Running head: SAFE STAFFING FOR QUALITY CARE ACT 1

Safe Staffing for Quality Care Act

Habeebat Lawal

CUNY College of Staten Island

NRS 705 Health Organizations, Policy, Finance, and Ethics

07/25/2019
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Safe Staffing for Quality Care Act

Patients have the right to safe, quality care, and implementing safe staffing guidelines

only helps to ensure such care is delivered. This paper will focus on a proposed bill- Assembly

Bill A2954 which enacts the "safe staffing for quality care act". The Safe Staffing for Quality

Care Act is a policy that hopefully the legislators will give their full support. If implemented, the

bill will set a mandatory minimum nurse-to-patient staffing ratio in New York healthcare

facilities (NYSNA, 2018a).

Policy analysis and relevance to health care

The proposed bill- Assembly Bill A2954 which enacts the "safe staffing for quality care

act" serves to protect the patients and nurses, therefore nurses are working collaboratively to

fight for the Safe Staffing for Quality Care Act to be implemented to set a mandatory minimum

nurse-to-patient staffing ratio in New York healthcare facilities (NYSNA, 2018). The Safe

Staffing for Quality Care Act will require New York healthcare facilities such as hospitals,

SNFs/nursing homes, etc. to institute minimum nurse-to-patient ratios by floors/unit. For

instance, in the critical care units, the nurse-to-patient ratio will be 1:2, rather than 1:3 or 1:4

(New York State Assembly, 2018). If the proposed law is implemented, facilities that violate the

Safe Staffing for Quality care Act will face civil penalties (New York State Assembly, 2018). If

assignment exceeds a nurse's abilities or if minimum staffing is not present, the law also provides

the nurse the right to refuse such assignment (New York State Assembly, 2018). If a nurse

refuses any illegal work assignment and/or is discriminated for refusing, the law “establishes

private right of action” which means the healthcare facility can be liable for a lawsuit (New York

State Assembly, 2018). Finally, under the law, all healthcare facility must disclose staffing levels

to the department and the public, including keep staffing records during all worked shifts (New

York State Assembly, 2018).

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Stakeholders

The key players in implementing the bill are patients and their significant others, nurses,

ancillary staff (PCA, PCT), healthcare providers (MD, NP, PA), nursing administrators, nursing

associations (ANA), legislators and policy makers. Patients will have better outcomes as a result

of adequate staffing and their significant others are also positively affected, with an increase in

satisfaction ratings being noted. Nurses and ancillary staff retention will increase because of

adequate staffing. The healthcare team consisting of the providers and the nurses will be

effective in rendering treatment. Nursing administrators will be able to focus on other issues

within the healthcare facility rather than scrambling to find short term fixes to staffing issues.

Nursing associations will continue to stand up for their assertions that priority is to the patient.

Lastly, legislators and policy makers must enforce any penalties upon healthcare facilities that do

not abide by the safe staffing ratios.

Relation to NP or CNS sore competencies

It is crucial that Congress pass the Safe Staffing for Quality care Act, to implement a

mandatory minimum nurse-to-patient staffing ratio in healthcare facilities in New York

(NYSNA, 2018a). Altman, Butler, & Shern (2016) also purported that Nurse Practitioners (NPs),

are advanced practice nurses that are “highly trained and able to provide a variety of services” in

areas such as leadership, quality, policy, and health delivery systems, should collaborate with

nurses in an effort to push this bill into becoming a law.

To garner support for the Safe Staffing for Quality Care Act, collaboration between

nurses and Nurse practitioners (NPs) can be powerful. NPs possess extensive education and

unique skills set that could compel legislators and policymakers to make the bill passed into a

law. The NP competency areas that relate to the Safe Staffing for Quality Care Act are

leadership, quality, policy, and health delivery systems (see Table I), (AACN and NONPF,
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2016). To ensure delivery of quality care, the NP should “evaluate the relationships among

access, cost, quality, and safety and their influence on health care” (AACN and NONPF, 2016).

