Policy, Politics, and Global Health Trends

Reflection Essay on the Value and Ethics of a Public Policy Issue 

Analysis of the Public Policy Issue 

The public policy issue identified is the problem of nurse to patient ratio. The health policy issue has been observed across many hospitals in the state of Virginia, the United States of America. The institutions have mostly lacked an effective balance in the ratio thus disadvantaging the existing nursing staff. The nurse to patient ratio bears a significance among the healthcare institutions within the state. The ratio therefore directly affects the institutions’ operability. An ineffective nurse to patient ratio reduces the safety of the patients at the organizations and decreases the access to medical care for other patients. An imbalanced nurse to patient ratio further leads to the cases of burnout among the nurses as they tend to overwork themselves while taking care of the patients. Therefore, the legislators in the state of Virginia need to consider the possibility of balances the nurses to patients’ ratio, which is to benefit both the patients and the nurses. 

Rationale for the Selection of the Issue 

According to Heath (2018), the nurse to patient ratio, as a healthcare and nursing policy that requires a policy change, is a determinant of the efficiency of the medical care practices in institutions across the United States of America. Researchers in the nursing industry has defined the term "nurse to the patient ratio" as the number of patients one nurse can attend to at a given time in a healthcare setting. The nurse to patient ratio is dependent on several factors, including the severity of the conditions that the patients have. The other factor is the available nursing workforce to take care of the existing medical cases of the patients. An ongoing debate in the nursing sector focuses on the nurse staffing ratios with a keen interest in the quality of care, safety of patients under the nursing care, and the access to nursing care. The issue of the nurse to patient ratio has aroused the interest of many scholars targeting the nursing industry. An optimal nurse to patient ratio in a given healthcare institution goes a long way into increasing patient safety, as the nurses can detect and deal with the severe cases in a good time. Therefore, part of the selection criteria for the policy issue concentrates on the importance of nurse to patient ratio in the healthcare institutions across Virginia. An increase in the nurse to patient ratios in a healthcare institution means that one nurse will handle fewer patients at a go. Thus, it is immanent to explore the aspect of increment in the quality of care among the patients as a result of the optimization of the nurse to patient ratio. The policy issue has also led to a rise in the cases of readmission of patients to the hospital. Hence, it is essential to review the issue of nursing to patient ratio, as evidenced among the healthcare organizations in the state of Virginia. 

Relevance of the Public Policy Issue to the Nursing Profession 

According to Nantsupawat et al. (2016), the issue of the nurse to patient ratio is a determinant of the nurses' burnout, the quality of care reported by the nurses, and the patient outcomes in the Thai hospitals. A cross-sectional analysis of the data collected from 2084 registered nurses in 94 community hospitals across Thailand (Nantsupawat et al., 2016). The data were collected using a survey questionnaire and the Maslach Burnout Inventory (MBI), which measures the patient outcomes and the perceived quality of care by the nurses (Nantsupawat et al., 2016). The findings of the research indicated that 32% of the nurses reported being affected by high emotional exhaustion. Conclusively, Nantsupawat et al. (2016) identify that burnout among the nurses is associated with adverse patient outcomes. One of the interventions to improve patient outcomes and reducing the nurses' burnout in Thai hospitals is the optimization of the nurse to patient ratio. Silber et al. (2016) explore the issue of the nursing environments in the various hospitals across the different levels of patient risk. A retrospective matched cohort design study was performed, including 25752 elderly Medicare patients enrolled under general surgery and 62882 patients being treated at a control hospital between 2004 and 2016 from Texas, Illinois, and New York (Silber et al., 2016). The conclusion of the study pointed out that the healthcare institutions with improved working conditions and the staffing levels, which were above average, were linked to better value compared to the hospitals with degraded working conditions were. Hospitals with enhanced environments were also associated with better care for high-risk patients. However, the researchers would not associate the environment to the healing of the patients (Silber et al., 2016). Nonetheless, the environment, when involving optimal nurse to patient ratios, evidenced by the above-average staffing levels, was associated with better care of the high-risk surgery patients. 

