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“Meeting the Need in Nursing” Address by Senator Richard T.
Moore October 28, 2005 "You must never so much as think whether you like it or not, whether it is bearable or not; you must never think of anything except the need, and how to meet it.” Those immortal words of Clara Barton ring just as true for us today as we consider the urgent need in nursing and how best to meet it. Anyone familiar with health care or the vital role of nursing in the delivery of care knows that fundamental changes are needed. Most would also agree that there is a critical need to improve health care quality and patient safety that must be addressed. While physicians and many others in and out of health care need to be among those leading that effort, the role of nurses in providing safe care – as the most numerous health professionals caring directly for patients – is pivotal! Nurses need to focus the attention of everyone involved with health care on improving patient outcomes. I certainly don’t need to remind anyone in this audience of the Institute of Medicine study that estimated the high number of deaths resulting from medical error and the numerous studies that followed highlighting the need for a national culture of patient safety and prevention of medical mistakes. Massachusetts hospitals have pledged to put patients first, and I know of no hospital that is opposed to improving patient safety. At the same time, increasing costs of health care and limited resources to pay for care have put nearly every health care institution in financial jeopardy. What’s more, investments in patient safety and quality by the health care institution bring financial rewards, not to the provider, but to those who pay for care. However, this misalignment of costs and benefits makes it difficult to bring about needed changes in the short run without risking the financial stability and survival of the hospital. Increasing the number of nurses academically and clinically prepared to deliver safe, high quality care for patients is cited in numerous studies as one of the most important steps we can take to improve patient care. Yet, as public policy makers and health care leaders call for investment in major reforms to produce quality and safety in health care, the task of implementing reform is made more difficult, not simply by limited financial resources, but by a growing shortage of nurses. Simultaneously, the impact on health quality and safety is magnified by a rapidly growing population of elderly with their attendant complex health needs. Let me frame the discussion about the need in nursing and how to meet it. The need, I believe, is to address a current, and seriously growing, shortage of nurses so that there will be adequate numbers of nurses to provide safe patient care in the years to come. There are two primary proposals on the public agenda for how best to meet that need. There is mandatory nurse to patient ratios and limits on mandatory overtime as embodied in House Bill No. 2663, on the one hand. On the other is Senate Bill No. 1260 to provide safe patient care through published nurse staffing plans that are measured by patient outcomes and limits on nursing hours to protect both nurses and their patients. No one involved in the debate over nurse-to-patient staffing ratios questions the existence of a nursing shortage. In fact, both the nursing union leaders and Representative Christine Canavan (D-Brockton), a former nurse and lead sponsor of House Bill 2663 to require nurse to patient ratios, cited the nursing shortage last November when they re-filed the nurse staffing legislation. Numerous government workforce reports, as well as a recent survey by the Massachusetts Hospital Association, that all note that while the nursing shortage in Massachusetts that was 11% in 2000 and eased in the last year to about 7%, the long crisis in the nursing profession is far from over. National studies indicate that most of the gains in addressing the shortage have been from nurses returning to clinical settings because of increased nursing salaries (around $55,000 - $65,000 per year, higher with overtime) and because of family financial need. Nevertheless, that 7% gap equates to 5,000 fewer nurses than are needed in hospitals. Federal authorities believe that gap will grow to 9,000 in just five years and 25,000 by 2020. With the workforce aging and fewer people going into the profession while those needing care are increasing, the shortage will persist and grow. Furthermore, with the nursing workforce median age around 47, we will see the retirement of experienced nurses in the next fifteen years as the shortage grows to nearly 30% according to the federal Bureau of Health Professions. However, the bill filed by the nursing union leaders actually increases the demand for more nurses despite their admission of the well-established fact that there’s a growing shortage of nurses. The MNA bill does not directly address the nursing shortage, although there is an expectation, supported by claims of nursing union leaders, that nurses who have left the clinical settings would return to the bedside if more nurses were required for safer patient care and improved working environment. Some have already returned because of improvement in clinical nurse salaries. The problem is that even if every licensed registered nurse, not currently working in clinical settings, returned to direct care duties, and that’s not likely to happen, we would still not have enough nurses to adequately address the shortage and achieve the mandated nurse to patient staffing ratio requirements. Furthermore, many of those nurses who may be willing to return to work would need varying amounts of continuing education and re-training in order to