Legislators, Again, Grapple With Mandatory Nurse-Patient Ratio

It’s an issue that crops up at the State House every few years and has never been resolved: Should there be a law limiting the number of hospital patients under the care of a nurse at any given time?

This question is back before state lawmakers in this session but this year it may also be on the election ballot.

Massachusetts Nurses Association members pile copies of studies in front of legislators at a State House hearing Monday. They claim the studies prove the need for mandatory, tight nurse-to-patient ratios at all hospitals in Massachusetts. (Martha Bebinger/WBUR)

Massachusetts Nurses Association members pile copies of studies in front of legislators at a State House hearing Monday. They claim the studies prove the need for mandatory, tight nurse-to-patient ratios at all hospitals in Massachusetts. (Martha Bebinger/WBUR)

Is there proof that assigning each nurse no more than four patients would improve care? At a State House hearing on Monday, Karen Coughlin, vice president of the Massachusetts Nurses Association, said yes. Coughlin pointed to one study in particular, “which found that every additional patient assigned to a nurse over four resulted in a 7 percent increase in the risk of death for all the patients under that nurses care.”

But this research, published in the Journal of the American Medical Association, also says it’s not clear exactly how many patients a nurse can care for, but five or six would be wise. California, the only state with a nurse-to-patient ratio law, has nurses caring for five general surgery patients and two in the intensive care unit.

Boston College nursing professor Judith Shindul-Rothschild argues that legal patient limit translates to better care for at least one disease in California as compared to Massachusetts.

“When we look at our patient outcomes for heart failure readmission, for instance, there is a difference,” Shindul-Rothschild said. “It’s not just staffing, but it’s partly due to staffing.”

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How Many Patients Does One Nurse Treat: Ballot Question On Staffing

“Just Ask!” That’s the slogan for a new campaign by the Massachusetts Nurses Association (MNA). The union is encouraging people to ask how many other patients their nurses will be treating that day. The slogan is meant to draw awareness to what the nurses union sees as a growing disconnect between the profit-driven healthcare industry and the quality care of its patients.

Alex E. Proimos/flickr

Alex E. Proimos/flickr

The campaign’s goal is to enact minimum mandatory staffing levels, capping the number of patients per nurse. After a similar measure failed to pass the state legislature in 2008, the MNA wants to take the issue directly to voters through a ballot initiative. The union has submitted the text of the Patient Safety Act to the Attorney General’s Office; the act’s terms include limiting nurses to having up to four patients in surgical units and in emergency rooms. Once approved, the union will need to collect 70,000 signatures by November for the Patient Safety Act to appear on the 2014 ballot.

Currently, California is the only state that has mandated nurse-patient ratios. However, this topic may well seem familiar to Mass. voters: state nurses have sought staffing legislation since 1995, and 2011 saw fraught contract negotiations between Tufts Medical Center and its nurses. CommonHealth analyzed how Tufts’ lower nurse ratio affected patient care.

Lynn Nicholas, president of the Massachusetts Hospital Association, alluded to the idea’s long history by calling the current initiative petition a “repeat of an arcane idea that has no merit” in a statement. Continue reading

UMass Memorial Replacing Nurse Lactation Consultants With Non-Nurses

From today’s WBUR newscast:

UMass Memorial Medical Center in Worcester is moving to replace nurse lactation consultants with non-nurses.

Hospital officials say the lay-offs will save money, but nurses say the new lactation consultants lack the same skill sets.

Julia Naya is one of the nurses who’s losing her job tomorrow: “I don’t know how someone can come in and do the assessments and have the same kind of nursing skills if they’re not a registered nurse,” she told WBUR.

UMass Memorial says the move frees them up to offer more personalized breastfeeding care and classes.

In other recent nursing-related labor news, Healthcare Finance News reports a two-day picket of Baystate Health facilities.

Tufts Medical Center Nurses To Strike May 6

A one-day strike by nurses protesting staffing levels is set

The registered nurses of Tufts Medical Center announced they will hold a one-day strike on May 6 beginning at 6 am, to “protest dangerous patient care conditions,” according to a statement from their union. The strike will be the first nurses’ strike at a Boston hospital in more than 25 years, and will end on May 7 at 6:45 am, the union said.

