Running Head: POLICY ANALYSIS

Health Policy Analysis Melody France MHA 620: Health Policy Analyses

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Problem Statement One suggested pproch to ensure safe and effective ptient care hs been to mndte nurse staffing ratios. In 1999 California becme the first stte to mndte minimum nurse-toptient ratios in hospitals. California is not the only stte to enct minimum nurse staffing ratios for hospitals, over the pst four yers t lest eighteen other sttes hve considered legisltion regrding nurse staffing in hospitals. Policymkers re forced to consider lterntives to nurses ratios due to nurse shortges. Whether minimum staffing ratios will improve working conditions enough to increse nurse supply is unknown. The United Sttes Helthcre System A chasm exists between the support for and opposition against mandated, legislated nurse-to-patient ratios. Some organizations advocate for ratios as a method to promote patient safety and nurse satisfaction. By contrast, groups in opposition state reasons such as loss of control at the hospital level, setting staffing levels based on ratios rather than patient dependency, and setting unrealistic demands for nurse recruiting in an environment of a nurse staffing hortage. Additionally, other reasons against ratios include an increase in hospital closures due to an inability to meet the staffing minimums; increase in Emergency Department diversions (denied access because a hospital cannot accommodate additional patients); delays in elective surgeries due to temporary operating room closures; and increased healthcare costs to meet legislated staffing levels. The United Sttes helthcre system hs chnged significntly over the pst two decdes. dvnces in technology and n ging popultion (bby boomers) hve led to chnges in the structure, orgniztion, nd delivery of helth cre services (Spetz, 2001). Low nurse stffing levels in cute cre hospitls re jeoprdizing the qulity of ptient cre nd is the leding cuse

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for Registered Nurses (RNs) to leve the profession (Spetz, Sego, et l., 2000). pprehension for the nursing workforce nd the sfety of ptients in the U.S. helthcre system now hs the unprecedented ttention of helthcre policy leders t every level (Spetz, 2001). One suggested pproch to ensure sfe nd effective ptient cre hs been to mndte nurse stffing rtios (Donldson, FN, Bolton, Jnet, Meenu Sndhu, 2005). Do patients get better care, experience fewer adverse events, and have shorter lengths of stay and lower mortality? Are nurses doing a better job, and by extension, are doctors and other hospital workers? And how much has the increased expense affected hospitals' bottom lines? Unfortunately, a solid answer remains elusive (Clark, 2010). As one might expect, hospitals and nursing organizations are divided in their perception of how things are going. The California Nurses Association says the ratios have improved nurse retention, raised the numbers of qualified nurses willing to work, reduced burnout, and improved morale. While it is easy to believe the ratios should give better patient outcomes, upon closer inspection, you need to realize that there are other factors involved besides whether or not the nurse had four or eight patients. What was the acuity of each patient included in this study? Was the patient compliant with treatment in this study? What prognosis did each patient have going into the study? Was the physician available and involved in direct patient care on the unit? All of these factors can affect patient outcomes as well. In 1999 Cliforni did just tht, it becme the first stte to enct legisltion mndting minimum nurse-to-ptient rtios in cute cre hospitls (Donldson, FN, Bolton, Jnet, Meenu Sndhu, 2005). ssembly Bill 394 (1999), directed the Cliforni Deprtment of Helth Services (DHS) to estblish specific nurse-to-ptient rtios for inptient units in cute cre hospitls. This ws done by creting hospitl Licensed nurses clssifiction to include both

