May 18, 2000, Elms College, Chicopee

(Unofficial MNA notes)

Presiding: Representative Christine Canavan, Representative Barbara Hyland, and Representative Cory Atkins

Rep. Wagner –Representative from Chicopee welcomes group. Reviewed that an amendment in the budget formed the Commission. "Nurses represent the front line of the health care industry. This Commission has determined that speaking to you is really critical to the debate on health care for the remainder of this session and certainly for next year. They' re charged with gathering information to recommend findings to the House and Senate."

Thanks to: Elms College faculty, administration and students.

Rep Canavan – "Purpose of the Nursing Commission is to give nurses the opportunity to speak to nurse legislators and legislators who are interested in nursing. The previous Nursing Commission concentrated on the Nurses Practice Act. This was established because we were receiving phone calls about nurses who were having problems in their practice. At the conclusion of these hearings, we will be giving a written report to leadership. Legislation may come out of it. It will provide basic working knowledge to all legislators about nursing and nursing practice."

Joanna Brady – RN for 40 years and 27 years as a school nurse in local public school system. School nurses are the only contact for many in the community. Nurses treat and work with their parents for appropriate medical treatment. Many medications are given and nurses are especially involved in medication management. Like Ritalin. Other than physicians order medications. And many out of state physicians practice medicine one day a week in our school system and then leave. Prescriber identification in schools is essential. Need valid authorization. I refused to administer a medication for which I could not prove that the prescriber was valid. I was then visited by two city officials with Ritalin and they demanded that the drug be administered. I was put on administrative leave for insubordination and escorted out the door. I submitted the document to the BORN and got no answer for one year. The determination from Nursing Board proved that is was not a valid prescription. I lost pay, and reputation. My supervisor filed charges with BORN against me. BORN reprimanded prescriber but that made no difference. BORN did not get involved to help me at all. Insurance reimbursed my lost pay and expenses. But I lost my promotion

I needed to be an advocate for school age children. I was reported to the nursing board. The school physician filed a complaint on hearsay, and it was accepted by the nursing board. It's hard to understand that the nursing board would open a complaint against my license on this hearsay. I have been harassed for refusing to do wrong. I must defend my right to practice nursing. There are no supports in practices settings.

Senator Linda Melconian -
"Delighted that you are having these state wide hearings. We are all concerned about health care, whether it is reimbursement issues, hospitals, community and acute, provider needs, we have a real crisis in this state. Some of the problem is the abandonment of responsibility. The backbone to any health care system is quite frankly, the nurses. The nurses provide professional quality trained care that patients receive in hospitals, in nursing homes and at home. They are overworked and understaffed and they are asked to do the Herculean efforts that are so important to a patient and to patient's rights and access. I thank all nurses who make a real effort to care for their patients even when they are working over hours and in underpaid situations. I look forward to the deliberations and the myriad of problems and to your report. I salute you and stand by the nurses."

Rep. Hyland – "I am privileged to sit on this commission and I must be the non- ranking republican, but I was happy to be appointed to this work. I was on health care committee. I have a number of relatives in the profession. I have gotten a good earful from them on good things and those that need correcting. I'm anxious for us to sit down when we are finished and come up with some good suggestions to take action on your behalf."

Rep. Atkins – "I share everyone's concerns for what you are challenged with on a daily basis. Joanne, I take my hat to you for standing on your principle. In the course of addressing medical errors, typing prescriptions is being recommended in hospitals. Would this help with the situation you have faced? What suggestion could we put in place to make it easier for nurses to readily identify if a script is authorized? Typing with designation, and written signature with telephone access could help. Licensees in neighboring states are accepted from pharmacy. Check on reciprocity for physician's licenses.

Does your school district have same policies? Some require only physicians, now it is any licensed prescriber. Does school district give you a list of preseciribers? No but they are now working on this. Maybe there should be assistance from the Department of Education. " To wait a year for determinations from the BORN was quite excessive", noted Brady. .

