Nurses, hospitals tangle over staffing levels

MARK BRODEUR, a nurse at Berkshire Medical Center in Pittsfield, says his unit, which serves patients recovering from anesthesia post-surgery, is usually staffed pretty well. But not long ago he says he found himself struggling to care simultaneously for three patients all requiring critical care.

“I had one incoming patient, so I’m hearing the report on that one at the same time I’m holding another patient’s airway open, at the same time my third patient is having an allergic reaction to the anesthesia and throwing up all over the floor,” Brodeur says. It was a nightmarish situation, he says, because he couldn’t attend to the vomiting patient without leaving the patient whose airway he was keeping open. “Nobody can be in more than one place at one time,” he says.

While every workplace has its pinch points, Brodeur says that nurses have a unique and critical role in the high-stakes hospital environment.  When nurses are not available to monitor vital signs of a critically ill patient who takes a turn for the worse, or provide care instructions to those being discharged, or assist frail patients getting in and out of bed, their absence puts the recovery, safety, and welfare of those patients at risk.

Amber Van Bramer, one of Brodeur’s colleagues at Berkshire, says nurses have a duty to take care of and protect their patients. “We need the resources to do that to the best of our abilities,” she says. “We’re not flipping hamburgers here.” (The spelling of Van Bramer’s name was corrected.)

Brodeur and Van Bramer are among hundreds of unionized nurses who are pushing for increased staffing levels in their contracts with hospital administrators at Berkshire, Baystate Franklin Medical Center in Greenfield, Baystate Noble Hospital in Westfield, and Tufts Medical Center in Boston. Some of the nurses have called one-day strikes, which were followed by management lockouts that hospital officials say were necessary to accommodate the contract terms of replacement nurses.

All of the nurses at these facilities are members of the Massachusetts Nurses Association, the largest nurses union in the state and an organization that has been pushing for higher staffing levels for more than 15 years. The union nearly took the issue to the ballot in 2014, but backed off when it agreed to a last-minute legislative compromise that established minimum staffing levels in intensive care units. Now it’s gearing up for another ballot fight next year that would extend minimum nursing staffing levels to all units of every hospital in Massachusetts.

Hospital officials say nurses are not walking picket lines and preparing for an expensive ballot question fight to protect their patients; instead, they are looking out for their own self-interest. The hospital officials say claims of unsafe staffing are inaccurate, unfair, and misleading and that the reports are invented as a way to engage the public and legislators in what has become an ongoing labor dispute over money. While the staffing issue is currently part of MNA contract negotiations, that would all change if voters approve the question being readied for the 2018 ballot.

The ballot initiative in several key ways takes staffing authority away from hospital administrators and gives it to nurses. The question would establish limits on how many patients a nurse can take on in every unit of the hospital. In many of the units, that number would vary depending on the status of the patient. For example, the number of patient assignments in the emergency department would vary from one to five per nurse, depending upon the patient’s status (critical, non-stable, non-urgent, and stable). The law gives nurses power in assessing where patients fall along this continuum.

More than anything else, this shift in management control envisioned by the nurses and their ballot question is what drives passions on both sides of the debate. David Schildmeier, a spokesman for the Massachusetts Nurses Association, says administrators at many hospitals across the state shave their operating costs by staffing at a “bare bones” level.

“This is why we need a law to hold hospital administrators accountable,” he says. “Otherwise they are going to cut costs by trimming the patient care budget in ways that an ever-growing body of evidence shows will hurt patients.”

Michael Wagner, the CEO of Tufts Medical Center, scoffs at any suggestion that his hospital is skimping on patient care. “We have spent a lot of time developing an evidence-based practice in patient care,” he says. “Nurses are in the middle of all that, but to say that quality of care is dependent on the number of nurses is so monochromatic, so incorrect. Patient care quality has nothing to do with the number of nurses. To connect the two is moronic.”

TWO VIEWS AT TUFTS

In mid-July, Wagner looked out his office window onto a scene that was arguably a hospital administrator’s worst nightmare—at least one of them.  Hundreds of Tufts nurses walked in a picket line outside the front entrance of the hospital wearing sandwich boards and talking to reporters, patients, and anyone who would listen about why the facility was unsafe for patients.

Wagner says the claim that more nurses would equal better patient care is a false argument.  He says the ballot initiative to mandate minimum staffing levels is based on nonscientific thinking, would cost hundreds of millions of dollars, and accomplish little beyond swelling the ranks of the MNA. “It’s a lot easier for them to talk about patient safety out there than it is for them to say that they want higher salaries and more benefits,” Wagner says.

Terry Hudson-Jinks, the chief nursing officer at Tufts, says that if the ballot initiative becomes law the quality of care in the hospital would actually suffer. She says the law establishes a rigid staffing model with a fixed number of patients per nurse, an approach that does not take into account all the different variables that occur in the everyday operation of a hospital. The acuity and number of patient needs is constantly changing, and to meet those needs a staffing model needs to be flexible, not fixed, she says.