Financial Impact of the Policy Issue at the Organizational and Community Levels 

One of the positive outcomes of optimizing the nurse to patient ratio is that it will increase the employment of nurses from the community to fill up the slots that require the extra nurses ( Kleinpell et al., 2015) . That will increase the financial wellbeing of the members of the community, which will be an important financial pillar to them. Heath (2018) discusses the financial implications of the nursing staffing on the healthcare organizations in the community around the state of Virginia. The optimization of the nurse to patient ratios at the healthcare institutions leads to the increase in the hiring costs for the new registered nurses who are meant to fill up the positions that have been realized after the human resource departments have identified the gaps in the hiring process. The rising costs of hiring new employees reduce the profitability of the healthcare institutions in the case where the revenues earned by the institutions in a given financial year are constant. Heath (2018) also identifies the increase in the costs associated with improved quality of patient care as an effect of the optimization of the nurse to patient ratios. In a bid to attract more patients to the healthcare institutions, the organizations have to go the extra mile in providing appropriate patient care, which is expected to cost more with time. A similar effect on the profitability of the hospitals with an increase in the hiring costs is observed with the increased quality of patient care. The profitability of the healthcare institutions is reduced with the increase in the costs invested in proper patient care. Kacik (2018) adds on to the breakdown of the costs involved in mandating the nurse to patient ratios provided by Heath (2018). Kacik (2018) investigates the cost of implementing the nurse to patient ratios mandates in the state of Massachusetts. The author states that the costs range between $ 676 million to $ 949 million a year to facilitate optimization (Kacik, 2018). The hospitals would have to employ 2286 to 3101 registered nurses and pay them 4% to 6% as the demand for the nurses' rises in the state (Kacik, 2018). The same costs could be explained for the case of the state of Virginia, especially regarding the hiring of more registered nurses and the increments in salaries along with the skyrocketing of the demand. 

How Nursing Values Impact The Position on the Policy Issue 

The professional values in the nursing sector in the various parts of the world enable the practitioners to have a position on the issue of the nurses to patient’s ratio. One of the values that have enabled me to have a position on the policy issue is the acceptance and taking responsibility for their actions in patient care (Elliott, 2017). Since I am used to handling my nursing tasks with responsibility, I can take care of patients in a better way, which is likely to make me overworked due to my desire to honor the professional values. Therefore, the desire for me to be accountable and responsible for all my actions makes me feel that the issue should be rectified soon. The other value is the need to safeguard patients’ privacy (Elliott, 2017). An imbalanced nurse to patient ratio leads to the state of one nurse having to deal with more patients at a time. Therefore, patients’ privacy may be compromised. 

Impact of Ethical Values to the Perspective of the Public Policy Issue 

Various ethical principles determine the perspective that the stakeholders of healthcare and nursing have on the issue of inappropriate nursing to patient ratio. The first ethical principle, which is important to a nurse, is beneficence. Beneficence is defined as the value of displaying the acts of mercy, charity, and kindness with the connotation of delivering good to other people. Nurses across the various healthcare institutions agree that inappropriate nurse to patient ratios leads to the undermining of beneficence as a moral principle (Preshaw, Brazil, McLaughlin & Frolic, 2016). The healthcare and nursing industry of the US has various regulations that determine the effectiveness and efficiency of the professionals. With one nurse handling more patients at a go, the importance of beneficence may be diminished over time as the healthcare professionals strive to ensure that the quality of patient care is enhanced. The other ethical principle that underpins the perspective that the various stakeholders have on the issue of the nurse to patient ratio is non-maleficence. Researchers in the healthcare and nursing sector define non-maleficence as the avoidance of harm or the infliction of the least harm possible to reach an outcome that is beneficial to the object of research (Preshaw, Brazil, McLaughlin & Frolic, 2016). The professional code of ethics for the nursing industry requires nurses to apply a non-maleficent approach to the care for patients in their settings. For instance, the registered nurses in the various healthcare organizations have to practice non-maleficence as they strive to increase the quality of patient care. A low nurse to patient ratio reduces the quality of patient care by reducing the time spent on a patient by a nurse. Therefore, the role of non-maleficence in the healthcare and nursing industry is reduced. The other ethical principle that underpins the perspectives that stakeholders have regarding the nurse to patient ratio in Virginia is autonomy. Modern nurses have had to incorporate the value of autonomy to their work, which benefits both the caregivers and the patients. Each patient is allowed to customize their nursing care across the healthcare institutions in Virginia. A low nurse to patient ratio leads to a reduction in the ability of the patients to direct their care (Adhikari et al., 2016). That is because of the reduction in the nursing professionals who are available for the patients at the healthcare institution. 