Jessica Berger, RN – I am a survivor of workplace violence. I am a member of the MNA Task Force on Workplace Violence. On April 18, 1998 I was working on a locked inpatient psychiatric unit. There were three health care workers to care for 23 patients. Two male patients, one admitted for homicidal ideation asked to be allowed to smoke in the smoking room. I first asked for permission from my supervisor who advised that I do this. One worker was off the unit and the other was in the medication area, out of sight. One patient lifted a green blanket over my head and ground my face into the floor. He broke my hair clip with kicks and my head was slammed into the floor. No one was around to help me. I felt blows to my back and neck. I tried to scream when I felt something tightened around my neck. I was being strangled and I thought I was going to die. And I was alone! I was dragged across the floor. The second patient then pulled the first patient off of me. I was lucky to be saved. I lost an entire month of work and still wrestle with pain and hip problems. Of all workers, nurses have the greatest record of workplace violence. We need to make it illegal to staff with less than five workers. Often the nurses are completely alone. Please enact legislation to criminalize staffing below the level of safe care. I see investments in capital expansions and crystal chandeliers, but not in staffing. When we are sick we will call upon a nurse, not a crystal chandelier. I speak for those who silently have faded into their disability. Please help us remedy… better staffing mandated by legislation

Rep. Atkins - We are going to have to struggle with this issue on many levels. Workplace violence is one issue and patient death is another. Your concerns are going to be taken into serous consideration. We are going to do the best we can on your behalf. Do you recommend five nurses or five security?

Berger - Security would be wonderful. Yes we do need security. The argument that we are having a shortage of nursing isn't a reason to address this problem. It doesn't have to be all nurses. Bare bones are 5 staff for any unit.

Mary Powers, RN - The long arm of the law as legislation will resolve some of the issues we have. I have been a nurse for 35 years and the largest change has occurred since health care has become a business. The care in health care and "compassion in heath care" is gone. Professional nursing care has been eliminated from the bedside to save money. At the community hospital where I work we have had 4 reductions in force in the last 10 years. This effects nurses, our nursing models. Fortunately we have a community that has rallied to our concerns. The Greater Pioneer Valley Health Coalition went the public to oppose the last proposed lay off of 35 nurses and the public support saved the nurses from any lay offs.

When care is taken from the beside to save costs it effects the caregiver and the patient. Support H 968. If not mandated by legislation safe staffing just won't happen. Rarely do we have the time to read charts and assess the level of care needed by the patients. Speed up mode leaves you in crisis nursing at every turn. Fragmented care without continuity coupled with early discharge. With adequate staffing the job can be done right the first time. It can be curative and preventative, hence decreased re-admission rates.

I have a deep concern for the future of nursing. There will be a severe nursing shortage for the next few years. Higher pay scales in other jobs are attractive to the younger generation. Precepting is always rewarding. It is increasingly difficult to find young women and men. Let nurses do what they do best, take care of sick populations.

Rep. Canavan – Tell me what the paper work is like now.

Powers "I recently transferred from med-surg to obstetrical nursing. Computerized documentation helps but is costly. Staffing generally has been cut. Nurses are the largest population as an area that they can cut. We recently received high patient satisfaction ratings in our hospital. This tells me that nursing is dong their job but at what costs? Job satisfaction is so poor. Even though we have a whistle blower protection bill we still have people afraid to speak out because you can still be reprimanded for speaking out."
Rep Canavan - Are you typically compensated for paper work time at the end of the shift?

Powers "If you are still there, then you're told you need organizational skills that you need to get your job done. Staffing is so fragmented there is no continuity. A lot of per diems are working. This affects the outcome of the patient and the satisfaction the nurse is getting at work.

Rep Canavan - What happens with sick calls? What is the typical of 7-3 assignment?

Powers – Typically now 8-10 patients. Typical evening shift 30-35 with five staff. Use both LPNs and RNs in that mix. Days are five to 7 on days. RN Ratios for 11-7 on med surg is four staff, 2RNs and 2 LPNs for 35 patients.

Rep. Canavan – What is the ratio of paper work vs. direct patient care?

Powers – I would estimated about 1-2 hours of time is documenting researching, filling. There is a lack of support services. I often pass dinner trays; mop floors and clean patient units.

