Policy, Politics, & Nursing Practice recent issues

In This Issue

Keepnews, D. M. — 2008-07-23

The Importance and Challenge of Paying for Quality Nursing Care

Unruh, L. Y., Hassmiller, S. B., Reinhard, S. C. — 2008-07-23

Historically, the economic value that nursing brings to the patient care process has not been recognized or quantified. Improving the quality of nursing care through work environment changes or increases in staffing is viewed by many as an added cost, but the benefits in terms of money saved through improved nursing satisfaction and patient outcomes are not considered. This article introduces nine articles that were originally presented at the Economics of Nursing Invitational Conference: Paying for Quality Nursing Care held at the Robert Wood Johnson Foundation in Princeton, New Jersey, June 13 and 14, 2007. Recommendations are to conduct research on the impact of policy and payment changes on the nursing workforce and quality of care and to correct the misalignment of socioeconomic and business case incentives for quality by payment systems and other changes.

Economics of Nursing

Aiken, L. H. — 2008-07-23

Pay-for-performance initiatives have renewed interest in payment reform as a vehicle for improving nurse staffing and working conditions in hospitals because of research linking investments in nursing and better patient outcomes. This article addresses the economics of nursing from a broad perspective that considers how both national policies such as hospital prospective payment and managerial decisions within institutions impact the outcomes of nurses and patients. Cost offsets are considered from the perspective of savings in patient-care resources that accrue from investments in nursing. Cost offsets are also considered from the perspective of the interactions among different strategies for investing in nursing, including the impact of staffing levels on patient outcomes with varying educational levels of nurses and varying quality of practice environments.

Is What's Good for the Patient Good for the Hospital? Aligning Incentives and the Business Case for Nursing

Needleman, J. — 2008-07-23

This article examines the social and business case for quality related to nursing and the need to restructure incentives to align the interests of the hospital and payers with the interests of the patients. Increasing the proportion of nurses who are registered nurses is associated with net cost savings. Increasing both nursing hours and the proportion of nurses who are registered nurses would result in improved quality and fewer deaths (creating a social case for improved staffing) but would be associated with small cost increases. Cost offsets associated with reduced turnover because of higher staffing would reduce the net cost increase but not result in savings. Under current reimbursement systems, hospitals that increase nurse staffing to improve patient outcomes will likely lose money as a result. Current proposals for pay for performance would create limited incentives for improving hospital nursing care.

The Business Case for Nursing in Long-Term Care

Horn, S. D. — 2008-07-23

Lower nurse staffing in hospitals has been associated with adverse patient outcomes; results in nursing homes (NHs) are less clear. We examined the association between nurses' direct care time and outcomes in long-stay NH residents and potential cost savings from decreased adverse outcomes versus additional wages for adequate nurse staffing. Data were from the National Pressure Ulcer Long-Term Care Study of 1,376 at-risk residents from 82 NHs. Primary data came from medical records. Hospital, pressure ulcer (PrU) treatment, and urinary tract infection (UTI) costs were from national statistics or cost-identification studies. Time horizon was 1 year. More registered nurse (RN) direct care time/resident/day was associated with fewer PrUs, hospitalizations, and UTIs. Annual net societal benefit was $3,191/resident/year in high-risk NH units with 30-40 min of RN time/resident/day versus units with <10 min. Thus, after controlling for important variables, more RN time/day was strongly associated with better outcomes and lower societal cost.

Adjusting for Nursing Care Case Mix in Hospital Reimbursement: A Review of International Practice

Laport, N., Sermeus, W., Vanden Boer, G., Van Herck, P. — 2008-07-23

The purpose of this study was to examine and review the different ways in which nursing care can be accounted for in a general hospital reimbursement system. The study is based on a literature review and a survey of international experts. It provides a typology of nursing care adjustment methods, using current and past practices of 14 Western countries as key examples. The results of our review indicate that it is necessary to take the variability of nursing care within DRGs into account, not from a cost-accounting perspective, but from a management perspective in terms of correct resource allocation. However, further investigation of these complex relationships is urgently needed.

Testing an Inpatient Nursing Intensity Billing Model

Welton, J. M., Dismuke, C. E. — 2008-07-23

There has been growing concern about the costs and intensity of inpatient nursing care, which consumes more than 40% of hospital direct costs and $165 billion each year. Allocating nursing labor as an average cost per patient and charged as room and board creates cost compression, distorts hospital payment, and hides the economic value of nurses. This article examines a method for adjusting daily room charges using nursing intensity weights assigned by the diagnosis related group. In a test using claims data from 286 hospitals in four states representing 1,856,256 patient discharges in 2002, the nursing intensity adjustment improved explained total cost variance by 8.5% for adult all payer patients (R² = .4448 vs. .4825) and 9.4% for Medicare only patients (R² = .4387 vs. .4798) compared to unadjusted days. This article discusses unbundling inpatient nursing care intensity and charges from room and board and recommends implementing this billing process at all U.S. hospitals.

