Background
The S.1357 also known as the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2019 is a bill introduced to the 116th Congress (2019-2020) by Sen. Sherrod Brown. The primary purpose of the legislation is to amend the Public Health Service Act to establish mandates for direct registered nurse-to-patient staffing in hospitals. It was introduced in May of 2019, has been read in Congress, and referred to the Committee on Health, Education, Labor, and Pensions which is as far as its legislative history goes (U.S. Congress, 2020).
Nurse staffing is a highly controversial topic in the industry. While it is known that staffing can have an impact on patient safety, quality of care, and human resources, nursing also accounts for 70% of wages paid by health services (Olley, 2019). Therefore, any decisions regarding staffing methodology have to be examined critically as they will have financial, workforce, and industry implications. While Medicare does stipulate for hospitals to have an appropriate number of nurses on staff for facilities to receive funding, the language is broad. Seven states require hospital staffing committees for nurse-driven ratios, another 5 require public disclosure, but only California has a set direct nurse-to-patient ratio in place based on the type of unit. The S.1357 bill is largely modeled after California’s successful implementation of staffing ratios (ANA, 2019).
Major Provisions
The bill establishes minimum direct care registered nurse-to-patient requirements that all hospitals would be required to implement and follow. The bill also mandates developing staffing plans in which nurses must participate. Staffing documentation and data reporting should be publicly available. However, the bill also includes reimbursement under Medicare and other federal programs to hospitals based on the net amount of additional acquired costs. The legislation also offers a variety of whistleblower protections and includes enforcement provisions (U.S. Congress, 2020).
Stakeholders and Positions
Nurses, whom the bill directly addresses, are the primary stakeholders. Nurses across the country overwhelmingly support a federal mandate on ratios, citing that it will create the much-needed equitable distribution of labor and appropriate time to care for patients. They believe that the current situation places an unfair burden on front-line medical professionals and ultimately creates an unsafe environment for patients (National Nurses United, 2019). Nursing unions and organizations advocating on behalf of individual nurses also support similar positions.
Another stakeholder in this debate is the patients themselves. While little is known regarding the opinions of patients on the issue of ratios, there is some research focusing on patient satisfaction and missed care from a patient perspective. A large meta-analysis was conducted by Gustafsson et al. (2020) demonstrates that patients report missed care when there is miscommunication with the staff or provided care is not done in a timely basis. Missed care is associated with patient-reported adverse events and patients noted that staffing adequacy was the primary cause, with lack of sufficient staff or experienced nurses. Given the significant healthcare expenditures in the U.S., patients often demand the best care and safety, which can only be achieved with an appropriate number of nurses.
Hospitals, particularly management and business administrators, vehemently opposed the federal regulations proposed in S.1357. First, as mentioned earlier, staffing costs are increasingly large, thus any major changes that would require hiring additional nurses will significantly impact already tight hospital budgets. The hospital industry argues that there is not enough evidence to support a front-loaded investment in nursing staff (Abraham, 2018). Hospitals also argue that the issue is not as straightforward as setting rigid ratios. Research is mixed on the issue, with not all studies demonstrating a straight correlation in improving outcomes. Furthermore, staffing may depend on a wide variety of factors such as acuity of the unit, situational factors, the number of diagnostic tests being conducted, and the financial performance of individual facilities. Stakeholders involved in hospital administration argue that the mandated ratios maybe even detrimental to care and workflow, while ultimately forcing many facilities to close due to financial burdens, leaving portions of the population without patient care (Thew, 2018).
Government agencies and political figures are stakeholders in this bill as well as the issue has become increasingly political. The CDC largely seems to support improving ratios, although not necessarily mandating them, publishing evidence in support of better patient ratios for nurses (Leigh, 2016). However, in terms of political figures, the concept is increasingly partisan which has made it difficult to pass similar laws at the state level and even more challenging at the federal level. Republicans typically vote against such legislation due to the belief that governments should not overstep boundaries and mandate such requirements. Furthermore, Republicans tend to support the financial aspect for organizations and point out other issues that may be causing the disproportionate ratios. At the state level and now at the federal level for this bill, it is Democrats that are pushing forward with the initiatives, but there is a slow gain of support among Republican co-sponsors as well (Abraham, 2018).
Impact on Nursing Practice
The bill is targeted to address a critical nursing shortage and patient safety crisis in hospitals across the United States. It is conservatively estimated that 250,000 patients die annually from preventable medical errors while under nursing care, largely arising because RNs are forced to take care of numerous patients at any given time, with virtually no limitations (National Nurses United, 2019). Nurses typically work long hours as is, but with overwhelming ratios, nurses are put in positions of being unable to keep up with the workload (forcing to speed up critical procedures) and exhausted both physically and mentally, resulting in human error. Also, the status quo of current staffing practices often leads to high turnover rates among nurses due to burnout, further exacerbating the issue and creating additional costs (Halm, 2019).
Set ratios can tremendously relieve the pressure of existing staff and allow for a more equitable distribution of workload, which promotes a culture of safety, attention to patient needs, and the sustainability of nurses in an already challenging profession. Appropriate staffing levels ensure that there is a greater efficacy in matching the needs of the patient and their families to the knowledge and skills of the nurse, creating a healthy work environment and enhancing quality and safety in the long term (Halm, 2019).
Nursing Action
This law is highly important for all nurses as it offers additional legal protections empowers medical staff, and allows them to more effectively provide better patient care without detriment to both the nurse and the patient. Nurses are taught to be advocates for evidence-based practice which extensively supports the need for mandated patient ratios in acute care, for safety reasons and better outcomes (Carlisle et al., 2020). The hospital industry has often opposed staffing mandates due to the financial burden of hiring more nurses. Nurses can advocate the hospital managers and executives to voice support of this bill providing relevant data to support such initiatives. Nurses can contact their state senators directly or use social and news media to present their cases (appropriately, within ethical and workplace guidelines). Major nursing associations are advocating and lobbying for this bill as well (Blitchok, 2018). More nurses joining these organizations, paying membership dues, and having a platform to voice concerns – can contribute to the passage of the legislation.
References
Abraham, T. (2018). Fight for mandated nurse-to-patient ratios heats up. HealthcareDive. Web.
ANA. (2019). Nurse staffing advocacy. Web.
Blitchok, A. (2018). Proposed federal RN ratios – What you can do about it. Web.
Carlisle, B., Perera, A., Stutzman, S. E., Brown-Cleere, S., Parwaiz, A., & Olson, D. M. (2020). Efficacy of using available data to examine nurse staffing ratios and quality of care metrics. Journal of Neuroscience Nursing, 52(2), 78–83. Web.
Halm, M. (2019). The influence of appropriate staffing and healthy work environments on patient and nurse outcomes. American Journal of Critical Care, 28(2), 152–156. Web.
National Nurses United. (2019). RNs applaud the reintroduction of federal safe staffing bills mandating nurse-to-patient ratios. Web.
Leigh, P. (2015). Higher nurse-to-patient ratio law improves nurse injury rates by one-third. Web.
Olley, R., Edwards, I., Avery, M., & Cooper, H. (2019). Systematic review of the evidence related to mandated nurse staffing ratios in acute hospitals. Australian Health Review, 43(3), 288. Web.
Thew, J. (2018). Nurse staffing isn’t straightforward. Here’s why. HealthLeaders. Web.
U.S. Congress. (2020). S.1357 – Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2019. Web.