Seachange Bulletin #132June 18, 2004Seachange Bulletin ArchivesEmail the editorSeachange Bulletin #132: Massachusetts Clash Sharpens Massachusetts may be known as a medical mecca, but the best medical care can go for naught if hospitals don't provide enough registered nurses to monitor patients following high-tech treatments and procedures appropriately. A patient undergoing heart or lung surgery could have the world's best surgeon utilizing the latest technology and cutting-edge medicines, but after surgery an overloaded nurse might lack the time and ability to monitor the patient. The nurse is more likely to miss changes in the patient's condition that could result in a debilitating pneumonia or fatal heart attack. One recent study found that cardiac patients are more likely to die at night in hospitals because of chronic understaffing; another found that the incidence of hospital-acquired pneumonia can be significantly reduced with good RN staffing. It is in recognition of the vital role nurses play in making the health-care system safe that the American Lung Association, American Heart Association, Greater Boston Diabetes Society, the American Cancer Society, the Mass. Senior Action Council and 60 other organizations have come together to fight for passage of legislation that would establish safe, minimum and flexible RN-to-patient ratios in all Massachusetts hospitals. By any objective standard, the quality and safety of patient care is in critical condition: the Department of Public Health reports a 76 percent increase in the number of injuries, medication errors and complaints by patients since 1998; 65 percent of nurses report an increase in medication errors due to nurse understaffing; and, most alarming of all, one in three nurses in Massachusetts reports an increase in unnecessary deaths of patients due to understaffing. The American Medical Association (sic) has found that each additional patient above four that a nurse cares for produces a 7 percent increase in the risk of death. If a nurse typically cares for eight patients rather than four, there is a 31 percent increase in the risk of death for those patients. None of the hospital industry's arguments stands up against this bill. The industry argues there is a shortage of nurses, but Massachusetts has the nation's highest per capita population of nurses. The respected research firm, Opinion Dynamics Corp., just completed a survey of RNs working part-time in Massachusetts hospitals. The survey found that fully one third will work more hours if the Safe Patient Care Bill becomes law. In terms of hospital staffing, this is the equivalent of adding more than 1,800 full-time RNs - more than enough to meet the bill's requirements. In practical terms, this news is much better than having to find and train new hires: These part-timers are already receiving benefits, and expensive recruiting and training costs would be eliminated. The industry argues that the cost of improving staffing is too high. Yet the evidence shows safe RN staffing to be cost-effective - at worst cost-neutral and, by most accounts, likely to save millions of dollars by reducing costly complications. The Coalition to Protect Massachusetts Patients has looked at the evidence, and we find that it all argues for the passage of this legislation. We can't afford not to respond to this crisis. The ultimate cost of doing nothing, as the hospital industry recommends, is far too high. It's time to guarantee every patient safe RN staffing, because safe staffing saves lives. Faye Gordon is the executive director of the Greater Boston Diabetes Society. Carlos Alvarez is the executive director of the American Lung Association of Massachusetts. Battle over nursing shortage heats up Scott Allen, Boston Globe, May 11, 2004 <http://www.massnurses.org/News/2004/05/boston_globe.htm> More than 1,000 nurses, former patients and consumer activists are expected to descend on the State House today to press for passage of a bill requiring minimum nurse-staffing levels at the state's hospitals. Among the demonstrators will be people with stories about the severe nursing shortage - such as a nurse practitioner who said he had to do his own suctioning when he was being treated for a collapsed lung. The demonstrators want the House Ways and Means Committee to allow a vote this week on a bill requiring hospitals to maintain minimum ratios of nurses to patients on every shift, a measure hospitals strongly oppose. 1,000 Nurses Call on Legislators to Mandate "Safe Staffing" Levels Michael C. Levenson, State House News Service, May 11, 2004 <http://www.massnurses.org/News/2004/05/state_house_news.htm> State House - Chanting "patients deserve a vote" and "safe staffing now," about 1,000 union nurses rallied at the State House Tuesday in support of legislation that would mandate lower nurse-to-patient ratios in Massachusetts hospitals. The nurses, members of the Massachusetts Nurses Association, filled a hallway named for the sacrifices of Civil War nurses with a sea of aqua-blue T-shirts as they listened to speaker after speaker decry the current staffing situation as a crisis that is threatening patient care and demoralizing staff. "We want everyone in this building to know there is no shortage of nurses. It is poor working conditions that are driving us away and we want this fixed," Karen Higgins, the MNA president, told the crowd packed into Nurses' Hall, which responded with cheers and chants. "Something has to be done to improve the care and safety for all our patients," Higgins said. Quincy resident Sandy Eaton, 60, a nurse at Quincy Medical Center since 1978, said he now attends to four or five patients per shift, up from three a decade ago, with fewer support staff. "It's not only physically draining, it's spiritually draining knowing you can't provide the care patients need," Eaton said. When he starts his 8 pm to 8 am shift, he said, "I feel like an actor going on stage for the first time. I have butterflies in my stomach." ... Nurses rally for safe levels of staffing Shaun Sutner, Worcester Telegram & Gazette, May 11, 2004 <http://www.massnurses.org/News/2004/05/worcester_telegram.htm> Boston - Hundreds of nurses rallied at the Statehouse yesterday for legislation that would require hospitals to hire more nurses and maintain mandatory staffing levels considered safe for patients. Clad in powder blue T-shirts, the nurses, members of the Massachusetts Nurses Association union, said patients are suffering because they are overworked and forced to care for too many people at a time. "We need this just to save lives," said Loretta Steele, a veteran nurse at St. Vincent Hospital at Worcester Medical Center who was at the event. "Patients deserve better. Hospitals can afford it with their profits." The bill's prospects, however, appear dim this year because of opposition from the hospital industry and key legislative leaders at a time when many hospitals are struggling financially. The measure was released from the Legislature's Health Care Committee last year, but it has languished since then, and California remains the only state that has such a "safe staffing" law. Now, legislative leaders are promoting a commission to study the fiscal impact of the bill after a budget amendment proposed by Rep. Jennifer M. Callahan, D-Sutton, to implement the safe staffing bill failed last month. Meanwhile, Sen. Richard T. Moore, D-Uxbridge, is pushing a competing measure that would leave staffing authority in hospital administrators' hands but make hospitals' staffing plans public and measure how hospitals meet nursing