Summary
Even though the fight for the 8-hour workday has been won over 80 years ago, the changes had little to no effect on the US healthcare industry. As it stands, over 65% of all nurses work 12-hour shifts, often with mandatory overtime, whereas the rest have 8-hour shifts, 10-hour shifts, or a combination of thereof (Dempsey, 2016). As it stands, only Maryland and California have prohibited mandatory overtime for nurses. Allegedly, the 12-hour shifts, along with overtime, are implemented to cut costs and reduce the prices of healthcare for the end-users (Dempsey, 2016). In reality, however, the costs associated with burnout, employee rotation rates, and poor quality of service are likely to exceed expenditures associated with hiring additional staff. The reason I chose this policy issue is that it affects the entirety of the healthcare industry in the US, and the lack of adequate policies to protect nurses and patients causes direct damage to both.
12-hour shifts with either mandatory or “voluntary” overtime have a significant contribution towards nursing mistakes, burnout, care fatigue, and the desire to leave the profession. Banakhar (2017) reports a variety of health concerns associated with 12-hour shifts, ranging from sleep disturbances to improper work-life balance, job dissatisfaction, depression, and the desire to leave the profession. Saville et al. (2020) point out that 12-hour shifts result in a lower quality of care, reduced staffing adequacy, decreased amounts of nursing checks, and a greater volume of professional mistakes that lead to comorbidities, increased expenditures, and prolonged hospitalizations as a result. 8-hour shifts, on the other hand, would improve the quality of service, thus lowering the above-mentioned parameters.
The fiscal impact of the existing policies is mostly negative and particularly dangerous to specific vulnerable population subgroups, such as the poor and the elderly. Older individuals constitute the larger portion of the hospitalized population, with patients aged 75 or older having at least 1 hospitalization per year (Webster et al., 2019). A third of them spend more than 4 weeks in the hospital per incident. Should they contract a hospital-acquired infection (HAI) or suffer as a result of negligence, it would prolong their hospital stay, resulting in greater expenditures for themselves and the facility (Webster et al., 2019). In addition, in the cases with working poor, prolonged hospitalizations and misdiagnoses result in missed workdays and greater poverty (Webster et al., 2019). The proposed policy of switching to an 8-hour workday for nurses will reduce the number of nursing mistakes, positively affecting the financial impact and increasing reimbursements.
As a nurse professional, I am sworn to abide by the ethical principles of nursing, which include justice, beneficence, nonmaleficence, accountability, fidelity, autonomy, and veracity (ANA, 2020). The issues of 12-hour shifts and associated problems they cause through a lack of policy are connected with beneficence, nonmaleficence, accountability, and autonomy. Beneficence stands for doing what is best for the patient. I strongly believe that a nurse must do everything to ensure that the sick are getting the best possible quality of care they can get. The constant drain 12-hour shifts place upon nurses effectively reduces their capacity to perform adequate care. I oppose the idea of 12-hour shifts on the ethical grounds of violating the principles of beneficence.
The principle of nonmaleficence means no harm. The connection between 12-hour shifts, prolonged overtime, and nursing mistakes is a proven fact (Banakhar, 2017). Nursing mistakes, though unintentional, directly harm the patient by exacerbating their current symptoms or forcing them to acquire new diseases as a result of improper treatment or diagnosis (Saville et al., 2020). Therefore, they serve as an indirect cause of harm for the patient, which is unacceptable and goes against the ethical code of the American Nursing Association (ANA, 2020). I am ethically obligated to promote policies against 12-hour shifts and mandatory overtime, on the grounds of nonmaleficence.
I am a strong proponent of conscious accountability in nursing. It stands for accepting responsibility for one’s actions. The 12-hour shift issue is, largely, a problem within the medical community. We have been accepting the situation as status quo for too long, enough for it to become the norm despite the 8-hour shift being adopted in virtually every other industry. It is our fault that we did not do anything about the issue. Therefore, it is our ethical responsibility as a healthcare community to fight and promote policies that secure the 8-hour workday for nurses, which can be done once we are united in the effort.
Finally, there is the principle of patient autonomy. I am a strong believer in Orem’s theory of nursing, which suggests that every patient has a desire to achieve personal autonomy (Alligood, 2017). Likewise, the inability to do so harms them on physical, emotional, and psychological levels. Prolonged hospitalizations, economic issues, and comorbidities as a result of nursing mistakes caused by exhaustion from 12-hour shifts, reduce patient autonomy. If policies to reduce nurse shift times will result in better healthcare and greater autonomy for vulnerable populations (elderly, poor, and others), then it is my ethical duty to support them.
