Discuss 2 Please don’t combine everything. Answer each question separately for clarity

1A:Identify a current healthcare policy in your current role that you would like to see revised. Why? What would be the projected outcomes?

1B: discuss both the obvious and the non-obvious stakeholders? 

1C: Which stakeholders to you have the potential to influence? 

1D: What barriers do you face with reaching stakeholders and allowing them to buy in?

1F Take the identified healthcare policy and. Identify both obvious and non-obvious stakeholders. 

1G:Also identify stakeholders that you have the potential to influence.

1H:Determine the effect of healthcare politics on the healthcare stakeholders, state and federal government, and the nursing profession (

1J: Analyze legislative process and the impact of special interest lobbies 

SECTION 2A

2A: How have you seen the diverse interests of healthcare stakeholders impact patient care in your nursing practice or in the practice of other nurses?

2B: In general, do you think political action committees (PACs) and special interest groups (SIGs) contribute to or detract from improvements in patient healthcare? Provide an example to illustrate your thoughts.

2C: What role should politics play in healthcare reform? What role should the DNP-prepared nurse play in the political process that impacts healthcare reform?

EVERYTHING YOU NEED IS IN THE ARTICLE

Nurse Staffing Ratios

Policy Options

Joanne Spetz

“The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities.”

John F. Kennedy

The importance of nursing to the delivery of high-quality health care has been recognized since the inception of the practice of nursing. Various factors contribute to the quality of nursing care including the expertise of nursing staff, availability of supportive personnel and other health professionals, good communication among the care team, and the nurse/patient ratio. It was not until the early 2000s that high-quality empirical research found consistent relationships between licensed nurse staffing and the quality of patient care (Lang et al., 2004; Kane et al., 2007).

Concerns about the effects of changes in nurse staffing levels in the 1990s, combined with the increasing influence of nursing unions, resulted in the passage of California Assembly Bill (AB) 394 in 1999, the first comprehensive legislation in the United States to establish minimum staffing levels for registered nurses (RNs) and licensed vocational nurses (LVNs) in hospitals. This bill required that the California Department of Health Services (DHS) establish specific staffing ratios. These were announced in 2002 and implemented beginning in 2004. Since then, other states and the federal government have considered developing regulations for nurse staffing in hospitals. In 2014, for example, Massachusetts passed legislation mandating a ratio of one or two patients per nurse in intensive care units (Associated Press, 2014).

The Establishment of California’s Regulations

Throughout the late 1990s and early 2000s, there was substantial debate about the changes in hospital staffing that had occurred in the 1990s and the effects of such changes on the quality of care (Aiken, Sochalski, & Anderson, 1996; Spetz, 1998; Unruh & Fottler, 2006; Wunderlich, Sloan, & Davis, 1996). In some states, legislators and regulatory agencies considered staffing requirements with an aim to increase the numbers of nurses and other health care personnel working in hospitals and other settings. As the 1990s ended, a shortage of RNs emerged, and concern about poor staffing in hospitals continued (Kilborn, 1999). It was in this environment that AB 394 was passed by the California legislature. Previous Republican governors had vetoed similar legislation, but union-friendly Democratic Governor Gray Davis signed AB 394, satisfying union efforts to pass minimum-ratio legislation. AB 394 charged the California DHS with determining specific unit-by-unit nurse/patient ratios.

The DHS began an extensive effort to determine the new minimum nurse staffing ratios, with little research to guide them (Kravitz et al., 2002; Lang et al., 2004; Spetz et al., 2000). To help develop the proposed ratios, the DHS commissioned a study by researchers at the University of California, Davis (Kravitz et al., 2002). It also received recommendations about the ratios from stakeholders, ranging from the California Hospital Association (CHA) proposal of a ratio of 1 licensed nurse per 10 patients in medical-surgical units and the California Nurses Association recommendation of 1 517licensed nurse per 3 patients in medical-surgical units. The ratios established by DHS were between those recommended by the CHA and the unions, with a 1 : 6 ratio in medical-surgical units starting January 1, 2004, and a 1 : 5 ratio in medical-surgical units commencing in January 2005. Other units have higher minimum-ratio requirements. The minimum ratios do not replace the requirement that hospitals staff according to a patient classification system (PCS); if a hospital’s PCS indicates that higher staffing is needed, the hospital should staff accordingly.

What Has Happened as a Result of the Ratios?

The implementation of California’s minimum nurse staffing ratio legislation led to legal challenges and state government efforts to expand RN education. It also drove increases in hospital nurse staffing and wages in California. Several studies have found that the ratios are linked to higher nurse satisfaction, but there is little evidence that the regulations improved patient outcomes. Some research has found that there may have been negative impacts on hospitals’ finances and ability to provide charity care.

Legal Challenges

Two days before the ratios went into effect, the CHA filed a lawsuit arguing that the staffing ratios should not apply if a nurse takes a scheduled break or unscheduled restroom visit. The DHS contended that if the ratios were to have any meaning, they must be effective at all times. The judge hearing the case agreed with the DHS in a May 2004 ruling (Berestein, 2004). The second major legal challenge to the ratio regulations came from Governor Arnold Schwarzenegger, who sought to delay the implementation of the stricter ratio of one licensed nurse to five patients scheduled for January 2005 due to the severe shortage of licensed nurses (Rapaport, 2004). The CHA filed suit against the DHS in December 2004 alleging that the emergency order had illegally bypassed the legislature (LaMar, 2005). In early March, a Superior Court judge tentatively ruled that the DHS had indeed not followed the law when issuing the emergency regulation (Salladay & Chong, 2005), and the judge’s decision was finalized in May 2005 (Benson, 2005a, 2005b; Gledhill, 2005).

