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!

[BrendanO, MSN, RN]

It's not clear to me from this post how "access to care" is being quantified. Are we talking about there not being a hospital within an x minute drive from everyone's house? Or are we talking about uninsured people? Because the latter category is who I mostly see this term being used to refer to. The nursing staffing ratio law will have no effect on how or whether people have insurance or other financial resources to seek care for themselves. Since it's not physically possible to be more than a one-hour drive from a major medical center in the entire state of MA, is the closure of a handful of community hospitals in the suburbs of Boston (already one of the densest concentrations of medical care facilities in the country) really going to affect "access to care"? Having lived in that area for 20 years, I really doubt it.

In terms of logistics of covering a floor during break times and sick time call-ins, the only thing a hospital needs to do is staff a larger RN float pool. Combine that with staggered shift start times across units, and that group of nurses could also circulate from floor to floor to provide staffing during breaks, meals, and meetings. It's not a complicated process at all; large school districts have been doing it for decades with substitute-teacher pools. Hospitals don't need to reinvent the wheel here, they just need to learn from the professions who already work according to these kinds of limits (i.e. most other highly-unionized professions).

[booter512]

Our hospital worked hard to get the minimum number of nurses for the staffing grid laid out by managers and admininstrators. But, every day, call ins and lousy schedules made by managers caused shortages. The staffing coordinator once told me that they work hard just to maintain "critical" levels of staffing every day If, on every unit, you had an out-of-staffing charge nurse (without other duties) who could help other nurses, the nurses in Massachusetts would probably have never have had to resort to try to get minimum staffing ratios. They had to do something. Virginia needs to do something. They got rid of LPNs at a time when we needed nurses, and now they're doing the same thing with ADNs. There does not seem to be a brain in the policy-making concerning nursing. Granted, minimum staffing level laws will pull the traveling nurses to those states, as they will be forced to pay more, leaving other states that rely on travelers even more short-handed. I think the first step would be to bring the ADN back. Quit forcing nurses to go back for their RN. Can hospitals afford more nurses? Our CEO made 1.2-1.6 million dollars before he retired. I'm sure our new one makes at least that.

[sweet sunshine]

If anyone worked the floor and took care of 5-6 acutely ill patients you would know why this needs to pass. As far as the pacu and er waiting for transfer it might be quicker because the nurse has 4 patients and will have more time focusing on discharging patients. Usually it's waiting for clarification from the doctor about discharge orders that hold up discharges not the nurse. When you have multiple doctors on a case and must get permission from each or they want to see the patient before discharge is what holds up discharges. This needs to change and doctors need to talk to each other and stop using the nurse as a go between them patients could be discharged quicker.

[BrendanO, MSN, RN]

They actually can't. Even large teaching hospitals cant afford it.

Do you have any actual financial statements to back this up? Because, for example, the Beth Israel Deaconess network has almost a billion dollars sitting in cash, investments, and endowments. Let's say compliance with this law requires them to increase nursing staff by 10% (a high estimate). My back-of-the-envelope calculations puts that at about $30 million more per year in salary/benefits (2.5% of their overall labor costs). They could cover the entire financial burden of this change for at least 35 years just from their financial reserves, without any cuts to services or facility closures. I'm gonna make a wild-ass guess that there's enough slack in their $2.5+ billion dollar operating budget to close the gap. Heck, they've had revenues in excess of expenditures of over $100 million for every single operating year for the past decade.

[46srh]

Although some may argue the necessity of this law, its practical application is severely lacking. Moreover, I don't want the voting public to have a say in our profession. There are other ways to accomplish the same or similar goal.

[Daisy4RN]

Over all I think the that ratios would be a good start. The problems I see with this bill is the 37 day implementation, and the fact that hospitals can do away with other staff. I am not sure that comparing Calif to MA is a fair argument. I worked in Calif before and after the ratios. There were definitely issues to work out and always will be. I don't know what you mean by access to care but Calif is large and spread out so logistically speaking there is always going to be issues there, if you mean uninsured then same thing, Calif has a large population of uninsured. I don't know how either of these would affect the actual care at the bedside that this bill is supposed to address. In Calif (at the time of the change) the hospital I worked at did downsize other staff, and has been (over the years) adding more ancillary work to bedside nurses. So, yes it may help the actual care of the patient meaning that nurses will have a max number of patients to handle (so probably more time for eyes on the pt) but it still doesn't help how busy nurses are because of the other and increased tasks. I see your point about some community hospitals (maybe?) having lower acuity so there could possibly be some wiggle room, but the example you gave doesn't play out at the bedside. Take a new post-op pt because you are discharging 3? No, usually discharges take more time, and esp if there are 3, it is impossible to be caring for a new admit while discharging 3 and give good care. Also, even though some hospitals did use LVN's, the practice has been done away with (pretty much) because of the high patient acuity and the tasks that LVN's are not legally allowed to perform, so much of the work was needing to be done by the RN. I think that although this bill is flawed it is a step in the right direction.