The administration at Baystate’s two hospitals and Berkshire Medical Center share the same philosophy. They say flexible staffing works well by allowing them to adjust in nearly real-time to subtle changes in patient numbers and needs.

Mary Havlicek, an operating room nurse at Tufts who was walking the picket line that day in July, says the stress of too many short-staffed shifts has lowered morale at Tufts. While the hospital says it hired more than 150 nurses in recent years to account for attrition and higher patient needs, Havlicek says nurses are leaving faster than new ones are coming on board. “Many of the younger nurses get trained here, then they leave for better paying jobs across town,” she says.

When a nurse calls in sick or goes out on leave, Havlicek says, managers send out “blast texts” to nursing staff looking for help filling the gaps. But Havlicek says many of these efforts are in vain, as the per diem nurses who ordinarily would be the ones to fill gaps are already working in the hospital when the texts go out.

”It makes me want to burst into tears when I think of what is going on. We are the ones who have to look the patients in the eyes when we can’t be there to help them,” she says.

Schildmeier, the MNA spokesman, says nurses and doctors are also the ones on the hook legally if something goes wrong.

“We are not asking for that much,” says Havlicek, her voice cracking with emotion. “Imagine if you’re an ICU nurse and you’re getting all these texts from your manager as you’re driving in, saying, ‘We need help. Can anyone cover ICU?’ It’s terrifying. You’re thinking what situation am I going to be walking into.”

To illustrate what sort of situations might occur, Havlicek recounted an incident in what she described as an understaffed Tufts intensive care unit, which is already regulated by a state law requiring set nurse-patient staffing ratios. More patients were hooked up to a high-tech filtration machine than could be monitored by the available staff, she says, so one of the nurses was asked by her supervisor to call the doctor to ask if one of the patients could take be temporarily withdrawn from the machine.

“That question should never have been asked,” Havlicek says.

On that point, Wagner, the Tufts CEO, is in full agreement. “That didn’t happen in this institution,” he says incredulously. “We don’t withdraw patients from the resources they need because we don’t have staff to monitor them.”

If the incident did in fact take place, he says, the nurse involved should have reported the incident through the process that all staff are trained to follow if patient safety is threatened. “That she was talking to a reporter instead is disgraceful. That nurse takes an oath,” he says.

BACK AND FORTH ON STAFFING

Nurses and hospital administrators argue endlessly over staffing issues, with neither side willing to concede any ground. This dug-in mentality surfaced at Tufts and BayState, but nowhere was it more evident than at Berkshire Medical Center.

Nurses at the Pittsfield facility recently compiled a spreadsheet documenting over 400 instances of unfilled shifts and other staffing concerns. Brodeur, whose unit deals with patients emerging from anesthesia, says the problem has gotten worse since the closing of North Adams Hospital.

Diane Kelly, the chief operating officer at Berkshire, says she doubts the veracity of the situation outlined on the spread sheet. “That data was collected for political purposes,” she says. “If these were real concerns, they would be reported through the quality tracking system.”  She says none of the concerns were reported through the system, even though all employees are trained and tested on the system to ensure that unsafe situations are identified and addressed.

In interviews, six nurses at Berkshire Medical Center say new hires receive training on the quality tracking process, but insist there is no mandatory annual training or testing. The nurses say they have been bringing unsafe staffing concerns up in monthly labor/management meetings for years and filing reports with managers with a copy to the union. But the nurses say administrators have not once suggested these concerns be reported through the quality tracking system. Indeed, one nurse, Jody Stefanik, says she asked administrators during one of the meetings whether she should use the quality tracking system to report staffing concerns and was told no.

Michael Leary, a spokesman for Berkshire Medical, says use of the quality tracking system is mandatory. “Any employee who sees, experiences, or feels there is a risk for a quality incident must report that incident using the form,” he says in an email. “Also, the hospital requires ALL employees to complete mandatory education, which includes the Quality Tracking system. I myself took my mandatory education test last week, and there were multiple questions in regard to the use of the Quality Tracking Form and how and why it is used. If an employee does not pass that mandatory test yearly, they cannot report to work.”

Schildmeier, the spokesman for the Massachusetts Nurses Association, accuses Berkshire Medical Center of “blatantly lying about the nature of the process that is used by nurses to report unsafe situations. BMC management’s response is a cynical ploy to divert attention from the fact that nurses, on hundreds of occasions, have been reporting dangerous situations that jeopardize the safety of their patients, and in the face of those reports, management has refused to address nurses’ concerns.”

The back and forth between Berkshire Medical Center and its nurses is not only confusing but troubling. If the managers are right, the nurses are concocting hundreds of incidents to solicit the sympathies of the public as they buck their managers for a raise. If the nurses are right, the hospital administrators are denying that units are short-staffed in a way that may impact the safety or even the survival of their patients.  Neither scenario is particularly comforting.

