C159 – Policy, Politics and Global Health Trends

A major concern for the healthcare industry today is the increasing trend of healthcare policy and politics. Healthcare policy involves decisions and actions that are undertaken to achieve certain healthcare goals within a society, state, or nation. The increasing trends in healthcare policy aim at making laws that can improve the quality of care and patient safety across various healthcare institutions. The major challenge observed in matters of healthcare policy is that its implementation rests with different government actors. Today, a lot of healthcare bills remain pending in the United States making healthcare delivery challenging. This paper analyzes a selected healthcare policy issue impacting the nursing profession and proposes changes to address the problem.

Public Policy Issue

The nurses’ vigilance at the bedside is essential to ensuring patient safety and it is dependent on several factors. One of those factors is an appropriate patient ratio that allows for maximum utilization of one’s skills and expertise to promote quality and safety. The issues of nursing staffing ratios and patient maximums are questions of care quality that have existed for decades with no clear policies to address the challenges. Evidently, appropriate nurse-to-patient ratios are observed to increase the quality of care provided alongside other benefits like healthcare provider satisfaction (Agency for Healthcare Research and Quality (AHRQ), 2019). The public policy issue of interest in this discussion is the nurse-to-patient ratio policy in the state of Georgia. This proposal addresses healthcare policy change that will lead to the passing of law regarding the nurse-to-patient ratio in the state of Georgia. This policy will help define the maximum number of patients nurses in different departments should handle in consideration of patient acuity and shift time.

Issue Selection

Safe staffing and nurse-to-patient ratios are not only issues of importance to Georgians, but also the entire nation. Nurse burnout, lateral violence, and other factors impacting job satisfaction all converge to inappropriate nurse-to-patient ratios. The main reason why this policy issue is of importance in the state is that staffing ratios have a direct impact on patient safety, quality, and access to care. It is established that about five nurses quit their jobs within the first year due to job satisfaction-related issues. Additionally, one nurse quits their job within the first two years of work because of burnout and lack of safe staffing (Driscoll et al., 2017). To date, California is the only state in the US that has well-defined minimum nurse-to-patient ratios to be maintained at all times in different units. This evidence suggests that Georgia nurses can greatly benefit from well-established laws governing nurse-to-patient ratios.

Issue Relevance

Nurses are being required to accept the responsibility to care for patients with increased numbers leading to unsafe delivery of care. When addressing the issue of nurse-to-patient ratios, the key emphasis is put on patient safety and access to care. Statistically, nurses who are in charge of too many patients run the risk of becoming stressed out leading to medical errors. Evidence from research demonstrates that more patients are likely to survive if nurses follow a hospital-mandated patient-nurse ratio (Driscoll et al., 2017). Regarding the issue of accessibility of healthcare services, poor staffing ratios limit the healthcare services required for patients. For example, nurses with many patients to serve are less likely to provide comprehensive health education. The result is a poor understanding of patient care and poor quality outcomes such as increased readmission rates. Consequently, the HCAHPS survey scores that are dependent on the patient’s experience decrease affecting the financial reimbursements to healthcare organizations.

Nurses’ vigilance at the bedside is crucial to their ability to ensure patient safety. Appropriate staffing ratios can help improve quality outcomes such as reducing incidences of falls, pressure ulcers, and healthcare-associated infections. Models supporting policies on nurse-to-patient ratios indicate that there will be reduced costs through minimization of errors and reduced readmissions (AHRQ, 2019). Another important aspect that calls for the establishment of this policy is the issue of legal action against medical providers after incidences of safety. Legislation related to medical registration is often a mechanism of dealing with providers who cause patient harm regardless of their intention. With the increased rate of compensation, accountability calls, and retribution for nurses, it is more appropriate to establish safe staffing policies.

