There has been an increase in the amount of research linking the quality of care in hospitals and nurse staffing. Nevertheless, most of these studies have not considered nurse staffing and nursing care as primary variables, but have instead considered them to be background variables (Rogowski, et al., 2013). Over the years, there has been an increase in the amount of literature connecting patient care to nurse-patient ratio. It is clear that in the midst of the increased competition for the market among health care organizations, there has been a change in the structuring of most of these organizations, with efforts being directed at cutting costs in view of increasing the profit margin. Nevertheless, this has been done at the expense of the quality of care that is provided for the patients as the small number of nurses in the hospitals are faced with a tough challenge in meeting the needs of the large number of patients. The nurse-patient ration in most health care organizations is high, such that each nurse has to make time for a large number of patients allocated to them, leaving each patient with only a small amount of time to be attended to. As a consequence, the nurses are unable to implement primary healthcare and patient-centred care as they do not have enough time to learn more of the specific needs of the patient for them to effectively meet them (Rogowski, et al., 2013).

I chose this public policy issue considering the fact that staffing has a direct impact on the care of the patients and affects all care departments within the hospital. A reduction in nurse staffing results in increased workload for the nurses, which in turn contributes to nurse burnout and reduced productivity (Kiekkas, 2013). This impacts the quality of care that the nurses provide for the patients and hence interferes with the proper recovery of the patients. By adequately addressing the issue of nurse staffing, the length of stay for patients in the hospitals would be reduced and chances for patient hospitalization would be minimized. For any organization to meet the required standards of quality for their products or services, they must increasingly invest in the required resources and technology (Kiekkas, 2013). In this vein, hospitals ought to direct increased resources towards employment of more nurses in order to provide patients with high quality care by reducing the number of patients that each nurses works on and the length of nursing shifts.

The promotion of adequate nurse staffing is integral in facilitating the achievement of different ethical principles. To start with, the principle of autonomy suggests that patients have the capacity to make decisions concerning what they want and how their care should be handled. This has been further promoted through the Patient Self Determination Act, which states that all persons that are deemed competent can make decisions concerning their care known. Without adequate nurse staffing, the few available nurses barely have the time to engage each patient and to determine their needs and wishes for care (Maenhout & Vanhoucke, 2013). Thus, staffing policy would be important in promoting increased patient engagement and patient autonomy. On the other hand, the theory of beneficence refers to engaging in action that positively affects others or the desire to do good other people. Nurses play a major role as patient advocates, whereby they campaign for the needs of the patients. In this view, staffing is an important issue as it directly affects the relationship that is established between the nurses and the patients. Reduced nurse-patient ratio through increased staffing allows nurses enough time to interact with each of the patients, thus allowing them to foster trust between them and the patients and to effectively identify the needs and preferences of each of the patients and to embrace holistic care in view of meeting such needs and preferences (Maenhout & Vanhoucke, 2013).

The principle of non-maleficence involves promoting actions that do not hurt or harm others. This principle underlies the oath taken by nurses to always uphold positive actions that would promote the health of the patient. Reduced nurse staffing is a major contributor to increased nurse workload and subsequent burnout and work-related stress among nurses (Kiekkas, 2013). As a result, most nurses are likely to make medical errors such as medication errors. Through proper staffing of hospitals with nurses, patient workload would be reduced and so would the chances of making errors in the care of the patients. In this case, nurses would avoid making errors that would harm the patients in one way or another, such as medication dosage errors that may aggravate the condition of the patient. Lastly, the principle of justice refers to the distribution of resources in a fair and equal manner, with proper consideration of the costs and benefits of such allocation. According to this principles, all individuals have a right to the equal distribution of goods and services regardless of their contribution towards them. In the hospital setting, all the patients have a right to proper services from al the health care providers (Rogowski, et al., 2013). As such, to ensure that such patients receive proper services from the nurses, it is important to ensure that the nurse-patient ratio is reduced.

