Running head: ANALYSIS OF H.R.

4266 1

Analysis of H.R. 4266: Nurse and Health Care Worker Protection Act of 2015

Marc David Brown

GNRS 504: Bioethics and Health Care Policy

Diana Amaya Rodriguez, PhD, MS, CNS, RN

Azusa Pacific University

November 16, 2016

ANALYSIS OF H.R. 4266 2

Analysis of H.R. 4266: Nurse and Health Care Worker Protection Act of 2015

The following paper will introduce the house bill number 4266, titled Nurse and Health

Care Worker Protection Act of 2015. The bill attempts to lessen nursing injuries by investing in

safe patient handling and mobilization technologies and education programs. This paper will

provide a background, summary and analysis using Malones (2005) framework on the bill. The

paper will next discuss ethical considerations, mainly focusing on utilitarianism and

nonmaleficence to highlight both the pros and cons of the policy presented by the house. A

section is included on nurse support for the bill by the American Nurses Association, and finally

a personal reflection.

Background

The Nurse and Health Care Worker Protection Act of 2015, or H.R. 4266, was

reintroduced to Congress in December of 2015 by Representative John Conyers and Senator Al

Franken (Mitchell & Dawson, 2016). It is legislation that attempts to protect patients, nurses,

nurse assistants, and other healthcare workers from injuries as a result of unsafe patient handling

and mobilization. Congress found that in 2014, registered nurses were the sixth largest

profession who were reporting musculoskeletal disorders and injuries as a result of their

employment, with 11,360 cases; the second highest profession in 2014 of reported

musculoskeletal injuries was nursing assistants with 20,020 cases (H.R. 4266, 2015).

In an investigation by congress, it was found that 52% of nurses complain of chronic

back pain, while up to 38% find their work-related injuries severe enough to leave the occupation

(H.R. 4266, 2015). The American Nurses Association (2013) states that these types of

musculoskeletal injuries are avoidable; there are proven records that safe patient handling and

mobilization can reduce injuries up to 95%. Workers compensation, bills related to medical
ANALYSIS OF H.R. 4266 3

treatment, and new-hiring of staff related to work-related injuries in healthcare costs the United

States about seven billion dollars annually (Mitchell & Dawson, 2016). The house bill 4266

(2015) states that evidence shows the use of new mobilization devices is able to reduce lost work

days and worker compensation costs.

A major proponent of safe patient mobilization is the American Nurses Association

(ANA). The ANA created a framework in 2013 which was a precipitant for H.R. 4266. Their

framework titled, Safe Patient Handling and Mobility: Interprofessional National Standards,

includes guidelines for creating and maintaining a safe patient mobilization and handling

program. Among the many arguments made by the ANA, they state safe patient handling and

mobilization not only reduces nurse injuries, but may aid the patient in getting up and moving

more quickly after an illness, injury or surgery (American Nurses Association, 2013). The ANA

president, Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, has supported H.R. 4266, stating:

Manual lifting is an unacceptable risk and practice when we have the technology

and knowledge to significantly reduce injuries. This bill signals that workers are

not expendable and injuries are not tolerable as just part of the job. It is a much-

needed step in the right direction to implementing safer programs that will help

save and extend the careers of thousands of registered nurses. (Mitchell &

Dawson, 2016, p. 15)

H.R. 4266

H.R. 4266: Nurse and Healthcare Protection Act of 2015 attempts to set forth a plan of

safe patient handling and mobilization education, employee rights including refusal of

assignments, technological investments for safe mobilization equipment by employers, and

evaluations of work environments by the employer as well as inspections by the Secretary of

ANALYSIS OF H.R. 4266 4

Labor (H.R. 4266, 2015). The policy states that the Secretary of Labor must create an interim

final standard on safe patient mobilization within one year of the passage of this act. H.R. 4266

has nine requirements which will be briefly outlined below.

Firstly, there must be a development of a program by the health care employer within six

months of the act passing which includes identification of hazards, assessments of risk, and how

to control risks within the work environment (H.R. 4266, 2015). The bill also requires that

employers must purchase and manage technology and equipment for safe patient handling within

two years of the interim created by the Secretary of Labor; employers must also incorporate new

technology into the planning of new facilities or their renovations (H.R. 4266, 2015).