Financial Impact

The setting of staffing ratios cannot occur in the relative version of legislative sessions without considering the financial impact of the policy. The passing of the legislation means healthcare organizations will have to incur the cost of hiring new employees. Currently, the healthcare expenditure of the United States is way too high than any other sector. Adding more healthcare workers will be relatively costly to the government and the public. It means the healthcare sector will need to expand to accommodate the new staff, and more programs will need to be set to train and monitor the activities of healthcare workers. Preliminary research indicates that issues with healthcare access will be observed if more nurses are allowed to the industry.

Passing laws on nurse-to-patient ratios can consequently lead to positive financial impacts on healthcare organizations. Improved nurse-to-patient ratios will lead to decreased hospital-acquired infections, readmission rates, and shorter hospital stays. The healthcare organizations will be able to save a lot from the minimization of the above poor quality outcomes. Secondly, it is very costly to replace one nurse in healthcare especially when there is a high turnover rate. Replacement costs are estimated at $82,000 for one nurse, but the establishment of good safe staffing laws can save the organization such costs (brooks et al., 2019). Lastly, the financial status of healthcare organizations today is greatly determined by Medicare and Medicaid Service reimbursements. Improved nurse-to-patient ratios can positively impact the HCAHPS scores and lead to more financial reimbursements to healthcare organizations.

Personal Values

Values are goals and beliefs that establish behavior and provide a basis for decision making. The nursing profession is built on morals and values that guide day to day care of patients. Firstly, I am guided by the values of quality and safety whereby I believe in providing care of the highest standard to the patients. These values should be demonstrated through effective interrelations, decision-making, and actions that bring about positive patient outcomes. Advocating for policies on safe staffing will ensure the improvement of quality and safety. My second value is integrity which dictates healthcare service delivery with honesty, confidentiality, and transparency. I honestly believe that proper nurse-to-patient ratios in Georgia will bring about improved quality and healthcare worker satisfaction. Through the values of teamwork and interprofessional collaboration, I intend to work with policymakers and colleagues to ensure the nursing profession is made better for this and the incoming generation. Lastly, I believe in inclusion where care to the patients is compassionate and valued. Without safe staffing policies, it will be difficult for nurses to provide holistic care with respect to the patient’s needs.

Ethical Principle or Theory

Ethical principles and theories provide a guide to the management of patients acceptably by the nursing profession. My support for the new legislation is based on the ethical principle of non-maleficence. While providing care, nurses must question their actions to whether they may harm the patient through omission or commission (American Nurses Association (ANA) , 2015). These errors are prominent when safe staffing policies are not established as healthcare workers handle large volumes of patients. Actions such as medication errors, poor response to patient needs, an inappropriate level of care are caused by inadequate nurse-to-patient levels. To practice safely, the nurses must serve the right number of patients as proposed in this policy brief.

Decision Maker

The proposed policy will be addressed to the president of the Georgia Board of Nursing, Dr. Darell Thompson.

Explanation

There are several reasons why the proposed policy requires the attention of the Georgia Board of Nursing’s president. The right staffing ratio for nurses and patients is an issue that has long existed in the US and despite capturing the attention of the powerful leader, it remains a challenge. Federal regulation 42CFR 482.23(b) requires hospitals certified by the CMS to have an adequate number of nursing staff at all times (Brooks et al., 2019). The law also mandates an adequate number of supervisory and staff personnel for each department. Georgia is among the states in the US with no policies governing the right nurse-to-patient ratios. Because the state government is charged with formulating these policies, the decision-maker is in a good position to push for the new change.

The issue of creating safe nursing staffing plans is supported by various professional organizations including the American Nurses Association (ANA) and AHRQ. These organizations have pushed for the establishment of staffing levels that are flexible and those that account for the patient acuity alongside other considerations like the use of technology (Paulsen, 2018). The core reason behind the above support is that a correct nurse-to-patient ratio can lead to clinical improvements in patient care and reduction of healthcare costs. For instance, safe staffing enhances safety outcomes by reducing the rate of HAIs, pressure sores, hospital readmissions and patient falls (McHugh et al., 2020). The availability of adequate nursing staff ensures that patients are periodically checked and necessary timely actions are taken to prevent adverse outcomes.

