Legislation is Key to Improving Patient Care & to Ending the Nursing Shortage
CANTON, Mass.—The Massachusetts Nurses Association (MNA), in conjunction with the Coalition to Protect Massachusetts Patients, announced today that it will re-file legislation on Dec. 1st that would require all Massachusetts hospitals to adhere to Department of Public Health (DPH)-established minimum registered nurses (RN)-to-patient ratios as a condition of licensure by DPH.
The legislation was passed favorably by the legislature’s Joint Health Care Committee last session and a 10-hospital Pilot Program was passed in the Senate budget. The House Ways and Means Committee is currently in the process of creating a subcommittee to work on the bill.
The filing of the legislation follows the release of numerous prominent research studies and reports that show understaffing of registered nurses is dangerous — mistakes, serious complications and preventable errors occur when nurses are forced to care for too many patient at once.
"The evidence also makes clear that poor staffing and dangerous working conditions created by the hospital industry have caused and continue to exacerbate a shortage of nurses; nurses who are no longer willing to work in hospitals," said MNA President Karen Higgins, RN. "Passage of this legislation is key to improving care for our patients and to creating conditions that will retain and recruit the nurses we need to provide safe patient care."
Below is a summary of key research findings:
- Last July, HealthGrades, Inc., a leading health care quality research firm, found more than 195,000 patients die needlessly every year in our hospitals from a series of complications directly related to poor nurse staffing
- Last May, a National Consumers League survey of patients found that nearly half of recently hospitalized patients reported their care was compromised by inadequate RN-to-patient ratios and that the majority of those surveyed supported legislation to regulate ratios.
- In 2003, the DPH reported a 76% increase over the last seven years in the number of medical errors, patient falls, complications and complaints by Massachusetts hospital patients, with the majority of complaints related to the quality of nursing care.
- In 2003, the Institute of Medicine (IOM) reported poor RN staffing and forced overtime were a major contributing cause of medical errors, and that improved staffing could reduce these errors significantly. The IOM report recommended ratios be established for intensive care units, that mandatory overtime be prohibited and every nurse be given the right to refuse an unsafe patient assignment.
- The Joint Commission of Accreditation of Healthcare Organizations linked poor staffing to 25% of serious medical incidents.
- JAMA reported that for every patient in addition to four assigned to a nurse, the risk of death and failure to rescue increases by 7%. The author of the study concluded that legislation to regulate RN-to-patient ratios was a credible approach to improving patient safety in hospitals.
- A 2003 survey of Massachusetts nurses found that more than 65% reported an increase in medication errors, more than 50 percent reported increases in patient injuries and complications, and nearly one in three nurses reported patient deaths directly related to having too many patients to care for.
State Rep. Christine Canavan (D-Brockton), who is a registered nurse and vice chair of the Joint Committee on Health Care, is the lead sponsor for the bill, which is entitled "An Act Ensuring Patient Safety." Canavan was also the chair of a special legislative commission which was formed in 2001 to study the crisis in nursing in Massachusetts. The Commission’s top recommendation was the need to establish RN-to-patient ratios in hospitals.
The bill would protect Massachusetts patients by ensuring that they receive nursing care appropriate to the severity of their medical conditions. To ensure maximum flexibility, the bill also requires that the Department of Public Health develop an objective system for monitoring patient medical conditions so that staffing levels can be adjusted and improved to meet patient needs. The bill would set minimum staffing standards specific to every unit and department in a hospital to ensure that major disparities in care levels do not exist in the commonwealth’s hospitals, and specifically provides that nothing in the bill "shall be deemed to preclude any facility from increasing the number of direct-care registered nurses."
Bill Draws Significant Public Support
The measure, which was nearly passed in the last legislative session, has won broad public support, with more than 80 percent of Massachusetts voters in favor of the bill, according to a survey conducted in 2004. The MNA, along with 70 leading health care and consumer organizations, last year formed the Coalition to Protect Massachusetts Patients, which has been advocating for the passage of the bill. The coalition includes the American Cancer Society, American Heart Association, American Lung Association, Health Care for All, League of Women Voters and the Mass. Senior Action Council.
The bill passed the Joint Committee on Health Care last year, and a compromised version of the bill passed the Senate as part of the budget process. Ultimately, after intense lobbying from the health care industry, the measure failed to be released for a vote by legislators. More than 102 legislators signed on as sponsors of the bill last year.
"The public wants this bill to pass, nearly every important health care advocacy groups wants this bill to pass, and a majority of legislators have put their name on this legislation," said Higgins. "The time has come to end the needless suffering of patients in our hospitals. We are confident that this is the year this legislation will become law."
