Staffing for Nurses in Hospitals

Proposal for mandatory staffing ratios
Introduction: Reflection
Public Policy Issue
This policy will mandate that mandatory staffing ratios be met by hospitals throughout the nation. This is an important public policy issue because it would oblige hospitals that are part of the Medicare program to create a committee that is partly made of nurses who can discuss the issue of staffing. As Fowler and Comeaux (2017) point out, staffing is still a major challenge for nurses. If there are too few nurses on staff it can lead to nurse burnout. The right ratio of nurses to patients is required to prevent nurses from being overburdened (Martin, 2015). The reason I selected this policy is because it is clearly important to nurses’ own health and ability to do their jobs. It can also play a part in preventing turnover rates from going too high (Laschinger & Fida, 2015). Therefore, this is an issue that can address a lot of problems in health care and improve community health.
Relevance
The policy on staffing ratios is relevant to nursing because it can be a solution to the problem of low quality care (Fowler & Comeaux, 2017) and it can be a way to ensure that nurses feel confident about their work (Martin, 2015). As Martin (2015) shows, better staffing ratios helps to improve quality care for patients. And as Laschinger and Fida (2015) show, when nurses feel they are giving quality care they are happier in their jobs and are more satisfied. When they are more satisfied they are more likely to stay in their jobs, too, which means lower turnover.
Financial Impact
The financial impact of mandatory staffing ratios has to be viewed in two ways. First, it has to be viewed in terms of the initial cost to the facility. Second, it has to be viewed in terms of the overall savings over time. First, the cost of mandatory staffing will be an increase in labor costs, which is likely to be over one million dollars for hospitals that have to increase staffing to meet the mandatory ratio (Reiter, Harless, Pink & Mark, 2012). These are the direct costs of nursing, which make up 30% of hospital costs (Reiter et al., 2012). Twigg, Myers, Duffield, Giles and Evans (2015).point out that increased staffing with a 4:1 ratio of patients to nurses can have a $40,000 cost per life saved for the hospital. Second, however, is the long-term savings. Twigg et al. (2015) also show that if staffing is increased by one full time RN equivalent per patient per day, the savings from years of life and productivity in society can be up to $13 billion. This shows that up-front costs exist but that there are also long term economic benefits for society.
My Values
My values impact my position on this policy in that I believe it is important for the right number of nurses to be on staff to treat patients. If there are too few nurses, patients do not receive the attention they deserve. Health care should be about putting patients first. I believe in patient-centered care and that hospitals should have a patient-centered care approach. They should have mandatory staffing ratios so as to ensure that quality care is always delivered.
Ethical Theory
The ethical theory of deontology is what underpins my perspective. Deontology or duty ethics argues that the morality of an action is determined by the role of the individual. The role of the hospital is to treat patients using quality care. If there are not enough nurses on staff, that quality care will not be possible. The hospital will not be doing its duty towards the patient. From the standpoint of deontology, the hospital has a duty to have the right ratio of nurses to patients because of the savings in terms of life years and economic benefit for society. If hospitals want to be in the industry they should be held accountable to society standards.
Policy Brief
Decision Maker
The decision maker who will receive this policy brief is Sen. Rand Paul from Kentucky. He is a member of the Senate Health Committee and will be able to draw attention to this issue because he is well-known in politics. This public policy requires Paul’s attention because a national law for mandatory staffing ratios will be effective at obliging hospitals to increase staffing (Fowler & Comeaux, 2017). Paul is a trusted senator who can help to promote this policy and see it through to legislation.
As Twigg et al. (2015) show, there is also an economic case to be made for investing in improving staffing ratios. That is one other argument that Paul can make to help promote this policy in the Senate. When there are too few nurses to treat patients, the patients do not receive the kind of quality care they require. They in turn do not get back to good or normal health. They lose years on their lives because there are not enough nurses on staff to help them learn how to care for themselves appropriately. Because nurses are overburdened they do not have time to engage in preventive medicine. All they can do is treat patients and move on to the next one. Emergency rooms are overwhelmed because there is just not enough help to go around.