There are currently many campaigns supporting the need to improve registered nurse-to-patient ratios. Among the top movements observed is the national campaign for safe RN-to-patient staffing ratios by the National Nurses United (NNU). These movements stress the importance of safe staffing in enhancing patient satisfaction. The HCAHPS scores are dependent on the quality of care delivered to patients and better quality is often observed when there is adequate staff. Apart from patient satisfaction, safe staffing can improve healthcare worker satisfaction through the prevention of fatigue and burnout (Paulsen, 2018). Inadequate ratios require nurses to work for long hours under stressful conditions.

The cost of healthcare in the US has risen in recent due to issues with policy change. Despite the formation of reforms such as the Affordable Care Act (ACA), healthcare costs continue to rise. For example, 2018 saw the US government spend about $3.6 trillion on healthcare (Pollack et al., 2018). Ensuring that there is a right nurse-to-patient ratio in healthcare facilities can help reduce some healthcare costs through various mechanisms. When there is sufficient number of staff, issues like hospital readmissions and longer hospital stays are avoided. The healthcare providers can assess patients and provide comprehensive care that can minimize costs.

Healthcare policy in Georgia involves the creation of laws and regulations governing the healthcare system by the state government. Dr. Darren Thompson is the current president of the board governing the nursing professionals in the state. I believe he is in a good position to influence policy change in the selected area because of his power. Thompson is the only nurse practitioner on the board and through his expertise, he can advocate for state policy change on nurse-to-patient ratios. As a member of the National Council of State Boards of Nursing Advanced Practice, he can influence the policy by calling for support from other nurses and boards across the nation.

Challenges

Safe RN-to-patient staffing ratios have been proven to save lives, yet under-staffing is a major issue that RNs struggle with every day. The major factor hindering the establishment of the laws across all states is the financial costs that will be associated with the legislation. Passing the new law will necessitate the employment of many nurses to meet the demands of the increasing patient population. Because of the financial challenges, the nurse-to-patient ratio policy has failed to gunner adequate votes in Georgia during the legislative process.

The second challenge to this new policy is political involvement from groups with different interests. Unfortunately, those formulating the policies are not the ones that pass the laws at congress. Additionally, there are few nurses at those posts that can help other lawmakers understand the depth of the problem. This challenge has led to the failure of the healthcare bills concerning staffing to mature. Lastly, the lack of strong nursing leadership has also contributed to the inability to see through a lot of healthcare policy issues today. Apparently, California is the only state with well-established nurse-to-patient ratios in the US. With strong nursing leadership, sound decisions can be made to enable the enactment of laws that could address the grievances of nurses.

Options/Interventions

There are three options that the decision-maker may decide to choose upon receiving the policy proposal. The first option that might be chosen is doing nothing about the policy issue. The president of the Georgia Board of Nursing may decide to turn down the proposal because of political reasons or lack of enough supporting evidence to push through the legislation. For instance, previous nursing strikes have addressed the nurse-to-patient ratio issue with no fruitful outcomes. The decision-maker might consider the new proposal a waste of time based on the past outcomes. Failure to accept the proposal will mean nurses will continue to experience the challenge of high patient volumes during shifts. Consequently, benefits such as improved quality of care and increased healthcare worker satisfaction will not be realized.

The second decision that the policymaker might take is to accept the policy proposal with some modifications or compromise. The decision-maker is a registered licensed practice nurse with a lot of experience in nursing and nursing policy issues. Choosing this option will mean that modifications to the new policy issue will be necessary to gain the attention of other legislators and perhaps yield positive results. For example, the policymaker might consider identifying critical hospital units such as the emergency department, intensive care unit, and the surgical unit that is in greater need of the policy change. Laws dictating adequate staffing in these departments will serve as the starting point before the whole nursing department nurse-to-patient ratio issue is fully addressed.