Policy Brief

This policy brief will be submitted to senator Jeff Sessions of Alabama, with expectations that he will draft a bill that establishes a reduced nurse-patient ratio and submit it to the senate. Nurses play a major role in patient care in the health care system. Various states have established safe-staffing ratios that promote the safety of both nurses and patients. Nevertheless, some of these ratios are still high while others are not properly enforced. As a result, the ratio of nurses to patients in most states is still high and has negative implications on both the outcomes of the patients and the nurses.

Nurse staffing has implications on the quality of the workplace and the quality of patient care. As a result of a high nurse-patient ratio, nurses are overwhelmed with an increase in the workload and extended shifts, an aspect that results in burnout and fatigue (Meyer & Clarke, 2011). This is because the nurses are expected to cater for the needs of the various patients that they have been assigned and any new cases that may come to the hospital. Such burnout leads to increased stress and even depression among the nurses and thus is a major contributor to increased dissatisfaction among the nurses. With increased dissatisfaction, there is an increase in nurse turnover, which places even more burden on the few nurses that are left to attend to the patients as they have to cover up the slots left by the nurses who leave. As such, it is important for the Senator to understand the impact of the policy on the safety of not just the patients but also the nurses. It is the role of the government to protect the welfare of the citizens. Citizens are placed at a risk of in-patient deaths as a result of poor quality patient care. It is only when the nurses have enough time with the patients that they are able to identify the various symptoms presented by such patients and to respond to them effectively (Twigg, Gelder, & Myers, 2015). With low nurse-patient ration, it is highly unlikely that the nurses will identify such symptoms and hence the patients are placed at an increased risk of death. A decrease in the amount of nurses as compared to the number of patients also yields various devastating results such as increased cases of pressure ulcers, urinary tract infections, acute care hospitalizations, reduced capacity among most patients to carry out activities of daily living (ADLs), and increased use of urinary catheters (Twigg, Gelder, & Myers, 2015). The low level of staffing legislation has also directly impacted the uninsured and poor patients, whereby the hospitals handling a high number of such uninsured and Medicaid patients tend to have a high ratio of nurses to patients as compared to those with a low number of these patients.

It is clear that there is a growing shortage of nurses, which, coupled with a reduction in budgets allocated to nurses, leads to few nurses caring for sicker patients for longer hours (Maenhout & Vanhoucke, 2013). Such inadequate staffing and working for longer hours have a negative impact on the health of the nurses as it leads to an increase in the risk of developing hypertension, musculoskeletal disorders, depression, and cardiovascular disease. In the US in 2012, there were 11,610 cases of Musculoskeletal Disorders which led to most nurses staying an average of eight days without reporting to work (DPE, 2016). With understaffing, there is a need for nurses to work overtime for longer shifts, an aspect that leads to cardiovascular problems. As earlier mentioned, it is also evident that increased nurse workload causes burnout, which is characterized by irritability, chronic fatigue, headaches, chronic insomnia, weight gain, back pain, high blood pressure, and depression. The impact that nurse understaffing has on the health of nurses is not only physical but also psychological and emotional. In August 2012, the portion of nurses who reported a score of 27 or more in terms of their emotional exhaustion was close to one third. This measure of burnout is medically considered as “high” (DPE, 2016).

Like nurses, patients greatly suffer as a result of understaffing, with increased cases of medical errors, bedsores, patient infections, cardiac arrest, pneumonia, accidental death, and MRSA being reported (Meyer & Clarke, 2011). As such, as patient are increasingly admitted into the hospital, the nurse-patient ratio increases, leading to increased cases of mortality in the hospital. Understaffing minimizes the time that the nurses spend with each patient as the nurses have to care for the large number of patients that report to hospital. Thus, the patients become exposed the cases of electrolyte imbalance, heart failure, urinary tract infection, respiratory infection, and sepsis, due to reduced monitoring. Long-term patients tend to be the most disadvantaged when it comes to facilities that are understaffed. In such cases, due to reduced attention from the nurses, these patients are likely to develop complications including skin trauma, pressure ulcers, and weight loss (Maenhout & Vanhoucke, 2013).

