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

  1. Massachusetts will be the second state in the United States to put a vote to a mandated nurse staffing ratio, behind California in 2004. This ballot support and opposition has been highly contentious and this vote may set a precedence for other states to support a similar law. The ballot measures are very strict, and the general public seem to be very confused as to the impact of the law on healthcare in the state of Massachusetts as a whole.

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

    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!
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    127 Comments

  3. by   PPediRN
    If hospitals are forced to implement this then they'll take away all the CNA's & other support staff. We can't win.
  4. by   Kratoswife
    Hospitals can afford it.
  5. by   umbdude
    I'm a definite Yes on this question and I'm spreading the word. I'm noticing that most people who are against this are already working in large hospitals where the ratios are already good and the resources are plenty.

    I worked in a for-profit psych inpatient hospital. RN regularly end up with 8 patients with low number of techs. Even when things are acute, management would say "our budget doesn't allow us to add more RNs or techs today," then these managers disappeared into thin air. Several psych hospitals have even worse ratios, such as 1:12. Guess what? People have been dying from these hospitals. My RN friends who work at these hospitals often say, "I sometimes don't even know who my patients are. I just give them meds and never see them again because I'm so busy." This is unacceptable and I do not work inpatient for this very reason. Sure, I can try to work for a better managed hospital, but they pay RNs like crap.

    If you are a patient ended up in one of these facilities, you are not getting good or safe care. Often it is the patients at the lowest socioeconomic class who end up at these terrible hospitals.

    Hospitals have been cutting corners for decades and it needs to change.
  6. by   umbdude
    Quote from Kratoswife
    Hospitals can afford it.
    Exactly!
  7. by   umbdude
    Quote from PPediRN
    If hospitals are forced to implement this then they'll take away all the CNA's & other support staff. We can't win.
    I believe there is a clause that prohibits hospitals from doing this.
  8. by   Bridgid Joseph
    Quote from PPediRN
    If hospitals are forced to implement this then they'll take away all the CNA's & other support staff. We can't win.



    You are correct- the law says you ot need to keep support staff until you are compliant with the law, then jobs are on the line for support staff
    Last edit by traumaRUs on Sep 29
  9. by   Bridgid Joseph
    Quote from Kratoswife
    Hospitals can afford it.

    Only until you are compliant with the nursing staffing, then all support staff can be downsized
    Last edit by traumaRUs on Sep 29
  10. by   Bridgid Joseph
    Quote from umbdude
    I'm a definite Yes on this question and I'm spreading the word. I'm noticing that most people who are against this are already working in large hospitals where the ratios are already good and the resources are plenty.


    I worked in a for-profit psych inpatient hospital. RN regularly end up with 8 patients with low number of techs. Even when things are acute, management would say "our budget doesn't allow us to add more RNs or techs today," then these managers disappeared into thin air. Several psych hospitals have even worse ratios, such as 1:12. Guess what? People have been dying from these hospitals. My RN friends who work at these hospitals often say, "I sometimes don't even know who my patients are. I just give them meds and never see them again because I'm so busy." This is unacceptable and I do not work inpatient for this very reason. Sure, I can try to work for a better managed hospital, but they pay RNs like crap.


    If you are a patient ended up in one of these facilities, you are not getting good or safe care. Often it is the patients at the lowest socioeconomic class who end up at these terrible hospitals.


    Hospitals have been cutting corners for decades and it needs to change.

    Most for profit hospitals will close- it won't make financial sense to stay open...
    Last edit by traumaRUs on Sep 29
  11. by   Bridgid Joseph
    They actually can't. Even large teaching hospitals cant afford it.
  12. by   KelRN215
    Quote from Bridgid Joseph
    They actually can't. Even large teaching hospitals cant afford it.
    They want you to believe they can't but they absolutely can. They can afford to pay their CEOs 6 figure bonuses. I can count on one hand the number of times I took care of 5 pediatric patients in the night shift when I worked in the hospital (and the times I did the charge nurse had no assignment but could have easily taken a patient or 2) and the hospital I worked for, which is also vehemently opposed to the law, would have almost 0 effect from it. There is not a single floor I can think of where nurses regularly take more than 4 patients, ever.

    Here's a report from a professor at my alma mater that shows that the costs of the law are actually much less than the opposition would like us to believe:
    https://safepatientlimits.org/wp-con...ital-Costs.pdf
  13. by   MunoRN
    The reason hospitals exist and get paid is to provide patient care, to do this properly an appropriate number of nurses are required, so the argument that having to provide an appropriate number of nurses interfere's with a hospitals ability to fulfill it's purpose is absurd.

    The basis of your argument seems to be that if hospitals have to staff appropriately, then will be short on nurses, yet there's nothing in the bill that prevents hospitals from hiring an appropriate number of staff.

    There's also nothing that prevents hospitals from exceeding the bare minimum required by the bill, for instances where as you point out, more nurses may be required than the minimum the law requires.

    And you're correct that some hospitals may not be able to compete given these requirements, particularly for-profit hospitals, but that's the point of a competitive market healthcare system, those that can't provide the same quality of care as other facilities won't survive, which is what's supposed to happen to facilities that provide poor quality care.
  14. by   Bridgid Joseph
    Quote from MunoRN
    The reason hospitals exist and get paid is to provide patient care, to do this properly an appropriate number of nurses are required, so the argument that having to provide an appropriate number of nurses interfere's with a hospitals ability to fulfill it's purpose is absurd.


    And you're correct that some hospitals may not be able to compete given these requirements, particularly for-profit hospitals, but that's the point of a competitive market healthcare system,
    So you think that we should decrease access to healthcare, and despite our #5 ranking nationally in MA for quality/cost/access to healthcare, and beef up staffing in certain areas, without increasing beds, and hope that care is improved, despite no literature to support this measure? 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.

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