standards. ... Nurse rally for staffing Jon Brodkin, MetroWest Daily News, May 12, 2004 <http://www.metrowestdailynews.com/health/view.bg?articleid=68048> Boston - More than 600 nurses and health care advocates from throughout the state rallied in favor of mandated hospital staffing at the State House yesterday, demanding a vote this year on a bill that would require minimum nurse-to-patient staff ratios. "We are not celebrating because we cannot take care of our patients the way we were taught to take care of out patients," Karen Higgins, a Boston Medical Center nurse who is president of the Massachusetts Nurses Association, told a cheering group of nurses and other ratio advocates. "We want a vote on this bill and we want it done this year." Nurses supporting mandated ratios argue patient care is often shoddy because nurses have to care for too many patients. Richard Ferri, a registered nurse from Cape Cod who edits two medical journals, said in 2002 he landed in three hospitals after four incidents of spontaneous pneumothorax, which causes a lung to collapse. Ferri did not name the hospitals, but said none of them had enough nurses to provide adequate care. "I was left to do my own care 99 percent of the time, and I was in the intensive care unit of three hospitals," he said. "This has absolutely got to stop." Less than two weeks ago, the House approved a 2005 budget plan that would create a commission to study nurse staffing ratios and report findings by Jan. 31, 2005. The Nurses Association opposes the study commission because it believes existing research shows ratios are necessary to ensure quality of care, group spokesman David Schildmeier said. The group will pressure the Senate to keep the study commission language out of its budget proposal in hopes of bringing the ratio bill to a vote this year, Schildmeier said. ... Hundreds of nurses protest staff levels Dan Ring, Springfield Republican, May 12, 2004 < http://www.masslive.com/news/republican/index.ssf?/base/news-4/1084353690156740.xml> Boston - Chanting "Safe staffing now," hundreds of nurses yesterday protested at the Statehouse in support of legislation that would mandate hiring more nurses. Members of the Massachusetts Nurses Association, dressed in blue T-shirts that said "rally for ratios," pressed for passage of a bill that would require acute-care hospitals to submit to minimum registered nurse-to-patient ratios in different units and departments. The bill would also ban the use of mandatory overtime. Nurses said the ratios are needed to ensure patient safety and good care. "There's currently no guidelines for what is safe and what isn't," said Peter J. Danielson of Orange, a registered nurse at Cooley Dickinson Hospital in Northampton. "It's only when the sweat is pouring off me and I know I can't get my work done, never mind help other nurses, that it is really, truly unsafe." Under the legislation, one registered nurse would be assigned to no more than three patients in an emergency room. The ratio would be one nurse to four patients in medical-surgical units where most patient care occurs. Danielson said that in his unit at Cooley Dickinson, one nurse is assigned to five patients during days and six in the evenings. The bill would allow staff to be adjusted to meet patient needs, based on an objective system for monitoring certain medical conditions. The bill has been approved by the Health Care Committee and is currently pending in the House Ways and Means Committee. ... More than 1,000 Nurses and Health Care Advocates Flood Massachusetts State House to Call for Vote on H.1282, A Bill To Set Minimum RN-to-Patient Ratios Massachusetts Nurses Association, May 13, 2004 <http://www.massnurses.org/News/2004/05/rally_for_ratios.htm> More than 1,000 registered nurses, former patients and advocates for patient safety flooded the State House in Boston on May 11th, marking National Nurses Week with a demonstration calling for passage of legislation, H. 1282, that would set state minimum RN-to-patient ratios in all Massachusetts acute care hospitals. Clad in aqua blue T-shirts, the sea of nurses overflowed historic Nurses' Hall, with nurses lining staircases and the balconies surrounding the area of the State House named to honor nurses who served in the Civil War. The boisterous crowd rocked the halls of the State House with chants of "Our Patients Deserve a Vote," and "Safe Staffing Now," a message from those on the front-lines of the health care system that, in the words of MNA’s president Karen Higgins, "The time has come to protect patients and pass this legislation." The event, which was hosted by the Coalition to Protect Massachusetts Patients, an alliance of 65 leading health care and consumer groups, was designed to move the bill out of the House Ways and Means Committee onto the floor of the House for a vote. ... Editorial Comment: View pictures & video from rally < http://www.massnurses.org/Events/2004/05/rall_for_ratios.htm> Nurses press for improved staffing Kathy McCabe, Boston Globe, May 16, 2004 <http://www.massnurses.org/News/2004/05/boston_globe2.htm> Nurses from the North Shore and Merrimack Valley joined more than 1,000 health care advocates at the State House last week to rally for a new staffing bill now before the House Ways and Means Committee. A rally touting the bill was organized by the Massachusetts Nurses Association as part of National Nurses Week. The bill would set mandatory staffing levels at Massachusetts hospitals. Nurse-to-patient ratios would vary by the level of specialty. The ratio in intensive care, for example, would be 1 nurse to 2 patients, while the ratio on a standard medical-surgical floor would be 1 nurse to 4 patients. In all, 13 ratios would be established, according to the Massachusetts Nurses Association. ''The patients deserve a vote," said David Schildmeier, spokesman for the MNA, the state's largest nurses union. ''This bill would make sure that when a patient walks into any hospital in Massachusetts, they're guaranteed a basic level of care, which is not the case now." The union has long complained about staffing levels at hospitals. Too many patients and too few nurses jeopardizes the safety of both worker and patient, the union says. A remedy has yet to be found, however. Other bills to regulate staffing levels have died on Beacon Hill. The union is more hopeful this time, however. The new bill cleared the Legislature's Joint Committee on Health Care. ''This is the first time that has happened," Schildmeier said. The House Ways and Means Committee is still a hurdle, however. The committee must release the bill before it can go to the House floor for a vote. The union this week plans to present the committee with an analysis of how the bill would affect hospital finances. State Senate Passes Amendment to Protect Patients by Establishing RN-to-Patient Ratios in Hospitals Measure Calls for Ratios to be Phased into All Hospitals Over Three Years The Coalition to Protect Massachusetts Patients, May 21, 2004 <http://www.massnurses.org/News/2004/05/amendment.htm> Canton - In a major victory for the safety of hospital patients in the Commonwealth, the state Senate passed an amendment to the state budget last night that would require acute care hospitals to establish and maintain safe, flexible, minimum RN-to-patient ratios. The Senate measure, championed by Senator Marc Pacheco (D-Taunton), provides for a pilot program that would phase in ratios in all Massachusetts hospitals over a three-year period; with 10 hospitals required to adopt the ratios in the first year, 15 more in the 2006, and the remainder in 