Measuring and Accounting for the Intensity of Nursing Care: Is It Worthwhile?

Finkler, S. A. — 2008-07-23

In June 2007, the Robert Wood Johnson Foundation sponsored a conference titled "The Economics of Nursing: Paying for Quality Nursing Care." The second topic at the conference was "the appropriateness and feasibility of measuring and accounting for the intensity of nursing care." Drs. Welton and Sermeus presented papers on that topic. This response to those papers focuses on why the hospital industry has not always accounted for and measured nursing intensity. Then it asks, "Why do we want more accurate information about nursing resources used by different patients?" It is not sufficient to say the data regarding nursing costs are not accurate. Nor is it sufficient to say that we now can improve the accuracy of the data. To move forward in this area, we need to develop compelling evidence and arguments that indicate that nursing-cost data of greater accuracy have a benefit that will exceed the costs of that data collection.

Paying Hospitals on the Basis of Nursing Intensity: Policy and Political Considerations

Ginsburg, P. B. — 2008-07-23

Some believe that explicit incorporation of nursing intensity into hospital payment systems would lead hospitals to increase the use of nursing resources. But 25 years of Medicare provider payment policies, followed increasingly by Medicaid programs and private insurers, means that any incorporation of measures of nursing intensity into payment systems needs to be consistent with concepts of prospective payment. But the main impact of such a step would be to increase equity among hospitals with different case mixes and blunt incentives to specialize in diagnosis-related groups with relatively low nursing intensity. Issues of the role of nurses in hospitals and the intensity of nursing resources used in care are more likely to be influenced by quality reporting and pay for performance than by incorporating nursing intensity into a prospective payment system.

Lessons Learned From Advanced Practice Nursing Payment

Sullivan-Marx, E. M. — 2008-07-23

For more than 25 years, advanced practice nurses have been incrementally included as a part of the health care financing structure. Following physician payment revisions at the federal level, advanced practice nurses were overtly recognized as Medicare providers and have participated in the establishment of current procedural terminology codes and the subsequent relative work values associated with payment. Success in this regard has been the result of business, political, and policy savvy that has important lessons for moving forward in any health care restructuring for both nurses and advanced practice nurses. Principles of valuing nurse work, time, and intensity in the Resource-Based Relative Value Scale are discussed with implications for future opportunities of measuring nursing work and any potential relationship to quality outcomes of care.

Challenges and Directions for Nursing in the Pay-for-Performance Movement

Clarke, S. P., Raphael, C., Disch, J. — 2008-07-23

Pay-for-performance (P4P) initiatives attempt to drive quality of care by aligning desired care processes and outcomes with reimbursement. P4P schemes have emerged at a time of great concern about safety and quality in health care and in the face of a growing nurse shortage. This article discusses the state of the literature linking structures for providing nursing care, measures of process heavily favored in P4P initiatives, and patient outcomes and outlines how P4P is expected to affect nursing practice. It also presents directions for managing practice settings to cope with P4P and for steering nursing's involvement in this area of health policy. As implementation broadens, it remains to be seen whether unintended consequences emerge or whether nurses are successful in using the programs and the data sets that result from them to justify investments in nursing services and solidify the profession's position.

In This Issue

Keepnews, D. M. — 2008-05-20

Health Care Workforce Policy in 2008 and Beyond

Keepnews, D. M. — 2008-05-20

Letter to the Editor

Adams, B. — 2008-05-20

The U.S. Presidential Election and Health Care Workforce Policy

McHugh, M. D., Aiken, L. H., Cooper, R. A., Miller, P. — 2008-05-20

The candidates for the 2008 presidential election have offered a range of proposals that could bring significant changes in health care. Although few are aimed directly at the nurse and physician workforce, nearly all of the proposals have the potential to affect the health care workforce. Furthermore, the success of the proposed initiatives is dependent on a robust nurse and physician workforce. The purpose of this article is to outline the current needs and challenges for the nurse and physician workforce and highlight how candidates' proposals intersect with the adequacy of the health care workforce. Three general themes are highlighted for their implications on the physician and nurse workforce supply, including (a) expansion of health care coverage, (b) workforce investment, and (c) cost control and quality improvement.