Policy Brief 

The following is the policy brief that outlines the policy change to address the identified issue in the healthcare settings across the state of Virginia. 

Identification of the Decision Maker 

The policy brief summarizing the nurse to patient ratio within the state of Virginia is addressed to the subcommittee for health professionals under the senate committees within the state. Specifically, the policy brief is directed to Senator Siobhan S. Dunnavant. The senator is a holder of the Bachelor of Science in Nursing (BSN), which makes her ideal for the comprehension of the policy issue faced by the state of Virginia, and the steps that are supposed to be taken to deal with the problem. As a BSN, she therefore understands the importance of providing patients with the safe care to the patients through the appropriate staffing levels. 

The Attention of the Decision Maker to the Public Policy Issue 

The issue of the nurse to patient ratio in the healthcare institutions located in the state of Virginia requires the attention of the senator for the reasons that pertain to the improvement of the quality care that the nurses provide. Therefore, the commission needs to address the issue for the following reasons. The optimization of the nurse to patient ratios in the medical care institutions reduces the cases of burnout and job dissatisfaction among nursing professionals. Nantsupawat et al. (2017) elaborate research performed to investigate how the working environment for the nurses affects the aspects of job dissatisfaction, the causes of burnout, and the intention to leave among the nurses in Thailand. The study applied a cross-sectional survey to collect the nursing data from 1311 nurses who work in 43 inpatient units in 5 university hospitals across Thailand (Nantsupawat et al., 2017). The variables measured were the burnout among the nurses, the dissatisfaction among the nurses, and their intention to leave their jobs. The nurses who worked at the university hospitals with reported favorable working environments had lower cases of burnout, and hence the reduction in the dissatisfaction of the nurses and increases the level of employee retention among the professionals (Nantsupawat et al., 2017). The nursing environment is, therefore, a significant factor contributing to the reduction in burnout, dissatisfaction, and the intention to resign from their job positions. 

Kear and Ulrich (2015) highlight the second reason why the senator needs to handle the issue of the nurse to patient ratio as the increment in patient safety and outcomes. Both patient safety and outcomes are the foundations of excellent healthcare delivery, which indicates one of the primary goals of healthcare and nursing. Patient safety is an aspect of nursing care that has been overly advocated for in the twenty-first century. The regulations of the healthcare and nursing industry protect the interests of the nursing sector of the US regarding patient safety. The various ethical principles stipulated in the regulations of the nursing industry provide for values such as beneficence and non-maleficence, which protect the interests of the patients under hospitalized care. The various healthcare institutions across the United States of America acknowledged the observance of patient safety by 2009 to increase the quality of patient care. Therefore, Kear and Ulrich (2015) believe that the observance of patient safety increases the efficiency of the patient outcomes, which attracts the patients to healthcare institutions. The optimization of the nurse to patient ratio for the healthcare institutions across the state of Virginia preserves the patient safety levels in the organizations and betters the patient outcomes. 

Challenges of Addressing the Public Policy Issue 

The maintenance of a proper nurse to patient ratio is a challenging task for many healthcare institutions. The first setback that the state is likely to face in the solution of the issue is financial constraints. The optimization of the nurse to patient ratio in the various healthcare institutions may require the hiring of more nursing professionals and the increment in the salaries paid out to the existing members of staff due to the increased demand for the workers. Healthcare organizations have to be prepared for the management of the costs to be incurred. The lack of enough funds to maintain the nurse to patient ratio at its optimum puts a strain on the financial resources that the organizations lack. Therefore, most of the healthcare organizations across the state of Virginia are not in a position to pool sufficient financial resources to support the optimization of the nurse to patient ratios in the light of enhancing quality inpatient care. 

The other setback in the optimization of the nurse to patient ratio in the state of Virginia is the lack of sufficient knowledge on the importance of having fewer patients attended to by a nurse at any given time. Nurse leaders in the various organizations in the healthcare industry play a fundamental role in the optimization of the nurse to patient ratio. A more in-depth look at the medical industry highlights a perspective beyond having more nurses in the workforce. Therefore, the nurse leaders have to be educated on the allocation of the duties to the healthcare and nursing professionals to ensure that some of the workers are not exploited by having more patients based on their skillsets. For instance, nurse leaders have to ensure that the new nurses in the healthcare and nursing industry do not have ultra-long shifts, which leads to emotional burnout and dissatisfaction. 