Patricia Healy, RN – Technology and practice are changing rapidly and are necessitating changes for increased knowledge and skills. There are new procedures and equipment and ways of delivering medications. Many research projects are going on and nurses don't often have information about protocols.

I would like to talk about the nursing shortage – especially in areas that require specialized skills. Cardiovascular ICU, Pediatric and cardiac cath labs. Patients are more critically ill. Admissions from ER are up to 9-10% as hospital admissions. Due to lack of insurance, many use ERs for care and are very sick. Average age of RN on my unit is 48. We are an older staff is and desperate hospital executives are responding by cross training nurses. Use general nursing skills to move nurse anywhere they are needed. Nurses may be expected to cover areas where she has very little expertise. Almost everybody goes. The problem with cross training is that we are deskilling our nursing work force. They may not have the opportunity to develop as a very skilled nurse. We may appear to have the same skills but often we don't and it's the patients who ultimately suffer. Adequate orientation is needed. There are ways in which the legislature could assist. Legislating against deskilling and minimizing float pools. All are training to work in 6-8 areas.

I would like to share a story with you that illustrate this. I was recently floated to Hematology/Oncology unit and had 8 patients. 6 Patients were on research protocols each with 6-10 medications that I had to deliver. I didn't know any of these drugs. Many nurses do not even know their own deficits. There is a direct relationship to the skill of nurses, and the number of nurses to patients and their outcomes. We need your help to define guidelines so we have much safer health care. Nurses group together and pitch in and help each other.

Canavan – Since nurses are patient advocates do you think that your colleagues mode to cover each other fills a niche and that lets the administration off the hook?

Healey - There are studies that nurses, more than any other profession, will do a speed up and can sustain that speed up for five years. What is most compelling is how difficult it is to leave my job and know that my patients could have had better care.

Linda Donahue, RN – BORN member – We have no formal testimony but extend full support for your work. Will support in writing. Will submit statistics of # of calls that come into the board.

Rep. Canavan - Has the BORN taken a stand on nursing shortage? Working on it.

Andrea Fox, RN – DSS nurses need your support. These nurses used to care for frail children in the care of DSS. They were all laid off in 1994 after seeking permanent positions in state employ. The State Labor Relations Commission has already mandated the Administration to re-instate the nurses but the Administration has refused to date. Please support H 2138 currently in House Ways and Means. I also have written testimony for a bargaining unit member from home care

Mary Zamorski, RN, NP – MSNO President – Family Nurse Practitioner. Out of 351 districts, 78 were awarded grants through a budget amendment and we thank you. We see ourselves as an extension of hospital nurses but we have 1 –2000 children. Only need one nurse per school district. That's 30,000 children in this part of this state. Special needs student have trachs, heart transplant,s and/or liver transplants and almost 20% of our children are special needs. Typical day in a middle school a nurse has about 1400 children. I will administer 35-55 medications at noontime alone. Simultaneously, serving children in the nurse' room, the gym, and teachers. It is difficult for the school nurse to practice safely and confidently when she has so many tasks. Then she'll probably travel to 3-4 more schools. While it's great that we got a grant from this year it will eventually run out. We'd like see it as important to hire a nurse as it is to hire a teacher. In the budget there is a foundation budget which should help staff a lot of the needs, but sometimes it isn't used.

Canavan – In your system do you ever have problems with identifying the prescriber? Are the nurses supported by the administration?

Zamorski - We have resolved it by contacting doctors and pharmacies. Many nurses are working towards certification because of pay equity.

Judith Mealey – RN for 28 years and NP for 10 years. I have worked in health care for the homeless program for last 12 years. Nurses can impact on the needs of special populations. Nurse managed with a supervising physician for prescriptive authority. 20 different sites throughout Holyoke and Springfield. Provides primary care and referral, if needed. Medical case management. Homeless have mental health problems, abuse and substance abuse. Difficult for them to fit into a traditional health care system. Some barriers have been because of Medicaid. Even though they have service, providers that except Mass Health are refusing to treat these patients. Clients have difficulty with the system, don't have calendar, phones, address and this makes it difficult. Why does this program work? We provide outreach to the people where they are. They can walk in any time and see us. We provide a team approach to our services. We have a nurse, a mental health worker, a substance abuse worker and former homeless patients. We provide transport if they need it. Staff reports patient to primary providers if needed. Advantages to nursing, we meet clients where they are! Try to impact on their health in any way that we can. Help with managing medications. Aggressive follows up and outreach – blood work and medication, to make sure the outcome is as good as possible. I'd like to share an example with you.
Mike was living in a abandoned building – unkempt and abusing after 8-9 encounters we brought food and clothes. He finally took a shower and saw a psychiatrist. Began on medications and he is now in a safe havens program and in now a totally different person than he was.