[openh2o]

So administrators and managers have been ignoring this problem for DECADES. A nurse's union finally came up with a solution that hospital admin had ignored, even though it is their legal responsibility to address the situation. Now they are complaining that the solution is too "hard", pretty sure that is called dereliction of duty, for not dealing with it in the first place. It is also too "soon" because they only 37 days to comply. I guess they are also the ones who decided that all those decades of time they used to ignore the problem do not count. Sorry, bad news for them, by not doing their jobs, they have abdicated that responsibility to people who are going to address it. They can apologize all they want. Saying sorry, I forgot to do my job for almost a century and I told everyone to go pound sand every time they gave me a chance to do my job, does not cut it. But now that someone else is doing it, and I don't like how they are doing it is no longer their concern, that is what abdicate means.

[tallnurseguy]

In terms of logistics of covering a floor during break times and sick time call-ins, the only thing a hospital needs to do is staff a larger RN float pool. Combine that with staggered shift start times across units, and that group of nurses could also circulate from floor to floor to provide staffing during breaks, meals, and meetings. It's not a complicated process at all; large school districts have been doing it for decades with substitute-teacher pools. Hospitals don't need to reinvent the wheel here, they just need to learn from the professions who already work according to these kinds of limits (i.e. most other highly-unionized professions).

Someone please put Brendan in charge of scheduling.

I became a nurse after going back to school 5 years ago and leaving executive management (V.P. Regional Director), i have a pretty extensive background in upper management and was at the head. I used a consensus model to run a 14m company, so i know it can work to allow those who do to decide how things are run.

In my view, any funding issues could be readily solved by eliminating a layer of management. Most large hospitals have roughly 3 layers of management: upper, middle and floor. I think middle is the hardest because their function is to carry out upper management ideas and policy. Middle management is usually pretty in touch with what goes on on the floor and, in my opinion, are better placed to make policy. Upper management are usually so far removed from the reality of day to day operations that they have to do a study or ask middle management for input, or just rely on their own 'wisdom' to solve issues.

Instead of making middle management the upper management minion, get rid of upper management and allow middle management to both make policy and implement it. Also, all management should spend at least a week every couple of months doing what they have set as policy.

Management is so often where burned out nurses escape to lol. My two immediate unit managers are nothing short of angels. They are the most amazing people i have ever worked for. They are responsible for hiring (read: setting the tone) for the critical care unit (5 units). In the 4 years i have worked with them they have never been less than affirming and understanding, and that filters down. The nurses and CNA's i work with practically bring me to tears on a regular basis by their profound, consistent kindness, consideration and professionalism.

All this, and we work at the zoo. 9 out of 10 days it's madness, but the people make me proud and keep me in place. My managers are in touch with this, upper management doesn't get it, even on an intellectual basis for many. They to often offer lip service and programs because that's what they think they're supposed to do, but they have either forgotten or never served on the front lines, so cannot respond effectively. Middle management often serves as a buffer between them and reality.

[Jedrnurse, BSN, RN]

Although some may argue the necessity of this law, its practical application is severely lacking. Moreover, I don't want the voting public to have a say in our profession. There are other ways to accomplish the same or similar goal.

What are these ways, and if they're viable, how come they haven't already been widely implemented?

[WanderingWilder, ASN]

In your example where you have four "light" patient and a coworker has three "heavy" patients you say with this bill the only option is for the nurse with the "heavy" patients to take the new admit instead of allowing you to take 5 to help out.

This situation is easily remedied by not assigning all the "heavy" patients to one nurse and giving the other nurse four "light" patients, three that are being discharged.

If the co-worker had two heavy and two light patients and you had two light and one heavy you could take the admit and still have a 4:1 ratio.

[LovingLife123]

What scares me more than the "lay" people voting this into law is administration thinking it's all about them to make this law. No, it's not. You've had years and years to fix this, yet haven't.

The voters are the bedside nurses out there who are finally getting a voice in staffing ratios. The way it should be.

I'm so tired of hearing hospitals don't have the money when all the executives are taking home multi million dollar bonuses each year to go with their 10 million dollar salaries.

[Kshores15]

I'm a nurse in Texas and I take care of 30+ patients by myself with one CNA on graveyard shift. And I have multiple psych patients and skilled patients. A law like this would be awesome but not as strict.