Tied to that, of course, is the uninsured. Recent U.S. Census Bureau figures show the total number of uninsured Americans rose 3.2 percent in 2003 to a staggering 45 million.

Additionally, I see medical liability as an issue not only for physicians, but also for many healthcare institutions, some long-term care facilities, and small hospitals. All are experiencing rising premiums. A state and federal concern, it is a wedge issue in terms of politics, with lawyers on one side, consumer groups somewhere else, and physicians and healthcare providers on the other.

Another wedge issue is stem cell research. There is pressure by both parties to include it in the discussion. It is tied to the election and also tied to how candidates are trying to distinguish themselves in the national scene.

The use of information technology (IT) continues to pick up speed, as well. While it is more of a high visibility issue than a hot button for the election, the need to modernize the healthcare industry is clear. With its continuing reliance on paper records, the possibility for mistakes is magnified. Records are not easily accessible when patients are moved from facility to facility, causing providers to duplicate efforts, slowing down productivity, and introducing further potential for error.

There is increasing recognition on the part of policymakers that lack of IT is adversely impacting quality and efficiency in the healthcare system. Senate Majority Leader Bill Frist (R-TN) and others have introduced legislation at the federal level, and the Department of Health and Human Services has created an internal position within the last six months to promote the use of IT in healthcare delivery. However, neither party owns support of the industry effectively using more IT.

HTSS: What effect does mandatory overtime and the new overtime pay rules that went into effect August 23 have on nursing?

MKW: The new pay rules, while not a problem for all nurses, definitely affects those RNs at certain salary levels who work particular hours in specific settings. With regard to mandatory overtime, we know it affects individual nurses and their families—in terms of the expectation that they have to be there and what hardship that places on them. The other side of the equation is what happens to the quality of patient care.

We have good, solid data showing us that patient safety is compromised. As important as the story is around the individual nurse, it is clearly a problem when mandatory overtime adversely impacts patient care. We need more research to better document what these outer limits are and identify other solutions to ensure that we do not push up against those limitations.

And that, then, should draw people's attention back to infusing an adequate number of nurses into the workplace—through scholarships, loans, and appealing to underrepresented groups like men and minorities. At the end of the day, patient safety cannot be compromised, there must be an adequate number of nurses—whose time should be used as efficiently as possible—and use of technology and other ancillary personnel needs to be maximized.

Many strategies will need to be put into place to maintain an adequate workforce so the demand for mandatory overtime is reduced. How nursing makes that case will affect the profession and burn out. What will resonate even more with the public and policymakers will be effect on quality care.

HTSS: What is your perspective on the need for mandatory staffing ratios?

MKW: We have well-established literature and research demonstrating that in certain areas of healthcare, if we do not have an adequate number of nurses—dropping below a set nurse/patient ratio—or do not utilize their skills effectively in that work environment, there is an adverse impact on patient care. But ensuring that we have an appropriate number of staff to deliver care is a very complex issue.

Questions nurse executives should ask themselves are How are my nurses spending their time? How are we utilizing other staff and technology to complete some of the tasks that may be assigned to non-RNs? What is the patient acuity level?