safely return to direct care because of the significant changes in medicine that have occurred in just a few years away from the job. In addition, these nurses may have physical and stamina limitations and would be approaching retirement in a few more years since they are part of the generation of what’s often described as the “aging” nursing work force. Therefore, without addressing the shortfall in the supply of new nurses, the demand will create an even larger group of nurses reaching the age to retire from clinical practice with too few replacements in the pipeline. Despite these factors, the nursing union leaders’ bill has no provisions to encourage and assist nurses to return to the clinical setting and no provisions to increase the number of nursing students that are needed for long term solutions to the nursing shortage. We know that more nurses would be needed to meet the demands of a nurse-to-patient mandated ratio law, but the idea that the need for nurses will be met by attracting and retraining those who left active nursing to back to direct care, is unproven and, in any event will prove grossly inadequate in the face of the growing shortage. Furthermore, it does not address the basic reason why we are not training enough new nurses. We don’t have enough nursing faculty and we’re turning away hundreds of qualified applicants as a result. I agree that more nurses are needed to ensure safe, high quality patient care, but we must educate and train more nurses to provide those additional nurses. We cannot simply demand more nurses be hired by passing a law, and expect such a law to make it happen when we know there’s a growing shortage. We need a comprehensive program to add more new nurses and retain those we have. That’s precisely why we need to enact my bill - Senate Bill No. 1260. I fully admit that there are any number of good academic studies which have been completed that tell us that more nurses per patient is better – at least up to some level when the benefits of additional nurses no longer increases patient care and safety. However, if I am willing to concede that, as we increase the supply of nurses to address the nursing shortage, more nurses per patient is generally better for safe, quality patient care, why can’t I support the nursing union leaders’ mandatory one-size-fits-all nurse-to-patient ratio law? The answer to this question is simple – no scientific study, let me repeat, NO scientific study, can tell us specifically what the right ratio must be! There are too many variables among nurses, patients, support personnel, technology availability, and hospital design, some of which can change during a shift, to determine an exact ratio that can be written into law. In a health care system that is more expensive than any other, and that is getting more expensive by the year, how can we justify increasing cost by legislatively mandating specific nurse-to-patient ratios – as the UMASS Medical School study determined – without evidence that specific ratios improve patient outcomes? My bill does cost money too, but most of the money is to help increase the supply of nurses and close the nursing shortage gap. So if we have more nurses, what would be a better way to deploy them than rigid nurse-to-patient ratios in order to improve patient safety and quality care? I believe the answer can be found in scientific studies that limit the number of hours that nurses should work in direct care! I agree with nurses that mandatory overtime should only be employed in extreme emergency situations when patients might be left without nursing care, but I also believe that voluntary overtime, while it may be more satisfactory – even sometimes desirable – for nurses, can be very dangerous for patients and even for nurses as they drive home fatigued at the end of an extended shift. In this area of policy, I believe that the health care workers who belong to the Service Employees International Union (SEIU), who are leading the effort to limit work hours for physicians, as well as nurses, have the better idea. Several good scientific studies have shown that doctors and nurses who work long hours without sufficient breaks and recovery times are likely to commit serious medical errors. Sleep deprivation cuts response times much as intoxication and that can be dangerous for the patients. With nurse-to-patient mandated ratios and the growing shortage of nurses, it is very possible that while a few more nurses may be working on a shift, it will be necessary to ask more nurses to voluntarily work overtime to meet the ratio requirements. The increase in overtime, even when it is voluntary and well-paid, will increase the likelihood of fatigue that leads to medical mistakes and driving accidents. Rather than creating a safer environment for patients, ratios that are filled by overtime-fatigued nurses are likely to be as dangerous, possibly even more dangerous, than requiring nurses to care for too many patients. During the most of the following program, you will hear about an academic study objectively conducted by skilled health care researchers at the University of Massachusetts Medical School’s Division of Commonwealth Medicine. They were asked by Representative Steve Tobin and me, as co-chairs of a special committee on nursing ratios, and at the suggestion of committee member Sen. Harriette Chandler, to analyze from both a health policy and economic impact standpoint the nursing union leaders’ bill (House Bill No. 2663) and my bill (Senate Bill No. 1260). The nursing union leaders have criticized this academic research not so much on its merits, but by challenging the motives of individuals and organizations with whom they disagree, and publicly questioning the integrity of the researchers. It’s as if, as Gandhi once