)

Ethical Factors:

Berkowitz posits the argument that in addition to the practical demands that are incumbent upon the healthcare industry in terms of addressing staffing shortage issues, there are substantial ethical imperatives at play too. Because of the limited accessibility of healthcare treatment opportunities for many portions of the population, staffing shortages which carry implications to the availability of healthcare providers carry ethical overtones. According to Berkowitz, "fairness and equity are important aspects of policy development. Fawcett and Russell (2001) consider the equity of a policy as the extent to which it allows the benefits and burdens of nursing practice to be equally distributed to all; in particular equal access to health services." (Berkowitz 2012)

This suggests that there is a tangible ethical dimension to the research problem identified here. The degree to which staffing shortages result in disruptions in equal distribution of healthcare access is the degree to which there is an ethical responsibility vested in healthcare providers and the industry as a whole to fill gaps in effective staffing. According to the text by Berkowitz, it is for this reason that policy action is, in addition to being of critical practical importance, also pointedly necessary for the achievement of an ethical stasis in the distribution of healthcare services. And given our current level of knowledge on the impending threats to nurse-to-patient ratios, there is an additional ethical imperative to act preemptively to prevent the increasing severity of this staffing crisis.

Political and Legal Factors:

Among critical issues of political and legal importance are the global ranking of the U.S. Healthcare system and the implications of socioeconomic disparity to this ranking. According to the text by Greis & Duda (2010), "The nursing shortage has broad implications for the future ability of the U.S. health care system to provide quality patient care. Meanwhile, the U.S. health care system has received a number of recent notorious distinctions. For example, in 2000, the World Health Organization ranked the U.S. health care system thirty-seventh in overall performance. Similarly, others have criticized the U.S. health care system for having significant disparities between high-income and low-income adults in the quality and quantity of care provided." (Greis & Duda 2010) This denotes that there is cause to bring significant public pressure to bear on public representatives and office-holders to the end of bridging gaps both in the socioeconomic disparity of the healthcare system and gaps between the U.S. And other industrialized nations with more adequate and equitable systems.

Issue Statement:

The primary issue identified here is two-fold; namely, there are critical nursing and healthcare staffing shortages through the American healthcare system and in spite of considerable empirical evidence that this leads to less desirable healthcare outcomes, greater rates of preventable death and higher incidences of medical error, it remains a top challenge for hospitals to find way to overcome staffing issues.

Stakeholders:

The key stakeholder in this policy discussion is the public at large. Users of the healthcare system at every level, and especially those in impoverished communities or otherwise compromised healthcare locations, are the likeliest victims of understaffed facilities. This group represents the most important stakeholder in the discussion.

Equally as important and frequently as mistreated are professional healthcare providers, nurses and prospective nurse managers. Their stake is particularly vested in the improvement of wages, working conditions, training and recruitment efforts. This is also true of nurse educators, who have a central role in addressing the present shortage. As Allen (2008) reports, "the lack of faculty to educate the growing demand for baccalaureate-prepared RNs directly impacts the nursing shortage. The nursing shortage thus directly impacts safe patient care. The main reasons for the lack of faculty to meet the demand for more nurses include the increased age of the current faculty and the declining number of years left to teach, expected increases in faculty retirements, less compensation for academic teaching than positions in clinical areas for master's-prepared nurses, and finally, not enough master's and doctoral-prepared nurses to fill the needed nurse educator positions." (Allen 2008) This means that nursing educators are also a key stakeholder.

Other stakeholders include healthcare facility administrators, corporate trustees and public office holders, who will often have entangled or competing interests relating to the profitability of operations and the political expediency of policy orientation. This will also be true of the various professional advocacy groups, nursing associations and lobby groups that will vie for influence in the discussion on any legislation relating to the nursing shortage.

Policy Objective:

A primary policy objective is to endorse any legislation that would aggressively enforce better recruitment of nursing students, better training of existing nurses, improvements in working conditions for nurses and mandated nurse-to-patient ratios. These objectives are underscored by evidence of the opportunities to save lives facilitated by mandated ratios. According to the text by Health Services Research (HSR) (2010), "key findings of the study reportedly include that 10-13% 'fewer surgical patients in New Jersey and Pennsylvania would die if hospitals in those states had as many nurses as California law requires.' Specifically, the study indicates that the ratios could have saved the lives of 468 additional patients during 2005 and 2006 in the two states." (HSR 2010)

Policy Options and Alternatives:

There are several policy options that are currently under consideration in Congress and the outcome of the implementation or adoption of these bills could be a significant improvement of nurse to patient ratios. Among them, S. 992, proposed initially in 2011 by the 112th Congress of the United States calls for "a bill to amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes." (GovTrack1 2011) Sponsored by Democratic Senator Barbara Boxer of California, the bill was aimed at bringing stronger regulatory pressure upon healthcare facilities and managed care complexes to ensure that staffing ratios were commensurate to the number of available beds and inpatients.

That this bill is currently under consideration is a testament to the perceived importance of such legislation where its sponsor and supporters are concerned. This is because this is an identical bill to one previously introduced by Senator Boxer in 2009. To the point, a second bill correlated to the proposal, S. 1031, would be suspended previously. According to GovTrack.us, "this bill never became law. This bill was proposed in a previous session of Congress. Sessions of Congress last two years, and at the end of each session all proposed bills and resolutions that haven't passed are cleared from the books. Members often reintroduce bills that did not come up for debate under a new number in the next session." (GovTrack 2009)

The legislative importance of this issue is underscored by the bill subsequently introduced by Representative Janice Schakowsky to the 112th Congress. H.R. 2187, called "Nurse Staffing Standards for Patient Safety and Quality Care Act of 2011," is designed to institute mandatory nurse-to-patient ratios that would require hospitals to maintain adequate staffing quotas. The nature of the bill is such that there is a significant demand for continued debate and revision. GovTrack.us reports that "the bill at this stage is intended to "go to committees that deliberate, investigate, and revise them before they go to general debate. The majority of bills and resolutions never make it out of committee." (GovTrack2 2011)

It is hoped that the pending legislation will make greater headway in establishing federal mandates on staffing ratios. According to Berkowitz, "staffing ratios have been mandated in some states through legislative action as a solution to inadequate nurse staffing an concerns aobut the quality and safety of patient care." (Berkowitz 2012) However, the text goes on to note that mixed expectations have greeted this state level legislation, causing some concern about the implications of a federal mandate on the same order. Certainly, it does strike the researcher here as reasonable that government intervention would be appropriate to bring greater regulatory consistency to healthcare staffing the consequent quality of health outcomes. However, Berkowitz warns that many healthcare facility administrators and enterprisers have argued that this imposed upon their capacity to conduct business with optimal efficiency and economic viability.

To this concern, policy alternatives may be considered. To the point, Berkowitz reports that in addition to legislative efforts mandating hospitals to maintain ratios more conducive to quality care outcomes, there are ways to improve staffing ratios that do not require regulatory imposition. Here, Berkowitz indicates, "Buerhaus (2009) has imposed several non-regulatory solutions to safe staffing including improving hospital work environments, incentives to hospitals for high quality care and a focused effort on reducing the nursing shortage." (Berkowitz 2012)