The third option for the decision-maker is to adopt and support the policy proposal and carry it forward through the change process. Darell Thompson heads the nursing board that is responsible for addressing nursing issues in Georgia. This option will be the most appropriate because of the long-awaited legislation on the issue of safe staffing in the state. If this policy goes through, it will be a major step towards achieving quality and patient safety in the state.

Course of Action

The main challenge of addressing this policy issue at the state level is the political interests of different groups brought about by the financial requirements of the new legislation. Because the majority of the politicians do not understand the healthcare concern, there is a need to improve their knowledge on the issue of nurse staffing. The persuasive course of action will involve inviting nurse educators, researchers, and policy analysts to discuss the relevance of the issue. The nurse educator will enlighten the decision-makers on the issue of safe staffing and how the lack of an existing policy on the issue has led to negative patient outcomes. The nurse researcher will present facts about the shortage of healthcare workers in the state and the negative impact brought about by poor nurse-to-patient ratios. The policy analyst will then explain the financial costs associated with the new legislation, the depth of its significance, and the potential benefits to the nurses, patients, and the state. Another course that can be beneficial is the involvement of professional organizations like NNU to provide leadership and guidance during the change process.

Success of Policy Brief

The process and outcome of the proposed policy change will be beneficial to the patients, healthcare providers, and the government. The first aspect that will dictate the success of the policy change is the acceptance of the policy by the decision-maker. Acceptance of the policy will indicate the desire to improve healthcare in the state through the legislative process. Secondly, the success of the policy will be observed when the policy goes through the committee stage during state hearings. It will be a big win for the nurses in Georgia if congress accepts the nurse-to-patient ratios policy change. At this stage, it will mean that only the governor will have the power to pass or decline the proposal.

The proposed plan of supporting the policy change is the involvement of professional organizations like NNU for leadership purposes. These organizations have the power to influence policymakers through their voice for the people. It will be a great success to the new change if professional nursing bodies will team up to support the legislation in Georgia. The long-term success of the new policy will be evaluated after the policy becomes law. Success will be evaluated in terms of sustainability and positive results on patient quality and safety. For example, one year after the policy change, the patient satisfaction scores should shoot because of the improved quality of care provided by the nursing team.

Identified organization or Community

Registered Nurse staffing ratios are an issue that is addressed by the National Nurses United (NNU) alongside other healthcare organizations in the US. Founded in 2009, the organization is made up of registered in the United States. It is the most active organization and it serves to air the major voices of unionized nurses.

 

Summary of Expressed Interest

Registered nurses in the US have been sounding the alarm over the nurse-to-patient ratios for nearly two decades. NNU is in support of legislation to improve the nurse-to-patient ratios in all states. In their article ‘RN Staffing Ratios’ the organization emphasizes the need to establish minimum RN-to-patient ratios to save lives and improve patient care access (NNU, n.d.). Inadequate staffing is dangerous to patients because it positively promotes errors, illness and leads to mortality. The organization provides a reference to the California law that establishes the right nurse-to-patient ratios according to the nursing units served. Additionally, the organization provides the proposed federal RN-to-patient safe staffing ratios that identify the correct ratios across 24 nursing units. It is through their interest in the policy issue that the state of California was able to pass the safe staffing law after a three-year law-making process.

CBPR Principles

To effectively work with the national Nurses United, the following CBPR principles will be considered

1. CBPR promotes collaborative and equitable partnerships in all research phases and involves an empowering and power-sharing process.
2. CBPR balances research and action for the mutual benefit of all partners.