The other pitfall faced in the optimization of the nurse to patient ratios is the pressure facing the professionals. With the primary goal of healthcare and nursing being increasing the quality of patient care in the community, medical practitioners can be faced with particular pressures to ensure that quality patient care is provided. The Department of Health in Virginia has come up with various regulations that shape patient care in the healthcare and nursing industry. The regulations in the department require healthcare facilities to maintain specific staffing levels. The desire by the healthcare organizations to maintain the specified staffing levels results in increased financial pressure due to the extra slots for the employees. Therefore, the state has to put into consideration the various pitfalls that face the healthcare and nursing sector. 

Primary Interventions for the Decision Maker 

One of the primary interventions that the senator has to handle the policy issue in question is to leave the issue the way it currently is. Also known as the status quo, the senator might decide to leave the policy issue as it is for political and social reasons, especially the various factors that might influence the decision of the senator. According to Hsieh (2015), healthcare professionals and their managers have been maintaining the status quo more than they did in the past. The trend is the same among the individuals responsible for the decision-making at the state level regarding health. One of the reasons that the senator might choose to fail to address the policy issue related to the inappropriate nurse to patient ratio is that he avoids interfering with the politics in the health sector of the US. Additionally, the nurse to patient ratio has been recognized in different states across the country, which makes it easier for the senator to desire to maintain the status quo. One of the effects of maintaining the status quo is that the patients in the Virginian hospitals will record a drastic drop in patient safety levels, which will increase patient dissatisfaction. Moreover, the straining and overworking of the existing nursing practitioners will result in cases of burnout and the eventual rise in turnover. 

The other primary intervention is that the senator accepts the policy change with slight adjustments and compromise (Kokangul, Akcan & Narli, 2017). For instance, the senator may decide to advise the hospital managers to reorganize the nursing employee base rather than employ new members of staff to work towards maintaining an optimal nurse to the ratio, which has been affecting the hospitals. The nurses may be reassigned roles to effectively take care of the patients as well as altering the length of their shifts to maximize the time that they spend with the patients (Kokangul, Akcan & Narli, 2017). Through the slight adjustments, the senator will have achieved an optimum nurse to patient ratio at the hospitals to benefit both the patients and the nurses. 

The third primary intervention that the senator can implement is the adoption of the policy proposal while carrying out the change process to optimize the nurse to patient ratios across the healthcare institutions in the state of Virginia (Rochefort, Buckeridge & Abrahamowicz, 2015). The proposed policy may lead to the employment of new nurses to expand the employee base, which leads to the reduction of the issue of the nurses to patient ratio (Rochefort, Buckeridge & Abrahamowicz, 2015). In the meantime, the senator will have resolved the issues of patient safety by maintaining an optimal nurse to patient ratio at the healthcare institutions across the state of Virginia. 

The Course of Action for the Decision Maker 

The senator has to implement a course of action to counteract the challenges, as mentioned above, in the implementation of the appropriate nurse to patient ratio in the healthcare institutions across the state. Most of the organizations are barred from achieving their goal of maintaining a safe nurse to the patient ratio by the lack of adequate financial resources to do so. The ultimate legislative solution from the senator to address the financial constraints among healthcare institutions is the appellation of funds from the state and federal governments. After the senator applies for the loans and grants for the healthcare institutions in Virginia and they are released, she will make them available for the hospitals within the state to facilitate the attainment of an appropriate nurse to patient ratio. The senator will invite a guest from another state to discuss how he or she was able to support the financial needs of the newly hired nurses to solve the policy issue of the nurse to patient ratio. The senator will also educate the healthcare organizations on how to balance the costs of hiring new nurses with the return on investments to avoid making losses at the expense of achieving an appropriate nurse to patient ratio. 

As observed, less turnover of the nurses owing to cases of burnout, and the less costly errors associated with patient care will reduce the financial pressure faced by the healthcare institutions in their quest of balancing nurse to patient ratio. Therefore, the senator will advocate for the appropriate use of the grants that she will make available to the healthcare institutions. Part of the appropriate use of the grants will be in the use of the funds to cater for the initial cost in the hiring of the new nurses to take care of the nurse to patient ratios within the medical care institutions within the state. 

