Health

HEALTH • June 15, 2015 21 MNA-backed ballot question that would have required disclosure of hospital financial informa- tion, the Massachusetts Hospital Association (MHA) agreed to a compromise bill that set ratios only for intensive care units. The House and Senate quickly and unanimously passed the bill, and Gov. Deval Patrick signed it into law immediately. A year later, any sign of agreement on staffing in other hospital departments has been obliterated. The nurses' union and the hospital group are again at each other's throats over the interpretation of the new law, the idea of extending staffing ratios to other hospital units, and the data around staffing levels and patient safety. MNA spokesman David Schildmeier said that, even though the law took effect in September, "very few of the hospitals are following it." "Our nurses are trying to live by it," he said. "They have to, or their licenses are in jeopardy." A matter of interpretation? But the MNA and MHA have different interpreta- tions of what following the law entails. The language of the law is that "the patient assignment for the registered nurse shall be 1:1 or 1:2 depending on the stability of the patient as assessed by the acuity tool and by the staff nurses in the unit, including the nurse manager or the nurse manager's designee when needed to resolve a disagreement." Schildmeier argues that this sets a baseline ratio of one RN to one patient in all ICUs, with nurses work- ing in the units given the option to take on a second patient if they think it's safe. The MHA, in a state- ment responding to questions from HEALTH, said that the law "made perfectly clear" that "there is no 'default' staffing level of one patient to one nurse as the union claims." The mention of an "acuity tool" in the law brings up another area of conflict. The concept of the tool is a way to determine what kinds of situations call for one-to-one care and which ones may allow a nurse to take on another patient. It's supposed to answer questions about whether patients need a dedicated nurse if they're on a ventilator, or just out of surgery, or in various other conditions. The legal language here is "The acuity tool shall be developed or chosen by each hospital in consultation with the staff nurses and other appropriate medical staff and shall be cer- tified by the Department of Public Health." The union argued that the tool should be the product of the committee, with nurses making up half the members. The MHA said the hospital is responsible for developing the tool, with the com- mittee serving only in an advisory capacity; a ruling by the state's Health Policy Commission last week giving hospital administrators the final say on the tool, though nurses will comprise half of the com- mittees, was a win for hospitals. While the battle over the implementation of the ICU law continues, the two sides are also butting heads again on the larger question of setting staffing ratios for all hospital units. Schildmeier said the union sees a California law that took effect in 2004, setting ratios for each unit of the state's hospitals, as a model for Massachusetts. Unionized nurses in some hospi- tals, including Saint Vincent Hospital and UMass Memorial Medical Center in Worcester, have won contract language setting nurse-patient ratios, but Schildmeier said ensuring that the hospitals follow the rules requires constant vigilance and use of the grievance process. Schildmeier points to the experiences of nurses who are union members to highlight the impossible dilemmas that RNs can face in understaffed hospi- tals. He described one nurse who heard alarms going off for two of her patients in an ICU at once and realized whichever patient she didn't attend to may die. In another case, he said, a nurse's supervisor pulled her away from holding a dying baby because she had other patients to care for. "These nurses, they're killing themselves," he said. To the MHA, though, legally defined nurse-patient ratios aren't the answer to providing better care. "The idea of having a predetermined, fixed num- ber of registered nurses assigned to every patient, in every unit, in every hospital without regard to the actual care needs of individual patients, never made sense and makes even less sense at a time that qual- ity patient care depends on developing integrated teams of professional care givers," the group said in its statement. Staffing studies yield mixed results Academic studies on nurse staffing levels don't come down definitively on one either side of the debate. "The evidence seems pretty clear that having more nurses is better than having less," said Grant Martsolf, a RAND Corporation researcher who has studied the subject. One 2014 study that Martsolf led found that higher nurse staffing levels shortened patients' length of stay, and reduced the likelihood of adverse events that could have been prevented with proper nursing care. But, Martsolf said, it's not clear at what point the additional benefit from adding another nurse is so marginal that it isn't worth doing. Martsolf said it's hard to draw specific conclusions about adding more nurses in particular units because the data researchers use is typically only available at a hospital level. When it comes to the California law that the MNA sees as a model, the results are also mixed. Joanne Spetz of the University of California at San Francisco said the legally mandated ratios seem to have improved nurses' job satisfaction and ability to accomplish patient-safety tasks. But, she said, when it comes to direct measure of patient outcomes, "Our nurses are trying to live by it, they have to, or their licenses are in jeopardy." David Schildmeier, spokesman for the Massachusetts Nurses Assocation, on the law setting staffing ratios in ICUs Continued on Page 30 PHOTO/WWW.ABSOLUTVISION.COM

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