Pushing the Limits

A landslide vote in the House supporting nurse-staffing limits in Massachusetts hospitals, has supporters cheering and opponents reeling … many didn’t see this development coming. But regardless of which side of the debate they fall on, health care professionals across the Commonwealth are remobilizing their awareness efforts as the issue moves forward in the Legislature.

It came as a surprise to many health care professionals.

On May 24, the Mass. House of Representatives voted 133 to 20 to set mandatory nurse staffing levels at hospitals.

The vote was a coup for the Mass. Nurses Assoc. (MNA), the largest union of registered nurses in Massachusetts, which originally drafted the bill. However, several major organizations in the Commonwealth have publicly opposed nurse-staffing limits, and openly supported another piece of legislation called the Patient Safety Act, submitted by state Sen. Richard Moore (D-Uxbridge) for close to three years now.

Efforts to increase awareness and knowledge of both bills, however, must begin anew with proof of overwhelming support in the House. No date has been set for a Senate vote on either bill, and it is still unclear whether any votes will take place before the current legislative session closes in July; however both opponents and proponents of staffing limits agree that the House vote is a major factor in the outcome of this potentially landmark legislation.

“A lot of bills will die once the session ends,” said Stephen Bradley, vice president for Government and Community Relations for Baystate Health. “There are about seven weeks left, though, and that’s a long time in the legislative world. I’m sure there will be attention paid to this issue given the considerable pressure from both sides.”

If passed into law, the nurse staffing ratios bill (its proper name is An Act Ensuring Patient Safety) would make Massachusetts only the second state in the nation to set government-mandated limits on how many patients a nurse can care for during a shift. California set similar limits in 1999; 14 other states have similar legislation pending. The ratios, which have yet to be determined, would be put into place by 2008 in teaching hospitals such as Baystate Medical Center and by 2010 at community hospitals.

Conversely, Moore’s bill would attempt to address staffing issues, in particular the widespread nursing shortage, through a state-run oversight process of hospital staffing patterns, guidelines to bolster nurse faculty at state colleges and universities, and the creation of the Mass. Center for Nursing, which would require a $30 million appropriation, among other measures.

Legislative Landslide

Sharon Adams-Babineau RN, vice president for Patient Care Services at Mercy Medical Center, said she’s seen the breadth of the opposition to staffing ratios firsthand at all levels of her own organization, and was taken aback by the endorsement of staffing limits by House leadership last month.

“Only one in five nurses in the Commonwealth support this bill,” she said. “It wouldn’t have been so much of a surprise if the vote hadn’t turned into such a landslide.”

Adams-Babineau added that with such strong support of the Patient Safety Act among Massachusetts hospitals, particularly in Western Mass., many felt the staffing-limits legislation would easily fail on the House floor. Indeed, supporters of the Patient Safety Act have been both visible and vocal throughout the life of the patient safety debate on Beacon Hill.

In a particularly visible move, the CEOs of every hospital in the Commonwealth signed a letter to legislators opposing the nurse staffing ratios bill, which was delivered the day before the May 24 vote in the House. Sixteen nurse, health care, and business organizations, including the Mass. Hospital Assoc. (MHA), the Mass. Organization of Nurse Executives, the Mass. Taxpayers Foundation, the Mass. High Technology Council, and the Mass. Assoc. of Registered Nurses, also signed a letter opposing the measure.

And locally, the Western Mass. Economic Development Council and the Affiliated Chambers of Commerce of Greater Springfield both oppose the legislation, in addition to nine of the area’s hospitals – Baystate Medical Center, Franklin Medical Center, Holyoke Medical Center, Mary Lane Hospital, Mercy Medical Center, Providence Behavioral Hospital, Noble Hospital, and Wing Memorial Hospital.

Those organizations joined forces last year to initiate marketing and awareness campaigns surrounding the issue of nurse ratios and to support the Patient Safety Act. Dubbed the Western Mass. Hospitals Coalition, the group has become one of the Commonwealth’s most active forces in opposition to nurse staffing limits, and includes hospitals with both unionized and non-unionized RN populations.

“Many, including nurses, have been vocal in their opposition to staffing ratios,” said Adams-Babineau, “but I suppose that put us in a sort of nirvana, thinking that this wouldn’t happen.

