Nursing Commission Issues Report on Nursing Crisis Echoes MNA Concerns, Calls for Legislation to Mandate Staffing and End to MOT

Statement of the Problem:

A CRISIS IN NURSING AND NURSING PRACTICE

The Special Legislative Commission on Nursing and Nursing Practice, appointed by Governor Agreo Paul Cellucci and the Massachusetts Legislature in March 2000 has been authorized by Chapter 127 of the Acts of 1999 to investigate and report on matters affecting the practice of nursing and the delivery of healthcare services by nurses. This report documents the findings and recommendations of the Commission, which were derived from the hearings on nursing care, which were held from May to October 2000.

In these hearings, it became apparent that the issues that affect the delivery of patient care are common to each of the regions of our Commonwealth.  It is the unanimous consensus of licensed nurses, health care personnel and administrators that the shortage of nursing care in the Commonwealth is endangering the quality of care that our nurses can provide to the patient. Each nurse working in a dangerous situation is jeopardizing his or her license to practice. The Commission is called upon to encourage the Commonwealth to take a leadership role; to commit her expertise and resources in support of quality patient care, to increase retention of experienced licensed nurses, to recruit prospective nursing students and to ensure safety for our sick and elderly, our school children, and our nurses, with safe practice guidelines for staffing and caregiving.

As many nurses and healthcare representatives testified, this crisis in nursing practice stems from several complex factors. The Balanced Budget Act of 1997 has had a major impact on the healthcare system of the Commonwealth and on nursing care for patients. Medicare cutbacks have been severe at the Federal level, in addition to inadequate funding of Medicaid by the State and decreases in HMO payments that have affected the quality of healthcare for all citizens of the Commonwealth. As our population ages and requires more health services, the acuity of the nursing shortage becomes more severe.

The shortage of nurses is the critical element of these crises. "Unlike previous shortages, this one is not expected to improve in the near term. It is expected to reach full impact between 2008 and 2010 and to have an effect far greater than any of the cyclical shortages that the profession has experienced in the past." (Testimony submitted to the Commission by Mass Hospital Association, Nov. 16, 2000.)  Many factors affect the shortage of nurses and further complicate the problems that are affecting the profession. These pressures are not unique to nurses but do affect every segment of patient care. Nursing issues are at the center, because it is these realities that define our patient care. All healthcare revolves around nurses. In all aspects of healthcare, a nurse is involved.

Nursing concerns that consistently dominated each hearing are as follows:

A) Staffing of licensed personnel and their ability to practice safely

B) Mandatory overtime and its effect on the nursing personnel and their ability to practice safely

C) Workplace violence as a result of inadequate staffing, licensed and non-licensed

D) Changing preferences for nursing as a profession, and the ability of nurse education programs to meet the needs for nurses and nursing students

E) Complaints (that are really systemic) are being filed at the Board of Registration in Nursing against the only licensed personnel, the nurse

F) Specialty nursing and how this field is affected by the nursing shortage

G) Home Health Nursing

H) Reimbursement

I) Licensing
 

Massachusetts lacks definitive data to conduct a comprehensive analysis of nursing care for its citizens. The Commonwealth does not have an ongoing system that assesses the supply of nurses who are currently employed at health care organizations. The Commonwealth does know how many nurses have a license to practice nursing. There is neither a mechanism nor an office in the state to assess where nurses are employed. It is also clear that the important statistic of nurse\patient ratio is unavailable in most health care facilities that provide patient care.

"The public should have the right to know how many other patients share the time, expertise and knowledge of the same registered nurse." (Karen Daley RN, MPH Oct. 24, 2000 Massasoit Community College)

This Commission has used information that is compiled from public hearings, material data, and hospital information to present a picture of the shortage (crisis) in nursing care for our residents. This Commission has revealed that we do need some vehicle to present a complete assessment of nursing care, in the Commonwealth.

Patients in our state have had their access to necessary professional nursing care limited by the following factors:

1) Hospital stays are limited, so that patients may be discharged in unstable conditions. 

2) Hospitals and hospital beds are closed.

3) Insurers have limited nursing home care visits.

4) Unlicensed assisting personnel have replaced nursing professionals.

5) Occupational related illness and injury have reduced nurses from the workforce.
  (MHA Testimony, Nov. 16, 2000, and M.O., RN Oct. 24, 2000)
 

A. STAFFING AND SAFETY:

"Poor staffing and poor systems equals poor care." (Dorothy Upson McCabe RN, MS, M.Ed. Oct. 24,2000)

In the managed care environment, strategies are designed to support budgetary goals by cutting the cost of nursing labor. Nursing staffs are downsized, resulting in fewer nurses caring for more patients. Registered nurses are replaced with lower paid unlicensed personnel performing nursing tasks. This results in licensed nurses being responsible for what an unlicensed person does, not the hospital.

