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A fierce battle between hospitals and thousands of registered nurses, one that has highlighted bitter divisions between the House and Senate, reemerged Tuesday, as lawmakers considered proposals to limit the number of patients a nurse may oversee.
But in a new wrinkle in the 15-year-old issue, hospitals say setting strict limits when Massachusetts is considering a fundamental overhaul in the way patient care is provided and paid for would be inappropriate.
Citing a nascent push to move the state to a system of global payments, or shared payments by a collection of providers of patients care, Massachusetts Hospital Association President Lynn Nicholas argued, “There couldn’t be a worse time than now to consider this bill.”
“We are busy working on reconfiguring the health care delivery system to make it more cost-affordable,” she told the Committee on Public Health, which held a hearing on competing proposals to regulate nurse-patient ratios and the number of hours nurses may work in a shift.
Hospital managers have long resisted a push to set a strict limit on the number of patients to which nurses are assigned. They argue that inflexible limits hamper nurses’ decision-making, fail to account for the severity of patients’ illnesses and haven’t improved outcomes for patients. They also argue that amid an economic downturn, financially strapped hospitals couldn’t afford stepped-up staffing levels that could cost tens of millions of dollars.
Setting strict limits that don’t account for the expertise and experience of nurses would be unreasonable they said. Christine Schuster, CEO of Emerson Hospital, said, “In a busy day in our ICU, I’d rather have five senior registered nurses and support staff than seven new graduates.”
The hospitals back a proposal (S 876), filed by Sen. Richard Moore (D-Uxrbidge) and co-sponsored by 20 lawmakers, that would establish committees of nurses and other staff at every Massachusetts hospital to develop individualized staffing plans. Such plans would govern “nurse-to-patient staffing guidelines” that take the acuteness of patient illness into account. In addition, mandatory overtime would be restricted to emergency situations in which “there is no reasonable alternative.”
Advocates for registered nurses say research has shown that care deteriorates and medical errors increase when nurses are responsible for more than four patients at a time.
Their favored proposals (H 3912/S 890), filed by Rep. Ellen Story and Sen. Marc Pacheco along with 70 co-sponsors, would phase in nurse-patient ratios over two years for teaching hospitals and four years for community hospitals and leave the determination on appropriate nurse staffing levels to the Department of Public Health after public hearing and expert testimony. It would allow the Department of Public Health to grant waivers to cash-poor hospitals and prohibit mandatory overtime for nurses. Ratios would be reevaluated every three years to account for changes in technology and treatment.
A fierce battle between hospitals and thousands of registered nurses, one that has highlighted bitter divisions between the House and Senate, reemerged Tuesday, as lawmakers considered proposals to limit the number of patients a nurse may oversee.
But in a new wrinkle in the 15-year-old issue, hospitals say setting strict limits when Massachusetts is considering a fundamental overhaul in the way patient care is provided and paid for would be inappropriate.
Citing a nascent push to move the state to a system of global payments, or shared payments by a collection of providers of patients care, Massachusetts Hospital Association President Lynn Nicholas argued, “There couldn’t be a worse time than now to consider this bill.”
“We are busy working on reconfiguring the health care delivery system to make it more cost-affordable,” she told the Committee on Public Health, which held a hearing on competing proposals to regulate nurse-patient ratios and the number of hours nurses may work in a shift.
Hospital managers have long resisted a push to set a strict limit on the number of patients to which nurses are assigned. They argue that inflexible limits hamper nurses’ decision-making, fail to account for the severity of patients’ illnesses and haven’t improved outcomes for patients. They also argue that amid an economic downturn, financially strapped hospitals couldn’t afford stepped-up staffing levels that could cost tens of millions of dollars.
Setting strict limits that don’t account for the expertise and experience of nurses would be unreasonable they said. Christine Schuster, CEO of Emerson Hospital, said, “In a busy day in our ICU, I’d rather have five senior registered nurses and support staff than seven new graduates.”
The hospitals back a proposal (S 876), filed by Sen. Richard Moore (D-Uxrbidge) and co-sponsored by 20 lawmakers, that would establish committees of nurses and other staff at every Massachusetts hospital to develop individualized staffing plans. Such plans would govern “nurse-to-patient staffing guidelines” that take the acuteness of patient illness into account. In addition, mandatory overtime would be restricted to emergency situations in which “there is no reasonable alternative.”