“Through the coalition,” she continued, “we feel that we’ve done a great deal to educate the public on what ‘staffing limits’ really means. But what this vote says to me is that there is not necessarily a true understanding out there of the potential impact of nurse-to-patient ratios.”

Agreeing to Disagree

The legislation passed in the House represented a modified version of the original legislation, which the MNA calls a ‘compromise bill.’ Among other aspects, the MNA states that the new bill directs the Department of Public Health to undergo a regulatory process utilizing research, data, patient outcome information, and expert testimony to develop safe standards and limits.The measure also includes nurse faculty and recruitment initiatives, prevents understaffing of other critical health care workers, including licensed practical nurses and unlicensed assistive personnel, and places these workers in the formula DPH will create to adjust nurse staffing based on patient needs.

“Everybody wins here; hospitals, nurses, and most important of all, the patients,” said Beth Picknick RN, president of the MNA, referring to the revised bill. “The 23,000 members of the MNA join with the 104-member Coalition to Protect Massachusetts Patients in applauding the efforts of all involved to reach this compromise and in doing so, address this important patient safety issue.”

Still, most nurse and hospital administrators and others who oppose nurse-staffing limits didn’t budge in their stance, despite changes to the bill’s verbiage. Further, the term ‘compromise’ was also called into question following the overwhelming House vote.

In a statement released by the Mass. Hospital Assoc. (MHA) following the House vote, the organization urged legislators to reject the “micromanagment” of health care in the Commonwealth.

“We would like nothing more than to reach a mutually acceptable agreement with the MNA over the issue of nurse staffing,” the letter stated. “But, ultimately, we could not compromise … we believe that the entire care-giving team must be included in the development of flexible staffing guidelines. The union, by contrast, believes government should set RN-only ratios.”

Bradley added that the MHA’s position is not a radical one; national standards for quality of health care delivery are measured by the number of hours spent with a patient by all clinical staff, not just registered nurses.

“The measure of clinical hours should refer to the total care-giving team,” he said. “We’re simply asking that the national norms be applied here, as well as an acceptable definition of ‘overtime.’”

Diane Brunelle RN, vice president for Patient Care Services at Noble Hospital, echoed the MHA’s sentiments and clarified that while some aspects of the bill were modified to more closely resemble the Patient Safety Act, the major sticking points regarding staffing limits remain unchanged.

“The current revision that went through in the House is not a compromise,” she stressed. “The language is still there that talks about limits, and we feel that the decision should rest with nurse managers. Ratios could also have a profound effect on community hospitals – the teaching hospitals will have to recruit nurses first, leaving a shallow pool for us to work with to prepare for 2010. That could put community hospitals in some dire straits, and this region especially cannot afford to lose any facilities.

“Mandates are also not going to cure the nursing shortage problem,” she added. “What we need is to get more faculty into the nursing programs to accommodate the growing number of applicants, and create a larger pool of well-educated nurses.”

Fair and Flexible?

Janice Kucewicz RN, senior vice president and chief nursing officer at Wing Memorial Hospital, suspects that confusion in the Legislature, or at least a lack of complete information regarding staffing limits, led to the lopsided nature of the House vote.

“I think the point being missed here is that care is provided by a team, not just by the RNs,” she said. “There is a whole pool of care-providers who are not even considered through the staffing limits bill, and to best utilize their talents, we need to be able to work within flexible guidelines.”

Kucewicz added that that she too sees the staffing limits bill doing little to address the ongoing nursing shortage.

“There is a notion out there that these staffing ratios will create jobs for nurses, and bring in nurses from private practices and other facilities to our acute care hospitals,” she said. “But it’s a misnomer that there are nurses out there waiting in the wings to take these jobs. Nursing schools only have so many open slots, and currently applicants are being turned away. All ratios will do at this point is contribute to a vicious cycle.”

While the futures of both patient safety bills remain unclear, work will continue through the Western Mass. Hospitals Coalition and other entities to increase understanding of the various components of both pieces of legislation involved, with particular emphasis on the bills’ potential effects on the nationwide nursing shortage.

“We won’t give up our cause,” said Brunelle. “The coalition will continue to work to do the most to bring nurses to the bedside.”

Jaclyn Stevenson can be reached at[email protected]