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July 13, 2005 - Since January of 1999, when I was named as Senate Chair of the Committee on Health Care, one of my highest legislative priorities has been to make our health care system safer for patients and health care professionals. In that regard, I also have a long track record of support for nursing and during this same time period, I have been honored by the Massachusetts Hospital Association, the Massachusetts Organization of Nurse Executives, the Massachusetts Association of Registered Nurses, and the Massachusetts Nurses Association. Therefore, I speak today as an advocate of patient safety and of nursing.
All of the four organizations that I mentioned – MHA, MONE, MaRN, and MNA – have a demonstrated track record of advocacy and action to make health care safe for all who need care. The Massachusetts Nurses Association, in particular, deserves credit for raising legislative and public awareness in the issues of patient safety and of the growing crisis caused by the nursing shortage here, and across the nation. However, I disagree with the path that the MNA has chosen as a solution. As an ancient Roman scholar once observed, “There are some remedies worse than the disease.” [Publius Syrus (85-43 BC) Moral Sayings, tr. Darius Lyman, Jr. 1862]
Proponents of a standard of nursing care mandated by Beacon Hill in response to political pressure, rather than by objective scientific research tell us that “We have a disturbing crisis in Massachusetts – nurses are being forced to care for too many patients, and patients are suffering the consequences in the form of preventable errors, increased lengths of state and readmissions.”
Except for the data that suggests a reduction in lengths of stay in hospitals, I don’t really disagree with that statement. However, the real culprit forcing the nurses to care for too many patients in some hospitals is not the hospital management or a desire to save money at the expense of patient care. The real culprit is a current and rapidly growing shortage of nurses. Most of the studies that proponents will cite in support of mandated nurse staffing ratios indicate that more nurses at the beside or in other direct care roles is, for the most part, something we should address, and soon!
Willing more nurses at the bedside by passing a law, won’t make it happen. We need to have enough nurses to attract to the job first, and we need to help to keep them there by giving them the support they need in technology and support staff so that working conditions are more manageable for nurses.
Proponents note that the Massachusetts Department of Public Health reports that medical errors and complaints at hospitals have increased by 76% in seven years. They don’t say, of course, that much of the increase is due to better reporting since the Institute of Medicine made patient safety a national priority in 1999 with the release of its study “To Err is Human,” and our own Massachusetts Coalition for the Prevention of Medical Errors helped to make it a priority for our Commonwealth. I might add that some of the increased reporting and activity at DPH under the leadership of Assistant Commissioner Nancy Ridley and at the Board of Registration in Medicine under the leadership of Nancy Achin Audesse was with the support and strong encouragement by the Legislature, and particularly the Committee on Health Care.
House Bill No. 2663 is not the best solution to a safer health care system!
Let’s look at what the bill requires:
- An acuity based patient classification system. In principle, this is a good concept. However, the language in the bill is too narrowly focused. It is primarily focused on how much nursing a patient needs, not the total care needs of the patient from physicians, technology, support staff, etc. In fact, the bill directs the DPH in subsection (b)(3) to develop the patient classification system “to be utilized by all facilities to INCREASE the number of direct care registered nurses to meet patient needs. Yet, the purpose of the classification system is to determine how sick the patient is, as well as how much and what kind of care is needed.
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- Specific minimum ratios of nurses to patients that vary by unit, but apply in a one-size-fits-all model to every acute care hospital in Massachusetts. That sounds simple enough! In fact, it’s too simple.
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- Despite considerable research, and a very thorough discussion by and with nursing experts sponsored by the Massachusetts Health Policy Forum several weeks ago at the Federal Reserve Bank, it’s clear that there is no hard science that tells us the appropriate minimum ratio of nurses to patients because of all of the confounding variables such a differences among nurses in experience, education, physical ability, and more; differences among patients in the type and degree of their illness and their needs for care; differences among facilities in design, availability of support staff, technology, etc. Likewise, there is no data that tells us the point at which further enrichment of nurse staffing will no longer lead to improved outcomes. How much will this cost taxpayers for the extra nurses that may be needed at the four public health hospitals and other state facilities and how much will it cost patients in higher premium charges.
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- Requires a toll-free hotline for reporting staffing violations, and DPH investigation of complaints. However, the bill does not provide the resources needed by the Department of Public Health – that has suffered from serious budget cuts – to pay for the hotline or the additional investigators that will be needed to investigate. How much will this cost taxpayers or patients through higher premiums?