Advocates for registered nurses say research has shown that care deteriorates and medical errors increase when nurses are responsible for more than four patients at a time.
Their favored proposals (H 3912/S 890), filed by Rep. Ellen Story and Sen. Marc Pacheco along with 70 co-sponsors, would phase in nurse-patient ratios over two years for teaching hospitals and four years for community hospitals and leave the determination on appropriate nurse staffing levels to the Department of Public Health after public hearing and expert testimony. It would allow the Department of Public Health to grant waivers to cash-poor hospitals and prohibit mandatory overtime for nurses. Ratios would be reevaluated every three years to account for changes in technology and treatment.
“I come before you representing 23,000 very frustrated, frontline, bedside nurses,” said Donna Kelly-Williams, newly elected president of the Massachusetts Nurses Association. Kelly-Williams said incidences of hospital acquired infections, pneumonias, deep-vein thrombosis and bed sores are a direct result of overworked nurses unable to provide adequate attention to patients, adding tens of thousands of dollars to patients’ bills.
“I would argue that hospitals truly cannot afford to continue these unsafe staffing practices,” she said.
Backers of the nurse-patient ratios highlighted personal experiences in which they or a member of their family suffered from hospital errors they said could have been avoided with a nurse’s attention. They noted CDC statistics that show 2,000 people die in Massachusetts each year because of medical errors.
John Bennett, president of the Massachusetts Senior Action Council, said that his wife was in the hospital for two major cancer operations.
“If I hadn’t been there constantly overseeing her care, I’m not sure if she would’ve survived that ordeal,” he said.
Iterations of proposed limits on nurse-patient ratios have circulated for more than a decade, and backers of strict limits expressed increasing frustration, arguing they have made concessions to hospitals over the years that should make such legislation more palatable. Last session, the House passed legislation that would’ve resulted in a cap on the number of patients nurses may be responsible for, and the Senate passed a version that stripped such a limit. The branches never agreed on a single bill.
Sen. Marc Pacheco (D-Taunton), who has led the effort in the Senate to impose a strict limit, told committee members that powerful hospital interests swayed the process in the Senate last session.
“Sometimes these votes will come up and sponsors haven’t been around just so we would not have an advocate on the floor to actually do anything on this,” Pacheco said, referring to Senate President Therese Murray’s decision to take up the proposal while he was out of the country last year. “It tells you the power and the influence that is behind the opposition to this bill. Make no mistake about it, those that come before you and that are saying that things are just fine the way they are, almost all of them that would be coming forward from that perspective are tied to the management of hospitals in Massachusetts.”
Not all nurses back the strict staff-patient limits. Nurses from New England Sinai Hospital, the Lahey Clinic and Winchester Hospital highlighted their hospitals’ efforts to implement creative solutions to improve patient care, emphasizing a “teamwork approach” that includes support from other providers. Sharon Gale, executive director of the Massachusetts Organization of Nurse Executives, pointed out that the Massachusetts Nurses Association represents about one-sixth of the state’s 120,000 nurses.
Gale and other supporters of the Senate proposal argued that new, innovative practices in nursing have not yet been fully measured and would show vast improvements in patient care. They pointed to California’s 1999 decision to implement nurse-patient ratios and wondered why no other states had followed suit since.
Rep. Jeffrey Sanchez (D-Boston) wondered whether, should lawmakers set a strict ratio, there would be enough registered nurses to meet the requirements. Massachusetts Nurses Association officials said Massachusetts has the highest number of registered nurses per capita in the nation but that most eschew working at hospital bedsides because of the difficulty of the job. Those nurses would return, they said, if more protections were implemented.
The competing bills share many of the same features, establishing a Nursing Advisory Board to make policy recommendations, establishing a Clara Barton nursing corps to help mentor new nurses, establishing a scholarship and loan-repayment program and a state match for hospitals that provide funds for nursing education.
Few committee members attended the hearing, co-chaired by Sanchez and Sen. Susan Fargo (D-Lincoln).
Fargo, who joined the panel an hour into the hearing, was the only senator who showed up. Other lawmakers on the panel included Reps. Michael Brady (D-Brockton), Jason Lewis (D-Winchester) and John Quinn (D-Dartmouth). For much of the first two hours of the hearing, advocates and lobbyists on both sides of the issue packed the room, requiring attendees to stand along the outer edge of the room.