LESSONS FROM CALIFORNIA

California in 2003 became the first and only state in the nation to pass a minimum nurse staffing law, which created nearly ideal circumstances to study whether increasing the number of nurses improved patient outcomes or was a waste of hospital resources. Suddenly, one and only one variable had changed in only one state. Once the law was fully implemented, nursing researchers interested in staffing issues found an experimental group (California hospitals), an ample supply of control groups (non-rural states with similar demographics and mix of hospitals), and baseline data for all these groups.

Initially, the research was not conclusive or showed little or no improvement in California. But over time a growing number of peer-reviewed studies have shown a variety of positive outcomes linked to lower patient assignments per nurse. The research suggests Tufts CEO Wagner was wrong when he said “patient care quality has nothing to do with the number of nurses.” A large number of the studies, however, have also suggested that nurse staffing levels alone are not enough to make a difference.

A 2011 study in Medical Care indicated that lowering patient-nurse ratios in hospitals where the nurse work environment is positive had a sizeable effect on patient mortality. But where the work environment was poor, increased nurse staffing levels had no impact.

A 2013 study in BMJ Quality Safety compared hospitals in California, New Jersey, Pennsylvania, and Florida, and found that each additional pediatric patient per nurse was associated with an 11 percent increase in the odds of readmission within 15–30 days after discharge for medical patients and a 48 percent increase in the odds of readmission within 15–30 days after discharge for surgical patients.  

One Massachusetts-based researcher, Judith Shindul-Rothschild of Boston College, has collaborated on a number of studies published in peer-reviewed journals suggesting a correlation between nurse-patient ratios and patient outcomes. A psychiatric nurse, Shindul-Rothschild has come under fire because she is a member of the Massachusetts Nurses Association and a past president of the union. She has also testified on Beacon Hill in favor of minimum nurse staffing levels.

“You have to consider the source,” says Michael Sroczynski, the vice president for government advocacy at the Massachusetts Health & Hospital Association. “That researcher frames things in a way that benefits that organization,” he says, referring to the nurses’ union.

Shindul-Rothschild says she often uses data about Massachusetts hospital staffing and quality measures that is available on the website patientcarelink.org, which is maintained by the Massachusetts Health & Hospital Association.

“It’s their data,” says Shindul-Rothschild. “They can run the reports just as well as anyone else.  I invite them to replicate what I did and tell me what’s wrong with it.  If they want to refute my findings, I have no problem with them writing a letter to the editors of the publication. That’s the professional way to do this.”

A 2016 article by Shindul-Rothschild and others published in the Journal of Nursing Administration compared California to New York and Massachusetts.  “When compared with states that do not have mandated nurse-to-patient ratios, California, which limits the number of patients assigned to RNs, has significantly lower pneumonia readmission rates,” they concluded.

The group’s 2017 study in the Journal of Nursing Care Quality showed that higher patient assignments to nurses as well as poor communication between nurses and patients and a higher incidence of patient falls are all factors associated with a nurse failing to remove catheters in a timely manner, which often leads to urinary infections.

A 2016 study published in the Journal of Emergency Nursing by the same team focused on 67 Massachusetts hospitals and concluded that emergency room wait times increase with each additional patient added to a nurse’s caseload. Shindul-Rothschild, who has met with policymakers in different states, says they all want to know what the “magic number” of nurses is. “I show them the data, and ask them: ‘What do you want [emergency department] wait times to be? 15 minutes? Half an hour?’”

Schindul-Rothschild says that the staffing data posted on the MHA site indicate that Tufts was an outlier in Massachusetts in terms of nurse staffing levels from 2012 to 2016.

In the Tufts medical surgical unit, according to Shindul-Rothschild, Tufts nurses had an average of 4.74 patients, or .67 additional patients compared to nurses at other Massachusetts teaching hospitals. Step-down nurses at Tufts had an average of 3.53 patients, or .47 additional patients, and emergency room nurses had an average of 12.65 patients, an additional 1.71 patients.  Tufts Medical Center says the year-to-date staffing data in 2017 show markedly lower nurse-patient ratios.

Using the same data, Shindul-Rothschild says Berkshire Medical Center had, on average, the second highest number of patients assigned to a nurse in the medical surgical unit (5.27) of all Massachusetts hospitals in 2016. Baystate Medical Center (Baystate Healthcare’s non-unionized hospital in Springfield) had the highest number, an average of 6.24 patients per nurse.

The back-and-forth struggle between hospitals and nurses over staffing levels is already intense. Between now and next fall, when minimum nurse staffing levels may go to the ballot, the battle lines are likely to harden. With hospital control, patient safety, and millions, perhaps hundreds of millions, of dollars at stake, the fight has just begun.