Policy Brief
The identified decisionmaker to receive the proposed policy brief is Kirsten Gillibrand, who is a Democratic senator for the New York state. She has always been a strong proponent of improving and socializing healthcare, which is demonstrated in her support of Medicare and Medicaid bills since the conception of those policies. In addition, she holds the position of a senator in arguably the most politically important state in the US, which is New York. Should the proposed policy pass in there, it would become much easier to use the bill as a precedent to promote the same ideas in other states or even on the federal level.
The issue demands the legislator’s attention because of the increases in expenditures for individual patients as a result of nurse mistakes, the chronic shortage of nurses in the industry, and the mounting losses of nurses due to burnout, physical, and emotional strain. 12-hour shifts with mandatory overtime have a negative effect on the quality of care, the liability to make mistakes, and the general satisfaction with the profession (Banakhar, 2017). According to Rodziewicz and Hipskind (2020), medical errors account for approximately 4 billion dollars in additional expenditures per year. These numbers, however, do not account for the costs of replacing nurses or for the loss of life, income, or work time by patients. Lawsuits towards specific healthcare workers contribute to nursing shortages by effectively eliminating individuals from the workforce (Rodziewics & Hipskind, 2020).
It adds to the already increasing shortage of nurses. According to Djukic et al. (2017), 18% of all new RNs quit their profession within a year, and 34% in total is lost within 2 years of practice. It constitutes a tremendous loss, considering the overall estimated increase in demand for nurses due to the significant growth of the geriatric population by 2040 (Djukic et al., 2017). The proposed solution of reducing work time per day from 12 or more hours to 8-hour schedules is supported by evidence, as indicated by Stimpfel et al. (2015), who asserted that shorter shifts result in decreased burnout, and higher patient satisfaction while retaining the same hours for employees. Therefore, attention to this matter is warranted on a legislative level, as it affects the physical, economic, and political aspects of everyday life.
There are several obstacles to promoting and adopting the policy. The primary objection raised is that nurses prefer 12-hour shifts. The majority of hospitals operate using the 12-hour shift system, and around 65% of those constitute highly-technological treatment facilities (Stimpfel, 2015). The second obstacle lies in the area of supply and demand for medical specialists. Zhang et al. (2018) report that the current nurse shortage is estimated at 150,000 specialists and is ought to increase as the demand for nurses will increase from 3.8 million to 11 million by 2040. With such shortages, many hospitals would struggle to find additional personnel to equip three shifts of 8 hours instead of two at 12 hours.
Additional problems would be associated with short-term increases in expenditures. The study by Bullard (2016) indicates that hospitals with 3 shifts spend more on their nurse salaries due to the laws of labor supply and demand. Hospitals with 12-hour shifts pay less per nurse, despite the approximately equal number of hours of work. However, this study does not account for additional hours spent by nurses in the workplace, such as mandatory overtime. The study also finds that the expenditure curve is evened out in the long term due to reduced rotation rates, lower numbers of nurse mistakes, and increased patient satisfaction.
Finally, there is a lobby for protecting 12-hour shifts. It is largely comprised of entities that benefit from the existing order, which constitutes hospitals that have always utilized the 12-hour model, people who do not wish to deal with the aforementioned increases in nurse market competitiveness, and a small number of researchers that find the comparative advantages of the 8-hour model to the 12-hour model inconclusive. Additionally, the 12-hour shifts are supported by nurses that have chosen the schedule of their own volition, as well as those who got used to it and would not want to readjust their way of life to accommodate a new model. These nurses, in their majority, constitute some of the older specialists in the profession.
When considering the primary options for the decision-maker, the three major ones are maintaining the status quo, coming up with a compromising solution to appease the opposing parties, and following through with the proposition without any changes. The status quo is not a preferred solution within the scope of the proposed legislation, as it would do nothing to solve the ongoing healthcare crisis. Maintaining the existing policies would only make things worse in the long run, as burnout rates are only going to increase as the deficit of healthcare employees grows and the struggle for the 8-hour workday from ANA is going to increase in its intensity. If the decision-maker wants to maintain the 12-hour shifts as they are now, they should find a solution to the nurse crisis, burnout rates, and increased chances for medical errors all at once. The proposed legislation targets all three, and pushing a single bill is easier than multiple ones aimed at the individual parts of the problem. It is sustained that the change to an 8-hour workday is inevitable, and the sooner the healthcare industry starts adapting to it – the better.