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RNs nd licensed voctionl nurses (LVNs) lso referred to s licensed prcticl nurses (LPNs) (Cliforni, 2002 July). Legisltion Several nurse-to-patient ratio laws have been either proposed or enacted at the state and federal levels. There is disagreement about the benefits and consequences of mandating ratios by governmental agencies. The advent of mandated ratios began in California with a bill introduced in 1999 with backing by the California Nurses Association. This ws not the first time legisltion hd contemplted nurse-to-ptient rtio. In 1996, proposition 216 would hve estblished stffing stndrds for ll licensed helth cre fcilities in ddition to creting sttewide helth insurnce system (Cliforni, 2002 Jnurry). The bllot proposition tht ws rejected by the voters in 1996. gin in 1998, ssembly Bill 695 ws introduced nd pproved by the stte legislture but vetoed by then Govenor Pete Wilson (Cliforni, 2002 Jnurry). Intense lobbying by unions representing Cliforni nurses would chnge everything with the pssge of ssembly Bill 394 (Cliforni, 2002 July). The intense lobbing pid off with the election of new governor, Gry Dvis, in November 1998, who ws endorsed by unions representing nurses nd other workers (Spetz, Sego, et l., 2000). Cliforni DHS proposed the minimum nurse-to-ptient rtios (Cliforni Hospitl, 2004). Thus rnged from one nurse per ptient in operting rooms to one nurse per eight infnts in newborn nurseries. The DHS proposed tht the minimum rtios for medicl-surgicl nd rehbilittion units be phsed in (Cliforni Hospitl, 2004). They initilly set minimum rtios for these units t one RN or LVN per six ptients nd within twelve to eighteen months the gol ws to shift to one nurse per five ptients (Cliforni, 2002 July).

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Cliforni Lw Regrding Nurse Stffing Prior Cliforni lw regrding nurse stffing in cute cre hospitls were extended under ssembly Bill 394 (1999). Stte nd federl regultions ffect the demnd for licensed nurses. Under the 1976-1977 stte legisltive session, Cliforni hospitls must hve minimum rtio of one licensed nurse per two ptients in intensive cre nd coronry cre units (Cliforni Hospitl, 2003). Federlly certified nursing homes re required to hve RN director of nursing nd RN on duty 8 hours dy, seven dys week (Cliforni stte). If the fcility hs under 60 beds, the director of nursing cn serve s the RN on duty (Hrrington, 2001). This legisltion lso requires tht t lest hlf of licensed nurses working in intensive cre nd coronry cre units be RNs (Cliforni stte ,Title 22, Division 5, Chpter 1, rticle 6, Section 70495(e). Legisltion encted in the erly 1990s requires hospitls to use ptient clssifiction systems to determine nurse stffing needs for inptient units on shift-by-shift bsis nd to stff ccordingly (Cliforni stte ,Title 22, Division 5, Chpter 1, rticle 6, Section 70495(e). In Jnury 2004, hospitls lso will fce minimum licensed nurse-to-ptient rtio requirements in other hospitl units, s estblished by ssembly Bill 394 (Cliforni stte, Chpter 945, Sttutes of 1999). Numerous estimtes of the effect of these rtios on demnd for licensed nurses hve been published. The DHS nlysis, conducted by reserchers t the University of Cliforni, Dvis, predicts tht 5,820 new nurses will be needed in Cliforni hospitls to meet the stffing requirements (Krvitz, Suve, Hodge, et l., 2002). Other nlyses conducted by independent reserchers hve reported tht the incresed demnd for nurses due to the rtios could be s low s 1,600 (Spetz, 2002).