• CBPR promotes a long-term process and commitment to sustainability

Approach and Collaboration

The National Nurses United has more than 170, 000 members nationwide including representatives from Georgia. To gain the organization’s support, I will persuade the regional representatives to reach out to the NNU presidents to discuss the new policy change. I will write a detailed email explaining the importance of the legislation and how it will benefit the nurses in Georgia. Upon acceptance of the organization’s involvement, a meeting will be scheduled to discuss the policy in detail and to highlight the roles of the organizational members. The National Nurses United works to promote effective collective bargaining representative for its members while promoting the economic and professional interests of nurses. For this reason, collaborative practice will be necessary to ensure the members’ skills and expertise are utilized to push the new policy change. Regular communication through phone calls, emails, and one-on-one meetings will be used to promote collaborative care.

Goal Alignment

The National Nurses United is the voice of registered nurses in the United States. The organization has helped shape the nursing profession through its spectacular achievements. For instance, NNU has organized over 6,500 RNS in the states of Florida, Lowa, Nevada, Texas, and Illinois. It has also sponsored major national legislation like the nurse-to-patient ratio bill in California that became law. These acts make NNU a reliable organization that can push for new reforms in the nursing profession. One of the goals that align with the proposed policy is that NNU advances the interests of direct care nurses and patients across the U.S. (NNU, n.d.). Additionally, NNU expands the voice of direct care RNs and patients in public policy, including the enactment of safe nurse-to-patient ratios and patient advocacy rights in Congress and every state. These goals align with the new policy change that strives to improve safe staffing through advocacy.

Action Steps

The implementation of the new strategy will involve various steps aimed at promoting the enactment of the nurse-to-patient ratios policy. The first step will involve the selection of an implementation team or committee that will help in reaching out to key stakeholders. The second step will involve contacting the nurse educator, researcher, and policy analysts to help in enlightening other policymakers on the new change. A meeting will be organized at the convenience of the decision-maker to discuss the policy issue and its relevance to the nursing profession. The formed committee will reach out to the regional NNU representatives to ask for the support of the union in the policy change process. Lastly, the complete proposal will be presented to the decision-maker to move it forward to a formal change.

Roles and Responsibilities

The National Nurses United members will assume the capacity-building and problem-solving roles during the policy change process. Firstly, the organization will provide the nurse educator responsible for educating the policymakers on the relevance of the issue to the nurses and the public. A licensed nurse practitioner will be the most appropriate individual to describe the challenges observed due to the lack of the nurse-to-patient ratio policy. The second role of the NNU members is to influence the decision-maker to consider the option of accepting the policy change. The union presidents Deborah Burger, Zenei Triunfo-Cortez, and Jean Ross will be persuaded to influence the decision-maker to accept the policy. The engagement of these leaders will serve to fill the capacity-building role that will also entail pulling resources to support the new legislation.

Key Elements of Evaluation Plan

The CBPR principles identified above will be used to evaluate the new policy change plan. The first CBPR principle explains the promotion of collaborative and equitable partnerships in all research phases including empowerment and power-sharing phases (Israel et al., 2010). The demonstration of teamwork and a multidisciplinary approach during the policy change process will indicate the success of the plan. The selected committee, NNU members, and the decision maker’s collaboration including attendance at meetings will dictate the effectiveness of the plan.

The second CBPR principle explains the balance of research and action for the mutual benefit of all partners (Israel et al., 2010). During the meetings, the nurse researcher, a member of NNU, will be responsible for presenting facts about the burden of staff shortages in healthcare. The acceptance of the policy by the decision-maker will indicate a balance between research and action. The third CBPR principle explains the promotion of long-term processes and commitment to sustainability (Israel et al., 2010). The maintenance of strong ties between the policymakers and the implementation team will indicate the success of the plan. Additionally, the NNU members’ demonstration of vigilance and commitment will be necessary for the success of the policy change.

Organizational Plan

The success of the organizational plan will be evaluated using short-term and long-term measures. Firstly, effective coordination of educational events for the policymakers will lead to the acceptance of the policy. Coordination of events during routine follow-up including attendance of meetings by members will indicate the success of the plan. Another strategy of the plan’s success is the passing of the proposal into the law governing nurse-to-patient ratios in Georgia. Regarding the long-term success, the new policy should demonstrate the improvement of HCAHPS scores due to improved quality within one year.

