Conceptual Paper

An Examination of Punctuating Events and the Future of Nursing: Policies, Pandemics and Beyond

Courtney N Haun¹* and Ethan Haydel²

¹Assistant Professor Director, Healthcare Administration Undergraduate Program University, Samford university, USA

²Healthcare Administration Student, Samford University, USA

Submission: June 17, 2022; Published: July 19, 2022

*Corresponding author: Courtney N. Haun, Assistant Professor Director, Healthcare Administration Undergraduate Program University, Samford university, USA

How to cite this article: Courtney N H, Ethan H. An Examination of Punctuating Events and the Future of Nursing: Policies, Pandemics and Beyond. JOJ Nurse Health Care. 2022; 12(4): 555842. DOI:10.19080/JOJNHC.2022.12.555842

Abstract

In the United States (U.S.), the health care sector has responded to the heightened need for more nurses due to the increase in the aging population, chronic illnesses, and the shortage of nursing educational resources. This article examines whether Punctuated Equilibrium Theory (PET) can help to explain how nurse staffing policy trends can lead to sharp, short-term shocks to the policy system and policy outcomes. Since the early 2000s, two punctuations occurred during the same time. In 2010, the Institute of Medicine (IOM) report titled The Future of Nursing gave thorough recommendations for states regarding nursing workforce improvement. The nursing and health industry were, nevertheless, greatly influenced by this report. In addition, the controversial Patient Protection and Affordable Care Act (ACA) sought to not only strengthen Medicare and Medicaid but also implement tighter restrictions on both state and federal health care policies. The context of COVID-19 is creating yet another punctuation and has subsequently led to an increase in hospital admissions and the need for more nursing services. We posit that the IOM report, the ACA, and the coronavirus pandemic have served as punctuations in the policy system where nurse staffing policies have significantly changed.

Introduction

Punctuated Equilibrium Theory (PET) suggests that the policy process is characterized by long periods of incremental change and short periods of punctuated change [1]. The impetus for policy change may be catalyzed by a focusing event or events that break open policy monopolies. While there is much in the literature regarding PET, a shortcoming is the lack of explanation regarding punctuating events and nurse staffing policies. We integrate a historical perspective of the nursing market and subsequent policies that were enacted to draw upon events that shocked the policy system. In turn, this paper highlights nurse staffing policy changes overtime. Specifically, we examine state policy to trace the relationship between punctuating events and the occurrence or lack thereof policy change. In 2010, the Institute of Medicine (IOM) report titled The Future of Nursing: Leading Change, Advancing Health gave thorough recommendations for states to implement regarding nursing workforce improvement [2].

This report was published after a large amount of evidence-based research came forth showing the strong ties between the amount of nurse staffing and patient quality outcomes, as well as the costs associated with these outcomes. The IOM report identifies thenursing profession, whose more than three million members make it the largest health care profession, ascentral to efforts to remake the U.S. health care system so that all Americans have access to high-quality and cost-effective care [3]. The committee’s report provides a blueprint for transforming the nursing profession to improve the quality of health care and the way it is delivered. [4] posit that health policy sources, such as professional organization, can influence nursing practice. This paper examines if the IOM report serves as a punctuating event leading to an increase in nurse staffing policy, otherwise explained through the PET lens.

The Patient Protection and Affordable Care Act (ACA) was signed into law on March 20, 2010 [5]. The major health care reform led to extensive nursing workforce policy changes, such as mandatory labor requirements, training adjustments, and an expansion of nursing education programs. The ACA primarily sought to expand both Medicaid and Medicare, as well as provide additional consumer rights and protections regarding health insurance policies. As a result, the ACA aimed to increase nurse training programs and provide loan payments and retention grants, which were intended to increasethe number of certified nurses in the U.S. [5].

Again, the ACA may be part of the punctuating context in light of an increase in nurse staffing policy, according to PET.Moving to a more recent health care context, the COVD-19 pandemic is yet another punctuation to the nursing landscapes. The aging population, chronic illnesses, shortage of nursing educational resources, and has exacerbated the need for nurse services. Now, implications due to COVID-19 as a punctuation in the nursing landscape has further increased the need for more nurses. Moreover, this dynamic could lead to further policy change that is yet to be revealed. Interestingly, an updated IOM Future of Nursing report is set to be released in spring 2021, yet again creating a mainstay to the conversation surrounding nursing workforce improvement [6]. Through a historical outlook, this paper seeks to demonstrate how states are pursuing solutions to these pressing issues facing the nursing profession through policy implementation. PET is utilized to describe this policy environment and potential changes to come.

