Nurse Staffing Ratios Up for Public Decision? Ballot 1 in MA

[Bridgid Joseph]

The ballot question 1 in Massachusetts (Nurse Patient Assignments Limit Initiative) which will be voted upon November 2018 was designed to establish patient assignment limits for registered nurses working in hospitals, with limits determined by the type of unit or patient with whom a nurse is working, and the maximum numbers of patients assigned would apply at all times. Massachusetts is a hub for medical advancement. In Boston specifically, there are 6 major medical centers within a few feet of one another. Most are teaching hospitals of Harvard University, so staffing, technology, and innovation to support patients and safety are at the forefront of care. Despite that, there has been a push by the Massachusetts Nurses Association (a union) to enact a similar law for over 20 years. It was brought as a ballot question in 2014 but tabled after allowing for a change in ICU staffing ratios (which showed no change in patient mortality or complications, in a study from Beth Israel Deaconess Medical Center). Now it's more stringent and on the ballot for November 2018.

Why does this ballot question face so much opposition? It seems like more nurses is a good thing, right? No one disagrees that nurses are good, and its beneficial for us to take care of our patients. That being said, attached to this proposed bill is not only tighter staffing ratios than California, a 37-day window to comply (to which California had five years), but there is also a $25,000 fine for each time there is not that exact nursing ratio on the unit. The fine doesn't seem like a big deal: staff appropriately or get a fine, right? What happens when staff call out because they are sick? If you can't find coverage to make a 1:4 ratio on the Med Surg floor, hospitals get hit with a fine, and many of them, especially the smaller hospitals, do not have the money to pay. What about leaving the unit for a lunch break, or getting coffee? Not if it means the nursing ratio will be off for any period of time. Shared governance or interdisciplinary meetings? Sorry, you will have to schedule those on your days off. Because of the quick turnaround time to become compliant, and the few numbers of nurses in MA, any resource staff, unit based educators, and/or clinical nurse specialists will be pulled into staffing. There will not be anyone extra to help and "cover" a patient for a quick break. In California, the law allowed for Licensed Practicing Nurses (LPNs) to be hired to assist with upstaffing, but not in MA; RNs only. Differences also include that MA law has higher RN numbers to start and the bill in MA has a prohibition against reducing levels of other healthcare workers (CA did not). MA does not allow any exemptions, whereas in CA 25 hospitals sought and obtained an exemption from the law.

These fines, threats of fines, and immediate need to upstaff is going to cause numerous hospitals outside of the metro Boston area to close. This will limit access to care, longer drives for patients from the suburbs, and longer wait times to get care (fewer hospitals and services,) shunting everyone into the city. Those hospitals will have the same patient ratio limitations and will be unable to open and further ambulatory services. Currently, according to the 2017's Best & Worst States for Healthcare Massachusetts is ranked #9 overall for Best hospitals (#1 being the best), with California ranked at #25, despite these ratio laws being fully compliant since 2009. Furthermore, Massachusetts has a current ranking of #3 for access to care, meaning access to healthcare is readily available throughout the state. California is ranked #48, meaning the public has less access to healthcare. It's pretty telling that despite making nursing ratios legally required, the state of California has not improved the patients access to care and their overall satisfaction with care.

On top of the other concerns with this bill, the "at all times" language, which requires ratios to be the exact same, day and night, doesn't allow for nurses to use their clinical judgment at all when taking care of patients throughout the day. If I have 4 patients, 3 of which are ready for discharge, I cannot take a new PACU admission to help out the unit. A nurse who may have three heavy patients, one requiring a Rapid Response and eventual transfer to the unit, may have to take that patient, or it negatively impacts throughput and the patient has to sit and back up the PACU waiting until someone can admit them. That scenario may seem extreme, but it is something staff face every day, and if I am willing to take that extra patient to support my colleagues and support patient care, my hospital can be fined $25,000? That makes no sense. However, it is the reality of this bill. 4 patients in a Boston hospital at night, is a very different assignment from one of the community hospitals, yet they require the same exact staffing? That doesn't add up.