The next aspect of the bill includes a requirement that employers utilize input from

employees on the best way of implementing safe patient handling, mobility and injury prevention

(H.R. 4266, 2015). Data tracking and review is required by employers to account for

discrepancies in the use of new handling and mobilization equipment as well as new worker

injuries and allow this data to be provided to employees and the Secretary of Labor. The bill

provides many rights to the employee, including the right to refuse an unsafe work assignment,

the right to not be prosecuted for whistleblowing, and the right for proper training and

education (H.R. 4266, 2015). The house bill 4266 (2015) demands that a notice be placed in the

workplace that states employee rights, mobilization information, and explains how to report any

injuries or incidences that occur in the workplace.

Finally, there will be an annual evaluation by the employer on safe patient mobilization

and handling. These will be documented in a written statement and include any new procedures

of the health care facility and what new technologies, equipment, and engineering was

implemented by the facility. This annual evaluation must involve the participation of nurses and
ANALYSIS OF H.R. 4266 5

other healthcare workers (H.R. 4266, 2015). The bill also states that the Secretary of Labor may

conduct unscheduled inspections to make sure that health care facilities and organizations are

compliant with the safe patient mobilization and handling set forth by this bill (H.R. 4266, 2015).

Policy Analysis

The following policy analysis will utilize the framework set forth by Malone (2005) to

aid individuals, mainly nurses, in analyzing health care policies. The problem H.R. 4266: Nurse

and Healthcare Protection Act of 2015 attempts to solve is the issue of registered nurses, nurse

assistants, and other healthcare professionals being injured on the job causing pain and suffering

for the individual, as well as unnecessary costs to the individual, employer, and government.

Malone (2015) suggests to assess where the policy currently is and the ways in which individuals

can help it move along in the legislative process; currently, H.R. 4266 has been presented to the

house but has not yet passed. The investigation and public attention have already occurred with

major nursing organizations backing it, most notably, the American Nurses Association. The next

step for the bill is to pass the house; this will require support from the public to push their house

representative to vote on the bill in the way they desire; this may include writing a letter

outlining their opinion of the bill.

Using Malones (2015) policy analysis framework, it appears H.R. 4266 would be a very

appropriate bill to support for the following reasons. The bill would affect a large population of

people, including registered nurses and other healthcare workers, as well as their patients. There

has been sufficient investigative work showing that there are a high number of avoidable injuries

taking place in the healthcare environment (Mitchell & Dawson, 2016). Finally, there is real and

tangible evidence that safe patient mobilization policy would reduce healthcare worker injuries

by a significant margin (Mitchell & Dawson, 2016).

ANALYSIS OF H.R. 4266 6

Ethical Discussion

When discussing a policy and its implications on the populations it affects, we must

consider ethical theory to guide the conversation or argument in order to conclude whether a

policy or action is morally sound. There are many ethical principles and theories that can aid in

creating a framework for these types of discussions. Ethical theory and healthcare have been

connected since the times of Hippocrates; but due to the incredible medical achievements of the

twentieth century, we require a much deeper and profound ethical discussion (Beauchamp &

Childress, 2009). The following section will discuss utilitarianism and use it as a framework to

assess H.R. 4266. The section will also discuss the principle highlighted in the Hippocratic oath

taken by healthcare professionals, namely nonmaleficence or doing no harm.

Utilitarianism

Utilitarianism was originated in the 19th century by two individuals, Jeremy Bentham and

John Stuart Mill (Beauchamp & Childress, 2009). It is based around the idea of utility, or

creating maximum value among the consequences of an action (Beauchamp & Childress, 2009).

To decide whether an act is morally right or wrong, you must add up the negative and positive

consequences of it. It is difficult to make statements about what consequence we are mostly

focused on maximizing for various reasons, many would argue that happiness should be the good

we are most concerned with. An issue pointed out by Upton (2011) is that humans gain happiness

from a wide variety of sources, some of the sources can even be considered morally deplorable.

