SAFE STAFFING IN MASSACHUSETTS: A YEAR OF LEGISLATIVE ACTION

Linda Curtin, RN, PhD(c), CCRN
Gail B. Gall, PhD(c), MS, APRN, BC
Brenda Vigue, PhD(c), MS, APRN, BC

Hospital registered nurse (RN) staffing is a health care industry challenge. Compounding the problem are cost control demands and patient safety concerns in the face of nursing shortages. Aging of the nursing workforce, attrition of direct care nurses, increased demand, and faculty shortages contribute to the problem. Nurses’ demands for safe staffing levels have shifted from nurses and nurse managers to union bargaining tables and state and federal legislatures.

The American Nurses’ Association (ANA) supports federal legislation for safe staffing in acute care settings. Provisions of bills filed in 2004 included eliminating mandatory overtime and floating RNs to units without adequate orientation, reporting of daily unit staffing levels publicly, protecting nurse whistleblowers, and linking federal reimbursement to safe staffing ratios. ANA strongly opposes bills mandating specific ratios. ANA supports nurse-driven staffing plans factoring patient acuity, qualifications of nurses and other personnel, technology demands and resources, and nursing specialty organization’s recommendations. (ANA, 2004).

Massachusetts Legislation

Two bills filed in Massachusetts for the 2005-2006 session offered divergent strategies for addressing patient safety and RN staffing. Both reflect agreement that a nursing shortage exist, but represent two schools of thought regarding causes and potential solutions. The House bill, supported by the Massachusetts Nursing Association (MNA) (2005a), proposes that inadequate nurse staffing ratios result in inferior patient outcomes and increased "nurse burnout". Mandated minimum nurse staffing ratios (MSRs) in acute care hospitals are seen as the solution for both improved patient outcomes and nurse retention. (MNA, 2005b).

The Senate bill, supported by the Massachusetts Hospital Association (MHA) and the Massachusetts Organization of Nurse Executives (MONE) reflects the belief that MSRs represent inflexible policy that will cause devastating economic effects to already financially stressed acute care hospitals (MONE, 2003). The Senate bill focuses on voluntary industry regulation while improving recruitment and retention of nurses (MHA, 2005). The major components of each bill are summarized in the Table.

Table. Comparison of House and Senate Bills

Legislative History

Three legislators, co-chairs of the Joint Special Committee on Nursing Ratio Legislation, authorized a two-part bill analysis by the University of Massachusetts/Worcester Center for Health Policy and Research (CHPR). CHPR is the state’s public sector health consulting group. The interdisciplinary project team released the report in two stages. The first was a comparative analysis of the two bills. The second evaluated hospital and public agency cost estimates and impact on nursing workforce development for each bill. (Hurwitz et al., 2005).

Patient Safety and Quality of Care.

Data collection and outcome measures, mandatory overtime, and acuity-based staffing plans were identified areas impacting safety and quality. The CHPR found that establishing a uniform data collection system would be most problematic. The House bill lacked any data collection provisions. In contrast, the Senate bill included nurse workforce data collection, but the three outcome measures chosen excluded nurses’ work environment satisfaction. CHPR recommended constructing outcome measures based on industry standards such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and National Quality Forum. (NQF). An additional problem was that the expanded work of the Center for Nursing, the intended repository of data, was not budgeted, thus creating an "unfunded mandate."

CHPR predicted that mandatory overtime limits, as required by the House bill could limit access to hospital beds. Neither bill addressed shifts exceeding 12 hours or rest between shifts, practices that impact patient safety, and are regulated in the transportation industry (Hurwitz et al., 2005). While the House bill mandated MSRs based on a Patient Classification Systems (PCS), the Senate bill required nursing input into acuity based staffing plans, allowing flexibility based on patient, nursing staff characteristics, and other factors. The CHPR identified potential costs in developing a uniform statewide PCS system and suggested that "best practice" models developed by magnet hospitals might provide examples for classifying patients and deriving appropriate staffing ratios (Hurwitz et al.).

