News & Events

Walkout looms at St. Vincent

Battle over nurse-to-patient ratios is nationwide problem

View Worcester Telegram & Gazette article here

Registered nurses Marlena Pellegrino, left and Dominique Muldoon are co-chairs of the union bargaining unit at St. Vincent Hospital. (T&G Staff/CHRIS CHRISTO)

By Lisa Eckelbecker

WORCESTER — Nurses at St. Vincent Hospital are planning to walk off the job Friday because of stalled negotiations for a new contract at the downtown medical center, but their dispute goes beyond Worcester and reflects a disagreement between nurses’ unions and hospital managers nationally about staffing.

Unions in Maine, Illinois, California and Minnesota have raised complaints about staffing levels in contract negotiations recently in what hospital officials describe as a national union agenda and what nurses call concern for their patients.

“Our fight for safe staffing is the agenda of the St. Vincent nurses,” said Marie E. Ritacco, a member of the nurses’ negotiating team and the board of the Massachusetts Nurses Association, the union representing 740 St. Vincent nurses. “That is the only thing we’re concerned about right now, but clearly there is a fight for safe staffing going on across the nation.”

The issue generally boils down to ratios. Nurses’ unions have argued that the way to guarantee safe staffing is to limit the number of patients handled by nurses on a unit. Hospital officials say ratios are too rigid and fail to account for complexities such as the skills of nurses assigned to particular units and the severity of patients’ illnesses.

The Massachusetts Hospital Association collects voluntary filings on staffing levels from hospitals and posts them on its website, but it opposes fixed ratios at hospitals.

“It’s a fixed sort of cookie-cutter approach that doesn’t allow for any sort of flexibility on a nursing unit,” said Karen S. Nelson, a registered nurse and senior vice president of clinical affairs for the Massachusetts Hospital Association.

The dispute is playing out as Massachusetts is considering changes in health care aimed at slowing medical spending. Nationally, provisions in the federal health care reform law signed last year by President Barack Obama also promise changes in how much hospitals will receive from government programs for care for seniors and the poor.

Uncertainty in the health care industry makes this the perfect time for nurses to raise disputes over staffing, said Gary N. Chaison, professor of industrial relations at Clark University in Worcester.

“Nurses feel under tremendous pressure because they constitute a major portion of the cost of operating a hospital, and they see staff ratios as a way administrators can reduce costs by increasing the patient load,” Mr. Chaison said. “They see ratios as an income and job-security issue.”

Hospital officials say they must consider costs.

Fixed ratios “would be a significant cost in an area where there’s so much reform and concern about the costs,” said Ruth P. Walton, regional chief nurse executive for Chicago and New England for Vanguard Health Systems Inc., the Tennessee company that owns St. Vincent Hospital and MetroWest Medical Center in Framingham and Natick.

There are generally few specific nurse ratio requirements for hospitals. Neither Medicare, the government’s health insurance program for seniors, nor the accrediting organization known as the Joint Commission require specific nurse staffing ratios, hospital officials said.

Although advocates for nurse staffing ratios have sought legislation in a number of states that would mandate staffing levels, only California has implemented measures. Some examples of California ratios:

  • Intensive and critical care units must have at least one nurse for every two patients.
  • Telemetry units monitoring cardiac patients must have at least one nurse for every four patients.
  • Medical-surgical units must have at least one nurse for every five patients.

Implementing the ratios was not easy. Some hospitals struggled in the midst of a nurse shortage to field enough nurses. One report by researchers from the University of California at San Francisco in 2009 found no significant impact on patients as a result of staffing changes.

Hospital officials dismiss current union-management talks about ratios as part of an agenda driven by National Nurses United, a union organization affiliated with the Massachusetts Nurses Association.

“I think they’re driving the same agenda that they did in California,” said Ms. Walton of Vanguard.

A number of studies cited by nurses, however, have linked higher nurse staffing levels to better health outcomes for patients. Some suggest that higher staffing levels even save hospitals money. Researchers from the Mayo Clinic and other health centers reported as recently as March in the New England Journal of Medicine that there was a link between increased mortality and nurse staffing that dropped below target levels at a large, unnamed academic medical center with nearly 200,000 patient visits between 2003 and 2006.

St. Vincent Hospital is licensed for 321 beds, including 51 psychiatric beds. On average, patients fill 219 beds, including 18 psychiatric beds, according to the hospital. About 31 percent of the nurses work full time, and the rest work part-time schedules of 24 hours, 32 hours or 20 to 35 hours a week.

The St. Vincent nurses have had some staffing ratios in their contracts since 2000, according to Miss Ritacco. The language provides that each nurse on a medical-surgical unit should care for no more than six patients, she said, but in practice each nurse may care for seven to eight patients. At the same time, the patients checking into hospitals are sicker than in previous years, she said.

St. Vincent management has proposed staffing additions that would cost about $3 million, according to Ms. Walton. The nurses want assurances they will have to care for no more than four patients on a medical-surgical unit.

“I think hospitals feel if they staff to the levels we’re asking for, they’re going to break the bank … There’s also an element of control. I think they feel they would be losing control if nurses decide this is the ratio we need,” Miss Ritacco said.

At UMass Memorial Health Care, which operates two hospitals in Worcester, there are no specified nurse-patient ratios in contracts. UMass Memorial generally staffs one nurse for every three to six patients on a medical-surgical unit, according to a UMass Memorial spokesman.

The number of workers other than nurses plays into decisions, as does nursing staff turnover, the severity of patients’ illnesses, the technology in use and outcomes such as falls, pressure sores and infections, according to Dr. Walter Ettinger Jr., president of UMass Memorial Medical Center. Finally, he said, there are costs to consider.

“We first of all have to be safe and effective, but we also have to be efficient,” Dr. Ettinger said.

St. Vincent Hospital and its nurses are scheduled to negotiate again tomorrow.

Meanwhile, some other unions and hospitals around the country reported progress in negotiations on Friday. Nurses from Eastern Maine Medical Center in Bangor announced agreement on a one-year contract. Nurses at Range Regional Health Services hospital in Hibbing, Minn., called off a three-day strike that was to begin Wednesday.

St. Vincent nurses have called for a one-day strike. The hospital said it had to guarantee five days of work to the replacement nurses it has reserved and wants to make sure the nursing staff isn’t turning over too much in a short period of time.

The St. Vincent nurses “will not be coming back to work until they’re called back after a minimum of five days,” said Dennis L. Irish, a spokesman for the hospital.

The nurses maintain they’re ready to talk.

“We still have time,” said Miss Ritacco.