If we are maximizing morally-deplorable happiness of a population than how is utilitarianism an

ethically-sound position. This brings out the other important aspect of a beneficial utilitarian

point of view, we must also uphold previous standards of moral good (Upton, 2011).
ANALYSIS OF H.R. 4266 7

Utilitarianism requires extensive calculations about the consequences of a given act or

policy. Therefore, it only works in situations where we are able to calculate consequences by

having sufficient time, economics, and information (Upton, 2011). In the case of the policy H.R.

4266, I believe we have many of those available, which allows utilitarianism to be put to good

use when assessing this policy. We have sufficient information on the cost verses benefits of

implementing safe patient mobilization equipment and training and can calculate the benefit that

individuals and the hospital will receive including less suffering of the employee due to

avoidable injuries, saved money by the employee and the hospital, and better patient outcomes

(Mitchell & Dawson, 2016). It is likely that if we viewed the implementation of this policy from

a utilitarian prospective, we would find that its implementation would maximize good outcomes

in many areas.

An aspect of utilitarianism that should also be looked at is that utilitarianism has winners

and losers. In order to maximize positive benefits for the majority of individuals, there are

minorities who may be hurt (Wheat, 2009). Wheat (2009, p. 1062) argues that utilitarianism is a

theory which is capable of mistreating people and using them as a means to an end. In

evaluating the policy, there may be certain groups that are disadvantaged due to the

implementation of safe patient mobilization equipment and education. For example, the hospital

must lose money investing in these technologies and the requirements may cause other important

programs to be cut from the budget (H.R. 4266, 2015).

It also takes away the autonomy of the healthcare worker, in that now they are forced to

use safe moving equipment which they may find too time-consuming or have a better way that

the hospital no longer endorses (H.R. 4266). Finally, it gives the hospital an upper hand in that

the policy requires postage of safe patient mobilization policies and if they are not followed, the
ANALYSIS OF H.R. 4266 8

healthcare worker will likely be blamed (H.R. 4266). Patients may be hurt as well to some

expense, in that the mobilization equipment is usually very slow moving, large and difficult to

maneuver; this may make it impractical in areas like the Emergency Department where patients

need to be quickly removed from cars or gurneys in an emergency situation.

In order for utilitarianism to be put into effect, all of the consequences previously

mentioned must be calculated to find the overall utility of the action of safe patient mobilization

programs (Upton, 2011). This would require a great deal of research, time and money, but it is

doable. If the overall effect of implementing the H.R. 4266 policy into law resulted in more

positive outcomes from the hospital, the healthcare workers, and the patient, then from a

utilitarian prospective, the policy is ethically sound.

Nonmaleficence

The main tenet of nonmaleficence is to not inflict harm on other individuals (Beauchamp

& Childress, 2013). Harm is defined as doing an action that results in pain and suffering

(Morrison, 2011). For example, moving a patient without using proper mobilization equipment

may injure the patient. On the other hand, the hospital or nurse leader may do harm to the nurse

by not requiring mobilization equipment or facilitating educational programs that teach safe

patient mobilization and handling. Beauchamp and Childress (2013) break harm into different

categories with different ethical ramifications, for example, was the harm done purposefully or

not? Is all harm bad? Is harm not required sometimes in order to get a better outcome, such as

giving a patient a needle stick to provide them with immunity (Morrison, 2011)?

Therefore, there may need to be better protections for a nurse who acts outside the scope

implemented in H.R. 4266, as there may be times that are emergent in which safe patient

mobilization technologies would only hinder care. Beauchamp and Childress (2013) state that an
ANALYSIS OF H.R. 4266 9

individual or healthcare professional, may harm a patient without having the intent in doing so or

even with the intent of providing faster care to the patient. Therefore, it is important for laws

such as H.R. 4266 to provide protections for the healthcare individual in extreme situations and

these may not be present in the current iteration. There are emergencies that justify risks that

non-emergencies do not (Beauchamp & Childress, 2013).