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- Bans mandatory overtime or mandatory on-call policies. I support limiting the hours of nursing work because there is a growing body of research that suggests that longer work hours with inadequate periods for rest in between are a major contributing factor – sometimes fatal – in medical errors. In fact, the bill probably doesn’t go far enough in that voluntary overtime or nurses working for other hospitals or nursing pools or on private duty, besides their primary work assignments are just as likely to commit errors from sleep deprivation. This is a goal that we should be working toward if we are truly concerned about patient safety.
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- Fails to protect other health care support personnel. While the bill suggests that in order to meet the minimum nurse staffing levels, health facilities should not reduce the staffing levels of other critical health workers who often help to ease the burden on nurses even if they are prevent, as the bill provides, from performing any duties that are the prerogatives of Registered Nurses. The bill does not prevent facilities from making personnel decisions needed to have the resources to hire enough nurses to meet the state-mandated ratios. This will lead to other health professions filing mandatory ratios for their positions as well. In labor terms, I think it’s called “feather-bedding.”
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- Provides for significant penalties of loss of license and/or a $25,000 fine per day. Of course, it’s unlikely that the DPH will rescind the license of a hospital to operate. Since that would mean that many RN’s would lose their jobs and have to go elsewhere, it can’t be something that proponents would promote. The fines, given the very difficult bottom lines of most hospitals, especially the community hospitals, could jeopardize the financial stability of the hospital and make it even more difficult to meet the financial burden of the staffing ratios, thereby jeopardizing safety measures such as adding new technology such as electronic records, and perhaps even access of the hospital is unable to compete.
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The real problem of inadequate numbers of nurses for safe patient care cannot be solved by mandatory, one-size-fits-all-nurse to patient ratios.
There are not enough nurses, even if some RN’s who left direct patient care were willing to return to nursing, to fill the demands of the proposed mandatory ratio law.
There IS a nursing shortage nationally, and in Massachusetts. A survey by MHA/MONE last year reported a vacancy rate among RN’s of 6.8%. It was especially acute in the third shift (11pm – 7am). It was nearly double for LPN’s. The federal Health Resources and Services Administration (HRSA) predicted in 2002 that the shortage of RN’s in Massachusetts in 2005 would be of 7%. That will grow to 12% in 2010, 21% in 2015, and 29.4% in 2020. How will acute care hospitals meet the additional requirements of a mandatory ratio law in an era of increasing demand for nurses? House Bill 2663, may be well-intended, but it does not make sense. We will have to find other ways to address this crisis.
Senate Bill No. 1260 -
the Patient Safety Act
This leads me to Senate Bill 1260 which promotes patient safety and safe nursing care from a different perspective.
- Senate Bill No. 1260 seeks to expand the number of nurses by promoting more nurse faculty. One of our biggest problems is the shortage of nursing school faculty. We’re turning away qualified applicants for nursing school because we don’t have enough faculty to teach them. A study by the American Association of Colleges of Nursing reported that nursing schools turned away 32,797 qualified applicants from four year and graduate nursing programs in 2004-2005 due to an insufficient number of faculty. In 2003, 18,105 were turned away as well. A year ago, there were 717 vacant faculty positions in 395 nursing schools with 4 year and graduate programs. Senate Bill No. 1260 will address this and give priority to supporting funding and other benefits for those who want to teach nursing. We also need to supplement nursing faculty salaries to be more competitive with clinical nursing and the Clara Barton Nursing Excellence Program (see SB 772 which was heard before the Committee on Higher Education on may 10, 2005) can help to achieve this. Even by accepting all qualified applicants to nursing school, we still need to attract even more people into nursing, and Senate 1260’s provisions will help to do that as well. Senate 1260 will address the supply, but we’ll still be behind unless we can open more seats in the nursing classrooms and fill them with new students, especially students who want to focus on geriatric health issues. We may not be able to catch up to the growing need for nurses, but if we don’t address it now, the shortage will get worse and patient care and safety will surely suffer even if we expand technology to help close the gap.
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- The other major part of Senate Bill No. 1260 is that instead of arbitrarily requiring a set number of patients for whom nurses would care, and hope that that produces safe care, we want to measure patient outcomes and hold hospitals to high standards.
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The standards would be nursing sensitive measures that have been tested and validated nationally as compared with a patient classification system legislatively mandated to be developed by the DPH designed to increase the demand for nurses as stated in House Bill 2663.
I want to express my willingness to work with the Committee on Public Health and with the proponents of both Senate Bill 1260 and House Bill 2663 and other interested parties to find an effective way to address the nursing shortage and improve patient safety and care. As you know, Senate President Travaglini and Speaker DiMasi have appointed a Special Committee on Nursing Work Force Issues, chaired by Representative Steve Tobin and me, to see if a consensus bill can be developed. The committee has begun its work, and I would ask that the Committee take no action on this issue until the Special Committee has developed its recommendations.
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