Challenges towards implementing the policy

The successful push of public policies to reduce the nurse-patient ratio has been impeded by various factors. One such factor is the constant availability of labour disputes. In this case, the increased burden placed on nurses and reports of poor working conditions have greatly contributed towards depopulating the profession, with most trained nurses leaving the profession to seek alternatives, and the number of students who enrol in colleges to study nursing reducing (McQuide, Kolehmainen-Aitken, & Forster, 2013). Another challenge is the low job satisfaction among nurses and the requirement to offer patients quality care. An increase in the number of nurses cannot solve this challenge, an aspect that requires hospitals to increasingly invest towards providing nurses with a proper working environment and conditions, one that would allow them to deliver their services with efficiency. Increased job satisfaction leads to an increase in nurse turnover, an aspect that makes it difficult to meet the minimal nurse-patent ratio (Spilsbury, Hewitt, Stirk, & Bowman, 2011).

Intervention Options

One of the direct interventions that can be taken up by the senator as a decision maker is to introduce a bill in the Senate that would introduce stricter legislative guidelines for a proper nurse-patient ratio. It is upon the legislature to convince other legislatures that a reduction of the ratio between nurses and patients would allow for an increase in the quality of care received by patients. Hefty penalties should be put in place to apply to hospitals that fail to observe such guidelines as this would ensure compliance. However, it is important to note that in as much as the nurse-patient ratio is an important factor in determining the quality of care that the patients receive and the health of the nurses themselves, there are underlying factors such as the working environment and conditions, which ought to be handled to effectively meet any goals for patient safety and quality of care. With the cause of the problem of understaffing being poor working environments and low compensation for the nurses, a second alternative for the decision maker would be to introduce a bill that will introduce a new system for nurse billing in the hospital, one that would be considerate of the intensity of care given to each patient. The current system of billing places the care receive by all the patients in the hospital at a similar level, whereas each patients needs dictate different levels of care (Maenhout & Vanhoucke, 2013). As such, a new system of billing would ensure that the nurses are well compensated and that there is enough investment towards providing the nurses with a proper working environment.

Proposed course of action

There is need for a two-level intervention for the problem of understaffing to be completely solved. The first level of intervention involves ensuring that the causes of reduced nurse staffing is properly handled. It is clear that nurse understaffing is mainly caused by a reduction in the number of nurses entering the workforce and a subsequent increase in the number of nurses leaving it. In addition, the percentage of the budget allocated towards the nursing department in most hospitals is low, making it difficult to hire more nurses. To handle these challenges, it is important to ensure that there is proper investment into maintenance of proper working environments and that the nurses are well compensated (Spilsbury, Hewitt, Stirk, & Bowman, 2011). This would allow for an increase in the number of people who enrol into nursing. In addition, it will reduce the level of nurse turnover. As a consequence, there will be enough nurses in the workforce to allow for the achievement of the second level of intervention, which involves reducing the nurse-to-patient ratio and encouraging hospitals to employ more nurses. Thus, the decision maker’s intervention should include introducing legislature that would allow for both increased compensation of nurses and improved working environments, and increased staffing of hospitals with nurses to meet the increase in the load of patients. This would meet the challenges of labour conflicts, low compensation, poor working environments, and increased nurse turnover.

Evaluation of Success

The success of this policy brief would be measured using a top-down approach. Establishment of strict federal level legislations to govern and monitor implementation of a minimum nurse-patient ratio would be a clear indication of the success of the policy brief. On the other hand, passing of stricter state lows to implement the provisions of the federal government would mark the success of the policy brief. In addition, establishment of a local commission that would oversee the implementation of the proposed nurse-patient ratio and bring the hospitals to accountability would also mean successful implementation of the brief. At the organization level, establishment of measures of care intensity to facilitate compensation of the nurses would also mean increased compensation of the nurses with an increase in their level of care and hence the success of the brief. On the other hand, increased allocation of the budget towards nurses and the subsequent increase in the number of nurses employed by the hospital would. Be an indication of the implementation of the brief.