With that concept now discussed, nonmaleficence still greatly supports the H.R. 4266

bill. If nurses always were able to do the correct action, we would not need policies and

procedures in place; safe patient handling and mobilization programs are important policy and

procedure aspects that lead to a safe working environment and lessen nonmaleficence caused to

the nurse and from the nurse to the patient (Ulrich & Sigma, 2012). Nurses have a large

responsibility to abide by ethical norms as their profession has been shown to be one of the most

highly regarded by the Gallup Poll (Ulrich & Sigma, 2012). People tend to hold the idea that

nurses have the patients best interests in hand and will advocate for them; the public looks at

nurses to always have valor when faced with moral or ethical challenges (Ulrich & Sigma,

2012).

Due to the public requirements of nurses, it is important that nurses make the right

decisions when confronted with moral dilemmas of nonmaleficence such as using safe patient

handling and mobilization or not. Ulrich & Sigma (2012) speak upon the pressures which occur

inside a nurses mind when choosing to abide by an ethical situation or not. Sometimes, nurses

need motivation to act morally and in a nonmaleficent manner for themselves and their patients,

and H.R. 4266 is capable of applying that motivation to the work environment on a daily basis

(Ulrich & Signma, 2012). The bill improves nonmaleficent behavior by supplying the tools

needed by a nurse to perform the correct action, by training them in how to do the correct action,
ANALYSIS OF H.R. 4266 10

by protecting their rights in whistleblowing when an action is not performed correctly, and by

giving them the right of proper training and equipment (H.R. 4266, 2015).

Nurses and H.R. 4266

The following argument for H.R. 4266 is provided by the American Nurses Association

(ANA). They are a group of 3.4 million registered nurses in the United States (American Nurses

Association, 2015). Their goals are to advance the nursing profession by pushing for high

standards in practice, as well as supporting a safe work environment (American Nurses

Association, 2015). For these obvious components of their agenda as a group, they have many

reasons to support H.R. 4266.

The ANA released a statement on December 16, 2015 supporting H.R. 4266 (American

Nurses Association, 2015). The president of the association, Pamela F. Cipriano, PhD, Rn, NEA-

BC, FAAN, gave praise to Representative John Conyers and Senator Al Franken for supporting

the bill. The major support of the bill is that it may be able to extend the occupational life of

nurses if implemented, as technology and safety classes would be mandated by the government

to be put into all healthcare facilities. The ANA (2015) states that it is moving safer nursing in

the right direction and will hopefully create longer careers for nurses. The ANA (2015) states that

occupational safety studies have shown RNs as having a very high likelihood of facing work

related injuries.

H.R. 4266 has the potential to lessen the amount of work related injuries that nurses face

on a daily basis. 42% of health care employees, according to the ANA (2015), are at risk of

developing significant neck and back pain. The bill used various aspects of the Safe Patient

Handling and Mobility: Interprofessional National Standards, which was created by the ANA to

address what their safety concerns are in patient handling and mobility and how the profession
ANALYSIS OF H.R. 4266 11

can move forward to safer practices. The ANA would like to take the bill further or implement

future bills which aid in increasing better facility designs, put into place a practice of selecting

technology, and integrating mobilization care plans into these safe mobilization programs.

Nursing Code of Ethics

The ANA supports a book of provisions that highlight the code of ethics that they find to

be most beneficial. The first provision that will be highlighted is provision five: The nurse owes

the same duties to self as to others, including the responsibility to preserve integrity and safety, to

maintain competence, and to continue personal and professional growth (American Nursing

Association, 2015, p. 55). This provision statement was meant to remind nurses the importance

of taking care of themselves first in order to safely take care others. It builds on earlier nursing

suggestions such as a 1926 statements which said, the most precious possession of this

profession is the ideal of service, extending even to the sacrifice of life itself (American Nursing

Association, 2015, p. 56). Nurses do not need to sacrifice their health such as their backs by

taking care of their patients; especially in a modern world where we have technology to aid us in

moving patients in a way that is safest for themselves and for their patients.