2007. The measure would make Massachusetts the second state in the nation to adopt such legislation; a similar law has been implemented successfully in California. "This legislation, which has won broad support and endorsement by more than 65 leading health care groups, marks an important step in the improvement of health care for all patients in Massachusetts hospitals," Sen. Pacheco said. The Taunton Democrat is chair of the Senate Post Audit and Oversight Committee, and former chair of the Joint Health Care Committee. "We applaud Sen. Pacheco for his leadership and commitment to protect the patients of the Commonwealth, and we applaud the Senate for their recognition that the time has come to provide patients of the Commonwealth with a guarantee of quality nursing care through the implementation of RN-to-patient ratios, which is supported by eight out of 10 voters in the Commonwealth and nine out of 10 frontline nurses," said Karen Higgins, RN, president of the Massachusetts Nurses Association, a member of the Coalition to Protect Massachusetts Patients, and the organization that filed the original safe RN staffing legislation. "While we believe all hospitals and patients would benefit by introducing the ratios in all hospitals at once, this is a reasonable compromise that allows the process of protecting patients and improving care to begin, and ultimately, for all patients to be protected over time." The MNA also praised Sen. Harriette Chandler (D-Worcester), former House chair of the Joint Committee on Health Care, for taking a strong leadership role in working with Sen. Pacheco to craft the compromise amendment and for promoting its passage among the membership in the Senate. ... Editorial Comment: Here’s a sampling from around Massachusetts (and from Hawaii too) of reactions to the Senate’s coming on board: Congrats! From all of us who count on you to deliver quality health care. - Isaac, MSAC Great victory, Sandy!! Congratulations! In solidarity, Greg HOOOOOOOOOOOOOOOOORAYYYYYYYYYYY!!!!!!!!!!!!!!!!!!!!!!!! Is this what I think it means! WOW. My hats off to the nurses of MNA. You are awesome. Can't wait to tell my colleagues that it's raining ratios in Massachusetts! Send some of that weather to Hawaii!! What state will be next. I think this will be national legislation by 2008 for sure (or sooner!) Good job and thank you for all of your hard work!! Congratulations MNA!!! We will post. - Robert Gaw, NASRO Unbelievable, Sandy! How did Mike Morrissey vote? Congratulations for all your hard work. It finally paid off! huzzahs!!!!!!! ... to and for you guys ... george papas, brockton That's absolutely FANTASTIC!!!! - BWR Congratulations!! - Alice C. Swift, Amherst, Massachusetts Fantastic!! Ellen Kagan Bill would set nursing quotas Robin Lord, Cape Cod Times, May 27, 2004 <http://www.capecodonline.com/cctimes/billwould27.htm> Provincetown - Richard Ferri had heard tales of how nursing shortages affected the quality of hospital care, but it didn't hit home until he experienced it himself. Ferri, a nurse practitioner, was hospitalized with a collapsed lung three times in 2002. Staying at three different health care facilities, including Cape Cod Hospital, Ferri said he monitored his own medication and even changed his own catheter because the nurses were too busy. "It wasn't bad nurses," said Ferri, of Provincetown. "It was just that everyone was so stressed out." An amendment added to the Senate version of the state budget is intended to address situations like Ferri's. The measure would create a strict 4-to-1 staffing ratio, boosting the number of nurses in Massachusetts hospitals. Currently there is no requirement for hospitals to provide minimum staffing levels. The Massachusetts Nurses Association is lobbying for the amendment, which must now survive debate in conference committee and scrutiny from Gov. Mitt Romney. A similar measure was passed last year in California and another version is under consideration at the federal level. "It will mean we'll have the staff we need," said Marilyn Rouette, nurses' union president at Cape Cod Hospital in Hyannis. ... A call to arms for nursing standards Richard Ferri, RN, Provincetown, Boston Globe, May 29, 2004 < http://www.boston.com/news/globe/editorial_opinion/oped/articles/2004/05/29/a_call_to_arms_for_nursing_standards> In 2002 I found out what it is like on the other side of a hospital bed. After more than 25 years of practice as a registered nurse, I became a critically ill patient. My left lung collapsed four times in as many months. This landed me in three different hospitals in Massachusetts, and ended up with my needing emergency open lung surgery. The trauma was coupled with the fact that I am HIV positive. Now toss in the issue that between my hospitalizations my parents died unexpectedly within weeks of each other. Life was more than challenging. What I needed was expert and competent nursing care. But because there are no standards for setting the ratios of nurses to patients, I couldn't count on getting it. As my condition grew more severe, the nursing care I received was spotty at best, and sometimes totally absent. I often did my own nursing care. Sometimes I even had to comfort the overburdened nurses. ... Nurse staffing bill will save lives Carlos Alvarez & Isaac BenEzra, Cape Cod Times, June 9, 2004 A patient undergoing heart or lung surgery could have the best surgeon in the world, utilizing the latest technology and cutting-edge medicines, but it could be all for naught if, after surgery, the patient’s nurse is overloaded with other patients. A nurse cannot be in two places – or at two bedsides – at once. The nurse is more likely to miss changes in the patient’s condition that could result in a debilitating pneumonia, or to miss the signs of a fatal heart attack. One recent study found that patients with cardiac problems are more likely to die at night in hospitals because of chronic understaffing; another found that the incidence of hospital-acquired pneumonia can be significantly reduced with good RN staffing. That’s why the American Lung Association, American Heart Association, the Massachusetts Senior Action Council, the Greater Boston Diabetes Society, the American Cancer Society and 60 other leading health-care and consumer organizations have come together to fight for passage of legislation to establish safe, minimum, and flexible RN-to-patient ratios in all Massachusetts hospitals. The state Senate has just approved a budget amendment that will set up a pilot program at 10 hospitals to test the idea, with full statewide implementation by 2007. We are confident this sensible compromise will prove what we have been saying: It will work. It is practical and affordable. And Massachusetts patients need it urgently: - The Department of Public Health reports a 76 percent increase in the number of injuries, medication errors and complaints by patients since 1998. - 65 percent of nurses report an increase in medication errors resulting from nurse understaffing. - And, most alarming of all, one in three nurses in Massachusetts reports an increase in unnecessary deaths of patients because of understaffing. One study by the American Medical Association (sic) found that each additional patient above four that a nurse cares for produces a 7 percent increase in the risk of death. If a nurse typically cares for eight patients rather than four, there is a 31 percent increase in the risk of death for those patients. We have heard the arguments of the hospital industry against this bill; none of them stands up to the evidence at hand. They argue there is a