Strength of Each Approach

The top-down approach involves making decisions from the highest level of authority. This approach is advantageous because less time is spent to influence decisions in organizations (McDermott et al., 2015). Secondly, evaluation of the plan’s success is easy because of the organized nature of activities. The bottom-up approach involves making decisions from the lower levels before the final decision by the manager. The approach is evidently advantageous because it allows employees to be part of the decision making process (McDermott et al., 2015). It is also observed that adaptation to the new change is easy when using the bottom-up approach. These two approaches have been used to influence the policy change above. The direct involvement of the decision-maker represents the top-down approach while the involvement of the healthcare organization represents the bottom-up approach.

Challenges of each Approach

The top-down approach poses challenges in the involvement of employees in decision making. When using this approach, communication should be very clear and distortion of information can lead to failure of action plans (McDermott et al., 2015). The bottom-up approach, on the other hand, is time-consuming due to the involvement of all parties in the decision making process. Additionally, challenges can be observed during the evaluation of plans due to the involvement of many steps in the formulation of policies.

Most Effective Approach

The most effective approach to address the nurse-to-patient ratio policy is the top-down approach. The decision making process for policies is complex and it requires clear channels of communication and advocacy that can only be achieved through the top-down approach. If the bottom-up approach is used, it can lead to delays in meetings, submission of reports, and evaluation of programs leading to failure of the change process.

References

Agency for Healthcare Research and Quality. (2019). Nursing and patient safety. https://psnet.ahrq.gov/primer/nursing-and-patient-safety

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Nursesbooks. org. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/

Brooks Carthon, J. M., Hatfield, L., Plover, C., Dierkes, A., Davis, L., Hedgeland, T., Sanders, A. M., Visco, F., Holland, S., Ballinghoff, J., Del Guidice, M., & Aiken, L. H. (2019). Association of nurse engagement and nurse staffing on patient safety. Journal of Nursing Care Quality, 34(1), 40–46. https://doi.org/10.1097/NCQ.0000000000000334

Driscoll, A., Grant, M. J., Carroll, D., Dalton, S., Deaton, C., Jones, I., … & Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6-22. https://doi.org/10.1177/1474515117721561

Israel, B. A., Coombe, C. M., Cheezum, R. R., Schulz, A. J., McGranaghan, R. J., Lichtenstein, R., … & Burris, A. (2010). Community-based participatory research: A capacity-building approach for policy advocacy aimed at eliminating health disparities. American Journal of Public Health, 100(11), 2094-2102. https://doi.org/10.2105/AJPH.2009.170506

McDermott, A. M., Hamel, L. M., Steel, D., Flood, P. C., & Mkee, L. (2015). Hybrid healthcare governance for improvement? Combining top‐down and bottom‐up approaches to public sector regulation. Public Administration, 93(2), 324-344. https://doi.org/10.1111/padm.12118

McHugh, M. D., Aiken, L. H., Windsor, C., Douglas, C., & Yates, P. (2020). Case for hospital nurse-to-patient ratio legislation in Queensland, Australia, hospitals: An observational study. BMJ Open, 10(9), e036264. https://doi.org/10.1136/bmjopen-2019-036264

National Nurses United. (n.d.). RN staffing ratios: A necessary solution to the patient safety crisis in U.S. hospitals. https://www.nationalnursesunited.org/sites/default/files/nnu/graphics/documents/Ratios-ANecessarySolutiontothePatientSafetyCrisisinUSHospitals.pdf

Paulsen R. A. (2018). Taking nurse staffing research to the unit level. Nursing Management, 49(7), 42–48. https://doi.org/10.1097/01.NUMA.0000538915.53159.b5

Pollack Porter, K. M., Rutkow, L., & McGinty, E. E. (2018). The importance of policy change for addressing public health problems. Public Health Reports, 133(1_suppl), 9S-14S. https://doi.org/10.1177/0033354918788880