To improve access to care, which is one of the Institute of Medicine’s aims for the health care industry and one of the Healthy People 2020 goals, mandatory staffing ratios should be required. The decision maker should argue in Congress that a bill to make staffing ratios mandatory is needed. The reason for this is simple: access to health care has to be improved, and nursing shortages are a big obstacle to access to care. Obliging hospitals to meet staffing ratios would solve that problem and help to make America healthier.
Main Challenges
The main challenges of addressing this policy are that hospitals are likely to push back against it and they have powerful lobbies in Washington. Hospitals want to protect their margins and if they are required to hire more nurses that will cut into their margins. They will lose money in the short-term and the economic benefit may be more in terms of what the community gains than in terms of what the hospital gains. That, however, depends on how much is saved in turnover. As there is a turnover cost of about $30,000 for each RN at a hospital (Rondeau & Wagar, 2016), it should be seen that when quality of care is improved through increased staffing ratios the costs will be canceled out by savings long term: turnover rates will be reduced because nurses will experience higher job satisfaction (Laschinger & Fida, 2015).
Getting Congress to appreciate this will be the main challenge because they will be moved by lobbies to protect hospital margins. The Congress should be able to argue back to lobbies that hospitals will end up not losing money by meeting mandatory staffing requirements and that the benefit for the community will be good. The Congress should discuss the need for positive corporate social responsibility by all hospitals and that this legislation will support corporate social responsibility.
Another challenge will be what to do about hospitals that cannot afford to meet staffing ratios. It could be possible for a government subsidy to be provided for hospitals that need to be in compliance but cannot be within the short term. This subsidy could be in the form of a tax write-off. That would allow hospitals to not be over-extended up front.
Primary Options
The primary options for the decision maker would be to have a focus group where people of different communities could come to give their perspectives on the issue. This could include health care professionals such as nurses and doctors. It could include patients. It could include community leaders and business industry leaders. Everyone could give a perspective on the issue of staffing ratios. The key is that health is an issue that impacts many different stakeholders so the matter of staffing is not just something that impacts hospitals.
The senator should be open to hearing from these different stakeholders. This will take away the ability of hospital lobbies to dictate terms or to give the only perspective that lawmakers hear. The best way for Paul to get around the obstacle of the health care lobby is to neutralize it. The health care lobby is powerful and can reach many different people. But if many different people come to show why mandatory staffing ratios could work to improve health outcomes and the economy overall, that would be good for this legislation.
The senator could work with health care organizations and community activists to locate individuals to participate in the focus group or to testify in Congress. The more voices that come to support the policy, the more it will gain support from legislators. The more that people are talking about it, the more likely it is to happen.
Another key way for the senator to get around challenges is to use social media. The president has shown how powerful social media is as a communication tool. By getting a topic trending using a Twitter hashtag or a Facebook page, the senator and other supporters would be able to spread the knowledge of the issue far and wide. Social media can be used to create movements like #MeToo. This kind of social movement can become political and change the lives of many. These options are all tangible because they are easily within the power of the decision maker and his aides to perform without much trouble, resources or inconvenience.
Persuasive Course of Action
A persuasive course of action for the decision maker would be to use social media to create a public campaign that will raise awareness about the need for mandatory staffing ratios. The public campaign could easily catch on via Twitter and Facebook and the decision maker could release statistics and publish infographics on social media that would help people to understand the issue. The need for national legislation would be argued over social media and then taken up in Congress.
Social media is a good place to argue for this course of action because it is where communication can easily be spread. Ideas can quickly take shape among users of social media. A grassroots movement can begin on social media. This is the type of support that can move Congress to act. It is needed for both the House and the Senate to come together over a bill like this. So there has to be enough support from both parties for it to work. That is why the social media movement can really help. It can appeal to people and patients on either political side.
The way to build the base is to get people from both sides of the political aisle to agree that this mandatory staffing ratio is needed. This can be accomplished by appealing to reason. People use reason to show why there is a need for a better access to care. Access to care is what allows all individuals to obtain the health services they need. Everyone will agree that more nurses on the staff will allow that to happen.