shortage of nurses in the state that is causing these conditions, but the fact is Massachusetts has the highest per capita population of nurses in the nation. The respected research firm Opinion Dynamics Corp. just completed a survey of RNs working part time in hospitals in Massachusetts. The survey found that fully one third will work more hours if the Safe Patient Care Bill becomes law. In terms of hospital staffing, this is the equivalent of adding more than 1,800 full-time RNs – more than enough to meet the bill’s requirements. In practical terms, this news is much better than having to find and train new hires; these part-timers are already receiving benefits, and expensive recruiting and training costs would be eliminated The industry argues that the cost of improving staffing is too high. Yet the evidence shows safe RN staffing to be cost-effective – at worst cost-neutral and, by most accounts, likely to save millions of dollars by reducing costly complications. The Coalition to Protect Massachusetts Patients has looked at the evidence, and we find it all argues for the passage of Safe Staffing Legislation. We can’t afford not to respond to this crisis. The ultimate cost of doing nothing, as the hospital industry recommends, is far too high. It’s time to guarantee every patient safe RN staffing, because safe staffing saves lives. Carlos Alvarez is executive director of the American Lung Association of Massachusetts. Isaac BenEzra is president of the Massachusetts Senior Action Council. Both are members of the executive committee of the Coalition to Protect Massachusetts Patients. H.1282 By the Numbers – Take Money Wasted in Hospital Board Rooms and Put it Back at the Patient ’s Bedside Where it Belongs Tuesday Reporter, Volume 4, #16 <http://www.massnurses.org/safe_care/Tuesday_Reporter/tr16.pdf> Legislators who want to know why they need to pass H.1282, Safe RN Staffing Legislation, need only look at some very revealing numbers. For example: The Cause of the Current Crisis 27% - the decrease of registered nurses in Massachusetts hospitals over the last decade, the largest cut in hospital nurse staffing by any state in the nation. (Health Affairs, 1996) 46% - the increase in the number of non-direct care administrators and managers during the same time period. (Health Affairs,1996) 27.5% - The portion of Massachusetts Hospital budgets allocated to non-direct care administrators, managers and consultants; again, among the highest in the nation. (New England Journal of Medicine, 2003) The Result 76% - the increase in medication errors, injuries to patients, complaints by patients over the last seven years, according to the Massachusetts Department of Public Health. 60% - Massachusetts voters who report a decrease in the quality of patient care due to nurses having too many patients to care for. (Opinion Dynamics Survey, 2003) 45% - Hospital patients in the last two years who report their safety was compromised because of inadequate staffing. (National Consumer League, 2004) 0 - What the hospital industry has done to address this crisis. The Solution 1.8% - the percentage of net patient revenues required to meet the RN-to-patient ratios under H. 1282. If administrators cut their portion of health care spending from 27 cents of every dollar to just a quarter, thousands of lives would be saved and thousands of dollars recouped from reductions in complications and staff turnover. (Andover Economic Evaluation, 2004) 82% - Massachusetts voters who support this idea. (Opinion Dynamics Survey, 2003) Industry’s Counteroffensive: Saba: Moore takes sensible approach to health care reform Francis M. Saba, Milford Regional Hospital President & CEO, MetroWest Daily News, April 30, 2004 <http://www.metrowestdailynews.com/columnists/view.bg?articleid=67028> Once again, Sen. Richard Moore (D-Uxbridge) has taken an effective leadership role on a critical healthcare issue with his recently proposed bill, An Act to Support the Nursing Profession and Promote Safe Patient Care. His proposal tackles the difficult issue of appropriate nurse staffing in a thoughtful and collaborative way, involving the nursing profession, other providers, the education industry and government. It provides real solutions to the commonwealth's ongoing nurse staff shortage by offering such initiatives as loan repayments and financial aid to new nursing grads or those entering programs, as well as encouraging greater collaboration between healthcare and education sectors to revitalize nursing programs throughout the state. Our hospital, Milford Regional, in its 100 year history, has always benefited from an outstanding, quality-focused and dedicated nursing workforce, and we are committed to working with our nurses to provide the support and resources that they need to fulfill their mission of care. Although Milford Regional has already taken significant steps to assure patient safety through such measures as our computerized medication dispensing system and our recently state-recognized medication reconciliation program, we further support Sen. Moore's proposal requiring greater accountability on the nurse staffing issues for hospitals through mandated disclosure of staffing plans. This, along with annually reported, nurse-sensitive performance measures on patient outcomes, ensures the very highest quality of care. We applaud and appreciate Sen. Moore's unwavering efforts to confront the extremely complex issues surrounding healthcare and, in doing so, crafting such a comprehensive piece of legislation. We are very grateful for the work that he does for the health care industry throughout the state. Safe stffing scare tactics Boston Herald Editorial, May 11, 2004 <http://news.bostonherald.com/opinion/view.bg?articleid=27365> All the slick radio ads and well-attended State House rallies can't obscure the bottom line about the safe-staffing bill. Health professionals, not legislators, ought to be in the business of managing patient care. Hospital administrators, not lawmakers, know better the nursing needs of their patients. State-mandated nurse-to-patient ratios do nothing to encourage more students to turn to the nursing profession, either. Ads designed to scare people into thinking they're doomed if they need hospital treatment because there's nary a nurse available to stick in an IV are effective. That doesn't make them right. Moore critical of health care reforms Brian Eastwood, MetroWest Daily News, June 12, 2004 <http://www.metrowestdailynews.com/localRegional/view.bg?articleid=70556> Milford - For too long, state Sen. Richard Moore said yesterday, the state has been fixing the health care "crisis du jour" without developing a long-term plan. "We've been lurching from crisis to crisis in health care, making serious, often shortsighted cuts without any vision of what kind of health care we want and can afford," said Moore, D-Uxbridge. Moore spoke at the annual luncheon of the Milford Area Chamber of Commerce, outlining a series of proposals for health care reform and urging Gov. Mitt Romney not to continue cutting health care. Chamber president Barry Feingold said the group invited Moore because he is "constantly at the forefront" of issues related to health care. ... State Budget Debate: Budget debate ignites other issues Steve LeBlanc, Associated Press, May 15, 2004 <http://www.metrowestdailynews.com/localRegional/view.bg?articleid=68291> Boston - A ban on new charter schools, an easing of sentencing laws for drug offenders and the repeal of a 1913 law being used to bar gay couples from other states from marrying in Massachusetts are some of the