Registered Nurse Safe Staffing Act Policy Analysis - Research Paper Example

 An Analysis of H.R. 876: Registered Nurse Safe Staffing Act of Introduction H.R. 876, the Registered Nurse Safe Staffing Act, was introduced to Congress on March 2, 2011 by the bill’s sponsor Democratic House Representative Lois Capps, representing California constituents. The bill serves as a proposed amendment to Title XVIII of the Social Security Act to ensure that patient protections are established in hospitals through the establishment of appropriate and safe nursing staffing levels for health facilities involved with the Medicare program. Representative Capps is considered a far-left representative in the House, a democratic ideology that values and provides support for social equality and the elimination of social inequalities that provide disadvantages to certain groups in a society (Smith & Tatalovich, 2003). The Registered Nurse Safe Staffing Act intends to fulfill the leftist ideology, providing protections for nurses and patients to ensure more quality care provision in Medicare-participating health centers. The bill intends to provide legislation demanding that hospitals develop committees to evaluate and develop unit-based staffing plans for registered nurses to ensure that the ratio of on-staff nurses and volume of patients achieves equilibrium. The bill, if enacted into law, would guarantee that at least 55 percent of the aforementioned committee members consisted of registered nurses who provide relevant patient care (Healthcare Employment Counsel, 2011). This would, ideally, give more representation to on-staff nurses by providing committee advice utilizing expertise in patient care and hospital operations. The bill, which has been introduced in Congress in several different forms since 2007, despite its best intentions, has very little chance of being enacted into law. Additional policy elements of H.R. 876 While the bill intends to ensure that hospitals are maintaining appropriate staffing levels and staffing plans, it also guarantees that violators of the proposed law would be subject to monetary recompense for failing to abide by the provisions set forth in the bill. As further protectionist measures, H.R. 876 would specify available protections for employees of hospitals and patients for whistle blowing in the event of grievances or complaints, thereby ensuring that discrimination does not occur as a result of the proposed operational changes within the hospital environment and that no hospital retaliation should occur as a result of said grievances (Congress.gov, 2013). Hence, the bill ensures that there is accountability within the hospital administrative hierarchy for failing to abide by the language of this proposed piece of legislation. H.R. 876 also clearly indicates the expectations for the role of the new hospital committees, including the establishment of a recurring evaluation system to measure the success or failure of staffing plan implementations. At least once annually, these evaluations must occur, providing the framework by which staffing plan modifications are made (Library of Congress, 2013). The proposed legislation also sets out that overtime be considered by the committee, thus providing further protections for on-staff registered nurses and ensuring that the hospital maintains staffing structures that provide adequate relief during times of absence. Reporting of staffing plans are also mandated by the bill to be submitted for public evaluation no later than 90 days after the date by which the committee has conducted its evaluation of staffing plan implementation (Library of Congress, 2013). If, according to the Secretary, any hospital has violated the provisions outlined in H.R. 876, they will be subject to a demand for corrective action to fix the violation and may also be subject to civil monetary penalties (Library of Congress, 2013). Hence, the bill provides the specific duties of the Secretary in ensuring that the legislation is adhered to and that violators are exposed on public Internet networks. Therefore, this proposed bill provides implications for the reputation of quality and integrity of hospitals that must comply with the law, if enacted, which could have revenue consequences as well as societal stakeholder negative opinion about the hospital brand. Background on bill development The Registered Nurse Safe Staffing Act was originally introduced in Congress in 2007, sponsored by former Hawaii Senator Dan Inouye as bill S.73. This bill, however, died after being referred to the Senate Finance Committee. Based on continuing pressures from nursing stakeholders, the bill was again reintroduced on June 15, 2010 as S.3491, which was also referred to the Senate Finance Committee, ultimately becoming a dead piece of legislation as well (Govtrack.us, 2013). Hence, this has been an ongoing debate between Republican representatives and Democratic representatives about the viability of the bill for improving stakeholder rights and patient needs, as well as the feasibility of enforcing and governing the bill’s provisions. After being killed on the House floor four times, H.R. 876 was introduced. This bill, too, was referred to a committee rather than achieving an appropriate vote. H.R. 876 was referred to the House Ways and Means Committee and House Energy and Commerce, in which the Chair of these