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.

Showing 9 comments
  • Patricia Andrews RN

    I agree completely with your very well-written defense of safe-staffing laws. I work in California and the staffing laws are very good for patients, their families, and nurses. Why do these administrators always ignore the fact that hospitals really only exist for patients to receive professional nursing care. Everything else can be done as an outpatient. And RNs are needed for proper outpatient care as well.

  • Stephen Downs

    It is sad to see the fabric of Tufts Medical Center being stretched to the breaking point!

  • SM, RN


    Your post is one of the most intelligent and non-biased I have read since this whole fight for staffing has begun in Massachusetts. Many studies have shown that ratios SAVE LIVES. The MHA argument that ratios should be adjusted based on patient needs (and therefore not mandated) is flawed in that this can be achieved WITH ratios. No one is saying they cannot give a patient more care than is mandated. However, the ratios are specific for various care areas and clearly they are intended to be a limit: based on this typical population, more than the ratio- defined- number increases the likelihood of adverse effects.
    Your work lays this issue out specifically. Where do places like the MHA get their information?
    I understand the MHA idea that not just nurses make a difference in quality outcomes, but anyone a the bedside without a license IS supervised by a nurse! And if truth be told, most of the residents in teaching hospitals are supervised more by nursing than by the attendings.

  • Nancy Adrian

    Your review of Nicholas is brilliant! I work at Tufts and will be attending meetings tomorrow.
    How do I get a copy of NE Journal of Medicine article from March 17th?

    thanks so much,


  • Louise

    I am a traveling ER nurse. I just wanted to share that I have witnessed short staffing at every institution I have come in contact with. It has gotten a whole lot worse in the last year!! The ER’s are seeing overwhelming numbers of patients a day. The floors are short staffed and cannot fill all the beds, therefore, the ER nurses turn into floor and ICU nurses. Countless times we have had 3-4 ICU patients at a time with 2-3 rooms/halls of rotating ER patients!! It is exhausting work!! Many nurses worry for the safety of their patients!! As one ER nurse who has five patients; one stabbing victim, one patient shot several times, two patients having a heart attack and one patient with the flu who is becoming violent and combative because they havent been seen by a doctor yet……who do you take care of first? Who’s life do you save first?? (while trying to save your own life from the combative patient!) It’s almost like the hospitals only look at numbers and not the care needed!! The short staffing is making us play a role in a higher powers job!! It needs to be addressed!! !12-16 hour shifts without even a bathroom break is out of hand!!

  • Ken Shanahan

    I am a nurse manager at Tufts Medical Center and I manage an ICU where a three patients to one nurse ratio is occasionally utilized (on average three times a month). I have followed Suzanne’s blog and while I respect and appreciate her contributions to our thinking about the nursing profession, I find myself in significant disagreement after reading her most recent posting and the commentary around it.
    Suzanne and her readers should be aware that the nurses – both managers and front-line nurses – at Tufts Medical Center have been playing a major role in driving innovations in health care delivery, resulting in some very positive changes in practice within the last two years. Some of these changes, for example protocols like IHI bundles, were implemented much in the way they have become standard throughout the industry. Change is always hard, however, and as many of your readers can probably understand, many professionals need to change how they have “always done it.” We as a leadership team are committed to supporting and engaging our staff during these continued changes. We are working together as a team to accomplish established safety, clinical as well as financial goals.
    Suzanne made some very negative comments regarding nurse managers which I found to be inconsistent with what I have observed in my career. I can tell you that managers I have worked for and with have always kept patients first in every decision. They have never been mere mouthpieces for hospital administration, in public or in private. They are not afraid to advocate for what’s best for their patients. Now that I am a nurse manager, I can say the same is true for myself and my peers. I can tell you without question that I, and all those managers around me, never stop thinking about the patient 24/7. As an expert in critical care, I know that there is a spectrum of patients within each ICU, which can change daily and even hourly. There are patients who are holding onto life minute by minute, requiring the attention of two RNs, while others are on a clear path to recovery, perhaps waiting for a bed on a medsurg or IMC floor. Therefore, people close to the patient’s bedside like myself and my team of nurses are in the best position to make the critical decisions hour to hour, day to day to ensure safe, effective patient care. I disagree with Ms. Gordon that RN ratios as defined by legislation or union officials are a better way to achieve that. That is my professional opinion, which I share confidently in private and in public. The unnamed nurse managers in Ms Gordon’s piece do not speak for all of us who are engaged in our professional practice and willing to embrace and drive change.

    Sincerely yours,
    Kenneth P Shanahan RN, BSN, CCRN

    • Suzanne

      Thank you for your comment. I have never suggested that nurses managers are “mouthpieces for management.” I do think that nurse managers are often put in untenable positions as regards broader hospital policy. I know a number of nurse managers who have been fired or harassed because they have not promoted policies with which they disagree. I think most managers would want more staff but are hampered by budgetary constraints that are not of their making. I actually think that managers today need ratios since many managers are managing upwards of 75 or even a hundred or more nurses when we know from management 101 that you cannot effectively manage more than 12. I have great respect for nurse managers but know that because of American labor law they have no protection and have a difficult time advocating openly for patient and worker safety. The issue here Kenneth is not whether you or any other nurse manage thinks about patients and patient safety 24/7, the issue is whether hospitals dominated by concerns about budgets and the bottom line give you the resources to put thought into action and theory into practice. And please, when debate ratios, let’s get the facts straight. No one is talking about inflexible mandates, or union controlled ratios. What we are talking about is ratios that are created transparently and that are flexible. That is what ratio bills provide. I am deeply concerned that at Tufts millions of dollars have been spent on hospital consultants who have absolutely recommended staff cuts and replacing RNs with less educated staff. Maybe you can’t say it in public, but I hope you too are concerned about this use of taxpayer money on expensive hospital consultants.
      Why don’t hospitals ask nurses and nurse managers how to organize work so it is more effective? Shouldn’t you and your staff be the beneficiaries of those resources? How many nurses could you have hired over the years had your hospital and so many others like it not frittered away countless millions of these expensive consultants who have not solved the nursing crisis, the health care crisis or cut a penny in costs to our skyrocketing health care costs?

  • Lorene

    I totally agree with every word spoken. Dont forget nurses are getting burnout and new nurses are leaving the bedside and going back to school to teach or become a nurse anethesist or leaving nursing all together.
    I have been a nurse for greater than 25yrs and it is getting worse and worse.
    Our responsibilities are great and always expanding.
    Too long our country’s priorities have been mixed up.
    They rather be entertain while dying than to be nursed back to good health by a real live dedicated angelic nurse who loves her patient and wants them well.
    Tell me what is wrong with this picture? God please help us! Go ahead and pay that entertainer 1-4 million a year but when they become sick or injured, who will take good care of them? Soon, there will not be many nurses left to nurse them back to good health. Then what?

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