topics state senators face as they launch their budget debate. Another proposed amendment to the state spending plan would require hospitals to meet strict nurse to patient ratios. The amendment, which has been the focus of an intense lobbying effort on Beacon Hill, would set minimum nurse to patient ratios for every unit of a hospital, as low as one nurse for each patient in emergency and delivery rooms and as high as one nurse to five patients in other departments. Supporters say the plan will guarantee better care for patients by allowing nurses to respond faster. "Hundreds if not thousands of patients suffer unnecessarily every day," said David Schildmeier, spokesman for the Massachusetts Nurses Association. Critics say lawmakers shouldn't be dictating staffing levels at hospitals - a job they say is best left up to hospital managers. "Ratios are rigid and inflexible and they don't allow physicians and nurse managers to tailor care in hospitals to meet the needs of their patients," said Paul Wingle, a spokesman for the Massachusetts Hospital Association. The ratios would require Massachusetts hospitals to hire an additional 7,000 nurses and would cost hundreds of millions of dollars, he said. The amendment, sponsored by Sen. Marc Pacheco, D-Taunton, is one of hundreds scheduled to come up for debate next week. ... Hammering out a compromise between House and Senate budgets no easy task Associated Press, May 21, 2004 <http://news.bostonherald.com/localRegional/view.bg?articleid=28866> Boston - When Senate President Robert Travaglini, D-Boston, gaveled the Senate budget session to an end late Thursday night he signaled the end of the public portion of the Legislature's debate on the state's new spending plan. Now comes the hard part. A panel of three House members and three senators will head behind closed doors to hammer out a compromise of the two versions of the budget. ... [B]eing watched closely is the question of nurse-to-patient ratios in hospitals, a proposal being pushed by the Massachusetts Nurses Association. The House voted to study the proposal, while the Senate approved a pilot program in 10 hospitals with an eye toward expanding it to all hospitals across the state. Hospitals oppose the move, saying lawmakers shouldn't micromanage staffing levels, while the nurse's union says the plan will improve care for patients. ... FY '05 budget debated Process moving smooth - and early Mary Carey, Daily Hampshire Gazette, June 12, 2004 < http://www.dailyhampshiregazette.com/storytmp.MFC?id_no=6120096&CSSUBSTART=1&TVS=1%24-75192823%2450%24Wed+Jun+16+17%3A18%3A46+EDT+2004-27015%240%2433314330 45363546423232453135423230304543393439444331464341433639&CSBOX=1%24180%240%24U SD%240.0%2410.0%2420.0%240.0%240%240%2433%3AUSD%3AUSD%3AL4%2C0%2C.05%2C.02%2C. 05%2C10%2C0%2C.25%2418%3AUSD%3AUSD%3AL1%2C.02%2C.05> The House-Senate conference committee, charged with negotiating a compromise 2005 state budget, is scheduled to work through this weekend in a final push to get the $23 billion spending plan back to the full Legislature for final approval next week. Sen. Michael Knapik, R-Westfield, who has served on the six-member committee for four years, said it's been a relatively smooth process this year compared to the previous three. In some years, the budget hasn't been ready for final approval until Thanksgiving, five months into the fiscal year, which begins on July 1. ... Still, there are substantial differences between the House and Senate budgets that pose a challenge to the committee. These include, for example, reforms in transportation and Turnpike funding and a measure calling for minimum staffing levels for nurses in hospitals. The Senate plan includes these measures but the House plan does not. ''Some things clearly will be dropped, because they are well beyond the scope of the budget,'' Knapik said. He thinks that the nurse-staffing bill may very well be referred to the House, so it can come up for a vote there. ''I think the goal is to accommodate as much as we can from both versions but also let the legislative process take its natural course,'' he said. Health is winner in budget talks Alice Dembner & Scott S. Greenberger, Boston Globe, June 16, 2004 < http://www.boston.com/dailyglobe2/168/metro/Health_is_winner_in_budget_talks+.shtml> After three years of deep cuts in human services, the Legislature is set to approve a budget that restores health coverage for tens of thousands of low-income children, people with HIV, and immigrants and that increases spending on vaccination and other disease-prevention programs. The $24.8 billion compromise budget for fiscal 2005 also includes $140 million more to pay for hospital care for the uninsured, whose numbers have soared since the economy soured. ''They solidly began ... repairing the damage of the past several years and addressing some significant health needs," said John McDonough, executive director of Health Care for All. ''At least for now, state government has stopped contributing to the problem of the growing numbers of uninsured." ... Included in the proposed public health budget is nearly $6 million more for vaccines than last year, which will restore immunization programs to prevent hepatitis, pneumonia, and meningitis in adults, according to Geoff Wilkinson, executive director of the Massachusetts Public Health Association. The budget also increased funding for school nurses and clinics that the governor had proposed eliminating. Legislators also included a nearly $10 million increase for the Children's Medical Security Plan, which subsidizes health insurance for children of families who make too much to qualify for Medicaid, but can't afford private coverage. The money would cover all 15,000 children on a waiting list that began when the state capped funding in 2002. ... Both houses rejected a controversial plan by the Romney administration that would have forced low-income patients on Medicaid to get primary care at community health centers instead of hospitals. They dropped a Senate proposal to mandate nursing staffing ratios at hospitals and a House proposal to prohibit doctors from referring patients to MRI facilities in which they have a financial interest. ... Budget offers booster for health care Passage in Legislature expected today David Kibbe, New Bedford Standard-Times, June 16, 2004 <http://www.southcoasttoday.com/daily/06-04/06-16-04/a01sr386.htm> Boston - The state Legislature is poised today to vote on a $22.5 billion budget that would restore millions of dollars in health care programs for the poor and elderly. The budget offers slight increases or the same funding in many areas - including local school aid - following several years of deep budget cuts. Legislative leaders said partially restoring deep cuts to health care was one of their top priorities this year. "We think that we put together a budget that is balanced, is progressive and is fair," said Sen. Therese Murray, D-Plymouth, who is the Senate's chief budget writer as chairwoman of the Senate Ways and Means Committee. The budget does not include any new taxes, and there would be no state layoffs, as was originally threatened by House leaders. Once it is passed, the spending plan goes to Gov. Mitt Romney, who has 10 days to sign the document and issue vetoes. The budget is due July 1. ... Several controversial items that had been backed by the Senate were left out of the final document, including a repeal of the 1913 law banning out-of-state couples from getting marriage licenses, legislation encouraging stem-cell research, mandatory nurse staffing levels and the reimportation of