Running head: POLICY ANALYSIS PAPER

Policy Analysis Paper

Patricia Thomas
Thomas Edison State College
Health Policy
NUR-529
Professor Gabua
June 11, 2015
Policy Analysis Paper
Abstract
In order for the patients to have safe and quality care, the staffing levels, education and
experience of the nursing staff needs to be made a priority. Hospitals that dont have adequate
staffing tend to have an increased rate of negative patient outcomes. Some of the negative
outcomes that are potentially caused by the decrease in nursing care are shock, pneumonia,
cardiac arrest and urinary tract infections (Stanton, 2004). This has led to state legislators
proposing laws that mandate adequate staffing. The inadequate staffing levels is a problem that is
affecting not only the patients, but also the staff. Nurse management and leadership play a
significant role in finding a balance among all involved. Throughout this paper, the author will

be discussing how the bills that have been proposed for improving nurse staffing ratios in order
to promote quality and safe care for the patients and less nurse burnout.
Key Words: Staffing, Nursing, Nursing Bill, Registered Nurse Staffing Act S. 1132, H.2083

The Policy
The Registered Nurse Safe Staffing Act of 2015 was introduced on 4/29/2015. It
amends title XVIII (Medicare) of the Social Security Act to require each Medicare participating
hospital to implement a hospital-wide staffing plan for nursing services furnished in the hospital
(S. 1132, 2015). It requires the plan to require that an appropriate number of registered nurses
provide direct patient care in each unit and on each shift of the hospital to ensure staffing levels
that: (1) address the unique characteristics of the patients and hospital units; and (2) result in the
delivery of safe, quality patient care consistent with specified requirements. It also requires each
participating hospital to establish a hospital nurse staffing committee which shall implement such
plan, specifies civil monetary and other penalties for violation of the requirements of this Act,

POLICY ANALYSIS PAPER

and sets forth whistleblower protections against discrimination and retaliation involving patients
or employees of the hospital for their grievances, complaints, or involvement in investigations
relating to such plan (S. 1132, 2015).
This piece of legislation was sponsored by Lois Capps (D CA). There are ten cosponsors from seven states, all democrats except for one republican, from Ohio. The bill was
introduced on 4/29/2015, and referred to the House Ways and Means on 04/29/2015 and the
Subcommitte on Health, on 05/01/2015 (Cong. Rec., 2015).
The following findings have been outlined in Section 2 (Cong. Rec., 2015), and also
recommended by the American Nurses Association (ANA):
- RN educational preparation, professional certification and level of clinical experience.
- The number and capacity of available health care personnel, geography of a unit and
available technology.
- Intensity, complexity and stability of patients.
- It also includes these patient protection, reporting, investigation and enforcement
provisions.
- RNs would not be forced to work in units where they are not trained or experienced
without orientation.
- Procedures for receiving and investigating complaints.
- Potential for civil monetary penalties imposed by the Secretary of Health and Human
- Services for each known violation.
- Whistleblower protections.
- Public reporting of staffing information.
Background

POLICY ANALYSIS PAPER

One of the key item to the Registered Nurse Safe Staffing proposal is to base staffing
levels on need rather than just strictly numbers. In this way, staffing levels would provide for
optimal care. As a result of massive reductions in nursing budgets, combined with the challenges
presented by a potential nursing shortage, employers have been struggling with fewer nurses
working longer hours and caring for sicker patients. This situation compromises care and
contributes to the nursing shortage by creating an environment that drives nurses from the
bedside ("Safe Staffing," 2015). In addition, safe staffing is directly related to patient outcomes.
A study published in the Journal of the American Medical Association in October 2002 linked
higher patient-to-nurse ratios in hospitals with increased patient mortality and increased nurse
dissatisfaction with their jobs. The study, which looked at outcome data from more than 230,000
surgical patients discharged from 168 hospitals, found that each additional patient per nurse was
associated with a 7% increase in the likelihood of patient mortality, and a 15% increase in job
dissatisfaction for the nurses (Rajecki, 2009, p. 1). Fine-tuning this line between what is safe
and beneficial, versus what is affordable and sustainable, is what needs to be done.
Stakeholders
Stakeholders of this proposal include stakeholders in most healthcare settings. There are:
1.) Providers, who view staffing from a technical sense of accuracy of diagnosis, appropriateness
of care and outcomes achieved. 2.) The Payers who focus on the most cost effective method of
care. 3.) Employers, who need to control costs and provide the appropriate care, and 4.) Patients,
who want compassion, care and positive outcomes, all at an affordable cost ("Healthcare
Stakeholders," 2014).
Conflict with the stakeholders includes the patients that expect an employer to offer a
wide variety of options for health coverage that can be customized to their specific needs. They