Measure Key to Ending Shortage of Hospital Nurses
The bill has also won overwhelming support from the nursing community, with nearly nine in 10 nurses supporting the measure according to an independent survey of the state’s front-line nurses. A number of national studies and surveys of the nursing workforce document that understaffing of nurses by hospital administrators and poor working conditions (such as mandatory overtime) created by administrators are the leading causes of the current nursing shortage, particularly in Massachusetts where nurse staffing levels saw the greatest reductions of any state in the nation during the 1990s.
A national survey of registered nurses found that nurses have the lowest job satisfaction of any employee group surveyed by the federal government. A survey published in JAMA found that for every patient beyond four assigned to a nurse resulted in a 15% increase in job dissatisfaction and a 23% increase in burnout for nurses. A survey of Massachusetts nurses found that an astounding 93% report being burned out by excessive patient loads; and 65% agree with the statement that working conditions in hospitals are "brutal" for nurses; nearly half of Massachusetts’ hospital nurses have considered leaving their jobs due to poor staffing.
There is no shortage of nurses in Massachusetts according to Julie Pinkham, RN, MNA Executive Director, "What we have is a shortage of nurses willing to work under the conditions created by the hospital industry. The fact is that our state has more nurses per capita than any state in the nation. The number one problem we face is one of retention."
According to the Board of Registration in Nursing statistics, the population of registered nurses in Massachusetts increased by 10% between 1992 and 2002, while the number of hospital beds to be staffed by RNs decreased by 30%. While 83% of Massachusetts nurses are working, only 45% are working at the hospital bedside (below the national average) and only half of those are working full time.
Safe staffing legislation is the key solution to ending the nursing shortage. A 2003 survey of Massachusetts nurses found that 42% of those nurses not working in hospitals would strongly consider returning to bedside care if safe staffing legislation were passed (a pool of 42,000 nurses). A 2004 survey of nurses currently working part-time in hospitals found that 33% would increase their hours if the bill were to pass (an additional pool of more than 1,800 RNs).
Fact Sheet on H. 1282 — What the Bill Does
Currently there are no standards in existence for nurse staffing in Massachusetts hospitals, and no requirements for hospitals to provide an adequate level of nursing care. RN-to-patient ratios, which have been linked to a variety of patient complications and mortality in hospitals, can vary widely from facility to facility. It is not uncommon for nurses in Massachusetts to have seven, eight or even 10 patients at a time, when a safe ratio would be no more than four patients for a nurse on a typical medical/surgical floor. This legislation attempts to reverse these trends by mandating nurse staffing that is sufficient to care for the planned and unplanned needs of patients. It is based upon significant nursing research and experience. The major provisions of the legislation include:
- To provide flexibility in staffing and to account for patients who require more care, the bill calls upon DPH to create an acuity-based patient classification system, which is a standardized formula for rating the illness level of patients (a tool to measure how sick the patients are on a particular unit). Based on the acuity of the patients assigned to a nurse, the ratio would be improved if those patients require more intensive care (meaning the nurse would be assigned fewer patients).
- Minimum ratios are established for different types of units/departments in a hospital. The proposed law calls for one nurse for every four patients in medical/surgical units, where most patient care takes place. In emergency departments, the proposed regulations require between a 1-to-1 and a 1-to-3 ratio depending on the severity of the patient’s conditions. Ratios are 1-to-1 in labor and 1-to-2 for intensive care units while other units range from 1-to-1 to 1-to-5 ratio.
- All acute care hospitals would be required to adhere to these ratios and the DPH acuity scale as a condition of state licensure.
- Strong consumer protections for safe RN staffing would be put in place, including a "prominent posting of the daily RN-to-patient ratios" on each unit.
- Each facility will provide each patient and/or family member with a toll-free hotline number for the Division of Health Care Quality at DPH, which may be used to report inadequate nurse staffing. Such a complaint shall cause investigation by DPH to determine whether any violation of law or regulation by the facility has occurred and, if so, to levy a fine for substantiated violations.
- The bill prohibits the practice of assigning nurses mandatory overtime as a means of meeting the ratios. Mandatory overtime has been used by hospitals as a means of staffing hospitals in lieu of recruiting enough nurses to provide safe care.
- Clear language related to the role of the licensed nurse and the inability for institutions to delegate to unlicensed personnel, duties which demand nursing expertise. Throughout the 1990s, the hospital industry attempted to cut costs by replacing nurses with unlicensed personnel, which led to deterioration in patient care and helped create the current shortage of nurses.