The ANA (2015) states that it is difficult to enforce one in taking responsibility for their

own self-care. Safe patient handling, mobilization education and technology are an easy way of

ensuring that nurses are taking the proper steps in preventing harm and injury to themselves or

their patients. If a nurse were to injure themselves on the job moving a patient without

implementing safe patient mobilization, they are unable to provide their services to other patients

and the years of knowledge that nurse has is now wasted as she is no longer physically capable

of doing his job. The ANA (2015) focuses tremendously on the importance of these types of self-
ANALYSIS OF H.R. 4266 12

care and safety measures so that an individuals job does not result in illness or injury for

yourself.

The second applicable provision of the Nursing Code of Ethics is provision six: The

nurse participates in establishing, maintaining, and improving healthcare environments and

conditions of employment conducive to the provision of quality health care and consistent with

the values of the profession through individual and collective action (American Nurses

Association, 2015, p. 72). This provision requires that the nurse participate in making healthcare

environments safe and ethically sound. It was changed in 2001, to include more emphasis on the

nurses role in improving environments based the latest scientific research and best practice for

staff and patient safety (American Nurses Association, 2015). It is divided into three different

parts, each part supports the implementation of safe patient mobilization and handling systems.

The first part of provision six states the importance of the nurse manager in implementing

safe environments and incorporating an open dialogue between the staff and the administration in

keeping environments and patients safe. The provision states that it has been shown to have

poorer patient outcomes with ineffective leadership that results in staffing problems, and other

issues (American Nursing Association, 2015). Therefore, H.R. 4266 aids many of these criteria

to help an effective nurse leader, as it aids in describing safe behaviors to the staff, and creates an

environment more capable of safely moving and handling patients; it was seen that an effective

nurse leader will gain many benefits from the policy (H.R. 4266, 2015). The second part of

provision six speaks upon the use of bargaining units and shared governance models that may be

used by a nurse to facilitate changes that lead to safer patient outcomes (American Nursing

Association, 2015). Therefore, nursing has a long history of promoting safe patient outcomes

through democratic action and this bill, H.R. 4266, is an example of that.
ANALYSIS OF H.R. 4266 13

Personal Reflection

My experience comes from my work in the emergency department and on pre-hospital

care working for the 911 system, which was why I incorporated some aspects of patient

mobilization in emergent situations. It is important to point out that the majority of patient moves

that occur are non-emergent in even these areas of our healthcare system and safe patient

mobilization and handling rules and technology as outlined in H.R. 4266 should still be

implemented to the highest degree possible. At the same time, I would be afraid the rights may

be taken away from employees who choose to assist a dying patient out of a car in front of the

emergency department to get them help before a lift or other mobilization machinery is available;

for example, it may diminish their chance of getting workers compensation when acting in a

way that may have been overly-adrenaline run but still a morally sound act.

I believe it is very important that facilities are required to buy safe patient mobilization

equipment and have them available to patients. The emergency department I work in does invest

in safe patient mobilization technologies, but the technologies tend to be under-utilized and not

taken care of as well as they should be. I am proud of my department for developing a safe

patient mobilization team which is trying to implement better standards of practice. They have

been very active in discovering and investing in new equipment, and this form of shared-

governance, as cited by the American Nurses Association (2015) is definitely active in our

department as we utilize ideas from all levels of our healthcare team.

I believe that God wants us to act in a way that is nonmaleficent and as previously

mentioned, utilitarianism may be a useful source of wading through difficult moral situations.

But it is important to remember that utilitarianism is still dependent on a previous morality that is

widely accepted such as Christianity to understand what outcomes we are most trying to
ANALYSIS OF H.R. 4266 14

maximize. The bible states in Philippians 4:8, Finally, brethren, whatever is true, whatever is

honorable, whatever is right, whatever is pure, whatever is lovely, whatever is of good repute, if

there is any excellence and if anything worthy of praise, dwell on these things. I believe that

these are the things we are trying to maximize and, in my own interpretation, this includes

excellence in patient care. For these reasons, I find the house bill 4266 written in good faith to

provide excellent patient care and decrease injuries among caregivers.