Nurse Satisfaction and the Implementation of Minimum Nurse Staffing Regulations

Spetz, J. — 2008-05-20

In 1999, California passed the first legislation in the United States to establish minimum staffing levels for licensed nurses in hospitals. Implementation of the regulation began in 2004. This article examines whether nurses who work in hospitals in California have perceived improvements in their working conditions. A statewide sample survey of registered nurses is used, and the survey data are linked with regional data to learn whether changes in satisfaction are associated with the degree to which regional employers were expected to increase nurse staffing when the ratios were implemented. Nurse satisfaction improved between 2004 and 2006, particularly with the adequacy of RN staff, time for patient education, benefits, and clerical support. There was a significant increase in overall job satisfaction between 2004 and 2006. However, improvements in satisfaction with the adequacy of RN staff were not associated with the degree to which regional hospitals were expected to increase staffing.

Advancing Diversity in Nursing: An Interview With Dr. Catherine Alicia Georges

Theodore, R. — 2008-05-20

Dr. Mary Elizabeth Carnegie: April 19, 1916--February 20, 2008

Georges, C. A. — 2008-05-20

On February 20, 2008, Dr. Mary Elizabeth Carnegie, an internationally renowned nursing leader, died after 71 years of a professional nursing career. In this tribute, Dr. Catherine Alicia Georges offers her reflections on Dr. Carnegie's contributions, leadership, and mentorship.

The Rural Nurse Work Environment and Structural Empowerment

Krebs, J. P., Madigan, E. A., Tullai-McGuinness, S. — 2008-05-20

Rural health care organizations struggle to attract and retain nurses, yet much of the research has focused on characteristics of the nurse work environment or empowerment in urban hospitals. The purpose of this study was to examine the nurse work environment in rural areas across settings by describing the relationship between structural empowerment and characteristics of the nurse work environment. Nurses ( N = 97) working in home care agencies and hospitals were surveyed. Significant differences were found between the groups, with home care nurses having significantly higher empowerment scores than medical/surgical nurses. A strong correlation was found between characteristics of the nurse work environment and empowerment. Policy makers are using evidence to guide development of policies, but much of the research has been conducted in urban hospital settings. This study begins to provide evidence that differences exist between urban and rural areas and between practice settings.

Human Papillomavirus Vaccine Legislation in Kentucky: A Policy Analysis

Dekker, R. L. — 2008-05-20

The purpose of this article is to discuss the problem of cervical cancer, examine policy solutions, and analyze factors that contributed to the failure of human papillomavirus (HPV) vaccine requirement legislation in Kentucky. During 2007, a Kentucky representative introduced legislation that would require HPV vaccination for all middle-school girls but allow parents to opt out for any reason. Evidence suggests that an HPV school requirement law would result in more Kentucky children being vaccinated than if there were no requirement law. However, this policy solution faced multiple factors that inhibited its ability to survive. Future proponents of HPV vaccine school requirement legislation can draw implications from Kentucky's experience. By building public support, undergoing a softening up period, and presenting a united, vocal front, proponents may be more likely to pass HPV vaccine legislation in the future.

Personal Influencing Factors Associated With Pap Smear Testing and Cervical Cancer

Ackerson, K., Pohl, J., Low, L. K. — 2008-05-20

Pap smear is a screening test that detects abnormal cells before they advance to cancer. Unfortunately, not all women obtain routine screening. The method used was a qualitative study exploring personal influences regarding Pap smears. Face-to-face interviews with 7 low-income African American women who do and do not obtain Pap smears (between 21 and 37 years of age) were conducted at a health department about their social influence, previous health care experience, and cognitive appraisal regarding Pap smears and cervical cancer. Women were found to be socially influenced by their family and their physician. Previous health care experience with the Pap and pelvic was perceived as negative. Cognitively, Pap smears were believed to test for sexually transmitted diseases, including HIV, and the women also felt that if one took good care of oneself it reduced the risk for cervical cancer. It was concluded that exploring beliefs associated with Pap smears and perceptions of vulnerability to cervical cancer and giving correct information and counseling may increase Pap smear screening in women.

In This Issue

Keepnews, D. M. — 2008-03-12

Evaluating Nurse Staffing Regulation

Keepnews, D. M. — 2008-03-12

Ongoing research on the impact of nurse staffing regulation can yield important information that can guide continued staffing policy efforts. Understanding the impact of such efforts should include evaluating the outcomes of recent legislation in Oregon and Illinois as well as continued examination of staffing ratios in California. Successful efforts will need to transcend traditional boundaries between researchers, policy analysts, advocates, and organizations.

Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Postregulation

2008-03-12

This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 postratios regulation data. For the current study we used postregulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

Patient Safety Legislation: A Look at Health Policy Development

Mattie, A. S., Ben-Chitrit, R. — 2008-03-12

On July 29, 2005, President Bush signed into law the Patient Safety and Quality Improvement Act. This long-awaited bill came after considerable debate in the Senate and the House that focused on patient safety highlighted by the Institute of Medicine's (IOM's) report, To Err Is Human. The IOM report brought the significance of patient safety issues to the national forefront and called for congressional action, but it was 6 years after that report before Congress passed legislation in this area. The article explores the development of patient safety legislation and provides a historical review and analysis of the events leading to the passage of the final bill. It provides background about the major issues requiring resolution and compromise, compares the positions of the competing stakeholders, and describes the importance and degree of influence that can derive from input by stakeholders in the passage of legislation.

Public Opinion and Smoke-Free Laws

2008-03-12

Public support for Lexington-Fayette County, Kentucky's smoke-free law, perception of health risks from exposure to secondhand smoke (SHS), smoking behaviors, and frequency of visiting restaurants, bars, and entertainment venues were assessed pre- and post-law. Two cohorts of noninstitutionalized adults (N = 2,146) were randomly selected and invited to participate in a 10- to 15-min telephone survey. Public support for the smoke-free law increased from 56% to 63%, and respondents were 1.3 times more likely to perceive SHS exposure as a health risk after the law took effect. Although adult smoking and home smoking policy did not change post-law, adults frequented public venues at least as much as before the law. Lexington adults favored the smoke-free legislation despite living in a traditionally protobacco climate. The smokefree law acted as a public health intervention as it increased perception of risk of heart disease and cancer from SHS exposure.

Including Marginalized Populations in HIV Clinical Trials: A New Role for Nurse-Researchers

Cohn, E. G. — 2008-03-12

This article proposes a new paradigm for nurse-researchers to strengthen communication with participants, investigators, and the community in clinical trials. The author reviews the current state of HIV vaccine development in response to the human and fiscal cost of the HIV epidemic, both in the United States and globally. A translational model is proposed for restructuring the process by which participants in HIV trials are recruited and the results disseminated. Finally, it is proposed that nurses should play a unique and essential role in implementing this new model, advocating for individuals, strengthening societal trust, and fostering equity.

Psychiatric Nurses' Attitudes Toward Consumer and Carer Participation in Care: Part 1--Exploring the Issues

Goodwin, V., Happell, B. — 2008-03-12

Consumer and carer participation in mental health delivery is now enshrined in Australian Government policy. However, strategies assisting in implementing this vision have not been explored. Nurses are crucial to the mental health workforce, both in numbers and by virtue of the therapeutic relationship. The willingness of nurses to encourage consumer and carer participation is therefore essential for implementation of this policy. This article presents part 1 of the findings of a qualitative study exploring nurses' opinions regarding consumer and carer participation. Data were analyzed using a content-analysis approach, assisted by the software package NVivo. The themes explicated were as follows: Consumer and carer participation—a help or a hindrance? Encouragement—an important role for nurses; and communication—a gift of nursing. These findings highlight the unique and important role nurses can play in encouraging participation and explore some of the issues involved if that role is to become a reality.

Health Disparities: What Can Nursing Do?

Smith, G. R. — 2008-03-12

Health disparities result from lack of caring within the society. Central to nursing, caring makes the profession best suited for leadership in reducing disparities. Nursing is losing its capacity for caring. Nursing's progress in gaining status has alienated it from the needs of other oppressed groups. It has also been seduced by the scientific model and does not always use its best judgment of truths about human suffering. Research has identified unequal treatment, discrimination, workplace and social status, income inequality, and policy decisions to deplete resources as social and economic determinants of health. All involve relationships. Nursing is the profession for which relationships are primary. Nursing can rebuild the capacity for caring and social and relational practice through transforming nursing education on the principle of mutuality. Nursing can also promote nurse-managed primary care and focus on changing local, state, and national policies to increase access, equity, and health protection.

In This Issue

Keepnews, D. M. — 2008-01-04

Meeting the Challenge of Health Reform

Keepnews, D. M. — 2008-01-04

Examining the Impending Gap in Clinical Nursing Expertise

Orsolini-Hain, L., Malone, R. E. — 2008-01-04

Much has been written about current and future nursing shortages and the numerical gap between nurses available and projected nursing needs. Very little analysis has focused on the implications of the pending expertise gap within the nursing workforce. A graying and retiring registered nurse workforce will greatly increase the proportion of novice nurses with minimal experience in bedside practice. The expertise gap will also affect nursing education. This article explores the implications of these phenomena. Without careful planning, efforts to address the numerical shortage may inadvertently worsen the expertise gap, contributing to unsafe care and affecting nursing retention.

