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Win or lose, the 2018 referendum to mandate nursing staffing ratios in Massachusetts, known as Question 1, promises to have big implications here in Rhode Island, even if few politicians, reporters and health care leaders have been talking about it

Photo courtesy of David Cicilline's Twitter feed

Congressman David Cicilline was one of many politicians who showed their support for union workers during the three-day strike and one-day lockout at Rhode Island Hospital and Hasbro Children's Hospital this past summer.

By Richard Asinof
Posted 11/5/18
Question 1 in Massachusetts about mandating required nursing staffing levels in hospitals has become a major turf battle between hospitals and nursing unions – all with little attention being paid here in Rhode Island.
If Question 1 is approved, how will the R.I. General Assembly respond to new efforts to legislate nursing staffing levels in Rhode Island? If Question 1 is defeated, how will the issue be played out in future labor strife at hospitals in Massachusetts and Rhode Island? Is there a need to rebalance the health care system around the role that nurses play? What can be learned from the evidence-based results of a nurse-run program at Clinica Esperanza to integrate clinical care into the health equity equation, particularly for immigrant populations? Why is it that there has been a lack of polling data connecting gender and health care in Rhode Island?
Last week, an email surfaced involving a state rep and the Speaker of the House, Nicholas Mattiello, regarding alleged sexual harassment by a committee chair against the representative, roiling Mattiello’s re-election campaign. One radio talk show host asked her listening audience: where were the women elected officials and why didn’t they speak up, if the allegations were known? The better question to ask, perhaps, was this: where were the men who were elected officials, and why didn’t they speak up. Taking responsibility for sexual violence, domestic abuse and sexual harassment in the workplace is not just a job for women; it is everyone’s job.


PROVIDENCE – All health care is personal, all politics are local. When the personal and political collide in electoral politics, it often all comes down to messaging: whom do you believe?

In the 2018 election, here in Rhode Island, the deciding factor in many election outcomes is likely to come down to this: who do women trust and believe – about protecting themselves from sexual assault and harassment in the workplace, about protecting their right to make personal health care decisions about their own bodies; and about protecting themselves and their families to access to health care despite pre-existing conditions?

Nationally, health care is the number-one issue that voters say they care about in the mid-term elections, if you believe the polling by Gallup, Kaiser and Pew. Unfortunately, there has been a dearth of polling and coverage about the gender gap related to health care by Rhode Island news media. Why is that?

In part, perhaps it is because many of the political reporters in Rhode Island are male, and, in their cocksure analysis, they tend to divide the electorate into familiar silos and patterns.

What is the evidence? All one needs to do is look at who has been asking the questions at the candidates’ debates: how many women reporters have shared the microphone? As best as ConvergenceRI can determine, women reporters’ participation has often been limited to student journalists, asking one or two questions, usually about climate change. Why is that?

No questions, no coverage
A symptom of that near-sightedness is the failure by political and health reporters in Rhode Island to cover one of the biggest issues in electoral politics next door in Massachusetts: the statewide ballot referendum, known as Question 1, which would mandate RN nursing staffing levels for patient care. Can you remember reading, listening or seeing a news story about it by Rhode Island news media? Why not?

The referendum battle pits the Massachusetts Nurses Association, the union that spearheaded the ballot question campaign, against the Massachusetts Health and Hospital Association.

The divisive issue found its way onto the ballot this year for a number of reasons: the consolidation of smaller, more rural hospitals in Massachusetts into larger health systems; the pressure on hospital administrators to find ways to lower costs, which have often taken the form of squeezing nurses to cover more patients, which has led to numerous nurses’ strikes [the administrators were rarely willing to cut their own salaries]; and the unwillingness of the Massachusetts legislature to address the burdensome issue.

The wording of the referendum is quite specific around staffing:

One patient per nurse: caring for a patient under anesthesia, in critical care or intensive care units, caring for active labor patients, and patients with medical or obstetrical complications, caring for a patient during birth and up to two hours after birth, and caring for a baby during birth and up to two hours after birth.

Two patients per nurse: caring for post-anesthesia patients, caring for urgent non-stable patients, and caring for babies in intermediate care or continuing care units.