Background

Punctuated Equilibrium Theory

While exerting the notion that the policy process is complex and dynamic [7], the pace of change is not always constant or linear as the incremental approach suggests [8]. Instead, the policy process can be marked by periods of relative stability then periods of change where there is punctuated equilibrium [1]. The interconnected parts of a subsystem including institutions and politics can be an impetus for change but sometimes reinforces it. A policy monopoly is a set of structural arrangements that allow for policymaking to be controlled by a small group. With nurse staffing policies, “policy monopolies” are those who expand the nursing shortage issue beyond special interests alone. Punctuations may be referred to as a result of “policy monopoly” breakdown. These breakdowns are the outcome of subsystem failures where radical shifts in policymaking can occur [9]. As described by Baumgartner and Jones, dynamics of institutions, in this case nursing associations and interest groups, can reinforce change to some degree [1]. With the nurse shortage, separate institutions such as health care facilities, accreditation boards, nursing workforce organizations, and more overlap when it comes to their mission and goals for better nursing outcomes. Together, the multiple institutions combined have more power and, because of this, they create a “professional community.” This subsystem has also been identified as an issue niche or issue network. Regardless of the term, the interactions between experts and the broader political system can result in bursts of change, such as wide-scale policy adoption [9].

To further describe these interactions, salience of an issue or an event are components of change. When a subsystem has an institutional structure responsible for policymaking and is supported by a powerful image it becomes a policy monopoly meaning that certain groups have the ability to maintain the image of the policy problem. Part of policy monopoly success is the ability to support a particular policy image. In this case, the nursing workforce issues such as shortage and poor care quality outcomes have been redefined to become more salient. Then, political actors such as nurses, action coalitions, and other health care organizational groups exert their authority and add to the shifting of power. The new policy communities include essential elements such as power and legitimacy where influence is used for policy success [9].

According to PET, there are also periods of disequilibrium where an issue is pushed to the macropolitical

agenda. At this level, small changes in the conditions can cause substantial changes in policy, otherwise known as positive feedback. For example, small changes that have been made at the state level such as nursing action coalition formation moved to sizable federal policy adoption (e.g., Federal Nursing Education Fund). However, negative feedback also occurs where a system maintains stability. The nursing

workforce not increasing or decreasing may be an example of this stability or a result of it. In the incremental approach, an increase of attention from the public on a policy issue will not result in institutional adjustments and instead leads to negative feedback when public interest increases [7].

In contrast, PET posits that issue salience will lead to issues emerging on the agenda, resulting in positive feedback [10]. With public support and investment, Baumgartner, Jones, and Kingdon argue that policy image is a way to understand policy processes [11]. Policy image can be a strength or weakness to the public because missing information may be present. The perceptions of policy by the public can lead to policy change and more involvement from multiple policy actors such as policy entrepreneurs [12]. Adding to these complex dynamics, institutions have the ability to venue shop for a policy home. Strategies to initiate the breakdown of policy monopolies include changing the venues within which the opposition is appealing, attempting to change the image associated with a particular policy, or expanding the scope of the conflict to include previously uninvolved actors. In this case, the IOM report, the passage of the ACA, and the COVID-19 context are events that describe policy change surrounding the nurse shortage dilemma and multiple ways the shortage could be mitigated, such as through policy initiatives. When opponents are successful with any one or all these strategies, policy monopolies are broken up, and previously dormant public issues are thrust back onto the institutional agenda, which occasionally results in policy change [12].

