Policy, Politics, and Global Health Trends Health, Medicine Coursework

Policy, Politics, and Global Health Trends
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Introduction
In this era where limited personnel are used to perform increasing workloads, there is a risk of a detrimental increase of mistakes, harm, and misjudgments. In the US, nursing is one of the fasted growing professions yet the country experiences significant shortages coupled with high turnover. As a result, the healthcare sector is particularly susceptible because the few Registered Nurses (RNs) who are employed are being asked to attend to more patients beyond their capacity. In response, the federal and state governments have formulated several mandatory nurse-to-patient staffing ratios, which are intended to enhance the quality of care and the safety of patients. However, some critics argue that mandatory nurse-patient ratios create unfunded mandate by increasing the general costs of care yet enhancement of quality and better treatment outcomes is not guaranteed. This paper examines the effect of RN staffing ratios on healthcare and existing policies that address RN staffing. The paper also explores a policy that addresses RN staffing ratio based purely on the input of RNs.
Why the selection of nurse staffing policy issue?
Since the 1950s, numerous researchers have reported connections between outcomes of patients and nurse staffing (Hartz et al., 1989; Shortell and Hughes, 1998). However, in the majority of these studies, the nurse-patient ratio was not treated as a primary variable but rather as a background variable. In the 1990s, it was hoped that the issue of RN staffing ratio would be addressed because there were sophisticated technologies that would capture the evidence linking the state of nurse staffing to patient safety and care. However, the 1996 IOM report on the significance of nurses and registered nurses on patients care indicated that, at that time, there was no proof that nurse-patient ratio affected patients’ outcomes (Clarke and Donaldson, 2008).
Currently, there is sufficient evidence to indicate that the inadequate number of Registered Nurses in the healthcare industry affects the delivery of healthcare. Some states such as California have responded by mandating hospitals to have a certain number of Registered Nurses in each unit. However, others have responded by allowing healthcare facilities to establish their own policies depending on their staffing situation. Furthermore, some policies have been criticized for addressing the shortage of nurses in hospitals by limiting access to healthcare. With the American population aging rapidly and the nurse-patient ratio increasing steadily, there is need to investigate, evaluate, and potentially propose policies that address nurse staffing.
The effect of nurse staffing on healthcare
When the debate of the influence of RN staffing on healthcare first emerged, it was only thought that nurse-patient ratio was a question of quality and care. However, in the last few years, studies have found out that the nurse-patient ratio also impacts the cost incurred by healthcare facilities and the health and wellbeing of nurses.
* Patient safety and outcome
In healthcare facilities, physicians are perceived by patients as being the most important party in their diagnosis and treatment. In reality, physicians spend very little time even with critically ill patients, whereas nurses are always present at the bedside of patients to monitor their progress and ensure they receive high-quality care. As a result, patient safety and outcomes are mainly depended on nurses but they can only be achieved if the right level of staffing is implemented. Several research studies have confirmed that the lack of adequate RN staffing affects patients’ wellbeing in numerous ways. For instance, the study of Tarnow-Mordi (2000) revealed that inadequate RN staffing in the ICU increases the mortality rate of patients from 2% to 7%. For patients who are not admitted in ICU wards, this risk increases by 12%. On the positive side, the introduction of an extra Registered Nurse per 1000 inpatient days is linked with a 4.5% reduction in the mortality rate (Mark et al., 2014).
* Nurses’ wellbeing
Like other employees, nurses’ wellbeing is influenced by the nature of their work. Nurses who attend to too many patients run the risk of being stressed and burning out. Furthermore, a study conducted by (Hughes, 2011) revealed that the high-intensity state of nurses' responsibilities means that they are at a high risk of making errors while attending to a large number of patients. This finding is consistent with the principle of human factors engineering, which suggests that when a person is performing a complicated task, such as dispensing medication, they should have the necessary support required to avoid making mistakes. However, opponents of high staffing levels argue that errors committed by nurses are not caused by inadequate staffing levels but rather by common operational failures that are part of their work (Alfredsdottir and Bjornsdottir, 2018). Nevertheless, since the implementation of staffing mandate policy in California, nurses in the state report higher levels of job satisfaction because they feel their workload is reasonable and led to providing better care (Aiken et al., 2010).