Three patients per nurse: in step down or intermediate care units, and caring for urgent stable patients.

Four patients per nurse: caring for pediatric patients, in medical, surgical and telemetry units, in observational and outpatient units, and in units not otherwise listed above.

Five patients per nurse: caring for non-urgent stable patients, caring for psychiatric patients, in rehabilitation units.

Six patients per nurse: caring for uncomplicated mothers or babies postpartum, and caring for well-baby patients.

If approved, the measure would require the Massachusetts Health Policy Commission to implement and enforce the initiative, with the capability to conduct inspections of facilities to ensure that that the nursing staffing ratios comply with the initiative. The commission could also report violations to the state attorney general, with the potential for the state attorney general to file suit in Superior Court, which could include civil penalties of up to $25,000 per violation, for each day the violation occurs.

The high cost of convincing voters
Together, by mid-October, the opposing forces had raised and spent some $28 million, according to reporter Shira Schoenberg for MassLive.

“The Committee To Ensure Safe Patient, which supports the ballot question, has raised $11.6 million so far. Nearly all of that – $11.3 million – comes from the Massachusetts Nurses Association, the union that spearheaded the ballot question campaign. Some additional money has come from individual nurses,” Schoenberg reported. “The biggest expenses have been for mailings and media buys.”

In turn, the Coalition to Protect Patient Safety, which opposes the ballot question, has raised $19.4 million so far, according to Schoenberg. “Most of that – $18.4 million – has come from the Massachusetts Health and Hospital Association. Much of the rest of the money has come from individual hospitals and health care providers and some health care-related trade associations.”

The issue is now in the voters’ – and patients’ – hands, with a lot of money being spent on both sides of the political equation. Once again, the outcome may come down to a question of the gender gap in health care: whom do women believe?

Here in Rhode Island
ConvergenceRI reached out to a number of folks in health care – health care systems, unions, nursing educators, and health regulators – to get their perspective on the upcoming ballot referendum on Question 1 in Massachusetts.

The questions included:
As a matter of providing the best health care delivery possible for patients, how important are nurses in the day-to-day operations of running a hospital?

Are you familiar with the ballot question in Massachusetts that attempts to set nursing staffing levels?

Is this a good idea or a bad idea, in your opinion? Please explain why.

How critical is the question of nursing staffing levels at hospitals and other health care facilities in Rhode Island?

Do you believe that this is a workplace issue that should be negotiated between unions and hospital administrators?

Is there a further role that the R.I. General Assembly or the R.I. Department of Health could play in the future on this issue?

The view from hospitals
ConvergenceRI asked the questions to both of the two largest hospital systems in Rhode Island, Lifespan and Care New England: only Care New England responded.

“Nurses play a critical and most essential role in the delivery of care and day-to-day operations of a hospital,” James Beardsworth, director of Communications at Care New England, replied. “We are extremely grateful and fortunate to have a cadre of dedicated and highly skilled nursing professionals who are committed to providing high quality care with compassion each and every day.”

Beardsworth continued: “While we are aware of the ballot question in Massachusetts, it would be inappropriate to speculate from afar or get involved in that debate. In general, we strive to provide the best care possible in a safe and focused approach in a collaborative and team-based environment and again, have the highest regard and respect for our nurses and all who work at Care New England.”

The view from unions
Convergence also asked the questions two of the major unions in Rhode Island; United Nurses and Allied Professionals, and Service Employees International Union; only UNAP responded.

Nurses, replied Ray Sullivan on behalf of UNAP, are “critical” to the day-to-day operations of running a hospital. “Any honest administrator worth her or his salt will tell you nurses perform essential and often life-saving tasks that are fundamental to a hospital’s mission.”

Further, Sullivan said that UNAP was very familiar with the ballot question in Massachusetts. “We are actively working to support it,” he said. UNAP has also [worked to introduce] similar legislation to establish safe and responsible nurse/patient limits in Rhode Island.”

Sullivan continued, saying UNAP was 100 percent supportive of Question 1. “This is a matter of patient safety and we are working to reverse the norm of nurses being pushed beyond the limit,” he said.

