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Registered Nurse in the Nursing Home Act


The Federal Bill H.R.5373 forms the basis of this paper’s analysis. It is a bill that is still undergoing the legislative process, having been introduced to the House recently. The bill seeks to amend a section of the Social Security Act to increase the mandatory requirement for registered nurses in nursing homes, from 8 hours to 24 hours.

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After discussing the bill and the legislative process undertaken so far, the paper moves on to discuss what it takes to have such a bill become law. It offers both the optimistic and pessimistic timelines for the bill to become law.

There is also a country comparison between the US and the UK on the approach taken to increase service quality in nursing homes. This serves as the basis for recommending alternative features of the bill, like a phased introduction of changes, which should make the bill plausible to members of the house and industry stakeholders alike.


Although many Americans have access to nursing facilities, there are few who are able to get the full professional assistance from such facilities as they would really wish. It was in this regard that the “Put a Registered Nurse in the Nursing Home Act” was convened. It is currently going through the legislative process in the Congress and it should soon become law.

The Act is an update to an existing law. Upon passing, it will amend the title XVIII (Medicare) and XIX (Medicaid) of the Social Security Act (Open Congress, 2014). The first part of the amendment refers to the skilled nursing care services that are supposedly available in nursing facilities across the United States. Meanwhile, the second one touches on nursing facilities. The law revises the standards of 24-hour licensed nursing service care.

Normally, these types of care have a registered nurse (RN) working for at least 8 hours a day. The RN is also present every day (Span, 2014). The upgrade brought by the amendment to the Social Security Act will have the above mentioned facilities have one RN who is professionally trained and qualified.

The nurse will offer assessment, surveillance, and direct care. These services are to be availed at the mentioned facilities for 24 hours a day, every day (Open Congress, 2014). As the bill passes on through the Congressional process, it will be referred to as Federal Bill H.R.5373 (Open Congress, 2014).

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The bill’s process so far

The bill awaits three more stages before it becomes law, as it was just introduced to the house. Currently it is under the House Committee on Energy and Commerce and the House Committee on Ways and Means, with the main issues for discussion touching on nursing and Medicare.

In the second stage, the bill will be passed by the House and then move on to be passed by the Senate in the third state, before being signed by the President into law. At any of these mentioned stages, the bill might fail to pass and be discarded or reintroduced after being re-drafted.

Lobbying and passing of laws in the United States

According to the constitution of the United States, all citizens are free to petition their government. They can use this privilege directly or through their representatives, who may be individuals or groups, to have the government provide them with services in a given way. However, the right does not mean that each citizen is entitled to have the government behave in a personalized way.

In fact, such an eventuality is impossible. Therefore, in petitioning the government, citizens have to gather support for their cause to make it convincing that it for the public good. Afterwards, they can move through the various stages of legislation to have their views, intentions, and ideas become law based on the strength of their ability to bring good to all citizens.

In 1976, the Congress enacted legislation that allowed charities to lobby freely for their causes (Birch, 2000). The Federal Bill forming the focus for this analysis had four sponsors who introduced it to congress.

Here is some background information that should shed light into the process of passing laws and help in understanding the work done so far on the Federal Bill H.R.5373 and what awaits it. At any given time, there are numerous small bills pending in the House and the Senate. Many people and groups are responsible for the ideas that are embedded in the bills. Most of the bills seek to amend existing laws as additions or subtractions to their provisions.

For example, a member of the House or the Congress may come up with a draft bill after getting an idea, or a constituent might write a letter to him or her about a compelling issue.

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It could also be a request by a union, corporation, or a not-for-profit organization. Professional lawyers are involved in the process of reviewing a draft bill to ensure it fits into the legal process. The bill is then signed by sponsors before being introduced for debate in the House or the Senate. Once the processing is complete, the bill is given a number, such as the Federal Bill H.R.5373.

Lobbying for the passing of bills is important because they are very many small bills seeking the attention of the House or the Congress. The co-sponsorship process and support from constituents help to make a bill relevant. For example, it is common to have endorsements by organizations and businesses that support the bill or the people who have already expressed support for the bill.

Value proposition of the bill

According to one of the sponsors of the bill, the Congress representative Janice Schakowsky, who introduced the bill, it is not right that any nursing home (NH) is not required to have an RN. In fact, nursing homes are not even required to have a physician on duty for more than 8 hours a day. The recommendation for 8 hours comes from the fact that this is the recommended working day duration in the United States (McKenzie & Rapino, 2011).