committees serves as the party responsible for determining whether the bill evolves beyond the committee evaluation stage (Govtrack.us, 2013). This, the fifth rendition of the proposed bill, was replaced by H.R. 1821, the Registered Nurse Safe Staffing Act of 2013, which was also referred to committee rather than achieving a vote on the floor. However, unlike the other bills that maintained only a singular Representative sponsor or two co-sponsors, the newest version of the bill, H.R. 1821, now maintained eight co-sponsors, including seven Democrats and one Republican. This would tend to show that the bill, and its many different introductions and renditions, was gaining bi-partisan support that involved more Congressional recognition that the bill maintained positive benefits for nurses, hospitals and general stakeholders in society. Unfortunately, H.R. 876, now referred to as active bill H.R. 1821, only maintains a one percent chance that it will move beyond the committee stage and ultimately become an enforceable piece of legislation (Govtrack.us, 2013). Between 2011 and 2013, only 11 percent of all bills introduced were able to evolve beyond the committee evaluation stage. Concurrently, only three percent of all introduced bills between 2011 and 2013 were actually put into affective law (Govtrack.us, 2013). The bill continues to be reintroduced by its Representative sponsors due to urging on behalf of practicing nurses all over the United States who are attempting to urge Congress to consider the merits and benefits of the bill. Nurses justify this pressure by arguing that insufficient hospital nurse staffing poses unnecessary risk to patients, imposes unjustifiable costs to provide health care to the patient, and forces extension of the length of stay experienced by patients (All Medical Personnel, 2013). Protesting nurses and nursing-related organization representatives have even protested outside of the House of Representatives as a means of fostering Representative and public support for the bill. However, despite these pressures, it is clear that committee chairs associated with the House Ways and Means Committee and House Energy and Commerce Committees find problems with bill language, its enforceability, or relevancy for attempting to regulate internal hospital operations using this framework for compliance. H.R. 876 can only become a priority in Congress if Representatives maintain a bi-partisan attitude and the bill achieves significant volumes of representative sponsorship. H.R. 876, the 2011 version of the bill, actually had 21 cosponsors, 20 of which were Democrat and one a Republican Representative. Hence, there is clearly disequilibrium between Republican sentiment about the viability or relevance of the bill. This is important since in the 112th Congress, the Congress in operation between January 3, 2011 and January 3, 2013, Republicans held the majority of representation in the House of Representatives (Zeleny, 2010). The current operating Congress, the 113th Congress, still maintains a majority Republican presence in representation, which could be a deciding factor as to why the bill continues to be referred to committee despite its co-sponsorship that has continued to increase since the bill’s first introduction in 2007. The 113th Congress will be in operation until January 3, 2015, hence it is likely that the newest introduction of the bill, H.R. 1821, will not evolve beyond the Committee stage. When attempting to understand why the bill is unable to evolve beyond committee evaluation, it is important to understand the dynamics of the various committees in which the bill was referred for evaluation and scrutiny. The House Ways and Means Committee provides rather simplistic opportunities for procuring campaign donations (Grier & Munger, 1991). Previous committee chair Sander Levin, a Democratic representative from Michigan, recently sponsored introduction of H.R. 6030, the Hire Now Act of 2012, designed to provide tax credits when payroll increases in companies. Levin also sponsored bill H.R. 5974, Invest in America Now Act of 2012, designed to amend the tax code of 1986 to include extending bonus depreciation. Though both bills ultimately died after being referred to committee, it illustrates the corporation-minded sentiment and values of leadership in the Ways and Means Committee. Both the Hire Now Act and the Invest in America Now Act favor the needs of business leaders and the financial opportunities for businesses. As H.R. 876 would ultimately impose additional costs on hospitals by changing the dynamics of staffing (including payroll increases), this piece of legislation is more supportive of nurses and non-corporate stakeholders and does not provide the economic protectionism to hospital administration and accounting practices. Hence, the Ways and Means Committee likely believes that H.R. 876 imposes undo costs for evaluation, payroll and restructuring of operations that goes against Levin’s general sentiment about corporate protectionism, even though these views are often conflicting with the Democratic perspective. Though this is only a subjective viewpoint about why the bill continues to die before reaching the floor for a vote, it does appear that the various committees in which the bills are being referred are pro-business (perhaps as a method of stabilizing a struggling economy through