Witnesses throughout the hearings testified that the short staffing of nurses combined with faulty systems is a ticking time bomb. Patients in understaffed environments are at risk for inadequate assessment of their conditions, increased infection rates, skin breakdown, medication errors, inadequate pain management, falls, and inadequate preparation for discharge. There is a positive correlation between an increase in licensed nursing staffing levels and reduction in medical errors and complications. (Massachusetts Nursing Association Testimony, submitted Oct 24, 2000)

Over the past two decades, studies have shown that care provided by registered nurses decreases length of stay, decreases patient complications, and increases patient satisfaction.  It is a flawed policy that removes nurses from the bedside. Nurses need time to provide nursing care safely. "My heart aches because I know I make a difference in my patients' care and I am so close to being burnt out that I feel like I smolder." (Shirley Webber RN, CNOR, June 15, 2000)

Staffing must include factors such as the patient's acuity level. There are no staffing guidelines except for dialysis and Intensive Care Units. Instead of short staffing a unit and then spending all their time trying to catch nurses making mistakes, administrators must provide assistance to the nurses by providing the resources needed to deliver good patient care. "There must be a safe, non-punitive environment that is system oriented with staffing patterns, which are commensurate with the patient care required." (Oral Testimony from an RN, Oct 24, 2000)

Insufficient staffing is evident in the following:

• Frequent use of mandatory overtime

• Use of temporary care

• Unfilled nursing vacancies (MNA, Oct 24, 2000)
 

A LPN in a long-term care facility on Cape Cod presented this data for the record:

11-7 Shift  Skilled Nursing Floor
 

60 Patients	40 Patients	40 Patients
2 RN	1 RN	1 RN
4 Aides	2 Aides	2 Aides (RN, 9/12/00)

 "The essence of the nursing concerns is that staffing patterns have left nurses unable to practice nursing at the level of standards to which nurses consider themselves ethically, professional, and legally bound. Patient access to nursing care is directly correlated to the outcome of care." (K.D., RN, MPH May 18, 2000).  It has been noted that in specialty nursing (e.g., critical care, operating room, and emergency room nurses) it is difficult to fill positions that require specialized training.

With an expected nursing job growth at 23% by 2006, faster than the average of all other occupations, and with both an aging RN workforce and faculty, who will replace our nurses who hold the system together today? "The competency of today's nurses is what is keeping the current system afloat." (Donna Mae Donahue, PhD, RN, Sept 21, 2000) It is the competence of these professionals who have prevented the collapse of the system, as we know it today. Working under such poor conditions, nurses jeopardize their licenses every day. "With deteriorating workplace conditions, safety, health, and workplace violence, we are in crisis." (Oral Testimony, RN, Oct. 24, 2000)

B. MANDATORY OVERTIME:

One of the indicators of severe workplace staffing issues is mandatory overtime. Mandatory overtime, which forces tired nurses to work extra hours beyond their scheduled shifts, is a negative working condition directly attributable to short staffing. Negative working conditions such as this contribute to the unattractiveness of the profession further exacerbating the nursing shortage. Because of nurses' concerns for patient safety, they have valid fears that understaffed and exhausting hours do contribute to increased medication errors, patient safety, infection, and other poor patient outcomes. "It is a dangerous practice that has to be stopped not only for the patients but also for the nurses themselves." (Jeanine Cunningham RN, Sept. 21) The current trend of inadequate working conditions that contribute to exhausted, overworked nurses clearly compromises the health and safety of the patient and the license of the nurse providing care. (MNA, Oct. 24, 2000)

"I have watched the nursing profession slowly bleed out nurses." (Teri Arthur RN, BSN, MSM, Sept. 12, 2000)

A nurse in central Massachusetts testified that within the current acute care atmosphere there is a level of increased stress, inadequate staffing, increased levels of anxiety and unacceptable scheduling patterns. "Today a nurse can not go into work, knowing that she/he will go home at the end of his or her designated shift. Today a nurse cannot go into work knowing that she/he has delivered the best care that the patient deserves...." The focus of the patient's comfort needs has been put aside for increased technology, increased responsibility and an overwhelming patient load. Nursing is not about bedside care anymore; nursing has become a catalyst for the patients' revolving door. Increased mandatory overtime, which is forcing nurses to work extra hours beyond their scheduled shifts, is purely a symptom of not having enough staffing." (MNA, Oct. 24, 2000)

"This (mandatory OT) is a practice used to staff hospitals. We are driving our nurses out with this kind of abuse." (J.C., RN, Sept 21, 2000)
 