A compromise between parties is the second solution. Between the three options, it is the most likely one to pass, as it may accumulate bipartisan support. However, this measure might lead to inconclusive and superficial results while stymieing any future efforts at adopting an 8-hour workday. Many hospitals implement peer pressure for employees to work overtime or consent to 12-hour shifts. Should the compromise involve a “voluntary” choice between schedules, there is a possibility that the majority of nurses would be pressured to choose the former, thus rendering the purpose of the legislation moot. Finally, the mixed method would add additional complexity to healthcare organizations, which will be forced to manage 8-hour and 12-hour employees within the same schedule.
The option endorsed in this paper is to proceed through with the legislation without any significant compromises to its core – implement a state-wide mandatory 8-hour workday for nurses. Doing so would be met with significant challenges already mentioned in this paper, but those challenges could be overcome. It is sustained that the long-term benefits of adopting the policy would eventually outweigh the short-term financial concerns, help reduce the nurse shortage as a result of burnout, and help improve the quality of care, thus reducing rehospitalization rates and associated nurse losses due to lawsuits.
The proposed persuasive course of action should address the three main arguments against the initiative – the preference of some nurses towards the 12-hour shift, the lack of personnel to establish 8-hour shifts, and the financial short-term component. The first persuasive action should involve nurses that prefer 12-hour shifts. The legislator can meet up with nurse representatives and invite researchers that stand by the 8-hour shift. That way, the opponents could listen to the arguments of their colleagues, instead of politicians that have never worked in a hospital before. Since all nurses practice evidence-based medicine, they could be shown the evidence for the effectiveness of 8-hour shifts, to sway their opinion. Once that base of supporters is convinced, the opposing legislators will not be able to promote that line of thought without support.
Addressing the issue of personnel shortage could be done by tapping into the pool of nurses that have quit the profession as a result of poor scheduling. Obtaining a nurse degree is a commitment one does not easily abandon. The non-legislative persuasive action could involve the decisionmaker meeting with the ex-nurses, learning of their current employment, and inquiring if a mandatory 8-hour shift would suit them better. A state-wide survey could be conducted to determine the number of nurses willing to return to work, should policies change.
Lastly, there is the financial argument, which is very convincing to politicians. Its lack of plausibility can be proven in a legislative action before the senators. Inviting an economic expert with the calculations of by how much the individual salary of every nurse would have to be raised to versus losses of money on reimbursements, lawsuits, turnover, and vacancy filling. The results should be more than convincing to the individuals more worried about the budget than the health conditions of the US citizens.
The legislative process for accepting the bill starts with a sponsor. Should the senator in question sponsor the policy, it will then have to pass the following stages of acceptance: Committee hearing (requires 218 or more votes out of 435), senate committee hearing (51% out of 100% majority), and finally, a conference committee between House and Senate versions. After that, the House and Senate would approve the bill, and it will be signed by the President. Long-term successes of the passed bill will be measured in the reduction of medical errors (by 20% at least), lower burnout rates in nurses (by 50% at least), and financial savings on reimbursements, resulting in lower required expenditures for state healthcare.
The Bottom-Up Approach to Policy Advocacy
The bottom-up approach differs from a top-down approach discussed above by creating a power structure of interested parties and community members to create the public demand, influence civil discourse, and be used as leverage in finding sponsors for the bill to facilitate a top-down approach. The organization identified to support the proposed policy would be the ANA-New York nursing network. It is a branch community organization of the American Nursing Association, which is the largest nursing organization in the US that has considerable political influence and weight.
ANA has been looking favorably towards the promotion of the 8-hour work shift. Their opinion has been indicated in the 2014 position letter, which voiced the organization’s strong support towards the 8-hour work shift as a means of reducing nurse stress, burnout, turnover rates, and improving the quality of care (ANA, 2014). The latest policy proposed to be implemented in Washington, House Bill 1155, sought to normalize the 8-hour shift as the standard for all hospitals and received bipartisan support from local senators (“House bill report,” 2019). It was also endorsed by the Washington State Nurse Association (WSNA), which is a constituent organization of the ANA, thus indicating supporting a similar bill in New York. ANA operates following the ethical and professional norms I share; therefore, it has a vested interest in promoting beneficence, nonmaleficence, responsibility, and patient autonomy, which relays well to the purpose of the proposed policy.
The three principles of CBPR that could be implemented when working with ANA to address the policy issue are as follows (School of Public Health, 2012):
- Recognizing the community as a unit of identity. When one part suffers – everyone does.
- Building on strengths and resources within the community. It is possible to implement the 8-hour work shift using existing community resources and tapping into the pool of disenfranchised nurses.