business protectionism) and believe that the act would impose undo costs to hospitals (which provide significant revenues to the national economy). Hence, to gain priority in Congress, those chairs responsible for determining the final fate of the bill would need to maintain a more balanced view that satisfies both the societal stakeholder and businesses. Social, Cultural and Ethical Dimensions of the Policy According to Maslow’s Hierarchy of Needs, a model in psychology respected for its universalism in human motivation, safety is a very influential motivational need (Craven, Hirnle & Jensen, 2013). Hospitals that are not providing nurses with adequate relief, ensuring overtime opportunities when conditions at the hospital require additional effort and dedication, and aligning proper staffing volumes, it provides risk to the nursing role. It is rather commonly understood that every year, there are many errors occurring in the nursing profession that could be prevented with better policies and operational systems. Inadequate staffing forces nurses to work exceptionally hard to cater to the health needs of many different patients that could be better serviced with higher staffing volumes. This can lead to medication errors and other situations that would jeopardize the careers of the registered nurses as well as patients. Hence, hospitals that are not providing adequate recruitment, retention and operational staffing procedures pose a risk to the security needs of nurses, which would in turn impact their sense of organizational belonging and create a de-motivating work environment. H.R. 876 (and its next introductions into Congress) could establish a better working environment for nurse stakeholders across the country, providing the psychological security required to ensure they remain dedicated and focused on their job roles and error prevention. Furthermore, Hader, Saver & Steltzer (2006) indicate that in the next decade, approximately 55 percent of currently practicing registered nurses will be retiring. The nursing profession is already having problems recruiting enough educated and certified nursing talent, which is contributing to hospital staff shortages across the country. H.R. 876 and whatever impending version of the bill that could improve patient to nurse ratios in the hospital environment maintains the potential to create a more enticing incentive for society’s stakeholders to pursue a nursing career. Even with a median income range as a registered nurse at approximately $65,000 annually, it is not providing the type of incentive to interest new students to fill the impending void in the nursing career. It is commonly known in society that the nursing job is very demanding and nurses are often forced to work long hours which has implications for family development and nurturing and other personal recreational needs. If the bill H.R. 876 were to be passed, it would establish that hospitals must be compliant to adequate staffing plan mandates that would reduce burdens on over-worked nurses. The online coverage of satisfied nurses, along with other media coverage and publicity of the impact of the new legislation on the nursing profession, could incentivize nursing as an educational option for future students as there would be less burden placed on the role, hence giving these stakeholders better social and familial opportunities. In situations where nurses have grievances against the hospital for alleged unethical behavior and policy formation, there are always risks of retaliation. Many hospitals are top-down organizations, or those in which decision-making moves vertically with very little opportunity for lower-level staff sentiment in decision-making and hospital operational strategies. Fairholm (2009) indicates that in order to build a dedicated culture, there must be open communications from administration and engaging internal stakeholders as a mentor and coach as well as establishing an inspiring vision. Hospitals generally do not provide these open systems where decision-making occurs horizontally, therefore H.R. 876 maintains ethical implications in favor of nurses that guarantee that there will be consequences by bureaucratic retaliators in the event of non-compliance to the legislation, thus giving a new type of protectionism and security to the nursing role. Economic and Environmental Dimensions There would clearly be new cost burdens placed on hospitals in the event that the bill passes and becomes an enforceable law. Hospitals would be forced to increase their recruitment and payroll efforts, establish committees and frameworks for evaluation, and also change the dynamics of work groups and work processes along the entire operational and value chain models. These activities, which might also require additional software and other technology support to ensure compliance, could pose significant cost burdens on the hospital revenue and earnings models. Unfortunately, higher staffing and operational evaluation teams cannot occur within a proverbial vacuum without the support of financial assistance and re-budgeting of key operational areas. Though this would be subjectively an unethical stance, it should be recognized that extended patient stays provide the hospital with significant revenues, especially with an estimated national median cost per day as a patient in standard care at $1500 daily. The goal of