POLICY ANALYSIS PAPER

also look for the employer to fund the majority of the cost of health insurance. Providers want to
provide the best service using the most accurate and newest tests and treatments and to provide
preventative care which the payer may not cover. Payers want providers to follow a clear,
evidence based, diagnostic plan and reach an accurate diagnosis and treatment plan with the
fewest visits and least number of tests. Employers want to maintain or lower their cost
contribution. They want the patient/employee to seek only needed care, follow providers
instructions, and recover quickly to full utility ("Healthcare Stakeholders," 2014).
Social and Economical Concerns
Perceived barriers to regulated nurse staffing include costs to implement additional
staffing and how to deal with the repercussions during nursing shortages. Also, requiring
hospitals to increase RN staffing without increasing reimbursements will lead to compensatory
cuts elsewhere (Stokowski, 2009). Some experts maintain that costs related to increasing the
proportion of RNs can almost entirely be offset by reducing hospital days, reducing
complications, and reducing patient deaths. However, in an article by Buerhaus, the political and
financial ramifications of mandated staffing would result in too much interference of
government, high cost of implementation, difficulty in having staff available for the dynamics
involved with the staff required, and needs of the patients (Buerhaus, 2010). Indeed, if you look
at the mandated nurse staffing ratios that was enforced in California, in 1999 it is easy to find
literature that strongly supports or negates the impact of the mandated staffing. Pros and cons
exist for both the current structure and the previous, which only proves that this is something that
is not absolute and is difficult to measure. Mandated staffing and staffing based on acuity, could
mean mandatory overtime and extra shifts. It could also have inexperienced nurses covering in

POLICY ANALYSIS PAPER

unfamiliar territory, just to ensure quota is up to regulation. Passing of this legislation could be a
set-up for failure.
Plan for Implementation
This policys recommendations can be achieved from the nursing level up to the hospital
and federal level. These recommendations have RN accountability and recommendations
assigned to them. If Congress passes this Act, hospitals will be required to establish committees
with the purpose of evaluating individual hospital units and assessing the nurse staffing
requirements per unit. Staffing of each unit will be based on the number of patients and the level
of care in each unit, the experience and skill levels of the registered nurses assigned to each unit,
and the number of support staff from which the RNs can pull. The technological resources
available in each unit will also be taken into consideration for adequate staffing. Medicare
hospitals will be required to release their unit staffing plans to the public. These hospitals will no
longer be float nurses to units where they are not adequately skilled. If hospitals are not
following the regulations the Act will impose upon them, they will be held accountable,
including monetarily where necessary, for any claims or complaints regarding nurse staffing
issues and related patient care. Nurses will be protected if they report issues surrounding
inadequate staffing (Tortorice, 2013, p. 1).
It is risk, but the long term effects of taking that risk are far greater than taking no risk
at all. Nurses need to be retained and need to feel supported.
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

POLICY ANALYSIS PAPER

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;
and agreement by all hospital administrators that adequate nursing care remains the key to safe
patient care.
BillImpact/ChanceforBecomingEnacted
The Registered Nurse Safe Staffing Act has brought this critical issue to the attention of
Congress year after year. This bill has been put before congress every year for well over 10
years. Looking back to the year 2005, up until this year, almost identical bills were introduced
yearly, and never enacted (S. 71, 2005). Hospitals, legislators, government, and CEO's need to
consider alternatives to take into account optimum patient care and potential nursing shortages.
Job burnout, nurse to patient ratios, unsafe work environment, and quality of patient care is the
responsibility of everyone. The costs involved, as well as additional resources needed to
implement and monitor this undertaking have prevented this bill from progressing through
congress. According to govtrackus.com, this bill has a 1% chance of getting past the committee
and a 0% chance of becoming enacted (H.R. 2083, 2015).
As nurses we can make a difference though! The ANA has been promoting and pushing
this bill for over a decade. Nurses can become involved in organizations, we can educate other
nurses, we can write to our congressmen and we can educate ourselves! We have voices, and we
are our best advocates. Through this, change is possible!

POLICY ANALYSIS PAPER

8
References

Buerhaus, P. (2010, 6/16/2010). What is the harm in mandating staffing regulations? Medscape,
28(2), 1-8. Retrieved from
https://www.tha.org/HealthCareProviders/Issues/Workforce/Buerhaus-Harm%20in
%20Mandatory%20Ratios.pdf
Cong. Rec. 1 (2015, 04/29/2015).
Rajecki, R. (2009). Mandatory nurse staffing ratios: boon or bane. Modern Medicine. Retrieved
from http://www.modernmedicine.com/modern-medicine/news/modernmedicine/modernmedicine-feature-articles/mandatory-nurse-staffing-ratios?page=full
Registered Nurse Safe Staffing Act, S. 1132, 114th Cong. (2015).
Registered Nurse Safe Staffing Act of 2005, S. 71, 109th Cong. (2005).
Registered Nurse Safe Staffing Act of 2015, H.R. 2083, 114th Cong. (2015).
Safe staffing. (2015). Retrieved from
http://www.rnaction.org/site/PageNavigator/nstat_take_action_safe_staffing.html
Stokowski, L. (2009, October 28). Safe staffing legislation. Medscape. Retrieved from
http://www.medscape.com/viewarticle/711116_6
Tortorice, J. (2013, November 15). The scoop on the registered nurse staffing bill. CeuFast.com
Blog. Retrieved from http://www.ceufast.com/blog/julia-tortorice/the-scoop-on-theregistered-nurse-staffing-bill/
Who are the stakeholders in healthcare? (2014). Retrieved from
http://patientsafetyed.duhs.duke.edu/module_a/introduction/stakeholders.html