The general population of MA is being asked to vote on a bill without any knowledge of how healthcare works as whole. This is not to say lay people don't understand good care, they are our customers and they deserve the safest and best care possible and their input is invaluable. However, they do not know how to run a hospital, how it is budgeted, how we currently run staffing matrix, and what this bill means not only to their care but the state of Massachusetts. It has been estimated it will cost the state $1.3billion to become compliant with the thousands of new RN positions (most Boston hospitals only hire BSN level nurses, which will no longer be possible). It is an estimated $900million annually to maintain these new staffing ratios, without any revenue to the state, and more headaches and difficulty for the public to access care. No other field asks laypeople to make a decision on how they guide their business/care (think Medicine). It is bad policy-making for nurses to do the same; we all believe that highly trained nurses at the bedside, with an appropriate number of patients, benefits not only patients but the work/life balance of our staff. This bill is not the way to do it. We don't want hospitals to close, and patients to have to search for care. We want the best care possible for all of the residents of Massachusetts, and eventually, all patients in all states, as this will set a precedence for mandated ratios in all states in the future!

[umbdude, MSN, APRN]

Most for profit hospitals will close- it won't make financial sense to stay open...

I disagree. Nurses simply do not make enough to make that kind of impact. For most for-profit hospitals, it will be a matter of making $1.5 million vs $1 million. Their stock price will drop, their CEO comp and perks might rise less than 15% per year.

This argument was used by CA hospital groups. It didn't happen. The ones that closed were the ones that were borderline on closing to begin with.

Not to mention, some of these hospitals have no business to stay open. I'd be happy to see them close.

[rn1233]

Finally another state is making an effort to reduce ratios. If hospitals don't want to staff appropriately, then they should be fined. And don't even get me started on "what should they do when nurses call in sick?" Clinical management and senior leadership still keep their RN credentials current (or at least they should). They need to put scrubs on, get out on the floors and start working. The days of sitting at your desk or in meetings all day needs to end.

There is no excuse for an ICU nurse to have more than 2 patients (sometimes only 1 is appropriate) or for a Med-Surg nurse to have a 6 or greater patient assignment. Hospital administrators should be ashamed to have let things get as bad as they are now. Patient acuity is higher than it has ever been and they still expect nurses to provide great care with less resources.

I can only hope and continue to advocate that other states will follow suit and start implementing safe nurse to patient ratios. This does not mean reducing support staff either. It takes an entire team to care for these patients and their families.

The CEO's can lower their salary to make necessary budget cuts if needed. I'm tired of seeing nurses leave the profession because the workload is too much and the pay is no where near as high as it should be for the amount of responsibility we have.

I'm glad to see the responses on this post are mostly in agreement for implementing a fine to hospitals if they don't maintain safe nurse to patient ratios.

I wish more nurses would stop "drinking the kool-aid" and speak up for what's right.

It's usually nurses that no longer take a normal bedside assignment every day that have contributed to this growing problem; often advocating against mandated ratios and unions for nurses.

Most have advanced their education (kudos to them) but eventually forget what it's like at the bedside and being responsible for too many patients. I'm not saying their role away from the bedside isn't important but if staffing is so short and you're so worried about the hospital getting a fine, then get back out on the unit and take a patient assignment!

[Jedrnurse, BSN, RN]

"The general population of MA is being asked to vote on a bill without any knowledge of how healthcare works as whole".

With that flawed logic you can make the argument that the public shouldn't vote on anything that doesn't have to do with taking a dump or breathing - activities we all do.

Don't take this the wrong way, but I am now in love with you...

[Jedrnurse, BSN, RN]

Well, you're right and wrong. I'm not a "paper

Pusher" I do have clinical responsibilities....at the bedside...but I'm not a med surg nurse.

I also don't appreciate personal attacks and judgements against me for educating the general public and other nurses as to the rigidity of the bill

I appreciate your read!

I did come off too strong and I apologize.

But I am sick of the derivative of the line, "this takes the decision-making ability of the experts who need the flexibility to deal with changing patient needs."

Well...

The "experts" have had this ability since the beginning until, like, the present, and continually make decisions that allow unsafe and exploitative staffing. Why would anyone think that things would magically change if the threat of this bill recedes...?