this piece of proposed legislation would, theoretically, shorten the duration of patient care necessary to provide quality care outcomes, thus reducing the revenue stream of hospitals in the process. Hospitals maintain a maximum capacity of beds for standard and more advanced care which also cannot be enhanced without costly capital-depleting construction projects for expansion. If the hospital were to attempt to offset costs by marketing as a means of competitive strategy in the event that the new legislation actually reduces patient stays, hospitals will be unable to over-reach their maximum capacity without additional cost expenditures. Though it should, under the deontological view of ethics, be necessary for hospitals to put, first, the needs of patient stakeholders, there must be consideration of the impact of potential revenue declines that sustain hospital longevity and the careers of many nursing professionals. Hence, H.R. 876 could significantly burden hospitals with economic problems in the short- and the long-term. Environmentally, better staffing plans and adequate staffing levels aligned with patient volumes could improve the methodology by which hospitals remove hazardous waste. As nurses would have more time to ensure supplementary services, such as medical waste bag removal in a timely basis, it would provide more security to patients by providing a safer and more health conducive care environment. Otherwise, H.R. 876 maintains little implications or advantages in environmentalism. A Plan for Policy Implementation and Plan Evaluation Fortunately, the language of H.R. 876 is concise about the responsibilities of hospital administration and executives, nurses, and the Secretary. Immediately upon passing as an enforceable piece of legislation, hospitals would have to evaluate the necessary framework and stakeholder involvement in committee development according to the new law. Executives would have to evaluate which types of specialized care nurses would be most relevant for participation in an ongoing committee responsible for implementation, planning and evaluation of new staffing activities. Since H.R. 876 explicitly states that nursing managers are not to be inclusive in committee development, this might involve more emphasis and reliance on human resources, including but not limited to survey and interview instrument development, to determine which group of nursing stakeholders would be most viable and beneficial for committee establishment. These committees would need to be inclusive of those with strong administration skills and those with knowledge of hospital operations (it should be recognized there is little cross-training in specialized roles in the hospital, thus reducing knowledge about holistic hospital procedures in all care divisions). Hence, there might be a significant undertaking in recruitment for maintaining a chair on the committee to remove bias and inefficiency. It would also be necessary for a series of metrics designed to evaluate performance, productivity and efficiency with a new staffing plan, which would have to be consolidated and collated for later distribution to the Secretary. This might require additional software implementation to ensure adequate record-keeping and reporting capabilities, which would require reliance on the information technology division throughout the duration of the new operational demands. Therefore, evaluation, implementation, records management and other compliance-related activities would require more interaction with disparate stakeholders along the entire hospital and administration model. Hospitals that are not accustomed to participative leadership and cooperative team networking might have to place more emphasis on training in areas of management, social systems theory, and project management to ensure that costs are recognized and efficiencies injected into the new compliance-centric processes. The Expected Future Value of the Policy Improving Patient Care Needleman et al. (2011) indicate that higher mortality rates are positively correlated with reduced nursing staffing levels. In light of these findings, the implications for improving patient care are substantially obvious: it could improve mortality ratios when nurses have more capacity for providing immediate and quality care. Unruh (2003) indicates that higher levels of nurse staffing availability have been correlated with reductions in lung collapse in patients, reduction in decubitus ulcers, the prevalence of urinary tract infections, and even reduces patient falls. Clearly, H.R. 876 and its mandates to ensure that adequate staffing is conducted as aligned with current patient volumes would improve responsiveness and ensure more focused care that can aid in quality and more manageable care for patients with a variety of health problems. As patients could be better guided by practicing nurses rather than being forced to move about their rooms or the hospital alone, it would have significant implications for the elderly by having more nurse capacity at their disposal. Rogers, Hwang, Scott, Aiken & Dinges (2004) indicate that when nurses are forced to work longer than 8.5 hours per shift, upwards of 12.5 hours, the odds of making errors increases 300 percent. Again, the implications of H.R. 876 becoming an enforceable law is rather obvious, as it would remove the shift burdens so often