prescriptions drugs from Canada. Sen. Murray and her House counterpart, Rep. John Rogers, D-Norwood, said those issues would be voted on separately at a later date, though Sen. Murray acknowledged it would be difficult to do so before the session ends for the year on July 31. ... New charter schools on hold Romney vows to veto moratorium Michael Kunzelman & Jon Brodkin, Waltham Daily News Tribune, June 16, 2004 <http://www.dailynewstribune.com/localRegional/view.bg?articleid=35363> Boston - Leaders of the state Senate and House of Representatives have agreed to impose a 19-month moratorium on new charter schools, but they scrapped a Senate-approved plan to tinker with the state's formula for funding charter schools. ... In many respects, the House and Senate budget compromise is noteworthy for what it does not include, such as a controversial measure that would mandate minimum nurse-to-patient ratios in acute care hospitals. The Senate had proposed using ratios in 10 hospitals next year, with the possibility of implementing the requirement statewide by 2007. But the ratios met heavy opposition from the Massachusetts Hospital Association and Massachusetts Organization of Nurse Executives. "This is bad policy, and bad policy for patient care," said Karen O. Moore, president of the nurse executives groups. Moore supports another proposal that would focus on increasing the supply of nurses. The Massachusetts Nurses Association will continue to lobby for ratios to be passed in the form of a bill, said Julie Pinkham, the group's executive director. "Based on our discussions (with legislators), there's time left in the session to move it forward," Pinkham said. The MNA wants to require hospitals to staff at least one registered nurse for every four patients in medical and surgical areas, and at least one registered nurse for every two patients in intensive care units. ... Current Status: Patient Care Advocates Disappointed by Conference Committee’s Failure To Include Safe Staffing Pilot Program in Final Budget Conferees Miss Opportunity to Protect Patients Urge Ways and Means Committee to Act on Staffing Bill before End of Session The Coalition to Protect Massachusetts Patients, June 15, 2004 <http://www.massnurses.org/News/2004/06/amendment.htm> Canton – The Coalition to Protect Massachusetts Patients announced today its disappointment with the failure of the House and Senate Budget Conference Committee to include a pilot program in the state budget that would establish and maintain safe, flexible, minimum RN-to-patient ratios in acute care hospitals. Advocates for safe staffing will now focus efforts on passing a similar measure, H.1282, which is being considered by the House Ways and Means Committee. "The Coalition to Protect Massachusetts Patients believes the time has come for RN-to-patient ratios to be enacted. As those who advocate for patients with chronic and debilitating diseases, we know the impact the current staffing levels have on patient care and we remain committed to seeing that they are improved," said Carlos Alvarez, Executive Director of the American Lung Association of Massachusetts and a member on the executive committee of the Coalition, an alliance of 70 leading health care and consumer advocacy groups. "This is a missed opportunity to protect patients and improve the safety and quality of care in our hospitals," said Karen Higgins, RN and president of the Massachusetts Nurses Association. "We have a true crisis in care in our hospitals, and every day that we wait for this legislation to become law, a patient in our hospitals suffers unnecessarily. The Legislature must act to adopt safe RN-to-patient ratios before the end of this session and we are committed to doing everything we can to make that happen." The conferees were considering a Senate measure, championed by Senator Marc Pacheco (D-Taunton), that would have provided for a pilot program that would phase in ratios in all Massachusetts acute care hospitals over a three-year period; with 10 hospitals required to adopt the ratios in the first year, 15 more in the 2006, and the remainder in 2007. H.1282, the original Safe RN Staffing bill, which was filed by the MNA and approved by the Joint Health Care Committee last November, is still alive and awaits action in the House Ways and Means Committee. ... Nurses lobby for set staffing ratios Diane Broncaccio, Greenfield Recorder, June 16, 2004 Greenfield - Saying the Franklin Medical Center sometimes lacks sufficient registered nurse (RN) staffing in some patient areas, local nurses have stepped up their efforts to back legislation that would set minimum RN-to-patient ratios for hospitals. This week, Franklin Medical Center nurses took out full-page newspaper ads, paid for with their local union dues, to urge support for House Bill 1282. H. 1282, "An Act Ensuring Quality Patient Care and Safe RN Staffing," would establish minimum RN-to-patient ratios in Massachusetts hospitals as a condition of Department of Public Health licensure. The legislation would establish several RN-to-patient ratios for different hospital departments, from intensive care units to medical-surgical areas and emergency rooms, with the staff ratios based on the level of patient need. For instance, the bill now recommends a ratio of one nurse for every two patients in the intensive care unit and one nurse to every four patients for medical-surgical units. However, the ratio could be increased, depending upon patient need. But Karen O. Moore, FMC's vice president and president of the Massachusetts Organization of Nurse Executives, says the bill will be costly to hospitals, won't solve the state's nursing shortage and will limit access to hospital care. She also believes there is a "lack of scientific evidence that this is a valid approach to nurse staffing. ... Staffing is important, but it's the rigid inflexibility of mandated staffing ratios that we know will create huge issues for access to care and significantly exacerbate the nursing shortage," Moore said. Currently, the Greenfield hospital has about 200 full-time equivalent nurses. Moore said staffing decisions are now made on a daily basis in collaboration with doctors, nurses and other staff, based on the conditions and needs of patients. "We would be assigning nurses to numbers - not to patients' needs," said Moore. However, Kristen Einhorn, Franklin Medical Center obstetrics nurse and co-chair of the FMC bargaining unit, said she's received several Unsafe Staffing Reports from nurses in medical-surgical areas. She said the reports are generally submitted "as soon as something out of the ordinary happens. ... The hospital is a small hospital, and the smaller a place is, the more difficult it is to staff," Einhorn said. "If you had 12,000 deliveries a year, you would have a better idea of how to staff it, because you would have an average of how many births per day to expect. At the Franklin Medical Center, there are some days when we have five deliveries and some days when there are none. I would think that's true for med-surg as well." Einhorn said she sometimes is sent down to help out in the medical-surgical departments when the maternity ward is not busy. Obstetrics, she says, is on the average, better staffed "because there are clear guidelines as to how the unit is staffed." Reading through recent reports, Einhorn said a nurse filed an unsafe staffing report this month, saying that three nurses and two aides were held responsible for 24 patients. One of the nurses was someone who normally works days but was being "floated" during the night shift. The three nurses