 C. WORKPLACE SAFETY:

Violence in the workplace was mentioned in each hearing. An emergency room nurse with 26 years of experience in an inner city hospital draws our attention to the violence in the ER that has increased in the last five years:

There has been an influx of psychiatric patients; others are on drugs and alcohol. We need one-on-one supervision of these patients. We put them all together and have one staff member to watch all of them. It is hard to have them (the patients) moved to a floor because of insurance issues. They (administration) are now pushing three-minute triage to move patients. You push them in and push them out... What if the reason they are there is domestic violence? How are you going to truly access this and intervene to prevent future injury in three minutes? (RN, Sept. 21, 2000)

Working conditions need to be healthy and safe in order to retain our nurses and recruit new nurses. According to the center for Disease Control and NIOSH, nursing is one of the most dangerous professions. Often the critical safe guard that is missing is sufficient staffing. "The disability of psychiatric nurses is the highest, as recorded by the Commonwealth insurance carrier." (Oral Testimony, RN, Sept. 12, 2000) We must address a comprehensive workplace violence prevention program.

There are safety issues in the workplace that affect the retention of nurses. Safety issues include the health of nurses who lift patients and lack of adherence to OSHA Standards (ergonomics), latex allergy, the quality of indoor air that is found in our institutions, and serious back injuries. The passing of the needlestick injury prevention legislation in Massachusetts was an important step. "This law, signed in August by the Governor would not have been possible without the tenacity and leadership of Representative Canavan." (KD., RN, MPH, Oct. 24, 2000)

D. NURSING AS A CAREER CHOICE:

There are several forces that are causing the decline in the numbers of men and women who are choosing nursing as a career. The themes that were most often mentioned throughout the sessions included the social preference for choosing nursing that are related to working conditions and control of their environments, the media and negative associations related to patient care, and nursing errors. The last concern centers on the constant fear of losing one's license to practice due to errors caused by poor working conditions. Prospective nurses are aware that their entire career can be scrapped for a mistake made while deep into the fourteenth or fifteenth hour of their work day. These people often shun nursing for a more stable profession.

"Much effort and money has been spent on recruitment, but little is done for retention. I contend that if the same effort and money were put toward retention, recruitment would not be a problem."(T.A., RN, BSN, MSM Sept 12, 2000)

The amount of required education combined with low nurse wages and predictable markets for nursing practice affect occupational choice. School nurses are the lowest paid nurses of all yet are required to have a Baccalaureate degree and be responsible for hundreds of potential patients.  In all fields of nursing the sheer difficulty of working with so many patients, unexpected layoffs, chaotic workplaces, and lack of respect for the profession cannot be ignored. The numbers of programs for nursing education and the capacity of current programs to graduate enough nurses is limited. Because of retirement, retention, and death, we will not be able to replace our current level of nurses. What are the incentives for new students to select nursing? (Oral Testimony, RN, Sept. 21,2000)

Social preferences for nursing as a career (multiplicity of career choice for woman) and capacity of nursing education program affect the number of nurses in our state.

• Supply of faculty
• Cost of tuition loan
• Length of time to earn degrees
• Nurses wages in the labor market
• Number of deaths and retirement
• The fear that managed care has led to cost cutting
• The physical demand on nursing and enrollment caps (RN, Sept. 12, 2000)

There are budget caps on nursing. There are decreases in the number of nursing students because of the 10:1, faculty/student ratio regulated by the Board of Registration in Nursing. Nursing education is expensive for colleges because of the number of faculty needed. (Oral Testimony, RN, Sept. 12, 2000)

There are inadequate numbers of nurses to care for an increasing diverse patient population due to immigration and refugees. A significant disparity in access to health care exists between the majority and minority populations in Massachusetts. A witness from Cape Cod with 28 years in maternity at the college and at a Boston hospital stated, "the workforce in nursing does not reflect the changing demographics of our society. It is only as we demonstrate that we value diversity will recruitment of minorities into our schools be possible and our profession enriched by our differences." (Oral Testimony, Sept.21, 2000)

E. BOARD OF REGISTRATION IN NURSING:

"The Board of Registration's responsibility is to protect the public." (Amy Fein, Attorney for BORN, June 15, 2000)

A school nurse with a heavy workload and two schools to cover testified, "I value my nursing license which I worked hard to earn and don't wish to end up losing it because I was at the wrong school at the wrong time." (P.C. RN, BSN Oct 24, 2000)

Nurses expressed many fears. Their work setting or specialty area made no difference. All of them vocalized that today's working conditions place their licenses in jeopardy. Working conditions set by profit margin often result in unsafe nursing practice thus placing the nurse's license and safety of the patient at risk.

