Running head: HEALTH CARE ISSUE ANALYSIS 1

Health Care Issue Analysis

Nicky Reed

Ferris State University

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Abstract

Health care is a revolving door of changing processes and policies. For all health care workers

across the nation the foremost import concern is to provide the safest and best quality care

possible. Policymakers forge forward every day to make a difference to the health care system.

The implementation of health care policy is always at the top of the agenda. Senate Bill 0574

(2015) is currently under consideration in Michigan. The focus of Senate Bill 0574 (2015)

would mandate a safe practice of nurse to patient ratios, aiding in reduction of potential patient

mortality.
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Health Care Issue Analysis

Nurse to patient ratios is a health care issue that has been debated for over a decade.

Nurses have been lobbying since 1999 when California initiated into law a revision to their

guidelines for safe and quality practice to patients. Safe practice for nurses is the utmost concern

to maintain the nursing workforce and provide excellent care. Early recognition of potential

harmful indicators and preventable mortality while caring for patients is the goal of all nurses

across the nation. The purpose of this paper is to provide a clear understanding of the patient to

nurse staffing ratios policy through analysis and insight from current organizational healthcare

leaders.

Jon Hoadley was the first Michigan Democratic Representative to introduce a policy

regarding nurse-to-patient ratios titled House Bill 5013 (2013). According to Michigan

Legislature, it is currently known as Senate Bill 0574 (2015). Presently, Senate Bill 0574 (2015)

is being referred to the committee on health policy (S. 0574, 2015). Rebekkah Warren,

Democratic Representative, recently introduced Senate Bill 0574 (2015) on October 21, 2015 (S.

0574, 2015). The purpose of this bill was grounded on providing a safe practice for nurses and

reducing the number of sentinel events in healthcare institutions. .

There are two goals of Senate Bill 0574 (2015). The first is to provide a structured nurse-

to-patient ratio, creating an environment for optimal safe and quality patient care. The second is

establishing staffing committees. Included in Senate Bill 0574 (2015) are the guidelines for

sufficient and qualified nursing staff ratios. The Senate Bill 0574 (2015) states the proposed

staffing ratios to be as follows, (i) Intensive Care/Critical Care- one to one, (ii) Operating Room-

one to one, (iii) Labor Deliver- (A) Second and Third Stage of Labor- one to one, (B) 1st Stage

of Labor- one to two, (C) Intermediate Care Newborn- one to three, (D) Non-Critical
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Antepartum- one to four, (E) Postpartum Couplet- one to three, (F) Postpartum Mother or Well

Baby Care, (iv) Postanesthesia Care Unit- one to two, (v) Emergency Room- (A) Nontrauma or

noncritical- one to three, (B) Trauma or Critical Care- one to one, (C) Plus one R.N. for triage,

(vi) Stepdown- one to three, (vii) Medical Surgical- one to three, and (viii) Pediatric- one to four

(S. 0574, 2015). Upon enactment of the bill, hospital institutions would be required to

implement a staffing plan and committee within three years (S. 0574, 2015). According to S.

0574 (2015) all units will organize a staffing committee which will consist of ½ of the members

to be registered professional nurses (S. 0574, 2015). In S. 0574 (2015) participation in the

staffing committee will be included in the scheduled work week (S. 0574, 2015). If hospitals fail

to submit annual staffing plans or do not meet the minimum required staffing guidelines the

hospitals will receive a violation for each day that it is not met (S.0574, 2015). The

administrative fines for each violation is no less than $10,000.00 or no more than $25,000.00 for

each violation (S. 0574, 2015). At this point many states across the nation have followed suit in

passing similar nurse to patient staffing ratio mandates. Many studies have found that heavier

nursing workloads are associated with poor patient outcomes, including more patient deaths,

complications, and medical errors (McHugh, Kelly, Sloane, et al., 2011). The California

legislation has increased staffing levels and created more reasonable workloads for nurses in

California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in

other states without mandated staffing ratios (AHRQ, 2012).