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Growing Numbers Of Reserch ssocites Research on the effects of altering nurse-to-patient ratios and the resulting outcomes appears to be inconclusive. Although it is intuitive to say that increasing nurse staffing will have beneficial results on outcomes, safety, and nurse satisfaction, there does not seem to be a significant body of research on how to achieve this effectively and efficiently. A comprehensive literature review conducted in part by the University of California Davis Center for Nursing Research (2002) states, We found no evidence to justify specific nurse-to-patient ratios in acute care hospitals, especially ratios that are not adjusted for case mix and skill mix. Growing numbers of reserch ssocites importnt benefits for ptients nd nurses will rise with the ssembly Bill 394 (iken, Clrke, Slone, 2002). It hs been rgued tht nurse stffing levels re now so low s to jeoprdize the well-being of hospitl ptients (Cliforni. Office of the Governor, 2002). Supporting ssembly Bill 394, minimum nurse-to-ptient rtios ssure qulity by estblishing minimum stndrd below which no hospitl cn fll (ssembly Bill 394, 1999). Reserchers disgree with Clifornis sttute requiring use of cuity-bsed ptient clssifiction systems becuse it is indequte nd difficult to determine whether hospitls re complying with this mndte (Cliforni Hospitl, 2004). Insted they support simple minimum rtios to enble nurses, ptients, nd fmily members to esily identify nd report inptient units with dngerously low stffing levels (Donldson, FN, Bolton, Jnet, Meenu Sndhu, 2005). It is believed tht working conditions hve lrge influence on the number of persons willing to prctice nursing in hospitls (Krvitz, Suve, Hodge, 2002). To most, minimum stffing rtios would improve working conditions, which would in turn reduce the numbers of nurses leving hospitl positions nd the nursing profession (Donldson, FN, Bolton, Jnet,

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Meenu Sndhu, 2005). Creting better work environment nd conditions lso my ttrct more young persons to nursing (Krvitz, Suve, Hodge, 2002). Incresed ttention to nursing nd rising slries re lredy rising interest levels; the mericn ssocition of Colleges of Nursing reports tht enrollments in bcclurete nursing progrms incresed in 2001, for the first time in six yers (mericn ssocition of Colleges of Nursing, 2001). The ssembly Bill 394 (1999), is gret nd will crete sfer environment for ptients, nd stffing rtios would help to llevite the nursing shortge but without nurses to meet the rtios one cnnot uphold nd follow the nurse-ptient-rtios. This is why Cliforni Governor Gry Dvis nnounced the Nurse Workforce Inititive in his Jnury 2002 Stte-of-the-Stte speech (Cliforni. Office of the Governor, 2002). The purpose of the Nurse Workforce Inititive (NWI) is to develop nd implement proposls to recruit, trin, nd retin nurses both to ddress the current shortge of nurses in Cliforni nd to support implementtion of new hospitl nurse-to-ptient stffing rtios lso nnounced in lte Jnury 2002 (Sego, Spetz, Coffmn, Rosenoff, ONeil, 2003). The Governor mde vilble $60 million over three yers for the NWI (Cliforni, 2002 July). His gol is to use components designed to ddress the nurse shortge using both short nd longer term strtegies. This cn rnge from working in prtnership with locl hospitls, scholrships for nursing students, creer ldder projects, workplce reform efforts, nd other strtegies to increse the number of nurses (Cliforni, 2002 July). n evlution will be done to determine which strtegies to increse the supply of nurses re most effective nd improve the understnding of the lbor mrket dynmics for nurses (Sego, et l, 2003).

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Stffing Rtios Whether minimum stffing rtios will improve working conditions enough to increse nurse supply is unknown. The experience of hospitls in Victori, ustrli, one of the few jurisdictions to implement minimum nurse-to-ptient rtios in hospitls, is instructive (Needlemn, Buerhus, Mttke, Stewrt, Zelevinsky, 2001). Lrge numbers of nurses returned to the nursing profession fter the minimum rtios were estblished. However, hospitls continued to fce shortge of nurses, becuse there were not enough returning nurses to meet demnd, forcing hospitl to close hospitl beds (Needlemn, Buerhus, Mttke, Stewrt, Zelevinsky, 2001). California's nurse-to-patient ratios, which were fully phased in by April 7, 2005, call for one nurse for every two patients in the intensive care, critical care, and neonatal intensive care units, as well as in post-anesthesia recovery, labor and delivery, and when patients in the emergency room require intensive care (Clark, 2010) One-to-three patient ratio is called for in step down units. One-to-four patient ratio is required in antepartum, postpartum, pediatric care, and in the emergency room, telemetry, and other specialty care units. One nurse for every five patients is required in medical-surgical units and one for every six in psychiatric units. Minimum stffing rtios ddress only one piece of the disstisfction with hospitl nursing. Stffing is mjor concern of mny nurses, but RN job stisfction indictes tht they re lso disstisfied with other spects of their work, including low slries, lck of control over work schedules, lck of opportunities for dvncement, lck of support from nursing dministrtors, lck of input into policy nd mngement decisions, nd indequte support stff to perform non nursing tsks (Spetz, 2002).