“We are very disappointed and angered by our administration’s failure to engage in a real negotiation to avoid a strike,” said Barbara Tiller, RN, chair of the nurses’ local bargaining unit, in a staement. “Management continues to turn a deaf ear to the concerns of nurses and a blind eye to the suffering of our patients. While none of us wants to strike, we are ready and willing to do so in defense of our patients and the future of nursing at Tufts Medical Center.”

In response, Tufts Medical Center management said it is prepared for the strike and will continue to provide “high quality care to patients.” In a statement issued Monday, the Medical Center said that it “learned today that it will be one of five hospitals facing strikes by NNU [the national nurses union] affiliates in that same week, along with St. Vincent Hospital in Worcester, Children’s Hospital Oakland (Calif.), Eastern Maine Medical Center in Bangor and Range Regional Health Services in Hibbing, Minn.

“The idea of National Nurses United taking five hospitals out on strike in one week proves they are focused on their national agenda and not on the patient care at these hospitals,” said Ellen Zane, President and CEO of Tufts Medical Center, said in the statement. “We are extremely disappointed that they would take this reckless, national approach in Massachusetts and in Boston. It is clear that this is a selfish, self-serving agenda designed to increase MNA/NNU membership, and thus generate more union dues. What is reprehensible is they are using our nurses as pawns in their scheme. It appears – as we suspected from last November when we initiated negotiations – that they had no intention of reaching agreement with us and only sought to line up several hospitals for strikes to gain publicity. Tufts Medical Center is committed to serving its patients and community, and we will continue to deliver high-quality care throughout any walkout.”

Zane emphasized that the hospital will provide outstanding care during the strike in which it will bring in other nurses to care for patients along with the entire care team at Tufts Medical Center, including physicians, nursing technicians, pharmacists, social workers and many other dedicated professionals.

Herald: Tufts CEO Takes On Nurses, Alerts Replacements For Strike

Ellen Zane, the president and CEO of Tufts Medical Center, is mobilizing hundreds of replacement nurses and is prepared to put them to work if Tufts nurses authorize a strike later this week, The Boston Herald reports.

Zane is taking a page from President Reagan’s anti-union battle book, lining up hundreds of out-of-state replacements for anyone who might dare to go on strike in an increasingly bitter union-management fight.

On Thursday, Tufts’ 1,110 nurses will vote on whether to authorize a strike. Their contract expired in December.

Zane yesterday called the Massachusetts Nurses Association’s threat of a hospital strike “reprehensible.” MNA spokesman David Schildmeier shot back that Zane’s threat to use replacements is “obscene.”

Zane told the Herald she’s contacted out-of-state nurses and is prepared to spend up to $4 million hiring at least 200 to keep Tufts open during what she’s classifying as a “very, very likely” work stoppage over a dispute about how many patients each nurse serves. The union wants a limit of four per shift — a demand Zane said could cost another $33 million a year.

CommonHealth Analysis: Nursing Staff Levels At Tufts Medical Center Trail Competitors, Data Suggest

There’s a heated dispute currently underway between the Massachusetts Nurses Association — specifically the 1,200 RN’s at Tufts Medical Center — and management at the hospital. They are engaged in contract negotiations that haven’t been pretty. The nurses accuse the hospital of allowing staffing levels to fall so low over the past year that patient care has slipped and conditions have become dangerous; the nurses have complained to the hospital’s board citing numerous examples of egregious care. The hospital, in response, says its care has in no way faltered, and that the complaints are part of a national union strategy to boost the nurses’ bargaining power.

So what’s the truth?

We decided to look at the numbers, and came up with a simple analysis of nursing staff levels based on publicly available 2011 data from a statewide hospital-sponsored website called Patient Care Link. According to these numbers, it appears that registered nurses at Tufts Medical Center do spend less time caring for patients in key medical units such as the emergency department and adult critical care unit compared to nurses at the other Boston teaching hospitals. Tufts also has a more meager nurse-to-patient ratio in its combined medical-surgical unit compared to other hospitals with similar units, according to the data from Patient Care Link.