Expansion of Nursing Education

To assist hospitals in meeting the staffing ratio rules, both former Governor Davis and Governor Schwarzenegger dedicated funds to expanding nursing education and reducing attrition from nursing programs. Between 2004 to 2005 and 2009 to 2010, nursing graduations in California increased by 72%, reaching over 11,500 new RN graduates per year (Spetz, 2013).

Are Hospitals Meeting the Ratios?

The inspection and enforcement mechanisms of the DHS are relatively weak. The DHS does not have the authority to impose fines or monetary penalties on hospitals that are found to violate the ratios, but instead requests and monitors plans submitted by hospitals to remedy the problem. However, other mechanisms do exist to ensure that hospitals adhere to the ratios. First, government payers such as Medicare and Medi-Cal (the state Medicaid program) require that hospitals meet all state and federal regulations and can deny payment to violators. Second, California’s cap on malpractice awards does not apply in cases of negligence, and a hospital could be deemed negligent if it consistently did not adhere to minimum nurse staffing regulations (Robertson, 2004). Third, unions draw public attention to hospitals that do not meet the staffing requirements, resulting in negative publicity for hospitals and increased scrutiny from DHS inspectors. Fourth, labor organizations that represent nurses have sought to incorporate staffing standards in their contract negotiations, with some success (Gordon, 2005; Osterman, 2005).

Several studies of all California hospitals have found that annual average numbers of RN productive hours and nurse staffing ratios in medical-surgical units increased markedly between 2001 and 2006 (Conway et al., 2008; Cook et al., 2012; Mark et al., 2012; Munnich, 2013; Spetz et al., 2009; Spetz et al., 2013). Spetz and colleagues (2009) found that statewide average RN hours per patient day increased 16.2% from 1999 through 2006, to an average of 6.9 hours per patient day. Interviews 518conducted with hospital leaders by a research team at the University of California, San Francisco (UCSF) revealed that many chief nursing officers and other managers said they had hired nurses to meet the ratios, and most noted that it is challenging to adhere to the ratios at all times, including during scheduled breaks (Chapman et al., 2009).

Aiken and colleagues (2010) surveyed nearly 80,000 RNs in California, New Jersey, and Pennsylvania to learn their experiences with staffing, the work environment, and patient care. They found that nurse workloads, measured according to the average number of patients per shift, were lower in California than in New Jersey and Pennsylvania and that over 80% of California nurses reported that their assigned workloads were in compliance with the state’s regulation.

Has the Mix of Staff Changed?

There have been concerns that hospitals may have eliminated support staff positions because of the minimum licensed nurse staffing requirements (Spetz, 2001). Analyses of staffing data collected by the Collaborative Alliance for Nursing Outcomes (CALNOC) suggest that the substitution of licensed nurses for unlicensed staff may be widespread as the increase in RN staffing was much larger than the overall staffing increase among their hospitals (Bolton et al., 2007; Donaldson et al., 2005). In a series of qualitative interviews, some hospital leaders reported that they had laid off ancillary staff to use budgets to hire more RNs (Chapman et al., 2009), and the survey conducted by Aiken and colleagues found that nurses perceived reductions in LVN and aide use (Aiken et al., 2010). However, more recent analyses have measured only a slight decline in LVN staffing (Cook et al., 2012; Spetz et al., 2009; Spetz et al., 2013) and aide staffing (Cook et al., 2012; Spetz et al., 2009).

Have Hospitals Reduced Services and Charity Care?

The California Hospital Association warned that strict minimum nurse/patient ratio requirements would force hospitals to reduce their services. To maintain the minimum ratios, hospitals might reschedule procedures, close selected units and beds, or shut their doors entirely. However, there have been few verified reports of the minimum nurse/patient ratios causing permanent closures of inpatient hospital units or beds. There is some indication that there was lower growth in the provision of uncompensated care services among hospitals on which the regulations had the greatest impact on staffing levels (Reiter et al., 2011).

Have Hospitals Suffered Financial Losses?

Since 1999, California hospitals have been financially buffeted by numerous factors, including changes in Medicare and Medicaid payment policy and requirements that hospital facilities meet seismic standards through retrofitting or new construction (Spetz et al., 2009). Thus, it is difficult to determine whether the staffing regulations had any discernable effect on hospital finances. Qualitative evidence reported that hospital CEOs absorbed the costs of the ratios by reducing other budget areas, and some hospitals were able to obtain higher insurance reimbursement rates to cover additional staff expenses (Spetz et al., 2009). However, one analysis found that hospital prices rose even more between 1999 and 2005 than could be explained by labor cost increases that resulted from the nurse staffing ratios alone (Antwi, Gaynor, & Vogt, 2009).

In an analysis of hospital financial data, Cook (2009) found no significant change in total annual labor costs for licensed nurses, total annual hospital costs, or hospital prices. Reiter and colleagues (2012) used data from Medicare cost reports to explore whether changes in financial status differed between California hospitals that had higher versus lower preregulation staffing levels, and between California and other states. They found that relative to hospitals outside California, operating margins for California hospitals with lower preregulation staffing levels declined, and operating expenses increased significantly.

Did Wages for Nurses Increase?

In theory, when the demand for workers rises more rapidly than the supply, wages should rise. Two studies have examined whether growth in the hiring of RNs caused by the staffing regulations is linked 519to more rapid growth in RN wages. One study found that wage growth among urban RNs in California was as much as 12% higher than in other states (Mark, Harless, & Spetz, 2009). A more recent analysis measured a 4.9% increase in RN wages between 2000 and 2007 with one dataset, and no increase at all with a different dataset (Munnich, 2013).