02.27.2004

The hospital industry's opposition to H. 1282 and why it is wrong
By Julie Pinkham
MNA Executive Director

As we head into the final months of the legislative session, the Coalition to Protect Massachusetts Patients will be pushing for passage of H.1282-safe staffing legislation that would regulate RN-to-patient ratios in Massachusetts hospitals.

Opposing this bill will be two principal groups: the Massachusetts Hospital Association and their subsidiary, the Massachusetts Organization of Nurse Executives (MONE).

Their opposition is based on the following arguments: 1) the bill strips nursing leaders of their ability to make "professional" judgments about staffing; 2) H.1282 fails to provide flexibility to account for the changing needs of patients; 3) there are not enough nurses to meet the ratios; and 4) the cost of meeting these ratios is too high, and will result in the decimation of the state's already fragile health care system.

My task here is to examine each of these arguments in light of past history, nursing research and common sense. Under such scrutiny, I'll show that none of these arguments against the bill holds any water.

Whether or not we pass legislation to regulate RN staffing in our hospitals boils down to a simple question: based on past performances, can we trust hospital administrators and nursing leaders to have sole discretion over staffing decisions in our hospitals? Here is some history to help you answer this question… In October, the Massachusetts Department of Public Health issued a report citing a 76 percent increase in injuries, medical errors and complaints in our hospitals related to patient care, with the majority of the problems arising from the quality of nursing care. Last June, Opinion Dynamics Corporation-a respected independent research firm that is often used by the hospital and insurance industry-reported that nearly nine out of 10 nurses report the quality of care they deliver has suffered because of poor RN-to-patient ratios, and more than two-thirds reported an increase in medication errors. This same survey also revealed that one in two nurses reported increases in patient injuries, read-missions and complications, and nearly one in three reported patient deaths related to nurses having too many patients to care for. Nine out of 10 nurses attribute hospital administration understaffing to the cause of the nursing shortage and the crisis we now face. These findings have been duplicated in more than five national surveys that have been conducted over the last two years. In fact, the Joint Commission on the Accreditation of Health Care Organizations and, most recently, the Institute of Medicine (IOM) linked hospital understaffing to serious harm to patients. And both bodies pointed to actions by hospital administrators to cut staffing in the last decade as the cause of this crisis. Those who provide care don't trust their "nursing leaders" to make decisions about staffing levels in our hospitals. In every survey of nurses on this issue, ratios are what nurses say they want and need most in order to provide safe care to their patients. The IOM agrees, and it recently came to a much more radical remedy than ratios. That body said that front-line nurses-not administrators-should have the right to stop admissions to their unit when they feel conditions are unsafe. The likelihood of such an approach ever being approved or allowed by the industry is pure fantasy. Remember, in 1998 the Legislature had to pass a "whistleblower law" for nurses to protect themselves from their own administrators who were firing and punishing them for simply "reporting" unsafe conditions.

It is clear from the record and the research: the hospital industry cannot be trusted to make good staffing decisions, so it's up to the government to step in and force the industry to provide the protections it refuses to offer.

Nearly every news story about this bill has included a quote from the opposition that was along the following lines: "This bill provides a one-size fits all approach to nurse staffing and it fails to provide the flexibility hospital needs." Either the MHA and MONE have failed to read the bill, or they are engaging in a purposeful misrepresentation of H.1282. Regarding the industry's "one-size fits all" claim, the bill actually provides 12 different ratios-each specifically designed for a hospital's specialty areas. H.1282 also calls for the creation of a standardized patient classification system that would do exactly what the MHA and MONE claim the bill won't do. We would point out that MONE has always had the "flexibility" to adjust nurse staffing levels. But what have they chosen to do? To assign staff by a projected "average" daily census and rarely, if ever, add nurses when units become full.

As a practicing RN, what would you rather have: a guarantee that on any shift you would never have more than four patients? Or would you rather continue to allow your "nursing leaders" to have the "flexibility" to make these decisions based on their assessment of your patients' needs? We've asked front-line nurses this question, and nine out of 10 say they'd prefer the flexibility of H.1282.