Through the lens of PET, after years of stability and incremental policy behavior, the IOM report and the ACA were punctuations to the nursing shortage problem. The report served as a “destabilizing event” and led to an explosive change of reform and legislation to correct the issue at hand. Political institutions, such as the Robert Wood Johnson Foundation, the American Nurses Association, and the Campaign for Action, were deeply involved in the policies that were passed during this time frame. The legal and institutional environment is a part of the policy community where power, prestige, and legitimacy expand a policy image. During this timeframe, the amount of institutions grew who were advocating for similar policy changes, allowing them to have more collective power in the policy process. Policy images about the nursing shortage played a critical role in expanding the issue, leading to policy communities such as the network of nursing action coalitions throughout the nation. In these institutional structures, they are forced to share power with other groups in times where salience or agenda access is absent, in turn regaining legitimacy and power [5]. Based on PET, we expect to see an increase in implemented policies surrounding punctuating events.

Methods

Aim

The aim of the study was to examine whether nurse staffing policy trends can be generalized to PET, the idea that policy monopolies are stable over long periods of time and usually change because of sharp, short-term shocks to the policy system. We posit that the IOM report, the ACA, and the COVID-19 pandemic have served as punctuations in the policy system where nurse staffing policies have significantly changed.

Design

The analysis was conducted in two steps as related to nurse staffing policy from 2004 - 2020: (1) the historical punctuating events in the nursing market, and (2) identifying state level nurse staffing policies. This period was chosen based on the availability of data for variables in the study. First, a historical narrative was used to synthesize the major events of the nursing markets, affecting nursing supply, demand, and policy. Scholarly sources on the major events were used to obtain the relative information. The historical analysis focused on occurrences in the health care industry that influenced nursing policy implementation as punctuating events. Second, implemented policies affecting nurse staffing were identified to create a timeline of nursing policymaking. The policies were limited to those directly related to nursing workforce staffing. A nurse staffing policy is a regulation that mandates a particular ratio of nurses, which is determined by the number of patients present in a health care facility. The following bibliographic search strategy was utilized to identify state level nurse staffing policies. Bibliographic search databases: The National Conference of State Legislatures and Congress, GovTrack.us, and Congress.gov. Search Terms: The following keywords were the search terms – nurse, nursing, nursing law, nurse staffing, health, certification, license, and staffing. Legislation selection criteria: Policies chosen were enacted status between 2004 and 2020.

Data Collection

The unit of analysis in this study is state/year, which created an n = 850 (17 years, 50 states). The data comes from the National Conference of State Legislatures and Congress, GovTrack.us, and theCongress.gov. Along with those sources, the Nurse Practice Act websites at each state’s Board of Nursing were collected in order to easily reference and triangulate individual states’ regulations. The only policies that were reviewed directly relate to nursing workforce staffing. A list of the nurse staffing policies by state between 2004 and 2020 is available in Table 1. A timeline of nurse staffing policies was created to assess if PET is an appropriate means to explain the IOM report and other events as related to the punctuation of implemented nurse staffing policies (Table 1).

Results

Historical Perspective

As aforementioned, in 2010, the IOM report titled The Future of Nursing: Leading Change, Advancing Health gave thorough recommendations for states to implement regarding nursing workforce improvement. This report came about after much research demonstrated the strong association between nurse staffing amounts and care quality outcomes in a variety of health care settings. As a leading organization in the health care arena, the IOM report was influential to the health care industry and was used to expand the political agenda surrounding a given health care issue and, ultimately, lead to policy change that may help solve the dilemma. The IOM report identifies the nursing profession, whose more than three million members make it the largest health care profession, as central to efforts to remake the U.S. health care system so that all Americans have access to high-quality and cost-effective care. The committee’s report provides a blueprint for transforming the nursing profession to improve the quality of health care and the way it is delivered (IOM,2011). Based on this report, all 50 states began pursuing solutions to the pressing issues facing the nursing profession through “action coalitions.” These coalitions, as well as others, served as political actors who pushed nurse staffing policies onto the political agenda.