Understanding the Medicare Part D Prescription Program: Partnerships for Beneficiaries and Health Care Professionals

De Natale, M. L. — 2008-01-04

The Medicare Part D prescription coverage plan became available to qualified beneficiaries under Medicare on January 1, 2006. The plans provided by private insurers and state programs have challenged Medicare beneficiaries in their understanding of enrollment issues, availability of medications at an affordable cost, and use of community resources for consultation regarding prescription coverage. A total of 72 beneficiaries were interviewed during their attendance at one of six senior centers during the months of September to December 2006. Each beneficiary noted that financial cost was a priority in his or her choice of prescription coverage. Results of this qualitative research study provide guidance to health care professionals planning instruction or providing informational assistance to beneficiaries and/or families.

Letter to the Editor

Kavanagh, K. T. — 2008-01-04

Authors' Response

Upenieks, V. V., Akhavan, J. — 2008-01-04

The Community Readiness Model: Evaluating Local Smoke-Free Policy Development

York, N. L., Hahn, E. J. — 2008-01-04

The purpose of this article is to review the literature on community readiness and assess the utility of the community readiness model (CRM) for understanding and affecting smoke-free policy development and implementation. The CRM evaluates a community's capacity for successfully developing and implementing prevention or treatment interventions. The purposes of evaluating a community's readiness are to: (a) identify the stage of readiness for policy change, and (b) determine stage-specific strategies to advance a community toward policy change.

Policy Issues Related to Expanded Newborn Screening: A Review of Three Genetic/Metabolic Disorders

Bishop Hubbard, H. — 2008-01-04

In 2005, a federal advisory committee recommended that the number of disorders in state newborn screening programs be expanded from 9 to 29. In view of this recommendation, state leaders will need to make cogent decisions regarding the expanse of their state newborn screening programs. They must consider several factors, including the costs and outcomes of the screening program. The expense of the initial screening test can be misleading because it does not include the cost of the entire program (testing, tracking, notifying, retesting, confirmatory testing, and follow-up). Also, outcomes such as false positive findings can be costly to newborn screening programs, result in additional testing for infants, and lead to parental concern and worry. This article examines some of the policy issues related to newborn screening and specifically focuses on three disorders recommended for newborn screening, cystic fibrosis (CF), medium-chain acyl CoA dehydrogenase Deficiency (MCADD), and beta-ketothiolase (BKT).

Recommended Newborn Screening Policy Change for the NICU Infant

Balk, K. G. — 2008-01-04

Newborn screening (NBS), the practice by which infants are tested for certain genetic and metabolic conditions by heel prick 3 to 5 days after birth, has been a beneficial and cost-effective public health strategy. Many of the screened conditions present in the first 2 weeks of life and are life threatening. Because of the risk of metabolic acidosis, seizures, coma, neurological devastation, or death, NBS is essential for prompt diagnosis and treatment, including dietary, hormonal, and other interventions. However, due to the fact that aminoglycosides, blood transfusions, nothing by mouth status, and the presence of heparinized solutions all potentially affect the screening results, NBS guidelines in neonatal intensive care units (NICUs) ought to be changed to obviate inaccurate results. These guidelines, originally initiated by nurses at the Johns Hopkins NICU due to the missed diagnosis and death of an infant, include screening the day of birth prior to any interventions, performing the screen at 1 and/or 2 weeks of life, and repeating screening as needed.

International Nurse Migration: Impacts on New Zealand

North, N. — 2008-01-04

As a source and destination country, nurse flows in and out of New Zealand (NZ) are examined to determine impacts and regional contexts. A descriptive statistics method was used to analyze secondary data on nurses added to the register, NZ nurse qualifications verified by overseas authorities, nursing workforce data, and census data. It found that international movement of nurses was minimal during the 1990s, but from 2001 a sharp jump in the verification of NZ-registered nurses (RNs) by overseas authorities coincided with an equivalent increase in international RNs (IRNs) added to the NZ nursing register—a pattern that has been sustained to the present. Movement of NZ RNs to Australia is expedited by the Trans-Tasman Agreement, whereas entry of IRNs to NZ is facilitated by nursing being an identified Priority Occupation. Future research needs to consider health system and nurse workforce contexts and take a regional perspective on migration patterns.