explained, “Intolerance betrays want of faith in one’s cause.” These same nursing union leaders were invited to participate in a reaction panel on today’s program to discuss their concerns with the UMASS Medical School’s research, but they declined. The legislative sponsors of the nursing union’s one-size-fits-all nurse to patient ratio bill were invited to participate as well, but they also declined. Front line nurses, and the patients they serve, deserve better than that! What better place than in America to be able to express and exchange our views on important issues of public policy? What better place than a college such as Becker to have an intellectual discussion of important academic research. Rather than have an intelligent conversation expressing different viewpoints on how best to address patient safety through nursing care – a process at the essence of academic freedom – those who have another opinion take the position that if we won’t agree with them, we must be against them. When will they understand that, it’s not about THEM, it’s about safe patient outcomes! Instead of rational discourse, they’ve picketed. They’ve issued silly cartoons. They’ve done all they could to shout down opposing views. They’ve made their demand for staffing ratios a highly politicized campaign rather than a rational discussion of policy options. It’s become a test of political power. While the MNA has helped to generate more publicity and attendance for this symposium than Becker’s public affairs team could have achieved alone, let me assert my firm belief that there is NO place for politics in patient safety! The debate should not be about arbitrary staffing ratios, the real issue is achieving safe patient outcomes in every health care setting! Therefore, I want to share with you how the UMASS study and its critique of my bill have contributed to improving my bill to more effectively provide safe nursing care. The UMASS report concluded that the provisions of Senate Bill No. 1260 would be the most appropriate legislative vehicle, at this time, to strengthen the role of nursing in promoting patient safety; and that there was no evidence-based research to support specific nurse-to-patient staffing ratios. However, the report also noted several areas that might improve the effectiveness of Senate 1260. Among the steps to improve Senate 1260 identified by the UMASS study were to address the issue of mandatory overtime that was addressed in House Bill No. 2663 because of concern about the impact of long work hours on patient safety and nurse retention, and to ensure that effective penalties would be applied for failure to comply with staffing plan requirements of Senate Bill No. 1260. The UMASS Medical School study also suggested that more funding will be needed to address the nursing shortage, and recommended targeting the $30 million Clara Barton program to addressing the nursing faculty crisis. I accept the UMASS Medical School critique of my bill as advice that will strengthen the effectiveness of my bill. Therefore, I am proposing several enhancements for Senate Bill No. 1260 to conform to the analysis of the issues related to nursing workforce that would improve patient safety. The redraft that I am developing will respond to the UMASS findings in several key points:
Let me conclude with these thoughts. Good public policy is created when it is developed in an open process that respects all views and works to develop a solution that best achieves the best result for the public. The need in nursing is to address the current, and future, shortage of nurses in order to promote greater patient safety and better care while improving the nursing workplace to attract and retain nurses. Senate Bill No. 1260 improves the supply of nurses to address the shortage. House Bill No. 2663 does not. Senate Bill No. 1260 improves the nursing workplace by providing new nurses with experienced nurse mentors and limits the hours of direct care to reduce fatigue and, hopefully, prevent burnout. House Bill No. 2663 only limits mandatory overtime, and it will add stress in efforts to comply with rigid mandates imposed by politicians, not based on scientific evidence. Senate Bill No. 1260 provides a means of evaluation nurse staffing plans by comparing staffing to safe patient outcomes. House Bill No. 2663 has no provision for evaluation of ratios. Senate Bill No. 1260 provides a mechanism for nurses to help set their case load. House Bill No. 2663 sets an arbitrary case load based on specific ratios, not recognizing the variables among nurses and patients that can change from shift to shift or within shifts. Senate Bill No. 1260 provides reasonable penalties for failure to make staffing plans public. House Bill No. 2663 requires excessive draconian penalties for failure to achieve and maintain the ratio requirements at any time during a shift. Finally, Senate Bill No. 1260 has the support of hospitals, nurse executives, and many nurses – support that is needed to ensure that the bill’s provisions will work to provide safe patient care. House Bill No. 2663 has the support of nursing union leaders and some nurses and is vehemently opposed by hospitals ensuring a contentious relationship between employers and employees that will place patients at risk, leaving patients as pawns in a contentious labor struggle. Furthermore, Senate Bill No. 1260 is fully consistent with “Nursing’s Agenda for the Future,” developed by all of the major national nursing organizations and released in April 2002. At least nine of the Nursing Agenda’s objectives would be implemented through my bill:
If Clara Barton were with us today, I believe she would agree that I’ve thought only of the need, and I’ve prepared a program to meet it! |
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