Complaints that reflect systemic problems are filed with the Board of Registration against the individual nurse, who is the only licensed personnel. Throughout several hearings, nurses questioned the role of the Board of Registration in Nursing to effectively look at the complexity of system failure. We need to set up a system approach for all errors, and to establish a non-punitive environment for Registered Nurses in Massachusetts. (RN, Sept. 21, 2000)

Unlicensed personnel are being supervised by nurses. Often there are 35 patients for each nurse. As the only licensed individual, the nurse is held responsible for the safety of all patients. Why are nurses held liable for what a non-licensed person does? These persons are trained by the hospital or institution so why not hold the training facility liable?

The Board of Registration in Nursing has new regulations regarding standards of conduct for nurses, and acts on complaints filed against nurses. The Board receives a complaint against a nurse's license and investigates to determine if there is a violation of a relevant law. The Board then determines "whether or not the individual nurse has the essential knowledge, skills and ability to continue to hold a license." (Written Testimony, Board of Registration in Nursing, Oct. 24, 2000)

"...nurses need protection to stand up against unsafe health care without the Board responding to the administrative and corporate bodies' issues through disciplinary regulations." (C.C. RN, CS May 18, 2000)

The failure of the system in which the nurse practices is not questioned.

A nurse for 29 years on Cape Cod states the acuity of patients (gravity of the illness) seems to be escalating. "Ratio of nurses to patients is 1-8. There are cardio-catheterized patients who need monitoring every 15 minutes. Staffing is per diem and floating. I may be the only nurse with the skills to carry out the medications. We don't have enough nurses. Every shift that I work, I work outside my license. I put my license on the line, but if I did not do it my patients would suffer. If the Board of Registration in Nursing wants to protect the public, they need to provide a safety net for the nurse too. The Board of Registration cannot hold the nurse responsible for an unsafe environment."(RN, Sept. 12, 2000)

"You are frequently working outside the standards of practice... it is crisis nursing at every turn." (M.P. RNC May 18, 2000)

A nurse at the Massasoit hearing testified, "To reduce the medication errors, it is mandatory that all Health Care Organizations adopt a voluntary non-punitive blame-free environment (with the exception of poor performance). A blame-free environment is essential to an error-free environment. Nurses in particular fear the regulatory system in Massachusetts. It is viewed by one and all as a punishment system. When a system is faulty and an error made, the nurse is blamed and often punished. The results are the underreporting of errors. In Massachusetts, nurses are afraid."  RN, May 18, 2000)

Nurses who refuse to work in an unsafe setting are threatened and harassed.
 

 F. SPECIALTY NURSING:

Since specialty nursing positions such as acute care, operating room, maternity, pediatrics, geriatrics, emergency room and critical care require additional training; the general shortage of nurses is intensified in these important settings.

An acute care nurse describes the situation of staffing at the hearing in Chicopee. "In any wings of the hospital, I would be responsible for 12 patients. In the last several weeks, we've been at 2 nurses for 38 patients. They told me to take 24 patients. They are acutely ill, with an overworked staff. Most people (nurses) don't stay on that unit .... I have a problem going into work and learning that I am not getting to that dressing today, and it's not fair to them (patients.)." (RN, May 18, 2000)

The cross training in hospitals to offset the lack of skilled nurses may be deskilling the young nurse. They may not have the opportunity to develop as a highly skilled nurse with a solid knowledge base. These nurses are robbed of the opportunity to build confidence in their ability to perform these skills. There are currently no regulations to prevent this occurrence. It contributes to the loss of young nurses. (RN, June 15, 2000)

An Operating Room nurse testified, "As an OR nurse, we are expected to take call. We rush in to save a life and have just rolled out of bed. You have worked your 12-hour shift, gone home to a late evening dinner, gone to bed early and boom ... the phone rings. You rush to reconnect that finger from the snowblower injury and are facing yet another 8 hours of work, under a microscope, no less trying to load suture that is hardly visible to the naked eye and keep everything under control. Often you face the emergency craniotomy of that poor 17 year old hit by a drunk driver who also has open fractures of the legs and also needs a splenectomy. This is a job for young nurses, yet there are very few young OR nurses. OR nurses need special training, yet programs to train them are few and far between ... Working in a level one tertiary care unit needs the best. Not the tired." (RN, June 15, 2000)

A nurse at the Elms College hearing illustrates this point. "I was recently floated to Hematology/Oncology unit and had 8 patients. Six patients were on research protocols, each with 6 to 10 medications that I had to deliver. I didn't know any of these drugs." Many nurses do not even know their deficits. There is a direct relationship to the skill of nurses and the number of nurses to patient outcomes. (RN, May 18, 2000) "Patient safety is the bottom line for staff nurses and many are forced to work outside their licenses to achieve this." (T.A., RN, BSN, MSM Sept. 12,2000)