Accountability

CHPR defined accountability as a transparent process in which data reporting, monitoring, and evaluation results are available to both the public and legislature. (Hurwitz et al., 2005). Under the House bill, hospitals would be required to report extensive data to Department of Public Health (DPH), and post staffing ratios publicly. Violation of the MSRs would result in fines, potential loss of licensure and possible litigation. Without funding for a uniform PCS or linkage to patient outcome measurements, the bill lacked evaluation capacity. Although the Senate bill linked nurse staffing and patient outcome data, the accountability function was constrained by limited nurse-sensitive data. Neither bill funded expansion of DPH capacity to monitor results.

Costs and Access to Care.

Both bills would impact hospital and DPH costs by increasing nursing labor costs and expanding regulatory requirements. Tutty and colleagues (2005) analyzed the House bill’s potential impact on different types of hospitals. Increases to the RN payroll would vary between 2.7% in a Boston area acute teaching hospital to over 200% in a DPH run multi-service hospital. In general, impact on urban and suburban hospitals would be less than rural and specialty hospitals. However, CHPR cautioned that true costs might be underestimated as variances in staffing, utilization, nursing wage increases, and measurements of staffing ratios for each unit would affect costs. Additionally, minimum PCS ratios failed to anticipate higher ratios with increased acuity. Improvements to patient care safety and outcomes might offset the additional expenses of richer nurse staffing, but the amount could not be estimated. CHPR forecasted that implementing DPH regulatory mandates would cost $400,000 yearly in the House bill, while the Senate version would be approximately half of that. Neither the amount offset by potential fines, nor potential savings from improved state oversight of hospital performance could be estimated (Tutty et al.).

Labor Market and Workforce Development.

CHPR predicted that the House bill would increase demand for RNs. The Senate bill expanded nursing education capacity through faculty development, facilities, and infrastructure, but CHPR considered the one-time budget allocation of 30 million dollars inadequate (Tutty et al., 2005).

Report Conclusions

The CHPR summarized key findings: potential economic impacts on hospitals, costs to public agencies, and impact on nursing education and workforce development. Criticisms of the House bill include failure to account for variations in care between specialty and general hospitals, a lack of scientific support for establishing rigid ratios, failure to link data to quality of care, creating unfunded mandates for DPH, and failure to address nursing workforce issues. The Senate bill, with voluntary nurse staffing plans, would still increase hospital costs. Additional funding would be needed for DPH oversight and for full implementation of the nursing education components (Tutty et al., 2005).

Current status

The 2005 Massachusetts legislative session formally ended in mid-November 2005 with the bills remaining in the Public Health Committee. Until the Committee issues a final report, lobbying continues and the possibility of a compromise bill remains until November 2006.

Conclusion

Massachusetts’ experience provides insight into how legislative initiatives might be designed, implemented, and evaluated. Both sides have engaged the legislature in debate and policy analysis. The CHPR report, in which nurse evaluators participated, identified the key areas for analysis: patient safety and quality, accountability, costs, and workforce development. The emphasis on identifying the appropriate data sources is paramount. The threat of nurse staffing regulation stimulated hospitals to voluntarily eliminate mandatory overtime policies. Magnet hospital nurse-staffing plans and nurse-sensitive outcomes have been showcased to legislators. Lawmakers have increased awareness of the complexity of staffing issues.

Massachusetts’ health care consumers, nurses, and hospitals have undoubtedly benefited from the scrutiny. It would be ideal for organized nurses to speak with one voice, yet this seldom happens. It is a professional strength and skill to see multiple facets of a problem and propose solutions from different vantage points. By involving the legislature in the process, nurses have risked further regulation of their profession in order to advance quality patient care.

THE AUTHORS

The authors are doctoral candidates in the Health Care Policy Program at University of Massachusetts, Boston. The 2005 Comprehensive Policy Examination required students to analyze and compare the bills described in the article.