Implementation Plan

Accredo Health Group, Inc., located in Memphis, faces a major challenge within the nursing department when it comes to the ratio between nurses and patients. The hospital has experienced major challenges when it comes to meeting the needs of the patients, an aspect that has seen a spike in various patient complications including increased falls and length of hospital stay. The hospital conducted a survey of the level of satisfaction among its patients and established that sixty percent of the patients are not satisfied with the services provided by the nurses. This is as a consequence of the low number of nurses in the hospital, which has resulted from an increase in nurse turnover over the past few years. The hospital is keen on promoting the level of satisfaction among its patients and establishing an effective work environment for the patients.

Collaborating with the organization

It would important to bring the organization to the realization of the various approaches that can be embraced in order to reduce the rate of nurse turnover and to increase the ration between nurses and patients, which would subsequently lead to an increase in the quality of care provided to the patients. As such, a proposal will be written to the administrator at Accredo Health Group, Inc., suggesting a partnership that would allow them to meet their challenges and to re-establish themselves as a quality providing hospital. If invited by the management, I will present to them the entire project and promote a clear understanding of all the elements and phases of the change process.

Personal and organizational goal alignment

The health care organization’s goal is to improve the quality of care provided to the patients and to reclaim its share of the market while promoting a healthy community, while maintaining low costs. This is in line with my goal for establishing a policy that would tackle understaffing in hospitals and facilitate quality health for patients, while upholding the safety of nurses. Through pushing forth with my policy, I would be able to assist the hospital in implementing initiatives that would ensure that there is a proper balance between the nurses and the patients, an aspect that would assure the patients of quality care.

Implementation Steps

The first step that would be taken to achieve the goal for implementing the understaffing policy would be to establish a coalition of stakeholders that would change the health care system. The commitment of all the stakeholders towards facilitating not only an addition of nurses but also an establishment of a proper working environment for the nurses would increase the chances of success with the project. The second step would involve collecting enough data that would inform the decision making process. Next, it would be important to goals for quality, spending, and any other appropriate measures. In addition, the hospital level policies concerning management of nurses should be amended to allow for a transformation of the working conditions of the nurses and increased employment slots and resources for the nurses. Lastly, the policies should be implemented.

Roles of organization members

The major actors in the implementation of this project within the organization would be the physician champion, nurse head, administrator, Human Resource Manager and Finance Manager. The role of the physician champion would be to establish physicians’ buy-in in providing nurses with a good working environ, where they will not feel intimidated. The nurse lead is important in assuring and informing the nurses of the coming changes, as well as presenting their grievances to the interdisciplinary committee. The Administrator is concerned with ensuring that all the actions within the hospital are coordinated towards providing nurses with the best working conditions so as to encourage them to work for the hospital and to reduce nurse turnover. The Human Resource Manager, on the other hand, would be involved with recruiting more nurses to handle the current shortage. Lastly, the role of the Financial Manager is to amass the required financial resources to facilitate the recruitment, maintenance, and compensation of additional nurses.

Developing a collaborative evaluation plan

To develop a collaborative evaluation plan, it is important to consider that the workplace is made of diverse professions and individuals from different backgrounds. As such, the first step involves embracing the CBPR principle that acknowledges the community as a single unit of identity (Braun, et al., 2012). This means that an emotional connection should be fostered among all the professions, as this would increase their desire to meet shared needs such as poor patient outcomes. Another principle that would be adopted involves building on the resources and strengths within the organization as this would allow for increased collaborative achievement. Lastly, it is also important to promote capacity building and co-learning among all partners within the health care organization (Braun, et al., 2012). This would allow the other professions to understand the needs of the nurses and to effectively respond to them, even as nurses learn about them.

