Government Affairs

Legislative Platform and Issues Briefing

OVERVIEW | BACKGROUND INFORMATION | SUMMARY OF KEY ISSUES


OVERVIEW

The Michigan Nurses Association advocates for Michigan's 117,000 licensed registered nurses, and is the largest nurses union in Michigan.  The mission of the Michigan Nurses Association is to foster high standards of nursing practice, promote the economic and general welfare of nurses in the workplace, and lobby the legislature and regulatory agencies on health care and workplace issues affecting nurses and the patients for whom they provide safe, quality patient care.  The MNA employs the following legislative platform in advocating for the registered nursing profession:

Protect Human Rights:

  • Defining health care as an essential human right  
  • Prohibiting discrimination in health policies/regulations
  • Requiring sensitive and competent care for diverse populations
  • Mandating informed choice in health care
  • Protecting privacy

Assure Access to Health Care and Protect Public Safety:

  • Promoting essential care for all residents of the state;
  • Supporting services targeting vulnerable populations;
  • Ensuring nursing care by qualified providers;
  • Assuring services that address fundamental human needs that impact health.

Improve Quality of Health Care for Residents of Michigan:

  • Demanding coordinated delivery systems that ensure quality while containing cost;
  • Advocating for systems that assure continuity of care and protect against impoverishment;
  • Instituting state policies and regulations consistent with national nursing standards;
  • Requiring programs that address health promotion maintenance and prevention of disease/disability.

Advance the Profession of Nursing:

  • Protecting the viability of professional nursing organizations;
  • Strengthening economic, employment and organizing rights of nurses;
  • Demanding occupational health and safety;
  • Providing public funding for nursing research and education;
  • Securing direct reimbursement for nursing services.


BACKGROUND INFORMATION(top)

A fundamental shift has occurred in the RN workforce over the last two (2) decades, from an ever-increasing diversity of occupational opportunities for young women, to more men choosing to enter the nursing profession, and a continued aging of the nursing workforce.  However, working conditions for nurses, especially direct care giving bedside nurses in hospitals, has deteriorated during this same time period to the point that retention of seasoned veteran nurses at the hospital bedside, and a resultant impact on recruitment of new nurses to the hospital environment, has reached crisis proportions and seriously jeopardizes safe patient care in Michigan's hospitals.

It might be surprising to learn that the key workplace issues for hospital RNs are not salary and benefits.  Rather, the primary concerns of hospital RNs are to have a work environment where safe, quality patient care can flourish through the elimination of mandatory overtime as a hospital staffing mechanism, and by ensuring that there are sufficient numbers of RNs in each hospital unit to care for the patient caseload.

Michigan and the nation is experiencing a steady exodus of RNs leaving the hospital setting and even the profession due to a hospital workplace environment that doesn't fully support nurses to provide safe, quality patient care. Did you know that 2004 marks the last year that Michigan will graduate enough nurses to replace those nurses leaving the profession due to retirement and/or frustration with working conditions such as mandatory overtime and inappropriate patient-to-registered nurse ratios?  Did you know that by 2010 (just over five years from today), Michigan will have a nursing shortage of over 8,000 RNs, and the nation will have a shortage of over 1,000,000 RNs?

Perhaps the most important strategy to address the looming impact to the health care infrastructure is to implement approaches and strategies to retain RNs in the profession by addressing the hospital-based work environment. A resultant outcome, and secondary strategy, is the building on improvements to the workplace environment to recruiting non-practicing RNs back into the profession, and bring about RN graduates wanting to work in the hospital setting. None of this can be achieved unless there is a significant change in the work environments in which RNs struggle to provide safe, quality patient care.