- Focusing on the local relevance of public health problems. The issues of quality, economic viability, and nurse employment are prevalent in New York and the US at large.
Contacting and collaborating with ANA is not difficult. They could be reached by phone, online chat, visiting their state offices, or attending conferences. ANA’s organizational goals include the promotion of better and affordable health to the population while ensuring a comfortable and safe environment for nurses (ANA, 2014). The proposed policy seeks to promote nurse welfare by introducing the 8-hour workweek as a standard in the state of New York, to serve as a powerful statement and example for other states. Doing so would help reduce burnout and turnover, improve the quality of health, minimize rehospitalization rates and HAI, prevent work traumas, and reduce healthcare costs in the long term. Therefore, ANA’s goals are congruent with the goal of the proposed public policy.
The action steps needed to achieve the chosen goal are as follows:
- Arrange for a meeting with New York ANA branch and propose them the policy document with the intent of getting their support;
- Work on the policy to eliminate redundancies, inefficiencies, and controversies;
- Use ANA’s connections to form a local group of support for the policy;
- Present the policy proposal, along with endorsements, to New York state senator Kirsten Gillibrand.
The responsibilities of the organization members would be two-fold. A policy the workgroup will be responsible for formulating a coherent policy proposal to be provided to the decision-maker, whereas capacity-building groups would coordinate and gather public support for the document. The former responsibility will be placed upon senior members of New York’s ANA since they already have experience dealing with other organizations, policy generation, and lawmaking. This group will be smaller in number and comprised of nurses with a long-standing reputation in ANA. The latter will be the larger group comprised of regular ANA members. Their task would be spreading the word, making the public aware of the issue, and accumulating public support through awareness campaigns.
The three CBPR principles we selected are recognizing the community as a unit of identity, building on strengths and resources within the community, and focusing on the local relevance of public health problems. We have selected these principles because they’re the most pertinent to the proposed policy plan and its promulgation to areas inside and outside of the state of New York. The first principle applies to the evaluation plan because the engagement of all members of the chosen community by the chosen organization is critical for the campaign’s success. The second principle is important, as the estimated success can only be achieved within the limitations of the community’s resources, with attention paid to strengths and weaknesses. Finally, the relevance of the problem to public health will generate additional support.
Each step of the plan can be evaluated using the following scorecard:
Analysis
Each of the approaches constitutes several strengths and weaknesses that need to be accounted for when promoting the selected public policy. The top-down approach requires, arguably, less time and resources, and could be extrapolated to several states (Pülzl & Treib, 2017). Meeting with a decision-maker or sending them a policy proposal is easier and can be sent to multiple senators at once. Should the chosen senator not respond, another might choose to sponsor the policy or bill instead. The strength of the bottom-down approach lies in the greater incentive for the chosen senator to get involved, as there would be considerable support behind the bill even before the proposal is sent to them.
The challenges behind the top-down approach constitute a lack of initial buy-in. The ideas behind the bill would need to be very persuasive for the senator in question to choose to act upon them (Pülzl & Treib, 2017). Otherwise, it is possible for them to simply ignore the proposal, in favor of more pressing matters. Another challenge is that the decision-maker may not be as informed of the matter or not view it as important. While it is possible to assume that the senator in question will support the bill, based on their agenda and public statements, it is never certain that they would, in the end. The issues with bottom-up approaches lie largely in starting the grass-roots movement to gather support, before promoting the policy (Pülzl & Treib, 2017). It requires time, influence, and financial resources. Collaborating with an organization, on the other hand, means losing autonomy in determining the direction of the policy.
I would recommend using the bottom-up approach to facilitate success for the proposed policy. Although slower and requiring the collaboration of many individuals and organizations, it would lend the proponent’s considerable political pull. Having power would enable the policy to become visible to the chosen senator and create a motivation for them to follow through. It is something a top-down approach cannot provide.
References
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American Nursing Association (ANA). (2020).Ethics and human rights. Web.
Banakhar, M. (2017). The impact of 12-hour shifts on nurses’ health, wellbeing, and job satisfaction: A systematic review. Journal of Nursing Education and Practice, 7(11), 69-83.
Bullard, K. L. (2016). Cost-effective staffing for an EHR implementation. Nursing Economics, 34(2), 72-76.
Dempsey, C. (2016). The question of 12-hour shifts. Web.
Djukic, M., Jun, J., Kovner, C., Brewer, C., & Fletcher, J. (2017). Determinants of job satisfaction for novice nurse managers employed in hospitals. Health Care Management Review, 42(2), 172-183.
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