To deal with hospitals and to prevent their lobbies from influencing politicians to vote against the bill, the Congress has to be smart. They have to realize that not all hospitals will have the funds to cover increased staffing. Subsidies should be made available to help hospitals cover these funds for the first few years. This should be written into the legislation. It could be a subsidy in the form of a tax credit. The hospitals that need the tax credit to increase their staffing ratios will be able to take advantage of it. This will appeal to the hospitals because they will appreciate the assistance from the government.
To avoid the challenges mentioned above, the decision maker should be willing to create a policy that will be acceptable to all stakeholders. It will be one that patients and communities feel is good and one that hospitals can work with and eventually budget into their finances. The best approach is one that will be slow and cautious, but the goal is to improve access to care. That should be the main goal that everyone is aware of, and explaining how improving staffing ratios by setting a mandatory patient-to-nurse ratio will help people to see that.
Evaluation
To evaluate the success of the policy brief, it will be necessary to consider the whole picture—i.e., the big picture first. The big picture that needs to be looked at is whether this policy will improve access to care for people and whether it will improve quality care for patients. It also has to look at whether the policy will improve job satisfaction for nurses and decrease their burden. This is what will impact turnover rates and make it so that hospitals are not losing $30,000 per year on RNs every time one leaves the industry.
Is the policy effective the way it is proposed here? First, it is one that will improve quality of care because it can be seen that when nursing staff ratios are improved nursing care improves (Martin, 2015). Second, because better quality of care will be provided, nurses will feel more satisfied in their work and will be less likely to want to leave the industry (Laschinger & Fida, 2015). Third, because there will be more nurses available to treat patients, there will be greater access to care. Fourth, because the access to care will improve, the health of the community will also improve. Nurses will be able implement more preventive care as they will have more time to work with individual patients and develop appropriate care plans for them. This is one of the needs of the Affordable Care Act, so this policy will also help to achieve that goal.
From this big picture evaluation, it can be seen that this policy will be effective. From the top-down, the legislators in Congress will be able to create a bill and pass it into law making it mandatory for hospitals to meet patient-to-nurse ratios. Hospital administrators already have to develop a committee in many states that nurses can be part of to represent the nurse employees that will work to ensure that the ratios are being met and that the hospital is properly staffed. The mandatory law would make it clear what those ratios must be.
Create a Plan
Organization to Work With
The American Nurses Association (ANA) is a nursing organization that has written a white paper on how to improving patient outcomes by having a mandatory staffing ratio. The ANA is a very popular organization and has many good points for how this policy issue can be addressed (Dousay, Childers, Cole, Hill & Rogers, 2016). The ANA has shown that it wants to address this issue by using the committee model, which means that it wants hospitals to form committees with nurses to ensure the right ratio is being used in the hospital. The ANA uses these criteria to determine what the ratio should be:
· intensity of patient's needs,
· the number of admissions, discharges, and transfers during a shift,
· level of experience of nursing staff,
· layout of the unit,
· and availability of resources (e.g., ancillary staff, technology) (ANA, 2019).
The ANA has clearly shown an interest in this issue and it wants to address it. This would be a good organization to work with.
The goal of this policy, however, is to move beyond the committee model and create legislation for mandatory staffing ratios. This would eliminate the need for the committee model and allow hospitals to forego that step and simply focus on compliance with the law. The ANA should be willing to work on this policy because it is helpful in solving the issues addressed above.
Three Principles
Three CBPR principles I could use to work with the organization to address policy change are:
1) to recognize the community
2) to address the community’s needs and use its strengths and resources to do so
3) to collaborate with partners in the community so that the community shares control in the policy
These principles will help to guide the policy along the way. Collaborating with the community starts with recognizing the community and reaching out to it. This can be accomplished using social media, which is a powerful tool for communicating today. The goal of the community aligns with the goal for the policy issue because every community wants good access to care and quality care, and that is what this policy aims to give.
