Potential Nurses Strike in Massachusetts

This morning I woke up to an op-ed in The Boston Globe penned by the president CEO of the Massachusetts Hospital Association Lynn Nicholas and entitled “Massachusetts Nurses Association (MNA) , the target of the attack — has long favored in Massachusetts and nationally. What’s so interesting about this article is that it adds a new twist to the hospital industry’s long-standing opposition to any kind of positive government regulation of nurse staffing in hospitals. The article has been prompted by the fact that the MNA has been engaged in negotiations with Tufts Medical Center centering on safe staffing issues. Nurses at Tufts have filed over 520 reports of incidents that have compromised patient care and have been begging the Medical Center and the legislature in the Commonwealth to deal with patient safety issues through contractual provisions that guarantee safe staffing as well as legislation around nurse-to-patient staffing ratios. In response MHA CEO Lynn Nicholas drags out the same old arguments against safe staffing and adds some new ones to the mix.

Let me say before I begin to analyze Nicholas’ arguments, that I am deeply concerned about patient care in Massachusetts and elsewhere in the nation. I spend most of my time talking to nurses, nurse managers, and patients, and what I hear both in Massachusetts and elsewhere is not reassuring. The worst news comes from hospital managers, who report — when they talk in private that is — that staffing in their institutions is getting worse not better. I spoke to two managers recently who told me that they spend almost all of their time trying to find nurses to staff their units and that the supply of experienced nurses is very limited, yet their hospitals won’t let them hire any new grads –thus assuring that the pipeline that produces experienced RNs is steadily flowing. One manager told me she has a 23 bed unit and is only allowed to staff for 18 beds. Another, who supervises an oncology unit has seven patients to one RN — in California, the benchmark for nurse staffing in the US, the ratio is 4 to 1. These managers reported that they feel ill when their cell phones ring because they know someone is calling them to find more staff if someone reports in ill or takes a personal day. That is the message they deliver in private. In public, they risk firing if they express anything resembling their real concerns. In fact, a Kentucky hospital recently fired a nurse manager because she’d launched a safe nurse staffing cause on Facebook which attracted 25,000 followers.
We should remember one thing when nurse managers speak out against safe staffing. Under American labor law, managers have no rights at all in the workplace. They are the ultimate example of the “employee at will.” They can be fired on the spot without just cause and have no recourse against employer retaliation. If an employer, like Tufts for example, fires them because they express their true concerns about patient care, they have no legal remedy and unlike staff nurses who join together to protest unsafe conditions, cannot take their case to the National Labor Relations Board. Although I have great respect for nurse managers, I believe that their employment status under American labor law makes it difficult, if not, in instances like this, impossible, for them to speak up protect patients. As the case in Kentucky shows, when nurses become managers, their hospitals take the position that they now represent the interests of the institution, rather than the profession or patients, and that they cannot take positions that contradict those of their institutions.
Yet, one of the positions that Nicholas articulates is — again a typical one –that staffing ratios make it impossible for nurse managers to assign appropriate levels of nursing care to patients and that staffing ratios represent a cookie cutter approach to patient care by denying managers flexibility to staff appropriately. This could not be farther from the truth and Nicholas must know this (if she doesn’t, we are in big trouble). Staffing ratios establish a maximum number of patients a nurse can take care of, not a minimum number of nurses per patient. If, as nurses allege, Tufts is asking nurses to take care of 3 patients in its ICU (a terrifying thought, since ICUs should be staffing 2 to 1 or 1 to 1) nurse staffing ratios of 2 to 1, would not prohibit the hospital from assigning three nurses to one patient if the patient needed help. Staffing ratios don’t preclude using aides to help nurses care for patients, although they would preclude aides from replacing RNs when an RN is the only appropriate caregiver. Hospitals lose no flexiblity in providing higher levels of nursing care to patients — which is what we, as patients, should be concerned about. Nor do staffing ratios, as Nicholas contends, impede managers ability to staff with veteran rather than novice nurses. If Nicholas and her colleagues are against government mandated staffing ratios in principle, one should ask them if they also favor eliminating the rule that we need two pilots in an airplane flight deck or 1 flight attendant for every 50 seats in an airplane. Do they also think we should permit state licensed family day care providers from caring for more than six children — of which only two can be infants? Let’s be consistent here, if you argue against staffing ratios in hospitals that take care of the sickest patients, then you should also be against them on airplanes or family day care homes — not to mention on fire engines and in schools.

Nicholas goes far beyond the usual hospital arguments against staffing ratios. In this article, she adds a new twist. That is pitting other hospital employees against nurses. She suggests that nurse are trying to hog the limelight when it comes to patient care and are implicitly ignoring the contributions of other hospital workers in the care of patients. She also implicitly suggests that if hospitals do better on nurse staffing they will have to fire nurses’ aides, ward clerks, patient sitters and so forth. Particularly in this economy — you know the one that pays hospital CEOs in the high six to seven figures and lower level employees in the low twos. If is refreshing to see a hospital association CEO worrying about the very employees hospitals have been jettisoning as they outsource everything that isn’t nailed down in a hospital room or corridor. This is a brilliant new tactic in the staffing debate but an old one when it comes to fighting against progressive change. Of course, other hospital employees are also critical, why they should be paid more and why many of them also need protections against excessive workloads.

Every hospital employee — from the janitor to the RN to the lab tech — needs good pay and decent working conditions. When nurses fight for their patients, they are not fighting against other hospital workers. They are setting a precedent that other workers should follow and engaging in a struggle other workers should support. Most importantly, it is a struggle all patients should support. We are the ones whose lives are on the line here. As someone who suffered a hospital injury after surgery because of problems of nurse staffing I know about this from personal experience. As someone who has written a book about safe staffing, entitled Safety in Numbers: Nurse-to-Patient Ratios and the Future of Healthcare, I have studied this issue for years. Over 70 studies confirm the relationship between quality patient care and nurse staffing. Indeed, the latest just came out. It’s entitled “Nurse Staffing Levels and the Quality of Care in Hospitals,” and appeared in the New England Journal of Medicine on March 17, 2011.