At Bristol, a witness and a Registered Nurse for 25 years working at a Boston hospital states that because of the nursing shortage, new graduates are coming into acute care. They are not receiving the support they need. Education departments have been downsized to cut costs. "Therefore, the vicious cycle continues, shortage exists, no support given, nurse is overworked, nurse leaves nursing." (RN, Oct. 12, 2000)

Shortages in staffing are also relieved by floating nurses who work through the hospital, often outside of their area of expertise. Mandatory overtime and floating affect the quality of care. When terms like productivity and efficiency are used, it does not mean that nurses are providing good care. The hiring of temporary nurses who are unfamiliar with the institution is a practice that has significant implications for the occurrence of medication errors. (RN, Oct 12, 2000)

An RN from Brockton noted that drastic cuts in nursing staff have devastated care. "Staffing is now based on projection, not actual beds, so there are not enough nurses when patients go beyond projections. There are mandatory overtimes employed by hospitals to accommodate for these shortages of nurses." (RN, Oct. 24, 2000)

Ratio must refer to direct patient care staffing only. We need to separate the financial charges for nurses from the hospital charges. There needs to be some link between the nurse and the revenue stream.

A 31-year-old RN at a long-term facility stated at the Chicopee hearing: 

Subacute - 38 patients: 1 nurse/5-6 aides 
Average medications per patient - 12 
On high end 36 medications per patient.

Because of high fuel costs, her facility cannot hire another nurse. (RN, May 18, 2000). The reimbursement for care is just too low and patient care suffers.

A Subacute Care RN for 4 years reports:

• 8-hour shifts are 12 hours due to mandatory overtime
• Patient ratios - 1 RN - 21 patients, 2 RN - 38 patients
• An RN was asked to push two medication carts which is unsafe (RN, May 18, 2000)

Unfortunately, we are not ready to provide support to a nurse working in an unsafe environment, but only too ready to punish nurses (through BORN) for what may be system inadequacies. (RN, Oct. 24, 2000)

Another example of problems in specialty nursing involves school nurses. The role of the school nurse has changed substantially due to the mainstreaming of sometimes very medically compromised children, as well as school administration of children's medications and increases in certain health problems, such as serious asthma. Staffing levels have fallen far behind these changes in the student population. (RN, Oct. 24, 2000).

"School nursing as a profession is also a unique situation in that nurses must comply with regulations promulgated not only by the Board of Registration in Nursing but also by the Department of Education." (M.R_ BSN, MS Oct. 24, 2000)

School districts do not as a whole, recognize the worth of a licensed nurse. (education, certification). Gone are the days of diploma only nurses. They are college educated.
 

 Long Term Care

It is poor policy to extend the administration of medication to unlicensed persons. Addressing the shortage of nurses in long term care for our elders, it is poor public policy to have unlicensed individuals administer medications. The elderly, unlike healthy individuals, metabolize medications in different ways. The reactions of elders to medication, and the serious side effects and their subsequent hospitalization, is the single largest Medicare and Medicaid expense. The effects of administering drugs by unlicensed persons may cause preventable deaths. It is not a task to administer medication to elders, it is a skill requiring education. (K.D. RN, MPH Oct 24, 2000)
 

G. HOME HEALTH NURSING:

At a Visiting Nurse Association of Southeastern Massachusetts, nurses care for 6,000 clients. There are 154 nurses who made 86,000 visits. There are more than 5,000 nurses working in home health care today in Massachusetts. With the current shortage, it is not possible to find enough nurses to meet the needs of Visiting Nurse organizations. (Written Testimony submitted to the Commission by an administrator at the Visiting Nurse Association, Oct. 24, 2000)

Home health care nurses are under appreciated and undervalued. Often this is evident in the governance of the state policies and practices and regulations. Examples given at the hearing by an administrator at the VNA are as follows:

Example One:

The state funded homecare program which last year was budgeted at $980 million and which in 1999 was supplemented with the new chronic care fund of $11.6 million has expressly prohibited the purchase of nursing services with those dollars - even in cases where the client required home health aide, and even though this delegated class of workers can care for patients only as an extension of a licensed nurse or therapist. After several years of advocating for a change by the home health industry, EOEA issued a Program Instruction which would allow for the purchase of nursing care. In practice, so far little has changed.