Benefits

The debate surrounding Senate Bill 0574 (2015) involves questioning if mandated ratios

will aid in decreasing mortality. Many critics of Senate Bill 0574 (2015) will say that there is

not enough research supporting mandated ratios. However, authors Kane, Shamliyan, Mueller,
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Duval and Wilt conducted a study in 2007 consisting of 28 individual studies analyzing the

effects of increased nurse to patient ratios and reduction of mortality. The study concluded that

an increase by 1 Registered Nurse (RN) full time equivalent (FTE) per patient day would save 5

lives per 1000 hospitalized patients in ICUs, 5 lives per 1000 medical patients, and 6 per 1000

surgical patients. Michigan Nurses Association agrees that increasing nursing staff would help

Michigan hospitals by improving care and lowering readmissions, improvements that would save

facilities money (The Advisory Board Company, 2013). For example, in one early study of

232,342 surgical discharges from several Pennsylvania hospitals, 4,535 patients (2%) died within

30 days of hospitalization; the investigators estimated that the difference between 4:1 and 8:1

patient–nurse ratios may be approximately 1000 deaths in a group of this size (Shekelle, 2013).

Furthermore, people who go into cardiac arrest while hospitalized are 5 percent less likely to

survive for each additional patient assigned to their nurse (Hugh, et al., 2016). An additional

thought would be reduction to readmissions. Nurse education (average proportion of BSN-

prepared nurses was 39%), generally was not associated with readmission except for pneumonia

where 10 percent more nurses with BSNs lowered odds of readmission by 3 percent (McHugh &

Ma, 2013). More nurses working in hospitals with good work environments were confident that

their patients were able to manage their own care when discharged (59% versus 48%) (McHugh

& Ma, 2013). The benefits of improving nurse staffing levels is evident with gross statistical

data to contradict negative accusations towards nurse to patient ratio mandates.

Nurses have long been the safety net for patients. Nursing standards assist in providing a

structure to practice. The American Nurses Association (ANA) addressees these standards

including the registered nurses ability to contribute quality nursing practice (ANA, 2010). In

order to meet these standards it must be considered to focus on ways for nurses to facilitate
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improvements within a system. Nurses must have time to create a professional foundation for

better quality care.

Another beneficial consideration to Senate Bill 0574 (2015) revolves around nurse and

patient satisfaction. Two-thirds of California nurses agreed that they are more likely to remain in

their jobs as a result of the legislation (Kane, Shamliyan, Mueller, et al., 2007). Providing a

conducive environment to facilitate a working relationship to maintain trust and communication

between the patient and nurse is ideal for satisfaction. An environment free of fear for the

patient and nurse will allow for less burnout for nurses and optimal environment for patients to

learn and understand signs of deteriorating condition. Studies reviewing the cause of nursing

burnout suggested it was not hours worked as the highest factor, but rather the patient safety

aspect. For example, a study executed by Halbesleben, Wakefield, Wakefield, and Cooper

(2008) found both exhaustion and depersonalization were negatively associated with nurses’

perceived patient safety grades. This suggests that higher burnout was associated with a lower

patient safety grade and creating a feeling of a less safe environment for nurses to practice

(Halbesleben, Wakefield, Wakefield, & Cooper, 2008).

Disadvantages

According to the American Society of Registered Nurses (2010) a disadvantage that bills

similar to Senate Bill 0574 (2015) face is hospital organizations not seeing the necessity of nurse

to patient staffing ratios. In 2010, the Massachusetts Hospital Association (MHA) insisted the

California law has not helped patients and that the public should not support staffing bills in

other states (American Society of Registered Nurses, 2010). Health care industry groups have

taken the position that the financial burden of passing law to mandate staffing ratios would be

astronomical. Furthermore, the California law has only shown "mixed results," according to
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Chris Mitchell, Michigan Health and Hospital Association's (MHHA) senior director of

advocacy. "Hospital leaders reported difficulties in absorbing the costs of the ratios, and many

had to cut budgets, reduce services, or employ other cost-saving measures," Mitchell said in a

statement (The Advisory Board Company, 2013). Not only is the financial strain a concern but

also the implication of more nurses.