In March 2010, the Patient Protection and Affordable Care Act, also known as the Affordable Care Act, was passed which represented “the largest and most complicated piece of federal legislation affecting the Unsheathe system perhaps since the passage of the original Medicare and Medicaid programs in the 1960s” [5]. The implementation of the ACA led to increased federal funding towards Medicare and Medicaid, limited private insurance companies, and enforced numerous health care workforce policies. While the ACA aimed to protect uninsured Americans, it also contained policies that addressed the nursing workforce shortage and limited nursing programs. The ACA may have resulted in the spike of nursing and health care workforce policies within the U.S., serving as a punctuated event that shocked the policy system. Because the IOM report and the ACA passage occurred during the same timeframe, this further emphasized issues in the health care environment and the need for changes to occur. More recently, another punctuating event impacting both the health care industry and the global population has occurred. In March 2020, an infectious disease caused by a newly discovered coronavirus began to spread throughout the U.S. population. Because of this, as well as underlying factors such as the aging population, the nursing workforce yet again was in great demand. The COVID-19 crisis has brought forth rapid growth in the number of illness cases and a substantial number of deaths. The crisis has had implications on the economy, health system, and patient care delivery. This has created much fear, stress, and even burnout for the nursing profession [13]. Although it is still to be determined, there may be turnover in the nursing workforce due to the unprecedented pressure to care for those affected by COVID-19. On the other hand, perhaps the COVID-19 landscape is painting a picture of the greater need for more nurses, in turn creating more opportunities to recruit, retain, and educate current and future nurses.

Identification of State Level Nurse Staffing Policies

A systematic review of legislative databases revealed that 14 states have enacted regulations addressing nurse staffing specifically. Figure 1 displays the total enacted state nurse staffing policies between 2004 and 2020. From 2005 to 2006, there were no state nursing policies enacted. Then, there is a sudden spike until 2009, with four policies enacted that year, followed by a sudden decline to zero in 2010. Part of the sudden increase may have been due to discussion around the nursing shortage crisis, right before the IOM: Future of Nursing report. After the report was released in 2010, as well as the passage of the ACA, there was then another increase in policies until 2013, with four policies enacted that year. Following that, there were zero policies enacted in 2015 and 2016. From 2016 to 2020, there have not been any policies implemented relating to nurse staffing. However, discussion at the federal level has occurred to amend the Public Health Service Act in order to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes [14] (Figure 1). Shows a map of the U.S. and the individual states that have enacted nurse staffing policiesduring the same timeframe. During this time period, 14 states enacted nurse staffing policies. It appears that perhaps neighboring states may influence surrounding states when it comes to the implementation of nurse staffing policies. The figure demonstrates that four states on the west coast implemented policies as well as six neighboring states in the northeastern region of the U.S (Figure 2).

It is also important to note staffing levels throughout the U.S. from 2004 to 2020 and if any significant changes occurred during this time period. If there was an influx in nurses, then there perhaps would not be as great of a need in policies to increase the supply of nurses. Table 2 shows the amount of policies implemented collectively across all states and the amount of nurses in the U.S. between 2004 to 2020. The nurse population includes registered nurses, licensed practical nurses, and nurse aides. 2020 Census data is not yet available but was included in the table to match the other historical information included in this paper (Table 2)

To provide a differing depiction of the data, Figure 3 shows the total nursing workforce collectively between 2004 to 2020 as a line graph. The figure displays a steady increase in nurses during this time period. Interestingly, there was a slight decrease after 2011 that persisted until 2015. Then, there was a steady increase in the number of nurses until 2018 followed by a decrease in 2019. Perhaps recommendations set forth by the IOM report and policies that were being implemented did not equate into substantial changes in the workforce until years later. It will be noteworthy to see the trends into 2020 and if the nursing workforce increases, decreases, or stays the same. With that said, PET can be utilized in describing this policy environment (Figure 3).

Note: RN=Registered Nurse, LPN=Licensed Practical Nurse

2020 Census data not availables

Discussion

From 2004 to 2020, we identify three major events with punctuating potential. Of these events, it appears that many policies were passed before (2008-2009) and after (2012-2014) the IOM report was released [15]. Then, there was a major decline in policy implementation between 2015 to 2020. Based on these findings, it is clear that nursing policy adoption occurs in connection to increased punctuating events. Specifically, the IOM report and the ACA appears to be a catalyst for nurse staffing policy change. Policies passed before the release of the report and the passage of the ACA was brought forth from the substantial need for more nurses and conversation surrounding health care and the need to improve outcomes during that time frame. With the slow progression of policy, we then see another spike of policies implemented at the state level. Moving forward, it will be interesting to see if the same patterns exist in these new and different contexts, such as COVID-19. If the same trend follows, perhaps there will be another spike in policies that will take place. It is important to note that a new, updated Future of Nursing report for 2020-2030 that was recently released by the National Academy of Medicine. This may serve as yet another punctuating event in the nursing market, potentially leading to more nurse staffing policies being implemented. Yet, based on the results from the 2020 presidential election, implications for policy based on the ACA and if changes are made may shift the policy climate away from nursing policy. Another potential scenario is that these events combined might reinforce policy outcomes. In either case, it will be interesting to see the implications that are bound to occur during 2020-2021 and the influence it will have on the nursing market in future research.