The argument, according to the sponsor and co-sponsors of the bill, is that RNs are the only professionals with the right qualifications and license to intervene at any hour in facilities that are full of delicate patients. If the law warrants the RN to be present at least for 8 hours, it is only fair to the patients and their loved ones that there is a professional to handle arising issues at any time of the day or night.

Putting the provisions in the law should ensure that harming of disabled people and the elderly who are put in nursing homes to get care does not continue to happen due to the lack of RN intervention when needed (Span, 2014).

The environment that brought this health care concern to the forefront

According to the Span (2014) news article appearing on the New York Times, a federal law that required nursing homes to have an RN on site was passed in 1987, but it only mandated the RN to be there for 8 hours a day. This does not mean that supporters of the bill did not understand the fact that patients in these nursing homes might need care at any time.

Their main reason for limiting the provisions to 8 hours was the need to accommodate the provisions of other legislations and policy on health care. Such provisions allowed such facilities to reduce their nurse staffing. This was a way of ensuring that they were able to sustain themselves economically by keeping the cost of health care provision at manageable and affordable levels (Span, 2014).

Sponsors of the bill and those who support it feel that times have changed and nursing homes should live up to their names. They should have a nurse at all times because needs of patients have increased and homes have also become well-endowed with relevant resources to accommodate the extra staff hours that the RN will provide.

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The nursing homes now receive Medicare or Medicaid reimbursement for the costs of operation; thus, the American taxpayers are already paying for the extra nurse (Miller, Gozalo, Lima & Mor, 2011). The facilities will not bear the cost alone; therefore, they have no reason not to comply with the new provisions once they become law. About 70 percent of all US nursing home days are paid for by taxpayers through Medicaid (Miller et al., 2011).

According to Tayler et al. (2013), who conducted a research on post-acute care and staffing in US NH between 2001 and 2010, there is an increase in the number of people opting to use NHs, instead of hospital-based facilities. As a result, nursing homes have been steadily increasing their staff numbers to cope with the increase in the number of patients seeking post-acute care (Tayler et al., 2013).

Based on the above findings, a rational thought that develops about the state of nursing homes in the US is that they are increasingly playing an important role of health care provision and they need to be better equipped. Very many citizens are hoping to find a hospital-like care in these homes, thus one way to achieve that would be by having registered nurses in the facilities at all times.

Furthermore, it is the intensity and complexity of care that was witnessed in the recent decades that informs the need for passing the bill. Meanwhile, innovations in hospital medical care are contributing to the discharge of patients early. However, many of the patients have fatal conditions that need delicate medical care (Span, 2014).


The Federal Bill H.R.5373 is not a large bill, such as the Social Security Act. Therefore, it may not get sufficient attention like the big bills to make sailing through the legislature process happen as fast as possible. Big bills benefit from the full attention of subcommittees and committees that are in charge of drafting them. They have House resources that are unavailable for small bills. Big bills are always refined and very elaborate by the time they are in the second or third stages of review on the Floor, such that it is easy for them to sail through.

Members are usually educated about the bills and the supporting structures of those bills. However, for small bills, success is enhanced when they are included as part of the big bill. When that is not forthcoming, they can still pass through the floor after considerable effort in lobbying is done by the sponsors of the small bills (Tauberer, 2010).

Pessimistic and optimistic timelines set to achieve the goals of the bill

An optimistic timeline for the bill to become law is three months. This timeline assumes that the bill will take a month in the three stages that remain before it becomes law and it will face no opposition. On the other hand, the pessimistic timeline for passing the bill is anywhere between six months and a year. Part of the long duration would be attributed to the difficulty of generating enough support from the public to have it pass through the House and the Congress.

The bill is likely to bring out strong resistance from nursing homes and their associated lobby groups because it directly affects the cost of their operation. Even though registered nurses are paid by Medicaid or Medicare to some extent, they will still impact on the nursing home’s financial bottom line due to an increase in staffing needs and the associated bureaucracies.

Moreover, nursing homes might interpret the precedence of the bill wrongly. They could see it as a way to introduce strict control in their operations, which would make their operating environment difficult.

Implications for the nursing practice

The US has more than 3.1 million registered nurses and 84. 8 percent of them actively practice nursing (Health Resources and Services Administration, 2010). Nurses are responsible for delivering an array of services in primary and preventive care and their numbers is four times that of physicians. A consequence of the bill will be a direct increase in the demand for nurses in nursing homes. Even with the present numbers, there are many nurses who are not working as nurses, but as administrators.