There is mixed concern in regards to nursing shortage existence. Nursing shortage is

greatly debated over the last few years across the nation. For instance, Chris Mitchell also noted,

"Hospitals simply cannot maintain a supply of nurses that do not exist" (The Advisory Board

Company, 2013). According to the U.S. Bureau of Labor Statistics, about 233,000 additional

jobs for registered nurses will open each year through 2016, in addition to about 2.5 million

existing positions (Advance Healthcare Network, 2016). According to the Michigan Health &

Hospital Association the number of new registered nurse graduates in the country more than

doubled from 74,000 in 2002 to 157,000 in 2010, the Bureau of Labor Statistics’ Employment

Projections 2010-2020, released in February 2012, indicates that the number of job openings for

nurses due to growth and replacements will reach 1.2 million by 2020 (MHHA, (2013). Health

care institutions will have to reflect into their infrastructure and formulate a plan to focus on

grooming the future of nursing within their communities.

Nurses are leaving the field because of burnout and unsafe practice causing health care

institutions to cycle through nursing staff. Many Executive Steering Committees are not

concerned with this influx as they feel,” a nurse is a nurse, is a nurse, is a nurse. A nurse who’s

been in practice for more than five years brings no more added value than a new nurse” (The

Advisory Board Company, 2013). Comprehension of the overall problem is pertinent in

addressing Senate Bill 0574 (2015)

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Organizational Insight and Rural Setting

In the late 1990’s federal policymakers first recognized the political and policy needs for

targeted rural legislation to address rural health care (Mason, Gardner, Outlaw, & O’Grady,

2016, p. 513). One of the challenges of rural hospitals is nursing retention and recruitment. This

is a concern made by Janice Stone, RN, MSN, Vice President of Clinical Operations that was

relayed during an interview amongst organizational leaders at Spectrum Health Gerber Memorial

(SHGM). Many requirements of rural hospitals such as SHGM is that all nurses be proficient in

many roles such as discharge planning, care management, all age groups from pediatric to

geriatric, & cross-training amongst different service lines (Obstetrics/Emergency,

Room/Intensive, & Care/Outpatient Surgery). This is a demand to aid in cutting cost and

utilizing the staff within the organization to relieve the shortage of nurses. When carrying such

heavy loads of responsibility may take time away from each patient. The multiple roles duties

could cause a risk of safety to patients. In relation to Senate Bill 0574 (2015), rural hospitals may

find it difficult to maintain the mandated nursing workforce. At SHGM sufficient staffing is

maintained with varying intervals of shortage amongst nurses according to President Randy

Stasik. At times short staffing may not be ideal but rarely have nurses felt unsafe in caring for

patients Intensive Care Unit and Medical Surgical Unit Director Dan Powell, RN, BSN states

amongst the executive leaders. Turnover for nurses at SHGM is high in the Emergency

Department. This is a high stress environment which needs sufficient staff at all times to

embrace the high value periods of time that are unexpected. Janice Stone also noted her view in

regards to the budget explaining that it would not be a concern. Ultimately expressing that

patient centered focus as being the highest priority and meeting our communities need in

providing safe and quality care. Words of trust and respect to patients were articulated by Randy
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Stasik, President and the leadership committee at Spectrum Health Gerber Memorial. Rural

hospital settings would be impacted significantly and a course of action for preparation is

elemental.

A shortfall of many organizations including rural hospitals is the mainstream of keeping

nurses educated. The continuation of education is ultimately a nurse’s responsibility as outlined

by the American Nurses Association in Standard eight in nursing scope and standards of practice

(ANA, 2010). The registered nurse seeks experience that reflect current practice to maintain

knowledge, skills, abilities, and judgement in clinical practice or role performance (ANA, 2010).

Health care organizations also have a commitment to maintaining professional competencies to

their staff. According to the American Hospital Association a key component to a retention plan

is offering employees training and continuing education opportunities (AHA, 2013).

Key stakeholders for Senate Bill 0574 (2015) are patients, nurses, hospitals, states, and

potentially insurance companies. Shorter lengths of stay and readmission rates are beneficial to

patients, nurses, hospitals and insurance companies. Hospitals with higher nurse staffing are less

likely to be penalized by the Centers for Medicare & Medicaid Services (CMS) for excessive

readmission rates than similar hospitals with lower nurse staffing ratios, researchers have found

(Wood, 2013). Medicare spends about $15 billion annually on preventable readmissions (Wood,

2013). Penalties are placed on hospitals with readmissions. Hospitals with higher nurse staffing

levels had 41 percent lower odds of receiving the maximum penalty for readmissions, compared

with hospitals with lower staffing, the researchers reported (Wood, 2013).