Support nursing clinics in general and reason why they work. The medical model is to find a disease and cure the disease. Works fine with many but doesn't work with homeless. Elderly and indigent populations use the nursing model as to how disease affects that person and how to manage their disease. In general, nursing clinics give people so much more time. Nursing clinics have shown decreased prescription costs. Clients often need time and understanding. Decreased emergency room visits. Health promotion and prevention, elder support services, maternal and newborn service, coordinating and referring can all be done through clinics. S. 470 A pilot program for nursing clinics.

Canavan – funding – Federal funding from the McKenney foundation. We are in the process of fitting into Medicaid billing. Nursing Clinics are designated as HQHC can bill for services. Federally qualified health center.

Steven Mikelis, RN - Concerns as an MNA co-chair. Staffing levels at local hospitals. In 1998 –1999 we had 400 unsafe staffing levels and brought them to the hospital. Day shift takes care of 9-12 patents. All patients are sick. Patients are getting less quality care and any problems that occur often are reflected on the blame for nursing care. Not taking responsibility for staffing levels that they are not giving. Important for consumer to know what is going on? Hospital should know they are held accountable. Consumers should know what the staffing levels are at their hospitals. I work in unionized place where we can bring our concern forward, non-unionized nurses must fear for their jobs. Legislators can force a public record about the staffing levels to determine what kind of care they will get. So they can know what kind of nursing care they are going to get. They could use it as an advertising tool if they were wise.

Canavan – We need to educate consumers between direct patient care and indirect patient care.

Barbara Farrell, RN – Live in East Long Meadow and have been a nurse for 37 years. The hiring of nursing is expendable. The resent closures of emergency rooms has been linked to closure of the institution. When nurses can be directly linked to the revenue stream, they will generate nursing support. Nursing care is not available because of reimbursement and this lack of access continues to grow because of rapid discharge. I am also the president of the Massachusetts Coalition of School Based Health Centers. Not all children are insured and that lack of access is evident everyday. Tobacco settlement money has been provided for that endeavor. We work closely with school nurses, doctors and parents. Children with nebulizers do not need to go to E.R. Children with diabetes can be managed in the school. Small demonstration projects across the state to fill out information around CMSP.

Also working with a demonstration project for CHF case management program for patients with free care. Nursing interventions with these patients keeps them out of the ER. Some of their issues are medication management, the indigent drug programs, and sometimes its things like a pair of glasses for a diabetic. So often that's not paid for.

Nancy Gilbert, RN – Over 31 years of practice. Main area of practice is long term care, sub-acute and home care. Faculty member at the Elms. As an educator, I bring students into these environments. Students and staff are great. Try to be positive every day and support students and staff. Poor staffing, mandatory overtime and inadequate funding really thwarts continuity of care. Federal issue – no funding freely so it comes to the state under Medicaid. We just play the shell game of who's going to pay for care.

In home care, the fastest going segment of the Medicare budget because of the Medicare decrease. The Balanced Budget Act of 1997 put parameters on home care spending. We haven't gotten rid of sick elders we've just shifted where they are getting care.

Home care was getting 6-.5- 7.5 patients a day. Up to 10 patients a day. OASIS survey assessment tool measures outcomes on admission, every 60 days and upon discharge. The home care nurses bring paperwork home.

Long term are sub acute units with a good reputation. 38 patients with 1 or 2 nurses and five to 6 nurses aids. Medications average are 36 meds per patient. Our students were called over conscientious because they questioned everything. Nurses don't have time to question because of the staffing. Can't get another nurse on unit because of the price of oil for the nursing home heating. Nurses work on service – not being paid for their time.