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Mine nd Msschusetts stte ffilites cut their ties with the mericn Nurses ssocition (N) in 2001, in lrge prt becuse they did not fully gree with the Ns opposition to minimum nurse-to-ptient rtios (mericn Nurses ssocition, 2003). This led to the estblishment of the mericn ssocition of Registered Nurses in Februry 2002, leders of unions representing nurses in Cliforni, Mine, Msschusetts, Missouri, nd Pennsylvni joined to estblish new ntionl ssocition (New Englnd, 2005). The unions will join forces on ntionl projects nd support one nothers stte legisltive, collective brgining, nd orgnizing cmpigns. ANAs recommendation allows hospitals the flexibility of tailoring nurse staffing to the specific needs of patients based on factors including how sick the patient is, the experience of the nursing staff, technology, and support services available to the nurses. This flexibility does not negate the accountability of hospitals to ensure safe and effective nurse staffing. States are looking at enforcement measures ranging from termination or suspension of a facilitys license and public disclosure of violations to fees, penalties and private right of action suits Future Outlook Further reserch is needed to estblish the number of sttes in which nurses unions hve sufficient politicl power to enct minimum nurse-to-ptient rtios. In the short term, the number of sttes is likely to be smll. Clifornis rte of unioniztion mong nurses, pproximtely 25 percent, is much higher thn tht of most sttes (iken, Clrke, Slone, 2002). In ddition, N ffilites re more powerful in other sttes thn in Cliforni. Proctive N ffilites my be ble to persude policymkers to implement other reforms tht ddress nurses concerns bout hospitl stffing (mericn Nurses ssocition, 2003). Other importnt

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vribles include the politicl influence of stte H ffilites nd elected officils ties to orgnized lbor (mericn Nurses ssocition, 2003). Cliforni is not the only stte to enct minimum nurse stffing rtios for hospitls, over the pst four yers t lest eighteen other sttes hve considered legisltion regrding nurse stffing in hospitls (New Englnd, 2005). Twelve sttes hve considered bills tht would mndte minimum nurse-to-ptient rtios in hospitls. Fourteen sttes hve considered legisltion tht ttempts to ddress nurses concerns bout stffing through other mens, such s requiring hospitls to develop stffing plns bsed on ptient cuity, mndting disclosure of nurse stffing rtios, nd estblishing tsk force to study nd monitor nurse stffing. Oregon, hs encted legisltion tht requires cuity-bsed stffing plns (New Englnd, 2005). Recommendtions Policymkers in other sttes my wish to consider well-designed cuity-bsed rtio system s n lterntive to minimum nurse-to-ptient rtios (New Englnd, 2005). Mny sttes hve regultions tht require hospitls to use ptient clssifiction systems to determine nurse stffing, but these regultions fce much criticism, s discussed bove. lthough mny of these regultory systems do not function well tody, they could form the bsis for strong but flexible stffing regultions in the future (New Englnd, 2005). Sttes could mndte prticulr ptient clssifiction systems, develop methods of ensuring tht stff nd ptients re wre of the required stffing during every shift, nd estblish effective enforcement mechnisms (New Englnd, 2005). lterntively, sttes could require tht hospitls submit informtion relevnt to their stffing needs every qurter nd could mndte rtio for tht qurter bsed on n nlysis of ptients needs, vilbility of support stff, nd other fctors (New Englnd, 2005). Texs is