were responsible for eight patients each, but five patients were at high risk of falling, which means they required more than usual care. Because "the situation was not workable," according to the report, an on-call OB-GYN nurse was called at 1 am, who arrived to start work on the medical-surgical unit at about 3:15 am. In another report earlier this month, the same nurse reported a night in which three nurses, two nurses aides and a "floating" nurse (from the less busy wing of the hospital) were responsible for 22 patients, with seven patients hooked to safety monitors and being at high risk for falling. Two patients were also on a suicide watch, which normally calls for one-to-one care by either a nurse or an aide, said Einhorn. However, one nurses aide was assigned to both patients, even though they were in different rooms and couldn't be watched by one person at the same time. Another night, said Einhorn, there were 19 patients being served by three nurses and a nurses aide, but the staff was unable to answer all patient calls promptly. One patient fell and an incident report was filed because of inadequate help. ... "At FMC, the nurses have a bargaining unit and we do sit down and talk about things, that makes it better than some other (hospitals)." RN Bonnie Beth Pierce has worked at FMC for about 20 years as an obstetrics/gynecology nurse and has helped out on the medical-surgical unit during very busy times. "I would say I've witnessed ratios that are not safe," she remarked. "That's why nurses are making out these reports. The patients in this community have a right to know." According to the Massachusetts Nurses Association, the need for safe staffing legislation has been substantiated by several studies. These include a National Consumers League survey of hospital patients, which found that nearly half of recently hospitalized patients reported their care was compromised by inadequate RN-to-patient ratios. Also, a Department of Public Health report said there was a 76 percent increase in injuries, medication errors and complaints by patients in Massachusetts hospitals over the last seven years because of poor nursing care. A study in the Journal of the American Medical Association found that for every patient beyond four assigned to a nurse, the risk of patient deaths increases by 7 percent. Moore said the bill would add between $250 million to $500 million in costs, and hospitals that failed to comply with required staffing levels would be subject to $25,000 fines. Moore said she supports an alternate bill proposed by Senate Health Care Committee Chairman Richard Moore. Moore's bill would provide funding for more nursing education and establish a center for patient safety and medical errors in the state. Massachusetts Nurses Association David Schildmeier said his organization appreciates the funding aspect of Moore's proposal, but believes that House Bill 1282 will do more to ensure safe staffing levels. He said 102 out of 200 representatives have co-sponsored the House bill. He said the bill also has the support of 70 health organizations, including the American Cancer Society. On Monday, a similar Safe Staffing Pilot Program that was to be included in the state budget failed to gain support in the House and Senate Budget Committee. That bill would have phased-in higher nurse-to-patient ratios in acute care hospitals. The Massachusetts Nurses Association, which has worked hard to raise awareness about the issue, says it will focus more efforts on the House of Representative bill. As Health Care System Fails More Americans ... MNA/Nurses to Participate in June 19th Bridge Demonstration for Affordable Health Care for All Thousands expected for symbolic Longfellow Bridge Walk and Rally on Boston Common Massachusetts Nurses Association, June 17, 2004 <http://www.massnurses.org/News/2004/06/bridge_walk.htm> Canton - On June 19, 2004, the Massachusetts Nurses Association will join more than 80 other community and labor organizations from across the Commonwealth in a march from Cambridge to Boston across the Longfellow Bridge to call for health care justice in America. Citizens across the country will march by the tens of thousands in additional regional demonstrations to join the Boston demonstration in their symbolic bridge walk as part of a nationally coordinated "Bridge the Gap March for Health Care for All" day of action. The demonstration is designed to highlight a growing crisis in health care, where 44 million Americans and more than 600,000 Massachusetts residents lack insurance and millions more are underinsured. Under President Bush, 4 million more Americans lost their coverage, average health care costs have risen nearly 50 percent, and premiums have increased more than three times faster than average wages. Russ Davis, the director of Jamaica Plain’s Jobs with Justice, which is organizing the local march, explains that the event has attracted an impressive range of people from 80 area organizations, including labor, women's, immigrants', veterans', and seniors' groups. "It's a people’s movement," Davis says. "This issue affects literally every segment of society except the extremely rich. People feel like there's a failure to recognize this as a major crisis." "For nurses, walking that bridge and standing up for reform of the health care system is our moral obligation. Nurses will be marching because we are tired of witnessing the needless suffering of too many patients who are under our care simply because they lack adequate insurance and access to preventive care. They are in the hospital because they have had to delay treatment until it is too late. They are there because they lack adequate prescription drug coverage and their conditions have deteriorated for lack of basic medications; and once they are there, they are receiving substandard care because of poor staffing conditions caused by failed health care policies," said Barbara Cooke, RN, a frontline nurse at Brockton Hospital and member of the Board of Directors of the MNA who will speak at the rally. Organizers hope the march will mark the first step in a movement for fundamental American health-care reform. The Bridge the Gap March for Health Care for All kicks off at Kendall Square in Cambridge at 11 a.m. on Saturday, June 19 and will culminate with a rally on the Boston Common at 12 noon. For more information, contact Jobs with Justice at 617.524.8778, or visit its Web site at <http://www.massjwj.net>. Editorial Comment: Healthcare professionals are asked to assemble in Kendall Square, Cambridge, (on the MBTA Red Line) by 11 AM in uniform if possible. MNA members are asked to wear their turquoise T-shirts and other MNA identifiers. We will march beside coalition partners supporting the safe staffing and universal single-payer solutions to the healthcare crisis. The concluding rally will be MCed by Jimmy Tingle. A variety of lively, culturally diverse musicians will participate. Bring the kids! Other Nursing News: Nurse finds satisfaction in helping her patients Alex Peshkov, Springfield Republican, May 2, 2004 < http://www.masslive.com/search/index.ssf?