For policy making, the NP should “advocate for ethical policies that promote access, equity,

quality, and cost and for policies for safe and healthy practice environments” (AACN and

NONPF, 2016). Regarding health delivery systems, the NP should “evaluate the impact of health

care delivery on patients, providers, other stakeholders, and the environment” (AACN and

NONPF, 2016). Finally, As a leader, the NP should “advocate for improved access, quality and

cost effective health care” (AACN and NONPF, 2016). NPs are recognized as both providers and

nurses, which puts them in a pivotal position to shape the healthcare system to deliver safe, high

quality, cost-effective, and patient centered care (Schram, 2010).

Policy relevance to HP2020 Goals and/or the STTI Global Initiatives

Safe, high quality healthcare should be accessible to everyone, based on one of the goals

of Healthy People 2020, which is to “improve access to comprehensive, quality health care

services” (ODPHP, 2018). However, based on the current shortage of staffing of nurses in

healthcare facilities in New York, in combination with increased workload, makes this Healthy

People 2020 goal almost unattainable (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007).

Relating the Safe Staffing for Quality Care Act to a global issue and sustainable goal

would be pertain to sustainable development goal 8 (decent work and economic growth), which

is aimed at promoting sustained, inclusive and sustainable economic growth, full and productive

employment and decent work for all (UNDP, 2019). Access to a highly skilled and educated

health workforce is critical to improving local, national and global health outcomes. Inadequate

staffing and the need for mandatory minimum nurse-to-patient staffing ratios, can relate to the

global issue of nurse shortages. Milstead (2019) mentioned some reasons why there is a shortage
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of nurses which includes, a stressful work environment, inadequate salaries, and an increased

demand for nursing services. A stressful work environment contributes to high turnover rates of

nurses, which has a direct impact on staffing, subsequently causing inadequate staffing (NSI

Nursing Solutions, Inc., 2016). In many clinical settings, nurses are overworked and

undervalued, caring for patients who are highly dependent on their care, but lacking the time for

adequate patient care or interaction (NSI Nursing Solutions, Inc., 2016).

According to Healthy People 2020, people should live long, healthy lives in a society

(ODPHP, 2018), which why objectives for improving the health of all Americans were

developed, An objective relevant to the Safe Staffing for Quality Care Act, is to “improve access

to comprehensive, quality health care services” (ODPHP, 2018). According to Kane et al.,

(2007) nurses play a significant role in delivery of quality care and patient safety. Studies were

conducted to determine the correlation between nurse staffing and patient outcomes, and results

showed that the work environment poses a major threat to safe nursing practice in hospitals

(Kane et al., 2007). Additionally, it was shown that inadequate nurse staffing levels negatively

affect patient outcomes and nurse retention in hospital practice (Aiken et al., 2010). Inadequate

staffing is considered a barrier to accessing safe, high quality health services and can “lead to

unmet health needs” (ODPHP, 2018). To improve patient safety and quality care, healthcare

facilities should implement mandatory minimum nurse-to-patient staffing ratios. By

implementing this act, it would create a positive impact on the “overall physical, social, and

mental health status and quality of life” of the people (ODPHP, 2018).

Literature review and updates

There is evidence to support the proposed policy of mandatory minimum nurse-to-patient

staffing ratios. Research shows that inadequate nurse staffing levels negatively affect patient
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outcomes and nurse retention in hospital practice (Aiken et al., 2010). Studies that have been

conducted since the implementation of California’s staffing law “reveals that the California

mandates are significantly associated with fewer negative outcomes for patients and staff”

(Aiken et al., 2010). “The odds of patient death increases by 7% for each additional patient the

nurse must take on at one time” (Aiken et al., 2010) indicating safe staffing could save lives.

According to Pennoyer (2010). Safe staffing decreases adverse patient outcomes in healthcare

facilities because when nurse staffing is increased, the number of adverse events including

pressure ulcers, catheter-associated urinary tract infections, and hospital acquired injuries

decreases.