Example Two:

There are inequities in the state budget itself. At present, the state spends more than 95% of its massive long term care budget on institutional care, leaving less than 5% for home care. Increases in rates of Medicaid payments, which translate into increases in salaries and benefits to nurses and other workers, are routinely built into the state budget for hospitals, nursing homes, and other providers. While these groups may not get what they want, the fact is it is assumed that they must get some increase. That has not been the case in home health. There have been only two rate increases in seven years, each one hard fought and insufficient. When our nurses tell us they are leaving us to take jobs in hospitals that are paying more per hour, we can do little. It is often the very same nurses who have told me that they have found more personal and professional satisfaction in being a visiting nurse. (VNA, Oct. 24, 2000)
 

 In written testimony, the Visiting Nurse Association made the Commission aware of the following concerns: (The following is actual testimony submitted Oct. 24, 2000)

• Private duty nurse rates - We understand that the state cannot just throw money at these problems, and we are sensitive to wage escalation battles. However, the state private duty-nursing program is abysmally underfunded, with just one increase since 1996 of 5.6%. With unfilled cases reaching previously unheard of levels, agencies would like to be able to use LPNs or staff nurses on overtime. The state LPN rate is not much higher than that for a home health aide and the state has refused to allow agencies to bill at an overtime rate that exists in the regulation but is not recognized by DMA. Please help us to get nursing to these most fragile children and their families.

• Paperwork - Our nurses are drowning in paper, with no end in sight. We have just implemented the federal requirement that we collect some 86 outcome measurements on all our patients, regardless of payment source, every 60 days. We as agency leaders are doing all we can to streamline this process with measures such as the use of computers in the field, and adding additional support staff to assist registered nurses with clerical aspects of their jobs. We have heard that the state plans to require yet another assessment tool for state funded cases which is duplicative and places an added burden on our nurses that they just don't need. Join us in convincing the state that the single federal home care outcomes assessment tool must be used.

• Continuing education   Home health agencies traditionally have not hired new graduates. Reimbursement, which does not cover normal operating costs, will not begin to cover the costs of the additional orientation, mentoring, and supervision that new graduates would require to work in this setting.

• Recognition of the evaluation, assessment and management skills of nurses when working with paraprofessionals - CNA's/HHA's. Increasingly, in the home health field, there are pressures to use the most inexpensive person to do the caring in the home. There are some tasks that can be successfully delegated, but the process requires skilled nursing oversight, which the system too often ignores. (VNA, Oct. 24,2000)

H. REIMBURSEMENT:

Reimbursements to healthcare organizations do not cover the cost of proper, safe care.

"Nursing services should be billed differently. They have always been seen as part of the 'room and board'." (G.C. RN, MSN Oct. 24, 2000)

Nurses testified to the following:

Nurses are willing to work hard, cover the off shift, holidays and weekends to care for their patients. When they cannot receive a decent wage because reimbursements to healthcare organizations do not cover costs, they become disillusioned and discouraged and potentially leave an organization or nursing altogether. This adds to the nursing shortage...

 The more we cut costs, and the more we ask nurses to be efficient, the less we are reimbursed and at the same time, more patients come to our doors seeking care...

The reimbursement system for health care is failing; we have a severely underfunded Medicaid program in this state, and it needs to be fixed. We owe that to the citizens who rely on MassHealth for their access to care, and we owe that to the nurses who care for them...

We need immediate relief through licensed Medicaid payments to our hospitals and a fully funded free care pool. Our low income and elderly citizens deserve the highest quality of care. We cannot continue to provide care if it is underfunded. You can already see decisions being made to close services such as inpatient, psychiatry, and obstetrics by financially distressed hospitals.

Decreased staffing does translate into less time spent at the bedside by licensed nurses. Nurses testified at each hearing that reimbursement rates play a key role in this unhealthy phenomenon but not the only role. Nurses feel strongly that their employers do not staff facilities according to patients and their acuity levels. They often spoke about high patient/staff ratios that not only referred to numbers but to patient physical needs. Nurses feel very strongly that their employers are not listening to them. As T.A., RN stated on Sept. 12, 2000, "The truth of it is, that management had an acuity tool. It was the nurse they put in charge."

Some nurses told the Commission about incidences of violence that could have been prevented if staffing levels had been "more realistic". J.B., RN, BA on May 18, 2000, spoke quite powerfully about an assault upon her person while working on an understaffed psychiatric unit. "I struggled and then my entire face was ground into the floor. Still blinded, I then felt a blow to the back of my head and then my head was slammed into the floor, breaking in half a six-inch hair clip. I screamed as loudly as I could, but no one was around to help me ... it was fortunate that one of the patients rescued me, because no staff was available in either of the two main hallways to intervene ... I lost an entire month of work to recover from this assault..." J.B. further testified that "Our CEO has written that our hospital is committed to providing a safe workplace. Paradoxically, one nurse after another suffers brutal attack after patient attack. The nurses who survive these assaults are sometimes completely alone in the hallway. These facts are well known to our administrators. Yet, those who decide about staffing levels have not remedied the situation, claiming there is no money to increase staffing. Ironically, I witness luxurious crystal chandeliers installed, fancy diagnostic equipment materializing, and brand new wings being built upon our hospital grounds."