SUMMARIES OF KEY ISSUES(top)

SAFE PATIENT CARE

1.  Prohibition of the Use of Mandatory Overtime as a Hospital Staffing Tool:

Nurses report a dramatic increase in the use of mandatory overtime as a regular hospital staffing tool.  The nursing profession is in fear of the safety and quality of care for their patients from a continued use of mandates that forces overworked nurses into a situation where they are providing unsafe patient care.  Today, overtime (mandatory and voluntary) is the most common method facilities use to cover staffing insufficiencies.  In fact, some employers have described mandatory overtime as a staffing model and have actually coined the phrase "mandation" to define the methodology.  Many nurses contend employers insist they work an extra shift (or more) or face dismissal for insubordination, as well as being reported to the state board of nursing for patient abandonment. Federal regulations place limits on the amount of time that can be worked in other industries whose work directly impact public safety (e.g., aviation and transportation).  Those regulations also set requirements for defined periods of time they must rest/be off duty before returning to work.  Health care is exempt from this type of overtime regulation. The Michigan Nurses Association opposes the use of mandatory overtime because it directly impacts the quality and safety of health care provided to patients.  Elimination of mandatory overtime is a critical step to reduce mortality rates, improve the quality of health care and reduce medical errors and nosocomial infections.

2.  Establishing Minimum Patient-to-Registered Nurse Staffing Ratios in Hospitals:

Lowering the patient-to-RN staffing ratio is not an insignificant or routine task, either from a management point of view or from a medical treatment point of view.  Over the past decade there have been a number of studies that have reached one or more of the following conclusions regarding the relationship of patient load to direct-care nursing availability in acute care facilities:

  • Fewer patients per nurse is associated with higher job satisfaction, lower burnout, higher rates of retention, and lower rates of turnover among nurses.      
  • Fewer patients per nurse is associated with higher quality of care, especially as illustrated by lower mortality rates, complications, and adverse events.      
  • Fewer patients per nurse is associated with shorter length of stay and, ultimately, lower overall costs per discharge.

The relationship between nurse staffing and patient outcomes is well documented.  Large proportions of nurses in the United States consistently report that hospital nurse staffing levels are inadequate to provide safe and effective care.  In one recent nationwide study of patient-to-nurse staffing ratios a principal finding was that three in five hospital nurses reported that the staffing level at their respective hospitals were having a negative effect on the quality of care that patients received (Peter D. Hart Research Associates, 2003).  Linda Aiken, in a presentation to the Michigan Nurses Association in October 2003, specified the link between nurse staffing and patient outcomes.  "Nurses are the surveillance system for early detection and intervention for adverse occurrences" and "Surveillance is influenced by nurse staffing ratios, nursing skill mix, and educational levels of RNs."  These observations are not isolated.  A recent report by the Joint Commission on the Accreditation of Healthcare Organizations reported that a lack of adequate nursing staff contributed to nearly one-fourth of all the unanticipated problems that lead to death or injury to hospital patients (JCAHO, 2002).  Another recent study reported that for every additional patient over four in a nurse's workload, the risk of death for surgical patients increase by 7.0% (Aiken et al., 2002).

The reasons for these findings are obvious.  Having too many patients reduces the time nurses can attend to and observe individual patients, and the extra workload often leads to fatigue, and in combination the two can lead to errors.  In addition, understaffing means patients often have to wait longer times for medication or medical procedures, and there is often not enough time to educate patients and their families (Peter D. Hart and Associates, 2003, p. 5).  The authors of an extensive review of several of these AHRQ-funded studies came to the rather blunt conclusion that "hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes. . . ."  (Stanton and Rutherford, 2004).

With respect to increased costs from implementing minimum patient-to-RN staffing ratios, national research demonstrates that increasing the staffing of RNs does not significantly decrease a hospital's profit, even though it boosts the hospital's operating costs.  A 1% increase in RN full-time equivalents increased operating expenses by about 0.25 percent but resulted in no statistically significant effect on profit margins.  In contrast, higher levels of non-nurse staffing caused higher operating expenses as well as lower profits" (Stanton and Rutherford, 2004).