Canavan – sub acute – patients should still be in the hospital – It's a mix of ill patients.

Gilbert - One gentleman had esophageal strictures and had heart failure. They took care of his esophageal problem but his heart failure went ramped. Took five weeks and had weeping edema and needed acute care setting.

Marie Beinvenue, RN – Sub acute nurses, our story needs to be told. I graduated 4 years ago. I have spoken to nurses who have been out 20 – 30 years and up to 5 years ago these patients would have been in the hospital. Want to speak to staffing levels. I was responsible for 21 patients. After asking for more staff and showing them the acuity of the patients. That's how they made their profits. Went to a facility in CT. where staffing was better. 30-bed unit with 2 nurses a supervisor and a secretary. In Massachusetts in any wing I would be responsible for 12 patients, they actually had 4 nurses for 52 beds. In the last several weeks, we've been at 2 nurses for 38 patients. I'm not sure how that's regulated. The DON approached me and told me to take 24 patients, and I received complaints about my negativity. Acutely ill and overworked staff. Most people don't stay on those units. There is an overworked sense that's why nurses are leaving the field. I have a problem going into work and knowing that I am not getting to that dressing today and it's not fair to them The nurses left are only there to earn their pay check.

Canavan. – Letting supervisor know that two med carts are unsafe.

Beinvenue - I refused they would tell me to go home. Afraid of being reprimanded for patient abandonment.

Marie Rohan, RN – Work for VA as an administrative nurse. Locality pays for the past two years. Talk about staffing and compare to local hospitals. Increase in the number or patr time nurses in local hospitals. Coordination of care for patients is appreciable. Increased responsibilities of nurse managers. At VA we are implementing a bar code medication system which will improve VA patient safety in the long run. But the new technology puts demands on nurses. If there's only one nurse at night, that nurse is now running medicine through a scanner and wrist ban through a scanner and if alone, other patients needs make this difficult.

The VA has developed a system-based expert based staffing methodology and it is tested as valid. We also have partnershiped with nurses who are in the union so the nurses meet with managers of the hospitals to talk about what's going on so that nurses have first hand information. Partnership for staff nurses to have a voice in all decisions.

Kathy Glasner, RN – RN in rehabilitation for 18 year and since 1964. Stress has been added to by myself and fellow nurses. During peak census periods nurses would stay one or two hours of overtime. We now have a decrease in staff, increased acuity and increased paperwork Mistake will be made because of this. I am leaving nursing, do you really want to work MOT, calling at all hours, every other holiday? Where are we going to get the nurses in t he future.

Gloria Craven, RN – There is an ongoing need to collect data about nurses and how they meet the needs of the commonwealth. We know there is a growing aging population and that with increased age, comes changes in function and the needs for nursing. We have no idea how many nurses we need with preparation in geriatrics, for instance. We know there is a lack of primary care in central Mass. Shouldn't we prepare and deploy nurse practitioners to meet these needs? The state should establish a permanent and ongoing database about nurses to meet the needs of the demographics.

Carol Charest, RN – (written testimony – handed in at the hearing) I am a n RN with 40 years of experience and certified in home health care. I have concerns about the proposed regulations by the Board of Registration in Nursing. Recent BORN response to nurses and health care crises gives nurses in Massachusetts good reason to lack confidence in the BORN. First, in the case of Barry Adams, he appeared before the BORN at the appointed time for what was expected to be his opportunity for a hearing of his evidence. However, the BORN informed him that they had already reached their decision and the session was promptly adjourned. In another event, the St. Vincent nurses advocated for quality patient care and safe practice and courageously took a stand against Tent that played out into a call to strike by the nurses. The BORN responded by stepping up the process to license nurses' from other states that crossed the picket line and were immediately employed at St. Vincent's Hospital. The media cited instances of extremely basic patient care safety violations…in my opinion, the BORN's response fell way short of their mandate to protect the health, safety and welfare of Massachusetts citizens. Please review the ambiguity and overreaching nature of the regulations so that nurses are protected by due process and not subjected to summary suspensions or because the BORN will find the nurse' refusal to engage in unsafe practice as an "abandonment" conduct.

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