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pursuing totlly different pproch to the nursing sitution tht is tilored to the unique circumstnces of individul hospitls. Under regultions issued 24 Mrch 2002, hospitls re required to estblish committees to develop nurse stffing plns nd to use dt on nursesensitive ptient outcomes to ssess nd djust stffing plns (Texs Nurses ssocition, 2002). t lest one-third of the members of these committees must be RNs engged primrily in direct ptient cre (Institute, 1999). The miniml nurse stffing on ptient cuity or nurse-sensitive outcomes respond to nurses justifible concerns bout hospitl stffing without imposing rigid mndtes (Hrrington, 2001). The flexible stffing pproches seem more pproprite thn rtios, given the complexity nd rpid pce of technology chnging the delivery of hospitl cre. (Hrrington, 2001). Nurses job stisfction nd retention my enhnce the opportunities for hospitl nurses to ply more direct role in stffing decisions (Krvitz, Suve, Hodge, 2002). The key is without more nurses no rtio cn be met. So the focus needs shift on reching s mny young people s possible by showing them tht they to could be good fit in the nursing community. They need to know tht nurses re people too, nd the trits of nurse, such s not being squemish over the sight of blood comes with time. Stepping out into the high schools nd brodcsting informtion bout nurses cn trnslte into only one thing, more students who pursue nursing creer. There is no better wy to strt, thn by plnting seed in the mind of young person who is bout to step out into the world nd choose creer. The more educting nd qulified young people helth cre workers cn get to chose nursing creer, the better off the nurse-to-ptient rtio becomes, llowing for sfer environment for future ptients, by permitting more effective helth cre. More focus should be given to the overall health and well

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being of the staff including such basics as access to nourishment and time away from the patient care area to eat; and providing exercise equipment or health focused programs on site. Helth cre orgniztions need to protect the public from unsfe, illegl, nd unethicl prctice. Nurses morlly nd ethiclly cn not prctice effectively in unsfe nd dngerous conditions. Regultory uthorities nd professionl nursing orgniztion must demnd inititives to reduce helth cre cost. The filure to mintin stndrds of prctice by incresing worklod, cring for sicker ptients will result in nursing errors nd overlooked medicl problems nd could led to deth. Hospitals need to focus on nurse recruitment and retention. It is incumbent upon hospital administrators and legislators to provide opportunities for those to enter and then remain in the profession. Todays youth need education and encouragement to consider nursing as a career. Novice nurses may prefer work shifts that accommodate work-life balance. Veteran nurses may need more creative scheduling or positions that are physically less demanding, perhaps shorter shifts for older nurses or those with physical disabilities. The utonomy of nurses is jeoprdized. Nurses re finding it difficult to spek out nd to tke ction when ptient sfety is t risk. Nurses need voice nd need to be herd. Nurses need to become politiclly involved. Writing to your locl congress mn or women to stnd up for wht is not right. Being silent is not the nswer. Justice is not being served when nurse to ptient rtio's re fr more thn one nurse cn hndle. s nurses struggle to defend nonmleficence to do no hrm. Consideration must be given to the utilization and education of other licensed care providers. LPN/LVN and other caregivers are available and their roles should be maximized in the acute care setting, rather than eliminating their positions. Hospital administrators must