Some of the hospitals lack the sufficiency in the knowledge regarding the importance of having one nurse handling fewer patients. The lack of such knowledge makes the nurse leaders of the various healthcare institutions across Virginia turn a blind eye on solving the issue of the nurse to patient ratio, which is widespread. The first non-legislative solution that the senator can give to address the challenge on the side of the senate in Virginia is to organize educational opportunities that target increasing the knowledge among the leaders on the issue of the nurse to patient ratio. Legislatively, the senator can institute mandatory health education for the nurse leaders to lessen the issue of the nurses to patient ratio. The education opportunities may be in the form of attending seminars and online for the healthcare institutions that have embraced the use of modern technology in their day-to-day activities. 

The desire to maintain a proper nurse to patient ratio has had many healthcare institutions across the state of Virginia exerting excessive pressure on their healthcare and nursing professionals while targeting to improve the quality of nursing care. The reduction of pressure faced by nursing professionals involves several solutions. One of the legislative solutions on the side of the senator is to create a formal but flexible staffing plan in the healthcare institutions across the state. The formality of the staffing plan ensures that the organizations are not haphazard and that the medical practitioners are able to coordinate their duties in taking care of their patients effectively. Also, the staffing plan ensures that the problem of nurse to patient ratio is dealt with uniformly across the state. The flexibility of the staffing plan is meant to ensure that in the case of particular members of the nursing staff call in sick, the remaining workers are not faced with the pressure to handle more patients than the safe nurse to patient ratio allows. 

Top-Down Evaluation of the Success of the Policy Brief 

The first phase of success in the policy changes will be realized when the senator agrees to be part of the policy change by implementing an optimum nurses to patient ratio at the healthcare institutions across the state of Virginia. The acceptance of the senator to join in dealing with the issue of the nurse to patient ratio in the state of Virginia will be the first indicator of the success of the policy brief to balance the nurse to patient ratio in Virginia. The second phase of success will take place when the senator writes a proposal with the agency responsible for the drafting of the bill. Then, the policy makers of Virginia will evaluate the success of the policy brief after the senator introduces the bill to the senate. The committee consideration phase will indicate the success of the policy brief as well. After the senator introduces the bill to amend the nurse to patient ratio, the participation of the public is encouraged to introduce the bill more to the people. The next phase of success will be recognized when the senate will make various decisions regarding what happens to the bill. That will indicate the likelihood of the bill being passed into a law within the state. 

The second reading of the bill at the senate level will be another evidence that progress towards maintaining an optimum nurse to patient ratio is being made. The bill will then be scheduled to be presented to the entire senate by the senator for the second time. The floor consideration phase of the bill will indicate more success for it with the third reading to the senate and a voting process involving all the members of the chamber. More success on the policy brief will be realized when the bill is passed on to the next chamber. The two chambers will compare the decisions that they make regarding the policy issue affecting the nurses and the patients within the city of Virginia. Another phase of success in dealing with the issue of imbalanced nurse to patient ratio in Virginia is the agreement of both chambers on the best course of action to take regarding the solution of the issue. The senate will then forward the policy brief as a bill to the governor, which will indicate additional success towards solving the issue of the nurse to patient ratio. Two thirds of the senate voting for the bill and thus prompting the governor of the state of Virginia to sign the bill into a law will be the last step of success for the policy brief. Therefore, the successful passage of all the above-mentioned steps of the law making process will provide for the top-down evaluation of the success of the policy brief. 

A Plan to Address the Public Policy Issue 

The following is the plan created for working out the issue of nurse to patient ratio with the organizations and community across the state of Virginia. 

Community Identification 

The community identified to have expressed interest in dealing with the issue of nurse to patient ratio is located within the city of Richmond, one of the largest urban areas in the state. The community works closely with the Richmond City Health District to combat other health issues such as abuse of opioid substances. 

Why the Community Has Expressed Interest in the Public Policy Issue 

The organizations and community across Virginia express varying levels of interest in the public health policy issues due to the pressing need of the institutions to reduce health issues in society. An organization that is concerned with the health issues within the city of Richmond is the Richmond City Health District, which closely works with the healthcare institutions to reduce human suffering and the spread of diseases (Virginia Department of Health, 2019). The Richmond City Health District also targets the education of residents living within the city. The community around the city of Richmond has expressed interest in the issue of nurses to patient ratio due to the increasing need for the quality of patient care to benefit the community. One of the reasons why the community has expressed interest in the public policy issue is that proper nurse to patient ratio increases the quality of patient care from the patients' perspectives. The increase in the quality of patient care enables the patients to pinpoint the value of intensive nursing care, which aims at reducing the health issues that are realized in the community. The other reason for the community's interest in the issue of the nurse to patient ratio is the need to safeguard the safety of the patients (Virginia Department of Health, 2019). Mostly, the decrease in the number of patients that one nurse has to take care of at any given time increases the likelihood of the patients being safe at the hands of the nursing practitioners. 

