In Massachusetts, where revolutionary fervor reached a flash point two centuries ago, another national conflict is producing hostilities.
In this case, it's the battle between hospitals and organized nursing over the restructuring of the nation's bedside work force.
Hospitals say they're doing it to provide patient-focused care, although labor contends the facilities are really seeking lower costs. Nurses say such restructuring jeopardizes patient care, but critics in the executive ranks say the underlying concern is actually the elimination of nursing jobs.
Whether changes in hospital staffing levels and patterns are hurting patients and nurses is the focus of a new national nursing commission, which is charged with examining the issue during the next 20 months (July 18, p. 18).
A preview of the conflicting research and testimony that the commission is expected to face during its deliberations has aired in Massachusetts, where a leaked copy of a nurse survey has ignited a war of words between the Massachusetts Hospital Association and the Massachusetts Nurses Association.
The conflict began Sept. 3, when NBC news broadcast a story on hospital restructuring and its impact on nurses and patients.
Part of the segment included highlights of a survey of Massachusetts nurses by Judith Shindul-Roth-schild, a professor and researcher at the Boston College School of Nursing in Chestnut Hill, Mass. The survey, conducted earlier this year, repeated a similar nurse opinion poll conducted by Ms. Shindul-Rothschild in 1989.
The survey, based on responses from nearly 1,800 registered nurses working at an unspecified number of Massachusetts hospitals, suggests that hospitals' work-force restructuring has put patients at risk of receiving poor care.
For example, 43% of the nurses surveyed this year said their hospitals operated with unsafe staffing levels, compared with less than 1% of the nurses who responded to the 1989 survey (See chart).
Also, 70% of the nurses in the new survey said their hospitals are using "unlicensed assistant personnel," or UAPs, to help provide bedside care to patients. Only 24% of the nurses in 1989 reported the use of UAPs.
And, most striking, this year's respondents said 15 patients died because of inadequate staffing levels. No patient deaths attributable to staffing were reported in 1989.
In an interview with MODERN HEALTHCARE, Ms. Shindul-Rothschild acknowledged that the results "can't be carved in stone" because they're based on nurses' opinions and poor care hasn't been validated by other data. But, she said, the results raise a red flag.
"There appears to be widespread substitution going on with UAPs replacing RNs and nurses reporting a rapid deterioration in care," she said.
Ms. Shindul-Rothschild limited her comments to the information released by NBC because the full survey results haven't been peer reviewed or published in a medical or nursing journal. She said she intends to conduct complementary research to verify or rebut nurses' charges of poor quality care.
She also said she didn't give a copy of the survey to NBC but agreed to be interviewed for the segment.
Five days before the NBC story aired, the Massachusetts Hospital Association issued a statement responding to the nurse survey after NBC approached the association for comment.
"We are concerned that nurses report increased job stress over shifting responsibilities and the changing healthcare environment," the MHA said. "However, there is no known data that supports the results of this survey of nurses' perceptions."
Two weeks later, the MHA publicly released data showing that hospitals' mix of registered nurses, nursing assistants and licensed practical nurses has stayed constant over the period examined in the Shindul-Rothschild surveys (See chart, p. 38). In fact, between May 1989 and May 1994, the percentage of full-time-equivalent nursing positions held by registered nurses at Massachusetts hospitals rose to 79.4% from 77%.
Over that same period, according to the MHA, inpatient days dropped 15.7% while registered-nurse FTEs dropped just 1.5%. And, registered-nurse FTEs per 100 patient census have risen to 165.2 this year from 135.6 in 1989, the MHA said.
"There's no evidence of dangerous levels of staffing at Massachusetts hospitals," said Therese Smaha, the MHA's director of professional relations.
But that hasn't stopped the Massachusetts Nurses Association from rallying around the Shindul-Roth-schild survey.
On Sept. 13, the MNA conducted a town-hall-style meeting at which Ms. Shindul-Rothschild, a registered nurse, spoke, according to an MNA spokesman. More than 200 nurses and nurse executives attended the meeting, he said.
The overwhelming majority of those in attendance expressed concerns about inadequate hospital staffing, said Margaret Barry, MNA's president and professor and coordinator of the nursing education program at Quinsigamond College in Worcester, Mass. She described the Shindul-Rothschild survey as "supporting evidence" confirming nurses' anecdotes about staffing problems.
The MNA has 19,000 registered-nurse members. About 15,000 members are unionized and belong to the association's collective bargaining arm.
Ms. Barry said the MNA's next step will be to develop an action plan to increase the number of registered nurses providing bedside care in Massachusetts hospitals. The MNA board and key nursing leaders in the state have scheduled a meeting for this week to discuss the action plan, Ms. Barry said.