Nurse Staffing Ratios

Staffing ratios have been mandated in some states through legislative action as a solution to inadequate nurse staffing and concerns about the quality and safety of patient care. Opinions vary widely about whether the implementation of mandatory staff ratios in hospitals will have the desired effect. Some say that these mandatory ratios will remove the ability of hospitals to effectively manage their costs, resulting in higher costs for taxpayers and patients. Others argue that voluntary methods to improve safe staffing have not worked and nurses are placed in high-risk care environments. Buerhaus (2009) has proposed several nonregulatory solutions to safe staffing including improving hospital work environments, incentives to hospitals for high quality care, and focused efforts on reducing the nursing shortage. Do you think this health related issue is amenable to a public policy solution, or could safe staffing standards be managed as a policy within the workplace? As a policymaker, what information would you need to decide whether this problem would benefit from a public policy solution?

Recommended reading: Buerhaus, P. (2009) Avoiding mandatory hospital nurse staffing ratios: An economic commentary. Nursing Outlook, 57(2), 107-112. (Also see Chapters 53 and 61.)

According to Longest (2010) there are best practices that leaders of advocacy organizations undertake to promote their health-related mission. Once the organization makes policy influence a priority, a governmental relations (or affairs) team is formed (or a firm is contracted) to do the work. If these teams are competent, they can transform the effectiveness of the organizations by giving the CEO (and/or board of directors) anticipatory guidance and lead-time. The ability of organizations to anticipate lead time and direct resources 68appro­priately is the key function of a strong public policy team. This anticipatory approach moves maturing organizations away from reacting to policy changes and toward strategic leadership (Longest, 2010). Effective advocacy organizations are continuously analyzing the environment. This requires that politically competent organizations primarily look out (not in) at the ever-changing political landscape.

Professional nursing organizations (e.g., the American Academy of Nursing, the American Nurses Association, and many nursing specialty groups) are concerned not only with public policy that impacts the health of all people, but also with policy that impacts nurses and the practice of nursing. These organizations, individually and collectively, support policies that are in the best interest of their members.

Engaging in Policy Analysis

Issue analysis is similar to the nursing process: it is necessary to clearly identify the problem (including the context of the problem, alternatives for resolution and the consequences of each, along with specific criteria for evaluating the alternatives) and recommend the optimal solution. Issue papers provide the mechanism to do this. This is a process that identifies the underlying issue, identifies the stakeholders, and specifies alternatives along with their positive and negative consequences. Issue papers help to clarify arguments in support of a cause, to recognize the arguments of the opposition, to lay out the evidence or lack thereof to an issue, and to develop strategies to inform policy analysts and advance the issue through the policy cycle (Box 7-3).

Box 7-3

Example of a Policy Decision Brief

Re: Health Care Fraud in the Military Health System

Issue Summary: Health care fraud burdens the Department of Defense (DOD) with enormous financial losses while threatening the quality of health care. Assuming that between 10% and 20% of paid claims are fraudulent, the annual loss to DOD is $600 million to $1.2 billion.


• The U.S. Attorney General has identified health care fraud as the second priority for law enforcement, following only violent crime.

• Because health care fraud perpetrators target DOD, Medicare, Medicaid, and private health insurers simultaneously, the Defense Criminal Investigative Service (DCIS) cooperates extensively with many federal agencies in joint health care fraud investigations.

• Federal agencies fighting health care fraud, except DOD, have received additional resources to enhance their efforts.

• The TRICARE Program Integrity Office currently has a staff of 10, and a caseload of 1000 active cases.

• The 1996 Kennedy-Kassebaum legislation provided for 80 additional U.S. attorneys to be hired specifically to prosecute health care fraud and abuse.