imposed on nurses due to the shortage of nurses in this profession and over-capacity issues. Having shifts shortened to more reasonable timeframes with better nurse coverage per 24 hour daily period could ensure that less patient deaths or reactions occur through improper medicinal dispensing. There are virtually unlimited positive benefits, theoretically, that would improve patient care all across the United States. The Role of Healthcare-Related Stakeholders in aiding Enforcement Nurses all over the country are writing to their Congressional representatives as constituents asking for support and acknowledgement of the potential benefits of H.R. 876 in improving health care conditions and ensuring quality of patient care. Additionally, support from funded organizations such as the American Nurses Association have social clout to exert pressure on legislators to begin holding hospitals accountable for their current staffing strategies and patient care focus. Nurses and other healthcare-related stakeholders have significant clout from many special interest organizations that have the resources, social and media exposures, and legislative support required to back nurses that believe H.R. 876 is a viable and worthwhile piece of legislation. Furthermore, the American Association of Critical-Care Nurses is attempting to create an incentive program to steer future students toward the nursing profession as a means of bolstering its shortage problems. This is also supported by the Robert Wood Johnson Foundation which has published a newsletter describing potential innovations in nursing to fuel more interest in undoing the current and projected future shortages in the nursing profession. Furthermore, many states have already established new funding promises for advancing nursing education and recruitment, which also fuels the foundation for being able to ensure adequate, international compliance to H.R. 876 if the bill were to be passed (or its future introductions and forms). These efforts help spotlight what needs to be changed in the nursing profession and nursing education network, as well as incentive schemes for improving interest in pursuing nursing as a long-term career option, which will ensure that the nursing industry maintains adequate volumes so that hospitals can change their staffing plans and staffing structures to meet higher quality patient care needs. Conclusion As illustrated, H.R. 876 is more advantageous to patients and to nurse stakeholders in comparison to that of hospital administration. Nurses would experience significant burden reduction and, perhaps in the best of scenarios, more opportunities to explore dimensions of their personal life not currently afforded by long shifts and demands for overtime labor. H.R. 876 would also motivate workers by appealing to their security needs and, through more inclusive policies and involvement in providing feedback on improvements, would improve their dedication to the hospital and their positions for providing social belonging; a universal need along Maslow’s Hierarchy of Needs. Clearly, the patient would be the most primary stakeholder positively impacted if H.R. 876 were to be passed in Congress. Benefits could manifest themselves in areas of cost savings during hospital stays, in quality of care provided while living as an inpatient in the hospital, and ensuring that more risks are removed during their stays. Patient needs, under deontological models of ethics, should be the primary consideration when assessing the viability and relevancy of H.R. 876. This bill, in its current language, satisfies this ethical view, despite any potential economic drawbacks to hospitals that must comply. However, the bill, and its many versions that died before reaching the floor for a vote, has little chance of passing despite its best intention References All Medical Personnel. (2013). Nurses ask Congress for Higher Staffing Ratios. Retrieved May 26, 2013 from http://blog.allmedstaffing.com/tag/national-nursing-shortage-reform- and-patient-advocacy-act-of-2011/ Congress.gov. (2013). H.R. 876 – Registered Nurse Safe Staffing Act of 2011. Retrieved May 25, 2013 from http://beta.congress.gov/bill/112th-congress/house-bill/876 Craven, Ruth, Hirnle, Constance & Jensen, Sharon. (2013). Fundamentals of Nursing: Human Health and Function (7th ed.). Lippincott Williams & Wilkins. Fairholm, M. (2009). Leadership and Organizational Strategy, The Public Sector Innovation Journal, 14(1), pp.26-27. Govtrack.us. (2013). S.3491 (111th): Registered Nurse Safe Staffing Act of 2010. Retrieved May 27, 2013 from http://www.govtrack.us/congress/bills/111/s3491 Govtrack.us. (2013). H.R. 1821: Registered Nurse Safe Staffing Act of 2013. Retrieved May 27, 2013 from http://www.govtrack.us/congress/bills/113/hr1821 Grier, Kevin & Munger, Michael. (1991). Committee Assignments, Constituent Preferences and Campaign Contributions, Economic Inquiry, 29(1), pp.24-43. Hader, R., Saver, C. and Steltzer, T. (2006). No Time to Lose, Nursing Management, 37(7), pp.23-29. Healthcare Employment Counsel. (2011). Nurse Staffing Bill Reintroduced in the House. Retrieved May 26, 2013 from http://www.healthcareemploymentcounsel.com/2011/03/11/nurse-staffing-bill- reintroduced-in-the-house/ Library of Congress. (2013). Bill Text – 112th Congress (2011-2012): H.R. 876 IH. 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