Similar Federal Legislation

Similar Federal legislation being introduced into the Senate is Senate Bill 864 (2015).

Introduced on March 25, 2015 by California’s Democratic Senator Barbara Boxer (S.864, 2015),
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“National Nursing Shortage Reform and Patient Advocacy Act” (S.864, 2015). The Federal

Senate Bill 864 (2015) bill is fairly similar to Michigan Senate Bill 0574 (2015) with exception

to addressing nursing shortage and patient rights. Noted within Senate Bill 864 (2015) is the

statement of prohibiting a hospital from: (1) taking specified actions against a nurse based on the

nurse's refusal to accept an assignment for such a reason; or (2) discriminating against any

individual for good faith complaints relating to the care, services, or conditions of the hospital or

of any related facilities (S. 0864, 2015). It further adds stipends to the nurse workforce loan

repayment and scholarship program including expansion of the nurse retention grant program to

authorize programs to implement nurse preceptorship and mentorship projects (S. 0864, 2015).

Buy-in from other legislative leaders such as Senators Brown, Markey, Sanders, & Baldwin will

assist in further political strategy for successful enactment of Senate Bill 0864 (2015). Nurses’

involvement in the legislative process will be paramount in being a voice for patients and

communities.

Conclusion

Federal and state legislations across the nation continue to heavily debate the concern for

nurse to patient ratio mandates. The need for providing safe and quality care for patients is the

utmost objective. The disadvantages of financial strain and nursing shortage are valid concerns

for health care institutions. Many people across the nation would find it difficult to place a

monetary value on their own or loved one’s lives. Senate Bill 0574 (2015) is precise with

exception to addressing the nursing shortage. A strategic plan to retain and foster the future of

nursing is essential in our nation’s health care system. Considerations for rural settings should be

deliberated to allow S.B. 0574 (2015) to be successful.

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References

Advance Healthcare Network, (2016). Nursing shortage expected to grow annually through

2016. Retrieved from http://nursing.advanceweb.com/Article/Nursing-Shortage-

Expected-To-Grow-Annually-Through-2016.aspx

The Advisory Board Company. (2013). Michigan lawmakers may mandate nurse-to-patient

ratios. Retrieved from https://www.advisory.com/Daily-Briefing/2013/03/05/Michigan-

lawmakers-may-mandate-nurse-to-patient-ratio

Agency for Healthcare Research and Quality. (2012). State-mandated nurse staffing levels

alleviate workloads, Leading to lower patient mortality and higher nurse satisfaction.

Retrieved from https://innovations.ahrq.gov/profiles/state-mandated-nurse-staffing-

levels-alleviate-workloads-leading-lower-patient-mortality?id=3708

American Hospital Association. (2013). Developing an effective health care workforce planning

model. Retrieved from http://www.aha.org/content/13/13wpmwhitepaperfinal.pdf

American Nurses Association, (2010). Scope and standards of practice. 2nd Ed. Silver Spring,

MD: American Nurses Association

American Society of Registered Nurses. (2010). Finally, An objective study on nurse-patient

ratios. Retrieved from http://www.asrn.org/journal-nursing/832-finally-an-objective-

study-on-nurse-patient-ratios.html#sthash.1ic3hE6M.dpuf
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Halbesleben, J. R., Wakefield, B. J., Wakefield, D. S., & Cooper, L. B. (2008). Nurse burnout

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Retrieved from

http://www.ona.org/documents/File/pdf/KaneRNStaffingPatientOutcomesMedCare.pdf

Mason, D. J., Gardner, D. B., Outlaw-Hopkins, F., & O’Grady, E. T. (2016). Rural health care:

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Michigan Public Health Code, S. 0574, 114d Cong. (2015).

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from http://www.mha.org/documents/staffing_ratios.pdf

National Nursing Shortage Reform and Patient Advocacy Act, S. 0864, 114th Cong. (2015).

Wood, D. (2013, October 13). Better nurse staffing shown to reduce readmission penalties.

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news/better-nurse-staffing-shown-reduce-readmission-penalties/