Community-Based Participatory Research Principles 

The first fundamental principle of the CBPR is the acknowledgment of the community as a unit of identity. The other fundamental CBPR principle is the building on the resources and the strengths of the community. The third fundamental CBPR principle is the facilitation of a collaborative and equitable partnership in the various phases of research. 

Approaching Collaboration with the Community and Organization 

The approach of dealing with the community regarding the health issue begins with the application of Community Based Participatory Research (CBPR). The community based participatory research is an approach that can ease the interactions between the researchers and the community in addressing a particular public policy issue such as the nurse to patient ratio. The approach to collaborate with the community begins with the education to the Richmond community regarding the importance of the nurse to patient ratio with the specific advantages of maintaining the ratio being discussed at length with the audience. The next step is the realization of the random selection of the individuals who take part in the research to investigate the effects of the proper nurse to patient ratio on the patients and the community in general. The results of the research will be shared with the general population in an attempt to further educate the people on the importance of the ratio to both the organization and the patients. 

Goal Alignment in the Selected Public Policy Issue 

One of the goals of the Richmond City Health District and the community in the analysis of the public policy issue of the nurse to patient ratio is to enhance patient safety in nursing care ( Virginia Department of Health., 2019) . The community has, for a long time, advocated for an increment in the safety measures that characterize the nursing care. The goal of the community aligns with the goal of the increasing nurse to patient ratio in that an increase in the nurses provides a wider variety of the skillsets that the nursing practitioners require to provide adequate patient care ( Virginia Department of Health., 2019) . The other goal of the community in the analysis of the public policy issue is the increase in access to nursing care. The goal aligns with the objective of the research on the nurse to patient ratio to increase the sufficiency of quality care in the nursing sector. 

Actions to be Taken to Achieve the Goal 

The first action to be taken towards the achievement of the goal of the nursing practitioners and the community is to arrange several town hall meetings across the various sides of the city of Richmond. The meetings are meant to sensitize the public regarding the presence of the issue of the nurses to patient’s ratio, how it is affecting them directly and indirectly, and the steps that are to be taken to deal with the issue. The second action taken towards the achievement of the goal is to hold talks with officials from Richmond City Health District. The meetings are meant to persuade the organization to support the initiative of maintaining an optimal nurse to patient ratio. The last step towards the achievement of the goal is to present the policy brief to the senator. the senator will go through the brief and take the appropriate steps to help the residents face the problem of the nurse to patient ratio. 

Roles of the Community and Organizational Members 

The first role that the members will play is the facilitation of the meetings at the town hall targeting the residents of Richmond. The facilitators will include one representative each from the Richmond City Health District, the Richmond community, and two nursing practitioners. The facilitators will also plan for the venues of the meetings to be held and make the prior announcements to the target audience. the facilitators will also oversee the talks with the Richmond City Health District to ensure that the process is a success. they will therefore solve the issue of lack of communication and disorganization of the members of community. The other role of the community members is to present the policy brief to the senator. a team of three community members and two nursing leaders will do so to ensure that the brief is delivered to the senator for the purposes of taking action. The team will therefore do away with the issue of communicating with the relevant authorities regarding the issue of the nurse to patient ratio. 

Key Elements of Developing a Collaborative Evaluation Plan 

The first CBPR principle we selected to use is acknowledging the community as a unit of identity. Our group will use this principle to illustrate the issue of the nurses to patient’s ratio by creating an awareness to the community that the problem affects the community as a whole and not just the patients at the hospital. This principle applies to the evaluation plan because the community as a unit of identity is faced with nursing issues that every member should look towards solving. The second CBPR principle we selected to use is the building on the resources and the strengths of the community. Our group will use this principle by engaging the community members in the meetings to identify the various gaps that they have regarding the community nursing and how to fix them. this principle applies to the evaluation plan because it is necessary to identify the strongholds of a community before embarking on the plan to improve the nurse to patient’s ratio. The third CBPR principle we selected to use is the facilitation of a collaborative and equitable partnership between the professionals and the community members. Our group will use this principle by sharing the systematic procedure that they will use with the community members and the Richmond City Health District. This principle applies to the evaluation plan since the equitability of a collaboration will increase the desire of the community members to be involved in finding lasting solutions to the issue of nurses to patient’s ratio. 