The Michigan Nurses Association supports hospitals being required to have minimum registered patient-to-nurse staffing ratios.  Patients and nurses face unsafe conditions today in too many Michigan hospitals, and minimum staffing ratios will not only save lives and improve the quality of care in hospitals, but will also save money.

OVERTIME PAY PROTECTION FOR NURSES:

In the face of a nurse staffing shortage already reaching crisis proportions, new federal regulations issued by the Bush administration's Department of Labor explicitly leave Registered Nurses who work overtime unprotected from receiving overtime pay. "While the new overtime rules do specifically spell out new, well-deserved protections for other groups of first responders such as firefighters, police officers and licensed practical nurses, they conspicuously fail to include Registered Nurses in this protected group and potentially open up new avenues for employers to exploit RNs," said Cheryl Johnson, RN, president of both Michigan Nurses Association and the United American Nurses, AFL-CIO, the nation's largest RN union. "Registered nurses should not have to read between the lines to infer that their overtime pay is protected, but should have the same guaranteed overtime protections as these other important groups."

In the absence of explicit federal protection of overtime pay for Registered Nurses, the Michigan Nurses Association supports a State legislative initiative to ensure protection of overtime pay for Registered Nurses.

ADDRESSING THE NURSING SHORTAGE AND ADEQUACY OF NURSE EDUCATION FUNDING:

Current shortages in the nursing workforce can be attributed to a number of root causes including RNs leaving the workforce due to objectionable workplace conditions, a nursing school faculty shortage, inadequate funding of nursing education programs, and a shortage of clinical education sites.  Compounding the challenges is the reality that the average age of the RN workforce is 46 years of age, and the average age of nursing faculty is 56 years of age.

The immediate solution to the nursing shortage is retaining the RNs currently in the workforce through improving workplace conditions.  A long-term strategy must focus on recruiting new nurses to the profession through an appropriate increase in nursing school capacity and clinical education sites, continued legislative appropriation of nursing scholarships monies, and addressing adequate financial support of nursing schools.

The Michigan Nurses Association supports adequate legislative funding of nursing scholarships, and creating collaborative partnerships and strategies between the nursing profession, nursing schools, hospitals, and the business community to address the long-term nursing and faculty shortages.

ENABLING APRNs TO FULLY PRACTICE WITHIN THEIR SCOPE OF PRACTICE AND NATIONAL CERTIFICATIONS:

Advanced practice registered nurses (APRNs) are registered nurses who have attained advanced degrees, expertise, and national certification in the clinical management of health problems.  Typically, an APRN hold a masters degree with advanced didactic and clinical preparation beyond that of the registered nurse.  Most APRNs have extensive practice experience as RNs prior to entering graduate school.  APRNs provide health care for individuals across the life span.  Practice areas include, but are not limited to, family, gerontology, pediatrics, women's and adult health, neonatology, mental health, and anesthetic.

Millions of Americans each year go without the health care services that they require because physicians simply are not available to care for them.  This problem plagues rural and urban areas alike.  Medicaid beneficiaries are particularly vulnerable, since in recent years, a number of health professionals have chosen not to care for them due to decreasing Medicaid reimbursement rates, and/or and unwillingness to practice in rural and urban communities where many beneficiaries live.  APRNs are an exception to this trend; they frequently accept patients that others will not treat and often serve in provider shortage areas.

MNA supports initiatives that remove arbitrary practice restrictions or policies that erect barriers for APRN practice including any laws, regulations, or policies that limit or prohibit prescriptive authority, require supervision by another health care provider, limit direct reimbursement, prohibit or limit institutional privileges, and make it difficult to obtain liability insurance. 

The Michigan Nurses Association supports legislative and regulatory initiatives that allow APRNs to fully practice within their scope of practice and national certifications, including independent prescriptive authority.