If the aim of having nurses in the homes is to offer patient care, then the number of nurses in demand will increase dramatically across the nation. There might be a shortage of nurses in the short-term, forcing many existing registered nurses to work overtime shifts for extra pay.

On the other hand, the nursing profession is likely to become lucrative as a career because the shortages will likely force an increase in compensation (Buerhaus, Auerbach, & Staiger, 2009). This should cause a spike in the demand for nursing courses offered by accredited higher education institutions in the country.

Other country comparison

In the UK, the law provides for nursing homes to be staffed throughout a 24-hour period, but the provisions only state that there should be an average coverage of registered nurses and care assistance (Royal College of Nursing, 2010). This leaves the actual number of registered nurses in the facility to depend on the number of patients that the facility has at any given time. Regulations also offer staff to patient ratios for registered nurses and care assistants.

For example, for early shifts, there should be 1 nurse to 5 patients. At night, there should be at least a nurse for ten patients (Royal College of Nursing, 2010). The regulations are expected to ensure that nursing homes have adequate staff to cater for patient needs, irrespective of their status as public or private institutions. A move to privatize nursing homes in the UK was informed by the need to minimize the government’s health budget and to allow market incentives to influence the provision of care (Kerrison & Pollock, 2001).

Through social security payments, the state is still able to honor its obligations of helping its citizens afford health care in the independent run nursing home, just like Medicare and Medicaid do in the US. However, the UK government avoids paying for fraudulent health claims by some health care providers because it does not directly fund the independent nursing homes.

Effects on consumers and providers of care (positive and negative)

One of the problems associated with a haphazard increase in staffing requirements for nursing homes is that the cost implications are not catered for fully in the associated funding institutions. In this case, freezing of the state budget for Medicare and Medicaid will have a direct negative impact on the ability of nursing homes to cope with the law (Joshua, Freiman, & Brown, 2007).

Adding registered nurses does not solve the problem of availing affordable and quality health care for people in the United States, but it is a step in the right direction. The goals of the bill will be felt by patients who might avoid further medical complication and death due to the presence of professional help.

Suggestions to improve policy outcomes

Rather than having a blanket provision for hiring a full time registered nurse, the bill could be improved to have the provision depend on the number of patients in the nursing home. Alternatively, the introduction of the provisions could be done gradually.

For example, the immediate impact should be to introduce 8 more hours for the RN and then review the progress before implementing the 24 hour requirement after a decade. This should give institutions time to increase their capacities in training nurses and the government to appropriate more funds for the nursing homes.


Birch, T. L. (2000). Advocacy by arts organizations: Tax laws and lobbying. The NASAA Advocate, V(1).

Buerhaus, P., Auerbach, D., & Staiger, D. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs, 28(4), w657-w668.

Health Resources and Services Administration. (2010). The registered nurse population: Findings from the 2008 national sample survey of registered nurses. Washington, DC: U.S. Department of Health and Human Services.

Joshua, M. W., Freiman, M. P., & Brown, D. (2007). Nursing home quality: Twenty years after the Omnibus Budget Reconciliation Act of 1987. The Henry J. Kaisner Family Foundation.

Kerrison, S. H., & Pollock, A. M. (2001). Caring for older people in the private sector in England. BMJ, 323(7312), 566-569.

McKenzie, B., & Rapino, M. (2011). Commuting in the United States 2009. Washington: US Department of Commerce: Economic and Statistics Administration US Census Bureau.

Miller, S. C., Gozalo, P., Lima, J. C., & Mor, V. (2011). The effect of Medicaid nursing home reimbursement policy on Medicare hospice use in nursing homes. Medical Care, 49(9), 797.

Open Congress. (2014). Put a Registered Nurse in the Nursing Home Act of 2014. Open Congress.

Royal College of Nursing. (2010). Guidance on safe nurse staffing levels in the UK. London: Policy Unit, Royal College of Nursing.

Span, P. (2014). Where are the nurses? The New York Times.

Tauberer, J. (2010). Who writes our law? Govtrack.

Tayler, D. A., Feng, Z., Leland, N. E., Gozalo, P., Intrator, O., & Mor, V. (2013). Trends in postacute care and staffing in US nursing homes, 2001-2010. Journal of the American Medical Directors Association, 14(11), 817-820.

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