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Nurses union to file ballot question asking voters to limit number of patients

The state’s largest nurses union intends to ask voters to do what the Legislature has refused to do: establish statewide limits on the number of hospital patients assigned to each nurse.

The Massachusetts Nurses Association plans to launch a Facebook campaign Monday and an Internet advertising campaign in September to build support for a proposed November 2014 ballot question that would cap nurses’ workload in acute care hospitals. Supporters must gather 70,000 signatures from registered voters by this November.

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The effort is likely to ignite a fierce public debate between the union and hospitals. There are potent feelings on both sides, and each says it wants what is best for patients.

Nurses have been pushing for staffing legislation in the House and Senate since 1995, and have won support — each chamber passed a version of the bill in 2008 but they were not able to agree in the end. The union believes workload limits are a pivotal issue now that hospitals are under growing pressure to control the cost of care. Some have laid off nurses or not replaced those who have left their jobs. The union’s campaign urges patients to “just ask . . . how many patients is your nurse caring for today?’’

“We have put our energy into this . . . and we got it to the finish line, but we haven’t been able to get it over,’’ said union president Donna Kelly-Williams, a nurse who works in obstetrics at Cambridge Hospital. “We cannot continue to do the same thing given the climate we are seeing.’’

The Massachusetts Hospital Association contends that patient limits etched in law will undercut hospitals as they try to develop new staffing models to increase efficiency and improve care. For example, some hospitals have added respiratory therapists to patients’ care teams, which may mean they don’t need as many nurses. Administrators need flexibility to decrease the number of patients assigned to new nursing graduates — and increase the number when a nurse is experienced, said Lynn Nicholas, president of the hospital group.

“This issue has had significant deliberation for many years and it’s been rejected year after year and not just in Massachusetts,’’ she said. “It’s a terrible idea.’’

So far, only California has enacted limits on the number of patients assigned to nurses. In the past two years, similar legislation has been filed in 12 states. The California law sets minimum nurse-patient ratios for more than 15 different types of units, but hospitals must increase staffing based on individual patient needs. In intensive care units, nurses cannot care for more than two patients at once; in emergency rooms, the limit is four patients; and on medical and surgical floors, it’s five.

The Massachusetts ballot question generally asks for stricter limits but makes exceptions for patients’ conditions. For example, the limit in ICUs would be one patient to a nurse, but a nurse may accept a second patient if the nurse determines both patients are stable. The limit in emergency rooms would be between one and four patients, depending on the patients’ conditions, while on medical and surgical floors, the maximum would be four.

Each hospital would be required to develop a “patient acuity system’’ that would describe circumstances under which specific patients would require more intensive nursing care, such as the use of specialized equipment.

Nurses involved in the ballot initiative said the number of patients that nurses are expected to care for now varies widely among hospitals. Nurses may not have time to sit by a dying patient or adequately educate a patient before discharge about medications and follow-up appointments — a lapse that can lead to an expensive hospital readmission.

“That education involves a lot of one-on-one time,’’ Kelly-Williams said. “It will save health care dollars to ensure patients are taken care of the right way the first time.’’

The union said that more than 40 studies in medical journals show that overburdening nurses with too many patients is linked to increased costs, complications, and mortality.

Nicholas said those studies do not show “an optimal or minimal number of nurses for every patient, at every hospital, and at every moment. That’s because there are many factors that go into meeting the unique needs of each patient, including the composition of the entire caregiving team, as well as the technology and resources they use,’’ she said.

Nicholas disputed the union’s assertion that hospitals have too few nurses. The hospital association runs a website that lists each acute care hospital and the number of nurses and other staff assigned to different units. She said this provides a high level of transparency for patients about their nursing care.

“There is nothing to fix there,’’ she said.

The site, however, does not allow patients to easily compare hospitals. Leonard Marcus, director of the program for health care negotiation and conflict resolution at the Harvard School of Public Health, said “you have to be a data geek to understand’’ it.

He said he does not support locking hospitals into specific numbers of patients per nurse. “What would be great,’’ he said, is legislation that required “more information for the public so they can compare nurse patient ratios’’ among hospitals.

Liz Kowalczyk can be reached at kowalczyk@globe.com. Follow her on Twitter @GlobeLizK.
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