Linda J. Curtin
E-mail: Lcurtin3@aol.com

Ms. Curtin's recent experience as a legislative intern for a State Representative evaluating the proposed bills, and completion of a Citizen’s Legislative Seminar, facilitated the policy analysis. As a Critical Care Clinical Nurse Specialist and Director of Nursing Staff Education, Linda has lectured extensively in the areas of critical and cardiac nursing care. As a regional faculty member for the American Heart Association Advanced Cardiac Life Support Program (ACLS), Ms. Curtin has organized and coordinated resuscitation education courses for nurses, physicians, and other health care professionals in the Southeast Region of Massachusetts.

Gail B Gall
E-mail: gallgb@verizon.net

Ms. Gall’s experience as in intern for Health Care for All and completion of the Citizen’s Legislative Seminar contributed to this policy analysis. As a nurse practitioner, Gail has worked in the US and abroad as a clinician and educator. She has conducted needs assessment, resource mapping, and quality improvement studies of programs for underserved populations. Issues examined include mental health and substance abuse, case management services for low-income women, and school-based health center (SBHC) funding and outcomes. As past president of the National Assembly on School Based Health Care, Gail has advocated for permanent federal funding for SBHCs, and currently is an advocate for expanded access to health insurance and school based health care in Massachusetts.

Brenda Vigue
Email: brenda.vigue@bmc.org

In 2005, Ms. Vigue participated in a health policy internship with Representative Ruth Balser (D-Newton), co-chair of the Joint Committee on Mental Health and Substance Abuse at the Massachusetts State House. During her internship, Brenda had the opportunity to attend legislative hearings specific to proposed nurse staffing legislation. Completion of the comprehensive exam further solidified her interest in this important health care issue. Brenda is the current President of Health Policy Scholars at the University of Massachusetts Boston. She is employed on faculty at Boston University Department of Family Medicine’s residency training program. Her interest areas include health policy as it relates to high risk and substance abuse populations. She received her Master’s Degree as a Family Nurse Practitioner at Boston College as a National Health Service Corp Scholar and her BSN from Northeastern University where she was the recipient of the University Award for Academic Excellence in Nursing. Her clinical practice has been focused on caring for high risk individuals including inner city, substance abuse, mentally ill, and correctional populations.

REFERENCES

American Nurses Association. (2004). 2004 Legislation: Staffing plans and ratios. Retrieved on July 6, 2005 from www.nursingworld.org/gova/state/2004/staffing.htm

Commonwealth of Massachusetts. (2005a). An act ensuring patient safety. House Bill 1282 (formerly HB 2663). Retrieved June 29, 2005 from www.mass.gov/legis/bills/house/ht02/ht02663.htm

Commonwealth of Massachusetts. (2005b). An act to promote safe patient care and support the nursing profession. Senate Bill 1260. Retrieved June 29, 2005 from www.mass.gov/legis/bills/senate/st01/st01260.htm

Hurwitz, D., Laszlo, A., Masters, E.T., Tutty, M., Kirby, P.B., Fitzpatrick, S.M., et al. (2005). Analysis of House bill 2663 and Senate bill 1260 as related to nurse staffing: Part I: Comparative analysis and policy implications. Center for Health Policy and Research, University of Massachusetts Medical School.

Massachusetts Hospital Association. (2003, June 18). Testimony on professional nursing workforce legislation. Retrieved July 7, 2005 from www.mhalink.org

Massachusetts Nurses Association. (Feb, 2005a). The truth about the nursing shortage in Massachusetts: There is none. Retrieved on July 10, 2005 from www.massnurses.org/safe_care/Tuesday_Reporter/2005_v5/06.htm

Massachusetts Organization of Nurse Executives. (2003, June 18). Testimony in opposition to House bills 1282 and 2600 mandatory registered nurse staffing legislation; Comments on Senate bill 635, an act to promote improved patient outcomes through registered nurse staffing in licensed health care facilities. Retrieved July 7, 2005 from www.massone.org.

Tutty, M., Kirby, P.B., Hurwitz, D., Masters, E.T., Fitzpatrick, S.M., & Himmelstein, J. (2005). Analysis of House bill 2663 and Senate bill 1260 as related to nurse staffing: Part II: Estimated costs to hospitals and public agencies and impact on nursing workforce development. Center for Health Policy and Research, University of Massachusetts Medical School.

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