[Jm0136]

I'm sure if this bill passes you're worried it will affect your bonus. At least nurses at the bedside can rest assure they will function ina safer and more effective manner.

[CKPM2RN, ASN, EMT-P]

Don't take this the wrong way, but I am now in love with you...

I also felt a bit of heart palpitations of love when I read this.

[tallnurseguy]

Well...

The "experts" have had this ability since the beginning until, like, the present, and continually make decisions that allow unsafe and exploitative staffing. Why would anyone think that things would magically change if the threat of this bill recedes...?

Yes, this. Self governance is a cool aspiration, but it too often falls short. It just hasn't worked. I've worked bedside critical care at two hospitals, one in VA the other in OR. In VA, a 'right to work' state, the conditions for nurses at the large teaching hospital where i worked were abysmal. The pay was close to what a CNA makes in OR and poor staffing was a continuous issue. But somehow, the 'non-profit' hospital could afford three helicopters and was buying up half the property in town. The much smaller teaching hospital where i work now does a comparatively descent job of staffing ratios because we have a strong union that forces it to happen.

I believe nursing patient ratios is only a start, it's basic and a minimal safe guard. Anyone who has worked bedside nursing knows this. Even with ratios, how often have you found yourself in hot water because management sent someone home, gave you one of her patients and you're now getting an admit at end of day? You've already worked 9 hours, and you have to learn 2 new patients in the final 3 hours of your shift, do admit, pass meds and throw in a rapid response or two. How many days a week do you find yourself operating in triage mode because of patient acuity? Can you remember the last time you cared for a patient who didn't have at least 3 co-morbidities to juggle in addition to the current DX/reason they are in the hospital?

I believe the purpose of healthcare should be to provide healthcare, not to make a profit off of human suffering. Nursing staff is the backbone of any hospital, they are the largest employee component, it makes sense that nursing should get a somewhat proportional amount of the budget.

[Bridgid Joseph, BSN, MSN, APRN, CNS]

I'm sure if this bill passes you're worried it will affect your bonus. At least nurses at the bedside can rest assure they will function ina safer and more effective manner.

I'm a single mother of two young women. I work long, hard, clinical hours. I have never received a bonus as a nurse, ever, and I don't make personal attacks on people through a fake name on the internet. I have my opinion, and at least I am willing to put my name behind it. You don't have to agree with me, but you do need to be respectful.

[dianah, ASN]

A gentle reminder to please post to the subject of the thread only, and refrain from any personal attacks or name-calling, which are violations of the Terms of Service.

[SavedNurse]

By no means did I assume you have any sort or professional writing experience or team; I did assume by your consistent articles about how easy it is to read between the lines of your agenda. I do admire your overt positivity, though so go ahead and run with that.

[Silver_Rik, ASN, RN]

And actually literature supports having BSN educated nurses, and that BSN only staff have decreased morbidity & mortality rates, however due to the quick need to increase RN numbers, MA hospitals (which many are BSN only) will have to throw that out the window, to possibly improve patient care? The ratios made absolutely n change in M&Ms for ICU patients.

The only research I'm familiar with its that BSN nurses improve outcomes in surgical patients. Has more been done recently showing a broader benefit?

Are you suggesting that staffing that is 80% BSN and 20% ADN nurses (none of the latest in supervisory roles) and consistently maintains safe ratios is more dangerous than an over worked and understaffed facility that is 100% BSN?

(Not to say I support this law. I'm not in MA so it's mostly relevant to where other states may go ; and I'm not a fan of inflexible rules. However, something should be done about ratios other than just trusting admin to handle it, and I work with very few BSN who would rather deal with high patient loads than work next to an ADN colleague.)

[Nurse Beth, MSN]

I'm in California and worked before and after ratios. I support safe staffing and nurse-patient ratios 100%. On the 44 bed Tele unit in my hospital, we have a 1:4 ratio, 2 dedicated monitor techs, 3 CNAs, 2 unit secretaries, a clinical (on the unit) pharmacist, a free Charge Nurse and a lift team. There's also a throughput nurse to assist with discharges M-Friday. RT gives their own treatments and Lab draws their own blood.