The workplace is extremely stressful and unfulfilling for many seasoned nurses. Their personal safety and that of the patients they care for was the most often repeated refrain of the hearings. Retaining these experienced and dedicated nurses becomes more difficult every year. Too many are leaving. This exodus of licensed nurses also carries with it an irony addressed by the following nurse:

"They may have escaped, but the patient cannot." P.D., RNC, NHA, May 18, 2000.

 "Nurses have always 'worked hard'. By this I mean that the physical, emotional and intellectual nature of nursing practice has always been and always will be laborious. That is not the essence of nurses' concerns. What concerns nurses is that the staffing patterns leave them unable to practice nursing to meet the standard to which they are ethically, professionally and legally held."
(Karen Daley RN, MPH, Oct. 24, 2000)

"Nursing cannot bear the brunt of a health care financing system that is broken."
(Barbara Weatherford RN, MS, Oct. 12, 2000)

"Managed care /HMO's have taken the 'science' out of nursing. It has become $$$$ for tasks done and nursing is being deskilled."
(Michael D'Intinosanto RN, June 15, 2000)
 

I. LICENSING:

In order to practice nursing, a state license is required. Every nurse takes an intensive examination after graduation from an accredited school of nursing. Once earned, every licensed nurse must earn the required number of Continuing Education Units (CEU) to fulfill renewal requirements which are every two years. A nurse works hard to earn a license and hard to retain it in good standing. If a nurse should have their license suspended or revoked, they cannot practice their profession. Loss of license is a real fear experienced by nurses practicing in today's health care environment. This was an overwhelming theme of everyone's testimony.

"Patient safety is the bottom fine for staff nurses and many are forced to work outside their license to achieve this." (T.A., RN, BSN, MSM, Sept. 12, 2000)

”... nurses are too stressed and are placed in situations that jeopardize their license." ( M.K. RN, June 15, 2000)

The nurses who testified admitted that the working conditions in their institutions often forced them to meet the needs of the patients without the requisite backup from administration. They spoke of feeling abused and unappreciated in today's workplace.

"...hospital nursing units have become the new sweatshops." ( T.A., RN, BSN, MSM, Sept. 12, 2000).

The licensed nurses also repeatedly expressed concern about the Board of Registration in Nursing (BORN) and its approach to the practice of nursing in today's environment. Many nurses testified that they felt that they were being "..held totally responsible for system failures."( T.A., RN, BSN, MSM, Sept. 12, 2000). They told us that they believed that BORN worked "on a culture of blame” and left them without a support system.

"The nurse should be able to rely upon the Board to perform exploratory verification of the complaints as 1) lying within its jurisdiction of decision making & to 2) discriminate between frivolities & legitimate allegations between nurse conduct and health system complaints." (C.C., RN, CS, May 18, 2000)

While nurses have a negative perception of BORN, the perception is not shared by the members of the Board of Registration. At each hearing, BORN was represented and at times testified in response to feelings aired by the nurses. BORN's full testimony is attached to this report. The Commission recognizes the "disconnect" between the professional nurses and their regulatory board. At a time when nurses feel that the regulatory structure is "...more about punishment & legalities than about improving the quality of care." (P.D., RNC, NHA, May 18, 2000). The Board expressed feelings of being squarely in the middle of the debate and unable to respond in the manner that the nurses want. They are a "regulatory agency" charged by the state to oversee licensing and protect the public. Nurses want the Board of Registration to support and protect both them and the public. 244CMR 9.00 defines the standards of conduct for all nurses licensed by the Board of Registration in Nursing. (See attachment)

When J.G., a school nurse refused to give a medication because the order was not properly filled out, she was disciplined by her school system and appealed to BORN. BORN took a year to respond. During this year, she told the Commission that she was continually hassled by her School Board. BORN found her to be correct in her actions and stated so in their written response but she indured much waiting for their response. "It was a very lonely road to stand up for the nursing profession & do what was right."( J.G. RN, May 18, 2000). According to the many nurses who testified, they all agree that "...we are at the mercy of our employers ......”.