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include staff nurses in the discussion and development of staffing policies and staffing plans. Nurse managers must be attuned to the staff they oversee. More emphasis should be given to the process of incident review, ensuring that it is for the good of the patient and never used for punitive reasons. Other factors affecting nurse workload need to be considered. This policy inititive hs listed mny of recommendtions tht re chievble from the nursing level up to the federl nd hospitl level. These recommendtions need to hve ccountbility ssigned to them. The nursing shortge cn be resolved, but someone needs to tke risk t mking tht chnge hppen. It is risk, but the long term effects of tking tht risk re fr greter thn tking no risk t ll. The chnges tht need to be mde re incresing federl funding to give nurses chnce t succeeding. Nurses need to be retined nd need to feel supported. Mgnet sttus is tht chnce tht we s nurses need to be given. Nurses need to be herd. Lon forgiveness through the Nurse Prctice ct cn be chieved. The fcts re, hospitls, legisltors, government, nd CEO's need to relly consider the lterntives if the nursing shortge is not resolved. Job burnout, nurse to ptient rtio's, unsfe work environment, qulity of ptient cre is the responsibility of everyone, if tht is not obtined the projections tht results from the increse demnd needed to fill the vcncy will become relity. It may still be unclear how the ultimate measure of patient safety and quality outcomes can be obtained. What is clear, however, is that state officials, legislators, health care organizations, colleges and the nursing community must work together for solutions. A requirement mandating hospital administrators to simply count the number of patients a nurse can care for does not seem to be an appropriate or realistic solution. Consideration must be given to identification of nurse sensitive indicators beyond patient ratios; establishment of consistent data collection; lobbying at state and federal levels for research and financial support;

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and agreement by all hospital administrators that adequate nursing care remains the key to safe patient care.

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References iken, L., & Clrke, S., & Slone, D. (2002). Hospitl Restructuring: Does It dverselyffect Cre nd Outcomes? Journl of Nursing dministrtion, 30(10), 457 465. mericn Nurses ssocition. (2003). Nurse Stffing Plns nd Rtios. Retrieved June, 10, 2007, from http://nursingworld.org/GOV/STTE/2003/rtio1203.pdfmericn ssocition of Colleges of Nursing. Clark, C. (2010) Does mandating nurse-patient ratios improve care? Retrieved from http://www.healthleadersmedia.com/content/NRS-245408/Does-MandatingNursePatient-Ratios-Improve-Care Dvis, report submitted to Stte of Cliforni, Deprtment of Helth Services, Licensing ndCertifiction. Institute for Health and Socio-Economic Policy. (1999 September). California Health Care: Sicker Patients, Fewer RNs, Fewer Staffed Beds. Retrieved 10 June, 2007 from www.clnurse.org/cn/pdf/StffingRtios6.pdf Krvitz, R., & Suve, M., & Hodge, M. (2002). Hospital Nursing Stff Ratios and Quality of Care. University of California Needlemn, J., & Buerhus, P., & Mttke, S., & Stewrt, M., & Zelevinsky, K. (2001). Nurse Staffing and Patient Outcomes in Hospitals. Washington DC: Bureau of Health Professions, U.S. Department of Health and Human Services. Retrieved June, 10, 2007, from http://bhpr.hrs.gov/nursing/stffstudy.htm New England public policy center and the Massachusetts health policy forum. (2005, July). Nurse-to-patient ratios: Research and reality. Retrieved 10 June, 2007, from http://www.bos.frb.org/economic/neppc/conreports/2005/conreport051.pdf

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Sego, J., & Spetz, J., & Coffmn, J., & Rosenoff, E., & O'Neil, E. (2003). Minimum Nurse to Patient Ratios: The California Workforce Initiative Survey. Nursing Economics 21(2), 65-70. Spetz, J. (2002). Revised Cost Estimates of Minimum Nurse-to-Patient Rtio Proposls. Sn Frncisco, C: Center for the Health Professions. Spetz, J. (2001). What Should We Expect from Cliforni's Minimum Nurse Staffing Legislation? The Journal of Nursing dministrtion 31(3), 132-140. Spetz, J., & Sego, J., & Coffmn, J., & Rosenoff, E., & O'Neil, E. (2000, December). Minimum nurse staffing ratios in California cute care hospitals. Retrieved June, 05, 2007, from University of California, Sn Francisco, Center for the Health Professions . University of California Davis Center for Health Services Research in Primary Care and University of California Davis Center for Nursing Research. (2002). Hospital nursing staff ratios and quality of care: final report on evidence, administrative data, an expert panel process, and a hospital staffing survey