Evaluation of success

One of the indicators of success would be an increase in the level of satisfaction among nurses concerning the efforts being made to make their work environment comfortable. In addition, a reduction in nurse turnover would indicate the willingness of nurses to work for the organization. Increased investment in the recruitment of more nurses would also indicate the success of the plan to reduce the nurse-patient ratio. An interest from other organizations and state officials in studying the effectiveness of the project and borrowing the policy would also indicate the success of the plan.

Comparison between Top-Down and Bottom-Up Approaches

Both the bottom-up and top-down approaches would present various challenges if used in the implementation of the nurse staffing project. One of the advantages of the bottom-up approach is that it allows for the realization of benefits in the initial stages of the project (Crescenzi & Rodríguez-Pose, 2011). In addition, the organization broadens understanding and identity management skills in the very first phase. On the other hand, one of the disadvantages of the bottom-up approach is that there may be need to change the established organizational structure later on in the roll-out phase. Another disadvantage is that this strategy mostly depends on the existing strategy as opposed to the business processes. The top-down approach is also advantageous in various ways, including the demonstration of the identity management solution by the first implementation (Crescenzi & Rodríguez-Pose, 2011). In addition, maintenance and operation resources are not as affected as in the bottom-up approach. Nevertheless, there are various disadvantages with this approach. One of the disadvantages is that there is limited coverage provided by the solution in the first stage (Crescenzi & Rodríguez-Pose, 2011). In addition, the cost of implementation is likely to be higher in this approach. With this approach, the benefit will not realize the solution’s benefit rapidly. Considering these pros and cons, it would be highly beneficial to implement the solution using the bottom-up approach as this ensures limited structural change and maximizes earlier realization of the benefits.

References

Braun, K., Nguyen, T., Tanjasiri, S., Campbell, J., Heiney, S., Brandt, H., . . . Ma, G. (2012). Operationalization of community-based participatory research principles: assessment of the national cancer institute’s community network programs. American journal of public health, 102(6), 1195-1203.

Crescenzi, R., & Rodríguez-Pose, A. (2011). Reconciling top-down and bottom-up development policies. Environment and Planning A, 43(4), 773-780.

DPE. (2016, May). Safe-Staffing Ratios: Benefiting Nurses and Patients. Retrieved from Department for Professional Employees: http://dpeaflcio.org/programs-publications/issue-fact-sheets/safe-staffing-ratios-benefiting-nurses-and-patients/

Kiekkas, P. (2013). Nurse understaffing and infection risk: current evidence, future research and health policy. Nursing in critical care, 18(2), 61-62.

Maenhout, B., & Vanhoucke, M. (2013). An integrated nurse staffing and scheduling analysis for longer-term nursing staff allocation problems. Omega, 41(2), 485-499.

McQuide, P. A., Kolehmainen-Aitken, R. L., & Forster, N. (2013). Applying the workload indicators of staffing need (WISN) method in Namibia: challenges and implications for human resources for health policy. Human resources for health, 11(1), 1-11.

Meyer, R. M., & Clarke, S. P. (2011). Shifts with nurse understaffing and high patient churn linked to heightened inpatient mortality risk in a single site study. Evidence Based Nursing, 14(4), 122-123.

Rogowski, J. A., Staiger, D., Patrick, T., Horbar, J., Kenny, M., & Lake, E. T. (2013). Nurse staffing and NICU infection rates. JAMA pediatrics, 167(5), 444-450.

Spilsbury, K., Hewitt, C., Stirk, L., & Bowman, C. (2011). The relationship between nurse staffing and quality of care in nursing homes: a systematic review. International journal of nursing studies, 48(6), 732-750.

Twigg, D. E., Gelder, L., & Myers, H. (2015). The impact of understaffed shifts on nurse‐sensitive outcomes. Journal of advanced nursing, 71(7), 1564-1572.

NURSE STAFFING POLICY BRIEF.

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