Evaluation of the Success of the Community or Organization (Bottom-Up Approach) 

One of the evaluative plans that we will use is the counting of the people who come to the town hall meetings on the selected days. If the percentage of those who attend is higher than that of those who did not attend, the community and Richmond City Health District will have succeeded. The evaluative plan for the holding of talks will be evaluated using a survey conducted with the officials of the Richmond City Health District regarding their willingness to work with the community regarding the issue of nurses to patient ratio. The evaluative plan for the action regarding presenting the policy brief to the senator will be evaluated after the issue has been rectified. The number of nurses in the hospitals will be recorded before and after the presentation of the policy brief. 

Strengths and Challenges of the Top-Down and Bottom-Up Approaches in Achieving Policy Changes 

The following is the analysis of the best method of approach to address the issue of inappropriate nurse to patient ratio at the various healthcare organizations in the state of Virginia. The approaches compared are the bottom-up and the top-down where their advantages and disadvantages are evaluated. 

Strengths of the Top-Down and Bottom-Up Approaches 

One of the strengths of the top-down approach in achieving the policy changes regarding the nurse to patient ratio is the simplicity of the model. The decision-making process in the top-down approach is more straightforward than in the other approaches since it involves decision making from an individual or a selected group of individuals. In other words, decision-making becomes more convenient when the number of people being involved is reduced. The other strength of the top-down approach in implementing optimum nurse to patient care is the speed in decision-making. Deciding while involving more people becomes more complicated. Thus, the top-down approach involves quick decisions. 

One of the strengths of the bottom-up approach is that decision-making is based on a vast pool of knowledge. Participation is encouraged in the bottom-up approach, which leads to the consideration of many different ideas, which are consolidated, into one. For instance, the community members will be free to join in the discussion of maintaining the optimum nurse to patient ratio, which increases the effectiveness and efficiency of the intervention. The other strength of the bottom-up approach is that it incorporates more transparent communication compared to the top-down approach. The clarity in communication is contributed to by the involvement of many people in the decision-making process. 

Weaknesses of the Top-Down and Bottom-Up Approaches 

One of the weaknesses of the top-down approach is that the low participation in the strategy is likely to lead to the implementation of negative ways in the case of a manager or nurse leader making an ill-advised decision. The decision would adversely affect the various members of the Richmond community in that the senator may decide to alter the policy change and thus provide the community with substandard policy changes. The other pitfall of the top-down strategy is that the decisions made require much knowledge at the top management level. That may lead to the exertion of pressure at the management level, which may further contribute to the making of the wrong decisions regarding the optimization of the nurse to patient ratio at the community level. That may lead to the difficulty of the senator in coming up with and implementing the various policies that may improve the situation of the nurses to patient ratio. 

One of the weaknesses of the bottom-up approach in the optimization of the nurse to patient ratio is the lack of cohesion. While the inclusion of many people becomes ideal for the decision making for the matters that affect the community, and improper management of the people involved in the process may lead to the confusion. The decisions made in such an environment may fail to be effective. The other weakness of the bottom-up approach is the likelihood of employees operating without checking in with one another. In implementing the strategy, nurses may assume that the communication made at the beginning of the task is adequate and avoid sharing ideas. That may lead to the making of improper decisions. 

Choice of the Best Approach 

The most effective approach to deal with the issue of the nurse to patient ratio in the healthcare institutions within the Richmond community and the whole of the state of Virginia is the bottom-up approach. The strategy magnifies the role of the community in identifying the pillars supporting optimum nurse to a patient ratio, such as patient safety, access to adequate and quality nursing care, and the satisfaction of the patients. On the side of the employees, the bottom-up approach is the best as it deals with the specific nursing practitioners while creating a staffing plan, which increases the level of inclusivity for the workers to their jobs. 

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Virginia Department of Health. (2019). Richmond City Health Department . Retrieved from http://www.vdh.virginia.gov/richmond-city/