Action Steps
The action steps that need to be taken to achieve the goals are to collect research on what the best patient to nurse ratio for staffing is. The evidence will be gathered by conducting a systematic review of the literature. The literature will show what ratios have the best outcomes. The 4:1 ratio has been identified as one of the best (Reiter et al., 2012; Twigg et al., 2015). This information will be used to help draft the policy. That policy can then be sent to the senator who can promote it in Congress and begin drafting a bill based on the policy devised. To write the policy it will be necessary to connect with members of the community and to work with the organization and the community leaders. They will have inputs that can be used to create an effective policy that meets all stakeholders’ needs, from patients to nurses to hospital administrators to legislators and lobbyists.
Roles of the Community
The community will play a role in solving the problem by discussing the access to care needs of the community and representing patients who have stories about the care they have received in the past. Their opinions will help to provide support for the policy. They will be useful for the focus group organized by the senator, too, as the senator seeks to gain support for the bill. They will also be needed to help make the social media campaign go viral to raise support for the policy.
Key Elements
Key elements of developing a collaborative evaluation plan using CBPR principles are to:
1) use a cyclical and iterative process, starting with the partnership and going through all the stages of development;
2) identifying what social factors lead to health
3) sharing the findings so that the community knows and has access to the language used
4) strengthening the relationship for the long-term
5) making sure the members of the team are able to learn from one another
Evaluation
The success of the community can be evaluated by measuring outcomes such as how many users are tweeting the #MandatoryStaffing hashtag or whatever the hashtag will be. It will measure how many followers promoters of the policy have. It will measure how many respondents from the community share their stories on social media. This is the type of bottom-up approach that is needed to evaluate the success of the community plan.
Strengths and Challenges
The strengths of the top-down and bottom-up approaches in achieving policy changes are that they tackle the issue from two different perspectives. The top-down approach starts with the decision-makers at the top—the people in Congress who write the laws. They have to be convinced of the big picture and why the policy will bring about the outcomes that the community desires. The strengths of the bottom-up approach are that the community has to buy in to the policy for the bottom-up approach to work. When the community buys into it, the policy can gain traction quickly and gain a lot of interest from legislators, especially if the media puts a spotlight on the movement.
The challenges of the top-down approach are that it can be very difficult to gain the attention of a lawmaker without having a big following behind the policy. The challenges of the bottom-up approach are that even if a movement for a policy change does gain traction in the community, there is no guarantee it will get attention from Congress.
The approach that I would recommend as the most effective to address this policy issue is the top-down approach because grassroots movements and community-based movements can take years to gain traction. The top-down approach can be more effective in addressing policy change because it goes straight to the source of power and moves from there. Getting a decision maker to agree that the policy is needed is a big step in the right direction.
References
ANA. (2019). Nurse staffing. Retrieved from https://www.nursingworld.org/practice-policy/advocacy/state/nurse-staffing/
Dousay, T., Childers, B., Cole, M., Hill, T., & Rogers, C. (2016). Lower Nurse-to-Patient Ratio: Higher Patient Satisfaction. Retrieved from https://scholarworks.moreheadstate.edu/cgi/viewcontent.cgi?article=1105&context=student_scholarship_posters
Fowler, D., & Comeaux, Y. (2017). The legislative role in nurse staffing ratios. MedSurg Nursing, 26(2), 12-14.
Laschinger, H. K. S., & Fida, R. (2015). Linking nurses’ perceptions of patient care quality to job satisfaction: the role of authentic leadership and empowering professional practice environments. Journal of Nursing Administration, 45(5), 276-283.
Martin, C. J. (2015). The effects of nurse staffing on quality of care. MedSurg Nursing, 24(2), S4-S4.
Reiter, K. L., Harless, D. W., Pink, G. H., & Mark, B. A. (2012). Minimum Nurse Staffing Legislation and the Financial Performance of C alifornia Hospitals. Health Services Research, 47(3pt1), 1030-1050.
Rondeau, K. V., & Wagar, T. H. (2016). Human resource management practices and nursing turnover. Journal of Nursing Education and Practice, 6(10), 101.
Twigg, D. E., Myers, H., Duffield, C., Giles, M., & Evans, G. (2015). Is there an economic case for investing in nursing care–what does the literature tell us?. Journal of advanced nursing, 71(5), 975-990.