REGISTERED NURSE STAFFING FOR LONG TERM CARE:

A number of recent studies have shown disturbing problems with America's nursing facilities.  In 1999, the GAO reported that "more than one-quarter of nursing homes have deficiencies that have caused actual harm to residents or placed them at risk of death or serious injury.  The Institute of Medicine (IOM) recently released a report (Improving the Quality of Long-Term Care, December, 2000) stating "Multiple studies indicate that staffing in nursing homes in inadequate to provide care that meets consumer expectations or maximizes residents' independence."

The 2000 IOM report and a longer IOM report published in 1996 (Nursing Staff in Hospitals and Nursing Homes:  Is it Adequate?) urge legislators to require the presence of an RN in all nursing facilities 24 hours a day, seven (7) days a week.  In both reports, the IOM asserts that the relationship between RN-to-resident staffing and quality of care in nursing facilities has been established beyond question.

The Nursing Home Reform Act of 1987 (Public Law 100-203) promised each nursing home resident the right to expect care and services from the nursing home which would allow him/her to "attain or maintain his/her highest practicable level of physical, mental, and psycho-social functions."  Congress has not required a specific standard setting out the number of hours per patient day that a resident should receive nursing care.  Instead, the 1987 law required each nursing home to provide 24-hour licensed nursing services which are "sufficient to meeting the nursing needs of its residents." 

Congress has only required facilities to provide the services of an RN for eight (8) hours a day, leaving many residents without access to an RN during the evening and night shifts.

The Michigan Nurses Association supports modernizing existing Michigan statute for minimum nursing home staffing ratios to ensure safe patient care to this vulnerable patient population.

MEDICAID FUNDING:

Adequate Medicaid funding is critically important to Michigan's health care system.  As the costs of providing needed medical care services continues to escalate, access to such services is jeopardized not only for Medicaid beneficiaries, but for all Michigan citizens, when Medicaid payments are not increased to keep pace with inflation and the growing Medicaid caseload.

If the state of Michigan does not pay its fair share of the costs incurred by hospitals and other health care providers to care for Michigan's most vulnerable population, costs will continue to be shifted to the privately insured community.  Failure of the State to accept its fiduciary responsibility through adequate Medicaid funding in turn increases the number of uninsured Michigan citizens, increases health care premium costs to employers, and shifts the financial burden of health care to employees with insurance in the form of reduced benefits and/or higher co-payments and deductibles.  Michigan's fragile health care safety net cannot sustain continued, inadequate funding of the Medicaid program for it impacts the entire Michigan economy.

The MNA supports legislative appropriations that prioritize health care, and ensure adequacy of Medicaid funding to avoid cuts to covered services and prevent the elimination of otherwise eligible individuals from the Medicaid caseload.


ESTABLISHING WORKPLACE ERGONOMIC STANDARDS:

Patient handling, such as lifting, repositioning, and transferring, has conventionally been performed by nurses.  The performance of these tasks exposes nurses to increased risk for work-related musculoskeletal disorders.  Nurses suffer a disproportionate amount of musculoskeletal disorders consequent to the cumulative effect of repeated manual patient handling events, often involving unsafe loads.  Among nurses, back, neck, and shoulder injuries are the most prevalent and debilitating.

The use of assistive equipment for patient handling tasks also benefits patients.  Adverse patient events related to patient handling and movement include pain (i.e., when lifting patients under their arms) and injury (e.g., falls, contusions, and skin tears).  The use of assistive equipment directly contributes to preventing such adverse events and improving patient safety, comfort, and dignity; and reflects the MNA's commitment to safe patient care.
 With the development of assistive equipment, such as lift and transfer devices, the risk of musculoskeletal injury can be significantly reduced.  Effective use of assistive equipment and devices for patient handling creates a safe healthcare environment by separating the physical burden from the nurse and ensuring the safety, comfort, and dignity of the patient.
 The MNA supports legislative action to fully fund the development and enforcement of MIOSHA regulatory policies to eliminate manual patient handling.

 

updated 2/16/05
All content © 2007 Michigan Nurses Association