* Financial cost
Generally, it is agreed that adequate RN staffing provides better patient monitoring and surveillance, which reduces the cost that hospitals incur when patients are readmitted. However, it is also true that reducing RN staffing increases the profitability and stability of hospitals, especially those with uncertain futures. As a result, the relationship between RN staffing levels with the financial cost of hospitals is mixed and depends on numerous factors. A qualitative study conducted by Everhart (2013) found out that adequate RN staffing has a positive association with the financial performance of hospitals that operate in competitive markets. The same study revealed that there is no significant relationship between adequate RN staffing and financial performance in hospitals that operate in less competitive markets. Nevertheless, since RNs are highly qualified and skilled nurses, adequate staffing levels provides a ccompetitive advantage to hospitals that operate in less competitive markets.
Evaluation of current RN staffing policies
Ever since the Institute of Medicine (IOM) published “To Err is Human: Building a Safer Health System” report, both the federal and state governments have implemented various policies that seek to enhance patient safety and outcome by increasing RN staffing levels. As of today, fourteen states and the District of Columbia have formulated and passed policies that address safe staffing. Generally, policies adopted by the federal and state governments are based on three approaches; the first approach requires healthcare institutions to establish staffing committees that structure staffing strategies that mirror the patient population, the second approach provides a specific RN staffing ratio that hospitals must adhere to, the third approach requires healthcare centers to disclose their RN staffing levels to the public.
* California mandate staffing policy (Assembly Bill 394)
In the United States, California is the only state that requires all healthcare facilities to adhere to an average nurse-to-patient ratio. Assembly Bill 394, which was passed in 1999, mandates the following RN staffing ratios;
* 6:1 patient-to-nurse workload in psychiatrics,
* 5:1 patient-to-nurse in medical-surgical units, telemetry and oncology,
* 4:1 in pediatrics,
* 3:1 in labor and delivery, and
* 2:1 in intensive care units.
The primary objective of Assembly Bill 394 is to enhance the quality of care and to ensure that RNs do not swap the nursing profession with another profession. Since the implementation of Assembly Bill 394, the staffing RNs in California increased considered coupled with better patients outcome. Since 2002 when Assembly Bill 394 became operational, California has experienced a steady elevation in the number of RNs staffing (Aiken et al., 2010). In terms of patients’ outcome, Harrison (2019) indicates in the first thirty days of patient stay, California RN staffing ratios have considerably lowered the chances of a patient dying. Furthermore, in 2006 when New Jersey and Pennsylvania had not introduced any form of RN staffing policy, they were recording 13.9% and 10% more surgical deaths than California respectively (Harrison, 2019).
A controversial feature of Assembly Bill 394 is that it considers healthcare facilities to be in compliance if 50% of their nurses are made up of licensed practical/vocational nurses. When compared to RN, licensed vocational/practical nurses are less trained, their skills are restricted to certain areas, and they receive low wages. Therefore, although this feature enables hospitals, especially those that compete in less competitive markets to meet the required staffing with less skilled nurses, it has been criticized for undermining its own main objective of improving patients’ outcome and safety through low nurse-patient-ratios. Healthcare facilities in California with a large size of licensed practical/vocational nurses have been shown to have poorer patient health outcomes (Huston, 2013). Furthermore, since licensed practical/vocational nurses are paid less than RNs, hospitals that employ them save 34$ to 47$ million per year, which indicates that Assembly Bill 394 increases the profitability of some healthcare facilities in California over patients safety and treatment (McHugh et al., 2012).
* Disclosure of RN staffing policies
Policies that mandate healthcare institutions to reveal their RN staffing ratio to t...