Conclusion

This paper was intended to introduce the house bill number 4266 titled, Nurse and Health

Care Worker Protection Act of 2015, with an analysis using the framework presented by Malone

(2005). The paper discussed ethical considerations, mainly focusing on utilitarianism and

nonmaleficence to highlight both the pros and cons of the policy presented by the house. The

nurse support for the bill was identified by the American Nurses Association as well as two

provisions from The Nursing Code of Ethics which helped assess the nursing ethics related to

implementing H.R. 4266. Finally, a personal reflection of my beliefs was included to reflect on

the safe patient mobilization policy.

ANALYSIS OF H.R. 4266 15

References

American Nurses Association. (2013). Safe Patient Handling and Mobility: Interprofessional

National Standards. Silver Spring, MD: Nursesbooks.org

American Nurses Association. (2015). Code of ethics for nurses: With interpretive statements.
ANA: Silver Springs, Maryland.

American Nurses Association. (2015, December 16). Congressional Bill Could Extend

Thousands of Nursing Careers by Preventing Injuries (12/16/15). Retrieved November

15, 2016, from

http://www.nursingworld.org/NurseHealthCareWorkerProtectionActPressRelease

Beauchamp, T.L. & Childress, J. F. (2013). Principles of biomedical ethics (7th ed.) Oxford

Press: NY.

Holy Bible: New International Version. (2011). Grand Rapids, Mich.: Zondervan.

Malone, R. E. (2005). Assessing the Policy Environment. Policy, Politics, & Nursing Practice,

6(2), 135-143, doi: 10.1177/1527154405276141

Mitchell, M., & Dawson, J. M. (2016). Take action: The Nurse and Health Care Worker

Protection Act of 2015. The American Nurse, 48(1), 15.

Morrison, E. E. (2011). Ethics in Health Administration: A Practical Approach for Decision

Makers. Sudbury, Mass: Jones & Bartlett Learning.

Nurse and Health Care Worker Protection Act of 2015, H.R. 4266, 114th Cong. (2015)

Ulrich, C. M., & Sigma Theta Tau, I. (2012). Nursing Ethics in Everyday Practice. Indianapolis,

Ind: Sigma Theta Tau International.

Upton, H. (2011). Moral Theory and Theorizing in Health Care Ethics. Ethical Theory & Moral

Practice, 14(4), 431-443. doi:10.1007/s10677-011-9295-6

Wheat, K. (2009). Applying ethical principles in healthcare practice. British Journal Of Nursing,
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18(17), 1062.
ANALYSIS OF H.R. 4266 17

Marc Brown
4033 Albatross St
San Diego, CA 92103

November 16, 2016

Representative Susan Davis

2700 Adams Ave Ste 102,
San Diego, CA 92116

Dear Representative Davis,

There is a bill that was recently presented in the house titled H.R. 4266: Nurse and Health Care
Worker Protection Act of 2015. I support this bill and I urge you to support it as well. After
working in healthcare for the past few years including as an EMT and a Tech in the emergency
department, I see nurses and other healthcare workers losing their careers due to preventable
work-related injuries. I, myself, have thrown out my back, and been put on light duty for a period
of time by incorrect patient movement practices and unavailable mobilization technology.

As stated in H.R. 4266, the technology does exist to safely move patients without injuring the
nurse or healthcare worker. The problem is, healthcare facilities do not have enough drive to
invest in these technologies. The bill is capable of creating policy that results in healthcare
facilities doing the right thing in investing in the best mobilization equipment available. The bill
is also vital in requiring a facility to create educational programs that teach safe patient
mobilization and handling. These programs would be required and annual evaluations would take
place to assess their efficacy.

The last aspect of the bill that I find very important is it requires facilities to post employee rights
in preventing injuries. They will have an anonymous number to report unsafe incidences and will
have whistleblower protections. The policy would require facilities to tell and post to their
employees that they have the right to safe mobilization and handling technology and the right to
preventative education.

For the reasons above, I believe this bill could have a huge impact in preventing injuries of
registered nurses in what is the 6th leading occupation of musculoskeletal disorders.

I appreciate your time and your representation of my views in the house.

Sincerely,

Marc Brown