Sullivan linked the question of nursing staff levels at hospitals in Rhode Island to the recent labor conflict at Rhode Island Hospital this past summer. “This was a significant part of our most recent contract campaign at Rhode Island Hospital and we were able to make progress in that regard,” Sullivan said.

Sullivan explained what, in his opinion, the difficultly in defining nursing staffing levels as a workplace issue that should be negotiated between unions and hospital administrators. “Management is often reluctant to bargain on these issues, but we did make progress in the last contract at Rhode Island Hospital where a joint worker / management committee will be established and overseen by an independent party to review staffing and resource concerns within the hospital,” he said.

Finally, Sullivan said he believed that the R.I. General Assembly might play a role in creating new legislative mandates around this issue. “Absolutely,” he replied. Rep. Chris Blazejewski and Sen. Joshua Miller have introduced legislation on our behalf in the past and we expect they will again in 2019.”

The view from regulators
ConvergenceRI also reached out to the R.I. Department of Health to get the agency’s perspective. Here is the response from Joseph Wendelken, the agency’s spokesman.

“Nurses are a critical part of hospitals’ work to provide the best care possible to patients,” Wendelken said. “In many ways, nurses are the backbone of a hospital. They are patient advocates, and they bring a wide breadth of specialized knowledge and experience to multidisciplinary teams that are often charged with treating very complex health issues.”

Wendelken said that the R.I. Department of Health was aware of Question 1 on the Massachusetts ballot, but refrained from taking a position on the issue.

“Generally speaking, it is important that hospitals have staffing ratios that will allow for the provision of safe, quality care,” Wendelken said. “I am not familiar enough with the situation in the hospitals in Massachusetts to say whether mandating those staffing levels is the way to go. I do know that California is the only state with mandated staffing levels right now. I’m sure the matter was studied carefully there, as it has been in Massachusetts. But without having reviewed that research, I’m reluctant to weigh in.”

Adequate nursing staffing levels, Wendelken added, are “very important both to ensure that patients receive safe, quality care, and as a safeguard for health care workers.”

Further, he said that it was usually a “good practice” for workplace issues to be handled through dialogue between administrators and staff, but the question was a bit out of the realm for the R.I. Department of Health. “Union officials or hospital administrators here in Rhode Island might have more to say on this one.”

Finally, Wendelken made clear that the agency did not want to speak for the R.I. General Assembly. What I can say, he continued, is that “we lend whatever expertise we can whenever approached.”

Sidestepping the question
At the Care Transformation Collaborative Rhode Island’s annual conference, “Building Capacity for Comprehensive Primary Care,” held on Thursday, Nov. 1, at the Crowne Plaza in Warwick, ConvergenceRI brought up the ballot question in Massachusetts to numerous participants – including physicians, nurses, health insurers, community agencies, social workers, and government agency staff – to get their opinions.

Perhaps, not surprisingly, all declined to comment, even off the record, given that nursing staffing levels in hospitals and other facilities have become a dangerous third rail of health care.

Regardless of the outcome in Massachusetts, the issue of nursing staff promises to re-emerge in Rhode Island. Consider this story the beginning of conversation and convergence on the issue.

Editor's Note: In reporting on this story, I did not include an allegedly "objective" study of the costs and outcomes of Question 1 by the Massachusetts Health Policy Commission because the conclusions seemed awry. Now, it turns out, there was good reason for that intuition. The researchers consulted about the report strongly disagreed with the conclusions drawn by the study's authors. In particular, Jack Needleman said that there was a categorical difference between staffing levels in hospitals in Boston compared to other parts of the state; in other parts of the state, Needleman believed that patient safety was in jeopardy.

Further, there were questions raised about the cost estimate used by the author's of the study. Finally, perhaps most damning, was the fact that the experience in California was alleged to have neglible impact, while one of the researchers consulted said that she had concluded a longitudinal study confirming her earlier work that mortality rates in California hospitals dropped by 4 percent as a result of the mandated nursing staffing requirements.

See link to story below, "Researchers at odds with nursing staffing report."

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