There is overwhelming evidence that says there are more than enough nurses in Massachusetts to meet the requirements of H.1282. It is undisputed that Massachusetts has the highest per capita population of nurses in the nation. It is also true that in the last ten years, Massachusetts' RN population has increased by 10 percent while the number of hospital beds has decreased by 30 percent. There is no shortage of nurses in this state. In backing their argument that the "nursing shortage" has caused this crisis and prevents ratios as a solution, the industry often cries, "But 83 percent of nurses in Massachusetts are already working!" We don't disagree. What they fail to mention is that only 45 percent of working nurses are at the hospital bedside and only half of those nurses are working full time. The industry also fails to mention why these nurses re not working at the hospital bedside. According to a research study in which the MNA and MONE participated in 2001, the answer was quite clear: nurses left the bedside because of staffing conditions and patient loads. In a survey conducted last June (previously referenced) almost nine in 10 respondents attributed the shortage to patient ratios. And in March 2003, the Journal of Nursing Administration (MONE's own professional journal) featured a study with the same result. Again, the evidence is clear and over-whelming: poor staffing conditions that were created and implemented by the industry created this shortage.

There is good news though. Nearly every study concludes that improving staffing and RN-to-patient ratios is the answer to stemming the flight of nurses from the bedside. In Massachusetts, 65 percent of nurses who've left the hospital bedside because of poor staffing conditions say they'll return if H.1282 is passed.

When all else fails in their arguments, we can count on the hospital industry to peddle fear in an attempt to convince the public of the dangers of this bill. Their threatening mantra: "The nurses needed to meet these ratios do not exist, so hospitals will have to close units in order to ensure an adequate number of staff." Applying the best and most credible research shows the cost of meeting the requirements of H.1282 to be a 1 to 1.7 percent increase in a hospitals budget. We argue that hospitals currently misuse and misapply far more than 2 percent of their budgets.

The front page of this month's Massachusetts Nurse includes an article about a study in from the Journal of Health Care Finance and Quality showing that increased staffing of RNs has no statistically significant impact on hospitals' finances/profit margins. In other words: increasing nurse staffing is, at worst, cost neutral. The study's author suggests that this positive result may be attributable to the impact adequate RN staffing levels have on reducing turnover.

In 2002, the American Organization of Nurse Executives, a national organization to which MONE belongs, commissioned its own report on RN vacancies and turnover. In that report, the following statement was made: "The national average turnover rate for RNs in 2002 was 21 percent (17.9 percent in Massachusetts). Such turnover levels represent substantial recruiting, training and orientation costs. For example, a facility with 400 RNs must develop a system to recruit and train up to 80 new RNs each year. Investments to reduce 'churn' may pay considerable dividends in decreased costs and improved quality of patient care." Another study by Valery Upenieks published last year in the Journal of Nursing Economics stated that hospitals with an RN-to-patient ratio of one to seven experience a turnover rate of 18 percent (close to Massachusetts' turnover rate). Conversely, hospitals with a ratio of one to four (as out-lined in H.1282) have a turnover rate of just 9 percent.

The author provided a calculation of the value of reducing turnover (from 18 to 9 per-cent) that showed that for every $1 invested by hospitals in meeting minimum RN-to-patient ratios, there will be a $1.20 return in cost savings associated with reducing RN turnover.

Sung-Hyun Cho, a nurse researcher in California, recently published a study in the Journal of Nursing Research, entitled, "The Effects of Nurse Staffing on Adverse Events, Morbidity, Mortality and Medical Costs" (March 2003). She found a direct link between RN staffing and incident rates for hospital-acquired pneumonia. The study revealed that pneumonia adds five days to a patient's hospital stay and costs $22,390 to $28,505 per incident. An increase of one hour worked by RNs per patient day was associated with an 8.9 percent decrease in the odds of pneumonia. Applying her findings to Massachusetts hospitals, an estimated $23 million could be saved annually by reducing pneumonia. When all else fails in the industry's attack on this legislation, you can bet they'll revert to using fear as a tactic and claim that passing this bill will result in the closure of community hospitals. Do not fall for such fear-mongering. The industry has closed 30 hospitals in the past decade due to their own mismanagement…not due to the cost of nurse staffing. It is clear that between savings associated with reducing nurse turnover and the reduction of just one complication, Massachusetts would experience a significant cost benefit by investing in H.1282. Implementing safe staffing legislation just makes sense. What is at stake in this debate is a matter of life and death for every patient in Massachusetts hospitals-as well as the very future and integrity of our nursing profession.

Most of the studies and the research supporting this article can be found on our web site at www.massnurses.org/safe_care/, or by calling our Department of Public Communications at 781.830.5717.