In a study conducted by Stamp, Flanagan, Gregas, and Shindul-Rothschild (2014), results

show that heart failure readmissions were reduced when nurse staffing was greater, and increased

number of patients received discharge information in California where mandatory minimum

staffing ratios are established. Everhart et al. (2014) shows that hospitals with higher than 300

beds with higher number of nurse staffing were significantly less likely to be classified as

“consistently high” fall rate group. A study testing the relationship between staffing and patient

outcomes in UK ICUs found that higher survival rates were associated with increased number of

nurses per bed, and that the number of nurses shows the greatest impact on patients at high death

risk (West et al., 2014). Spetz, Harless, Herrera, and Mark (2013) found significant improvement

in patient mortality in event of a medical or surgical complication with increased nursing

staffing, as well as, a reduced incident of pulmonary embolism, deep vein thrombosis, sepsis,

and decreased lengths of stay. In a study by Frost and Alexandrou (2012), cardiac readmissions

and inpatient hospital mortality were reduced with increased nurse staffing levels. Shekelle

(2013) compared the differences in nurse-to-patient staffing ratios (1:4 versus 1:8) and
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correlation to the deaths of 4,535 surgical patients that died within 30 days of discharge, and

concluded that the 1:8 nurse-to-patient staffing ratio may have been a factor in the deaths. Safe

staffing is a cost-effective way to improve patient care and can lead to savings for the healthcare

system because although “nursing workforce costs may rise, that increase is mitigated by overall

savings from improved patient outcomes and avoided adverse events” (New York State

Assembly, 2018).

Financial impact of implementing and sustaining proposed policy

“Safe staffing is a cost-effective way to improve patient care and can lead to savings for

healthcare facilities” by reducing nurse turnover, negative patient outcomes, thus improved

patient care and overall savings for the healthcare system (NYSNA, n.d). Funding will be

required from the government for the implementation of the policy, to pay for the increased

staffing needs but the expectation of safe staffing ratios is that profit will be generated in the long

run as a result of improved patient outcomes and reduced adverse events. “Nursing workforce

costs may rise, that increase is mitigated by overall savings from improved patient outcomes and

avoided adverse event” (New York State Assembly, 2017). The government have a

responsibility to use taxpayers’ dollars efficiently and equitably, and since money will be

involved to offset the costs of complying with the policy, especially money funded by the

government, the expectation is that the policy will produce sufficient revenue and be sustainable

(Milstead, 2019). Poor staffing in hospital ICUs increases the risk of pneumonia and other

preventable infections possibly adding thousands of dollars to the treatment costs (NYSNA, n.d).

Healthcare facilities could ultimately save and make money by means such as decrease in 30 day

readmissions resulting in hospitals being reimbursed by Centers for Medicare and Medicaid

Services (CMS), reduced falls, hospital acquired infections, and medical malpractice lawsuits
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saving hospitals from taking on the financial responsibility of these incidences, and a decrease in

nurse turnover resulting in hospitals not having to come up with additional money to train new

staff. Such savings would show the policy is sustainable and can generate profit. For instance, In

California where a safe staffing policy was implemented, “hospital income rose dramatically

after ratios were implemented, from $12.5 billion from 1994 to 2003, to more than $20.6 billion

from 2004 to 2010” (NYSNA, n.d).

The issue of nurse shortages can contribute to poor staffing and the need for safe staffing

ratios. Milstead (2019) addressed reasons that causes nurses shortage of nurses including a

stressful work environment, inadequate salaries, and higher demand for nursing services. A

stressful work environment contributes to high turnover rates of nurses, which has a direct

impact on staffing, subsequently causing shortage in staffing (NSI Nursing Solutions, Inc.,

2016). There are strong financial repercussions for hospitals with high RN turnover

rates. Replacing an RN could cost healthcare facilities approximately $82,000 to $88,000

(NYSNA, n.d). An organization held a survey in 2016 regarding RN turnover rates nationwide

called the National Healthcare Retention Survey; the survey entailed data from 138 participating

hospitals within the United States (NSI Nursing Solutions, Inc., 2016). The survey results

showed that the cost of RN turnover can have a profound impact on an already diminishing

hospital’s financial status (NSI Nursing Solutions, Inc., 2016). Based on research cited, the

average cost of turnover for a bedside RN ranges from $37,700 to $58,400 resulting in the

average hospital losing $5.2 million to $8.1 million (NSI Nursing Solutions, Inc., 2016). The

survey results that also showed that nurses working in the areas of emergency services, med/surg

and step down have had a consistent turnover rate a rate higher than other areas (NSI Nursing

Solutions, Inc., 2016).