"We need a health care system that makes it easy to do the right thing and harder to do it wrong." (T.A., RN, BSN,MSM, Sept. 12,2000)

"...seems that a nurse is 'guilty until proven innocent'." ( P.14., RN, June 15, 2000)

"...I ask that you hold those who create this environment responsible for the consequences." (T.A., RN, BSN, MSM, Sept. 12, 2000)

Mandatory overtime is dangerous because nurses are often too tired.  "Recently an OR nurse told me she came to work at 7am to scrub-in for cases. She left the hospital at 1 am. How would you like to have been her last patient on the table 18 hours later?" (J.C., RN, Sept. 21, 2000)

"We are at the mercy of our employers because refusal of mandatory overtime could constitute abandonment of patients. This could be grounds for dismissal and loss of your nursing license." (J.C., RN, Sept. 21, 2000)

"I'd like to emphasize that patient abandonment is now a regulatory matter and is not relevant to any discussion of mandatory overtime, which is clearly an employment matter." "In almost no instance would the Board ever entertain refusal to work an extra shift as requested by an employer as grounds to find a nurse guilty of a regulatory violation." (Rachel Timely, RN, BSB, MSN, PhD, Chairperson of the Board (BORN), Oct. 24, 2000)
 

 CONCLUSIONS

"More than any other factor, what is driving good nurses out of practice is intolerable working conditions and the frustration of not being able to deliver safe patient care." (M.O., RN Oct. 24, 2000)

Nurses licensed to practice in Massachusetts are working in a health care system that is hurting from personnel shortages and financial cutbacks. This system forces them to work in an environment that is not conducive to excellent quality care. Their working conditions are stressful for all and intolerable for many. They feel that there is little to no support for them and therefore there is no help forthcoming. They are leaving the profession in numbers that are alarming. Nursing schools are hurting financially and seeing their enrollments decline. Licensed nurses are scared of what the future holds for them. They want better working conditions so that they can practice safely and compassionately.

"It must become illegal to have one nurse caring for 60 patients in a nursing home ... It must become illegal to have one nurse responsible for 8 acute care patients. This is not only dangerous but also unacceptable." (K.D., RN, MPH Oct. 24, 2000)

The nursing shortage is caused by two main factors: inability to retain licensed nurses & the inability to recruit new nursing students. Recruitment and retention, both are vitally important to correct the crisis. Of the two, retention is the first that should be addressed because it would have the quickest results. Recruitment strategies should be underway as soon as possible because it takes several years to achieve the desired result. It must be noted that improvement of working conditions must be addressed for both recruitment and retention. Nurses must stay and students must want to join them.

"The health care system has its roots in the military model where it is expected that the foot soldiers would have everything to do and nothing to say. No one listened to staff nurses because they felt they did not have to. There was always an army of young nursettes ready & willing to throw their bodies into the trenches and do the work." (T.A. RN, BSN, MSM Sept. 12, 2000)

Retention ... 

1) improved working conditions

2) mentor/support for new nurses
 

Recruitment 

1) financial support for non traditional students while in school

2) loan forgiveness for students who achieve licensing and work in a Massachusetts health care facility/institution for a designated time period or who choose a field of nursing that has severe shortages of personnel 

3) improved working conditions to make the profession more attractive to new students
 

 Finally, on the issue of improved working conditions. The following must be truthfully addressed and discussed in earnest: mandatory overtime, patient/staff ratios, unlicensed personnel, career ladders, weekend/holiday shifts and support services.

RECOMMENDATIONS

1) Legislation to limit mandatory overtime to a level that would permit nurses to work in optimum physical and psychological condition.

2) Legislation to establish patient/staff guidelines that are based in reality and based on patient acuity levels.

3) Comprehensive legislation to improve the image of nursing as a profession and entice and retain women/men into the field.

4) A legislative study of the constraints that nursing schools are under whether regulatory or financial and recommendations for relief.

5) A legislative study of BORN's scope of power and whether it should be expanded to include licensing support services that take into account the system failures that can lead to errors.

6) Licensed nurses who are currently practicing must be included on all levels when studies are being done and legislation is being written. They are the best judge of acuity since they are the patient's first line of care.

"The answer is not to throw more nurses into a troubled setting." (T.A., RN, BSN, MSM, Sept. 12, 2000)

"Recently (perhaps within the last six months), the world of opportunity for graduating seniors (sic from nursing schools) appears to have broadened. However, often the fragile systems of support for novice transition, although bolstered from a year ago, cannot meet the overwhelming demand for competence characteristic of current practice settings.  As a consequence, I believe that I have seen beginning practitioners lose confidence in their ability to practice safely. Many choose to leave and go in search of more supportive environments." (D.M.D., RN, PhD, Sept. 12, 2000)

"Without legislation that regulates the amount of time a nurse can safely work, without legislation that regulates the amount of patients that a nurse can safely administer to, eventually, there will no longer be a nurse at the bedside." (K.L., RN, June 15, 2000)
 
 

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