Limitations

In light of the research design, it is replicable and can be built upon to allow for the inclusion of time points beyond 2020. However, there are limitations to the study that warrant mention. It is difficult to generalize these findings as the study only accounts for years 2004 - 2020 based on available variable information, making findings less generalizable to the entire history of nursing supply. Future research should include the exploration of significant differences in the amount of nurse staffing policies at the state level, such as the 14 states that have enacted policies. Other research could help indicate early adopters, such as California, when it comes to nursing policy. Policy diffusion may help to explain and be an indicator of nurse staffing policy adoption that should be further studied. Despite these caveats, this study contributes to the literature on PET and its application in the field of health care, specifically nursing. With the lack of studies applying PET, this study helps to bridge this gap by focusing on the ties between punctuating events and nurse staffing policies. The enactment of a nurse staffing policy can be viewed as a factor that influences the supply of nurses. This study highlights the practical implications for states and health care organizations that seek to understand the importance of punctuating events and their influence on policy and supply of the workforce. There is particular importance for health care organizations who suffer from a large degree of nursing turnover or a lack of nurses to provide services.

Conclusion

The findings have notable implications for PET, policies surrounding nurse staffing, and methodologyin public policy research. PET is a theory that exhibits the dynamics of the nursing shortage as a public problem and policy subsystems involvement in the policy process. By combining human dynamics such as bounded rational decision making, being limited by attention to a problem, and how policy image can change thinking towards an issue, PET explains the policy environment surrounding nurse staffing policies. Where the IOM report created pressure for change, the salience of the nursing shortage crisis across the nation sparked groups to come together for the implementation of solutions through policies. At the same time, it is important to consider the implications on policy change from the implementation of the ACA. Since 2011, we can see periods of stasis in policy at the state level marked by bursts of policies being enacted. Another important recent punctuation to note is COVID-19 and the context of influence in the nursing market. Although not perfect, PET allows for an understanding of policy changes with periods of stability. The inference from PET is that large shifts in attention can lead to assumptions about pressures for change. The interactions within this process and between policy issues and predictions about what will happen are difficult to study. But, although met with limitations, allows for a model that can trace the occurrence of large policy changes with periods of stability [12]. Nurse staffing policymaking appears to be predicated by other factors occurring in the market, such as the identified punctuating events.

Nursing policy is consistently made during times of crisis, and only appears to be aimed at mitigating the current crisis, rather than anticipating or preempting the next. However, some events cannot be predicted, such as the precedence of COVID-19. A continuation of this approach is likely to result in nursing policy being defined by the current conditions of the nursing market. Favorable conditions [16]. Will likely result in a lack of policy interest, while unfavorable conditions will likely result in a significant increase (e.g., large increase inpolicy after the IOM report was released). Since the analysis only includes 17 years of data, future research should continue to look at the reactive nature of nurse policymaking with an eye towards mitigating current health care issues. We are left with a “cliff-hanger” in the story of the nursing workforce and improvement policies. It will be interesting to see how the IOM - The Future of Nursing 2020-2030 report will be perceived and if the PET will continue to explain the policy phenomena. In general, research should try to better understand the relationship between punctuating events and nursing policy. Future events may help to better understand this relationship, such as the coming updated IOM report. Nurse staffing policy may not be a simple pursuit and should be considered in other lights. Additionally, we have defined nurse policy at the state level as congressional policy action aimed specifically in the U.S. As such, it may be useful to broaden the definition and level of government at which this theory is tested. As punctuations continue in the nursing workforce, the policy system where nurse staffing policies occur will continue to change.

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