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Another possible benefit of implementing this policy is increased patient satisfaction and

decreased medical errors. Staffing challenges and nursing shortage can play a role in patient

satisfaction. According to White, Jackson, Besner, and Norris (2015), staffing ratios may affect

how well nurses are able to meet their responsibilities. Whenever there are staffing issues, or

many patients are kept waiting. When nurses are burnt out from working too long and having too

many patients, they might pay less attention to meeting all the needs (physical and emotional) of

the patient. The nurse is working hard to keep up and perform assigned tasks, but it is possible to

fall behind on these tasks due to many variables such as high patient load and patient acuity

level. Some patients want to be seen and cared for right away, but the nurse has to prioritize.

Whenever a nursing unit is short staff, it can lead to dissatisfied patients and medical errors

(American Sentinel University, 2014). The highly demanding and busy units such as the ICU

may put patient safety at risk and lead to medical errors. The Centers for Medicare & Medicaid

Services’ (CMS) focuses their reimbursement on patient satisfaction and quality of care. The

survey scores through the Hospital Consumer Assessment of Healthcare Providers and Services

(HCAHPS) program is based on patient satisfaction (Guadagnino, 2012). Therefore, it is

important to ensure patient satisfaction during their hospital stay. However, it may be harder to

meet the expectation or standards, due to high patient to nurse ratios. The goal of the Safe

Staffing for Quality Care Act is to set a mandatory minimum nurse-to-patient staffing ratio in

New York healthcare facilities in order that patients can receive the safe, high quality care that

they deserve (NYSNA, 2018). Some of the variables that may exist during implementation are

nursing skill level, patient acuity, and cost.

According to Milstead (2019), “program evaluation follows a set of guidelines to provide

information to assist others in making judgments about a program, service, policy, organization,
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or whatever is being evaluated”. Periodic evaluation to determine if the policy is achieving its

aim and set the goals is necessary, therefore the government must be periodically updated on the

progress of the implemented policy by use of periodic evaluations. The evaluation would

measure “short-term and intermediate outcomes that logically link to long-term outcomes”

(CDC, 2018). Evaluation results would show if the policy is effective, sustainable and generates

profit. For example, when a safe staffing policy was implemented in California, “hospital income

rose dramatically after ratios were implemented, from $12.5 billion from 1994 to 2003, to more

than $20.6 billion from 2004 to 2010” (NYSNA, 2018). “Outcome evaluations focus on the

benefits a program produces for the people who use the program” (Milstead, 2019). Specific

outcomes and impact outcomes that an RN/APRN might identify in order to provide evaluation

data for program sustainability of safe staffing ratios include: better patient outcomes, saved

lives, improved quality of care, shorter hospital stays, fewer readmissions, fewer adverse events

(falls, hospital acquired infections), and a decrease in nurse turnover.

Conclusion

The implementation of successful safe staffing ratios in California can serve as a model

for policymakers. Healthcare issues has been at the forefront of the political agenda in the last

decade as healthcare costs continue to be one of the economy’s biggest expenditures. Moreover,

the number of people requiring healthcare coverage continues to increase, and a possible loss of

funds for benefit programs such as Medicare and Social Security looming, there is an urgent

need for initiatives to address the need for high quality, safe, cost-effective care, which could be

ensured by adequate safe staffing (Schram, 2010).

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Table I

NP Core Competencies Relation to policy

Quality Evaluates the relationships among access,

cost, quality, and safety and their influence on

health care.

Policy #4: Advocates for improved access, Advocates for ethical policies that promote

quality and cost effective health care. access, equity, quality, and cost.

Policy #7: Advocates for policies for safe Advocates for policies for safe and healthy

and healthy practice environments practice environments.

Health Delivery Systems #4: Facilitates the Evaluates the impact of healthcare delivery on

development of health care systems that patients, providers, other stakeholders, and

address the needs of culturally diverse the environment.

populations, providers, and other

stakeholders.

Leadership #2: Provides leadership to Advocates for improved access, quality and

foster collaboration with multiple cost effective health care.

stakeholders (e.g. patients, community,

integrated health care teams, and policy

makers) to improve health care.

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