Nurses: Less Time With Patients

Our analysis basically calculated the number of hours nurses are scheduled to work, and divided that by the average number of patients seen in the particular unit. This measure is called “nurse hours per patient visit.” So, for instance, in its emergency department, Tufts provides 1.98 nurse hours per patient visit (again, the average number of hours a nurse cares for a patient during that patient’s visit to the ER), according to the website numbers. That’s fewer nurse hours compared to the other teaching hospitals: we calculated 3.2 nurse hours per patient visit at Massachusetts General Hospital; 2.36 hours at the Brigham & Women’s Hospital and 2.31 hours at Beth Israel Deaconess Medical Center.

Let me say here that Patient Care Link is far from a precise measurement of staffing levels. It’s a site sponsored by the Massachusetts Hospital Association. It’s voluntary and non-binding. And all it asks is that hospitals submit their staffing plans. Still, these are the numbers that are available. And short of sneaking into the hospital undercover and doing headcounts, this is all the public has to work with. If anyone out there has a better way to figure this out, please let us know.

A spokesperson for Tufts Medical Center doesn’t dispute our numbers, per se, but says such comparisons don’t offer the full picture and that patient care at the hospital remains top-notch. “The numbers don’t truly tell the whole story,” says Tufts’ Julie Jette.

Nevertheless, here are the numbers:

Boston Teaching Hospitals
Unit Type Tufts MGH BWH BIDMC
Emergency Department
RN Hours Per Patient Visit
1.98 3.2 2.36 2.31
Adult Critical Care-Surgical
RN Hours Per Patient Day (24 Hours)
15.2 20.49 19.79 17.54
Hospitals with ACC Med/Surg Combined
Tufts Newton-Wellesley Good Sam Winchester
Adult Critical Care- Medical / Surgical Combined
RN Hours Per Patient Day (24 Hours)
13.33 15.48 15.45 15.04

Longer Wait Times

Nurses say this dip in staffing — with fewer nurses available for more patients — has a detrimental effect on patient care. Barbara Tiller, an RN at Tufts for 21 years, says patients now wait a lot longer for a nurse. “These are patients in pain, ringing the bell, and waiting 20, 40 minutes,” she says, “or patients who can’t get out of the bed to toilet themselves, and then they end up waiting there in a wet, soiled bed.” Continue reading

Revamp Nursing To Help Save The Health Care System?

A U.S. army nurse practitioner

Last month, the Institute of Medicine put out a sweeping, 600-page report called “The Future of Nursing: Leading Change, Advancing Health.” It’s about how America’s 3 million nurses can help save the health care system as it struggles with shortages of both doctors and nurses, and rising patient demand from newly insured people and an aging population.

The report calls for nurses to help lead the redesign of the health care system; to practice at the highest level their education and training allow; and to make the nursing education system better.

Really, it made me think, why have I not heard more about nurses and health care reform? Anyone who’s ever spent time in a hospital knows who really runs the place…

This week brings some meaty discussion of the report’s recommendations, and revives the decades-old argument between doctors and nurses about how broad the nurses’ “scope of practice” should be. (Nurses: “We can fulfill many of doctors’ traditional functions, such as prescribing medicine and ordering tests.” Doctors: “Uh oh. No, you can’t. You don’t have our education.”)

The surgeon and author Pauline W. Chen writes about the Institute of Medicine report at, and NPR’s “Talk of the Nation” devoted more than a half-hour to the topic. The full transcript is here.

Though Dr. Chen’s piece supports the idea of expanding nurses’ roles, she writes that significant physician pushback is looming:

The expert panel [that wrote the report] is scheduled to convene again at the end of this month, this time to discuss implementing their recommendations. They will have their work cut out for them. Critics like the American Medical Association have charged that the report overlooks the extensive education and training of physicians and ignores the importance of physician-led teams in ensuring patient safety. In its official statement, the AMA warns that “with a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage.”

Readers, what do you think? Can and should nurses do more?