/base/news-0/1083316736254220.xml?nnfp> Antonina Saykina has been involved in health care for about a quarter of a century now. She's spent the last four years as a registered nurse for a home care agency in Western Massachusetts and previously worked five years as a nurse's assistant here. And before 1993, when she came to America from Siberia, she was a district therapist. Now she visits (her patients) by driving a car around the area, but for 15 years in Russia, she just walked. Nowadays, the Russian model of healthcare organization basically consists of two parts: private (often pretty expensive) and state (generally free) hospitals and clinics. Decades ago, in Russia there were only state hospitals and "polyclinics" serving people within a certain district of a city. "I served 2,500 people in my district," Saykina recalled. "I used to spend three hours a day for appointments and the rest of the day for home visits." (In Russia, a doctor may make a home visit for a patient convenience, if the patient has a fever and feels too sick to visit a clinic.) Saykina praises the Soviet-era emphasis on preventive medicine, but says that "American medical equipment is far ahead of that in Russia, as well as surgery and emergency rooms." ... The Nurse Is In: Plymouth woman takes care of the caregivers Chad Berndtson, The Patriot Ledger, May 11, 2004 <http://ledger.southofboston.com/articles/2004/05/11/life/life01.txt> ‘What are the chances of you or someone you love being in need of a nurse?'' asks Plymouth native Sue Tobin. ‘‘Wouldn't it be best to have a happy nurse?'' It is that logical follow-up question that prompted Tobin, 49, a mother of five and active oncology nurse, to start Coach4Nurses, a coaching practice with the aim of restoring happiness and a positive attitude to nursing. Tobin said she began to feel unhappy in her own nursing practice, and she would leave patients' bedsides ‘‘frustrated and discontented.'' Right when she was about to leave nursing, she discovered coaching, which helped her to de-stress and be positive in her work. ‘‘I livened up my day, I had fun at work, my patients were really satisfied, and I generally felt much better,'' she explained. ‘‘It was realizing that I had the power to change how I behave in my nursing practice. It was an internal attitude, through coaching, that kept me at the bedside.'' Tobin found that a lot of nursing friends had similar gripes, and that burnout was common. Many of them were fatigued by long hours, short-staffing and being blamed for things beyond their control, much of which Tobin attributes to a change in the culture of patient care over the past few decades. ‘‘Patients are now coming in sicker and leaving sicker,'' she said. ‘‘Our job as teachers and facilitators has become much more difficult to do because of organizational issues in the health care industry.'' ... Editorial Comment: While supporting therapeutic options for burned out nurses and others slaving in the salt mines of contemporary health care, we must note that the above article appeared in the Quincy Patriot Ledger on the same day in Nurses Week that 1000 nurses and allies rallied in Nurses Hall for a systemic solution to unsafe clinical situations and the consequent stress and burnout. The Ledger interviewed many of the Quincy nurses who attended the rally. Not a word of the rally or of the specific situations raised by these nurses ever appeared in print. We must also note that nurse therapist Sue Tobin is off to the ANA convention in Minnesota, where frontline nurses continue to be betrayed by ANA’s incessant opposition to mandated minimal RN-to-patient ratios. Pension issue stalls contract Marlborough Hospital nurses plan informational picket tomorrow Jon Brodkin, MetroWest News, May 26, 2004 <http://www.metrowestdailynews.com/localRegional/view.bg?articleid=69225> Marlborough - Contract talks between registered nurses and management at Marlborough Hospital appear to be stalling, as nurses have balked at a hospital proposal they say would decrease their pensions. Marlborough Hospital is targeting the pension plan as it struggles with financial problems that led to the elimination of 22 jobs in March. Contract talks broke off after about two hours yesterday, in the 16th negotiating session since last August, said nurse Kevin McManus, vice chairman of the bargaining unit, which is part of the Massachusetts Nurses Association. The last contract, which covers more than 160 nurses, expired in October. Nurses, who also want an increase in pay, plan an informational picket outside the hospital tomorrow, McManus said. Another bargaining session is scheduled June 9. McManus said the picket will be the first such action by Marlborough nurses in more than 20 years. "I would like to believe that it would once again let them realize that this is a serious issue for us and we're not willing to erode our contract that significantly," he said. The current pension plan is funded solely by the employer and provides nurses a guaranteed retirement benefit, regardless of the pension fund's investment returns, McManus said. Hospital officials want to require nurses to also make contributions, making the plan similar to a 401K and leaving nurses at risk of losing some of their retirement benefits in the stock market, he said. Nurses say the proposal could lead to a two-thirds cut in the pensions of some employees. ... Hospital pays nurses $614,000 in overtime back wages Associated Press, June 7, 2004 <http://news.bostonherald.com/localRegional/view.bg?articleid=30967> Worcester - UMass Memorial Medical Center paid $614,000 in back wages to hundreds of nurses following an investigation by the US Department of Labor, the department announced Monday. Investigators found the 367 registered nurses at the hospital's University Campus in Worcester did not regularly take their 30-minute meal breaks, but the medical center automatically deducted the time from their pay. Since the nurses were paid hourly, they were entitled to time-and-a-half overtime pay, according to the Fair Labor Standards Act. The probe by the department's Wage and Hour Division covered a two-year period from July 2000 to July 2002. The medical center paid $614,449 to the nurses for their uncompensated overtime work. "This was not an issue of nurses not being paid their rightful wages at all," hospital spokesman Mark Shelton said. "This is a document issue that we addressed with the department of labor back in 2002." Shelton said the hospital is phasing in an automated electronic timekeeping system to better document workers' hours. Web Directory: AARN < http://www.aarn.org> Australian Nursing Federation <http://www.anf.org.au> California Nurses Association <http://www.calnurse.org > Canadian Federation of Nurses Unions <http://www.nursesunions.ca> CCDS < http://www.cc-ds.org> Committee for Health Care for Massachusetts < http://www.healthcareformass.org> Irish Nurses Organisation <http://www.ino.ie> Labor Party < http://www.thelaborparty.org> LabourStart < http://www.labourstart.org> Maine State Nurses Association < http://www.mainenurse.org> Massachusetts Ad Hoc Committee < http://www.MassDefendHealthCare.org> Massachusetts Green-Rainbow Party < http://www.green-rainbow.org> Massachusetts Nurses Association <http://www.massnurses.org> MASS-CARE < http://www.masscare.org> New York Professional Nurses Union <http://www.nypnu.org> New Zealand Nurses Organisation <http://www.nzno.org.nz> PASNAP < http://www.pennanurses.org> PNHP < http://www.pnhp.org> Québec Nurses’ Federation <http://www.fiiq.qc.ca> Revolution Magazine < http://www.revolutionmag.com> Saint Louis Area Nurses Coalition <http://www.slanc.org> Seachange Bulletin < http://www.seachangebulletin.org> Southern Arizona Nurses Coalition < http://SAZNC.homestead.com> Union Web Services < http://www.unionwebservices.com> Women’s Universal Health Initiative <http://www.WUHI.org> FAIR USE NOTICE: This site contains copyrighted material the use of which has not always been specifically authorized by the copyright owner. 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