Earlier this week, the Massachusetts state legislature's Joint Committee on Public Health heard – yet again – testimony on a nursing union's misguided legislation to mandate one-size-fits-all nurse staffing ratios. And as we've done for the past 15 years, MHA, our member hospitals and the Organization of Nurse Leaders of MA/RI/NH/CT (ONL) voiced strong opposition to mandated nurse staffing ratios in Massachusetts.
This editorial in the Boston Herald gives a good overview of the hearing and the shortcomings of the union’s unwise proposal.
The union has it wrong on every level. The importance of registered nurses does not need to be artificially inflated by mandating the use of registered nurses when patient care does not require it. Respecting the professionalism of registered nurses does not mean that legislators remove bedside nurses' discretion to determine what staffing levels meet a patient's needs. Supporting registered nurses does not mean that the job security of other dedicated members of the caregiving team and those who support the teams must be threatened.
There is a reason that in the 20 years since a California nurses union campaigned to pass a registered nurse staffing mandate that not one other state in the country has adopted such a radical approach: it doesn't work. It is not controversial to say that providing care to patients in a hospital setting is as complex as it is important. It is too important and complex to be done by a fixed formula.
When you look closely at what the union proposes in their legislation, they prove that their proposal is fatally flawed. In California, their law dictates that the staffing levels in hospital medical-surgical units be 5 patients to one nurse. But in Massachusetts they would dictate that the ratio in such units be 4 to 1. At the national level, the union calls for telemetry units to be staffed at a 1:3 ratio, but in Massachusetts the union would mandate that telemetry units be staffed at a 1:4 level. So it is evident that by their own tacit admission there is no single staffing ratio that can apply to all patients in similar units regardless of the severity of a patient's illness, the experience and education of nurses, and the composition of the caregiving team supported by other medical resources.
The union also claims that there are many studies that support their position. I encourage everyone to look at those studies. We have and so has ONL, and we found that none of the studies support the union's claims. Not one. The studies point out that nursing care is important. We couldn't agree more. They demonstrate that variation in nursing care and other factors can make a positive impact on patient care. We agree. But what they don't say is that there is a predetermined, set staffing formula that meets the needs of every patient in a unit.
Massachusetts is in the forefront of ensuring that every person has access to high quality care that is effective and affordable. We are making great strides towards achieving those goals, and hospitals are fully engaged in that effort. That is why hospitals increasingly are paid not simply to provide services, but by determining that the care they provide produces good outcomes for our patients. And we are in the midst of a transformation where caregivers are increasingly working to keep patients healthy so that they do not need to be in hospitals. What the union proposes runs counter to what healthcare reform is all about in Massachusetts.
On average, 75% of hospital costs are used to pay for those who work in hospitals. The largest portion of hospitals workers are nurses and Massachusetts nurses are the highest paid in the country, except for one state – California. So it's easy to understand that increasing the number of nurses in hospitals without tying such increases to the actual care needs of patients will have serious implication for all the others who work in hospitals. It will even drive up the cost of nurses in non-hospitals settings such as home healthcare and community health centers.
Despite union claims to the contrary, the quality of care in Massachusetts is good. In fact, on the critical measures of Patient Care experience and Mortality measures, Massachusetts out-performs California. If the union's mandated staffing formula could deliver quality care as they claim, then after more than 20 years of experience, California should be leading the entire country in quality care measures – but it isn't.
Is there more we can do? Absolutely. That is why MHA and ONL have filed legislation to increase transparency about not only staffing, but also patient outcomes. And because research shows that nursing education is a critical component in improving care, the legislation promotes an increase in the number of registered nurses with 4-year college education. This legislation focuses on the needs of patients and respects the professional status of nurses. It’s the right focus.
So we're achieving a great deal with more to do. And there are different ways to achieve improvement. But the evidence is clear that government – as opposed to nurses and doctors by the bedside - making staffing decisions is not an answer, it's a problem.