Nurse Staffing Ratios Up for Public Decision? Ballot 1 in MA
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.
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!
Professional Firefighters of MA president promoting Yes on 1. My husband's a FF and they're backing us, plus the teachers and many others. I find it embarrassing that other blue collar professions understand the problem, and see through the propaganda provided by the nurse leader and hospital organizations, yet some of our very own cannot figure this out. That's my burden to bear.
Anyway, if you'd like to see the video on Facebook and haven't already...
My new least favorite argument against is this, "EDs will be crazy". EDs are crazy now! The only way there will be trouble is if the hospitals don't allow management to hire and staff more nurses. I know I sure as hell would not want to be patient number 8, 9, 10, and I sure as hell wouldn't want to be the nurse taking patient number 8, 9, 10. Wouldn't it be nice if the ED wasn't constantly losing nurses with 5, 10, or more years of valuable experience to burnout?
I digress... I'm not hearing great things about the passing of this ballot question, so I'm a little down. I just thought it would be nice for us in MA to help set an example and try an alternative to something that's obviously not working. It's not as bad here as other places in the country, I'm aware of that, but we're good at setting examples, and I'm afraid we will set the example that hospitals who employ us, and supervisors who are supposed to take care of us so that we can do our job, can just squeeze every ounce of energy and faith before we break. I know I wanted to do this job at the bedside for 30+ years, but it just seems like no body makes it that long in these conditions anymore. Not without scars, anyway.
I am a member of Nurses of PA, which is pushing for staffing ratios in PA. While I cannot admit to knowing the bill presently being considered in MA, I CAN offer research into staffing ratios, as well as the citations from research:
Research Summary: Staffing Ratios, Safety, Costs, and Nursing Shortages
Short-staffing leads to more patients dying. Safe ratios would save patients' lives.
Every additional patient-per-nurse in a Pennsylvania hospital increases that
patient's risk of death by 7%.i Surgical patients in hospitals with 8:1 ratio have a 31%
higher risk of death. In many PA hospitals, nurses now have 2-6 additional patients.
Introducing safe nurse-patient ratio laws in Pennsylvania is projected to reduce hospital
patient deaths by 10.6%.ii
Research from other states suggests that short-staffing increases patients' risk of death
by between 4 and 6%. This risk is higher within the first 5 days of admission.iii
Lower patient-to-nurse staffing ratios have been significantly associated with lower rates
of hospital mortality, failure to rescue, cardiac arrest; hospital-acquired pneumonia,
respiratory failure; patient falls (with and without injury); and pressure ulcers.iv
Higher numbers of patients per nurse was strongly associated with administration of the
wrong medication or dose, pressure ulcers, and patient falls with injury.v
Safe staffing saves money by reducing nurse burnout and reducing lost reimbursements
Short-staffing leads nurses (both new and experienced) to leave the bedside. This is
costly in itself: the cost to replace a single burned out nurse was $82,000 in 2012.vi
High levels of nurse burnout and turnover lead to lower quality care and more infections.
In Pennsylvania, hospitals in which burnout was reduced by 30% had a total of 6,239
fewer infections, for an annual cost saving of up to $68 million.vii
More hospital-acquired infections, more patient falls and pressure ulcers, more early
readmissions and longer hospitals stays - all of which are caused or exacerbated by
short-staffing - are costing Pennsylvania hospitals millions in lost reimbursements.viii
A national study found the financial costs and benefits of increasing nurse staffing for
hospitals more or less evened out (a
increase or reduce staffing turned on the value placed on human life.ix
There is not a shortage of registered nurses in PA. But dangerous short-staffing is
driving nurses to leave bedside care.
Pennsylvania has (and will have) more than enough licensed registered nurses. The PA
Department of Health regularly surveys all RNs and LPNs renewing their licence. The
most recent survey showed only 76% of RNs were employed in nursing, with 6%
unemployed.x Pennsylvania is projected to have a surplus of 5% (8,200) RNs by 2030.xi
Pennsylvania is also training and graduating more than enough registered nurses.
Enrollment in Pennsylvania RN programs has increased by 49% since 2003 (from 15,651
to 23,278), and by 138% since 2002 (from 2,939 to 7,003).xii
There is, however, a serious problem with nurse retention. Nurse burnout and turnover
in Pennsylvania has reached record-high levels in the last 2-3 years. Our survey of
1,000 bedside nurses last year found 79% reported increased turnover since they
started.xiii
Short-staffing is the single biggest driver of nurse burnout and turnover. In the PA
Department of Health's most recent licensure survey, the highest factor of 'job
dissatisfaction' was staffing (37% unsatisfied), and for respondents under fifty who were
planning to leave nursing the most common reported reason was stress/burnout.xiv
Improving staffing to safe levels would reduce nurse burnout/turnover, encourage more
licensed nurses to return to the bedside, and make the single biggest difference in
improving nurse retention, patient safety and saving hospitals the cost of high turnover.
The introduction of safe ratio laws has been proven to increase the 'supply' of working
nurses. After passing a ratios law in 2004, the California Board of Nursing reported a
60% increase in applications for nursing licenses from other states,xv a 4% increase in
RNs overall, and an 18% increase in the number of applicants for the certifying exam.xvi
i Aiken, Clarke, Sloane et al, 'Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job
Dissatisfaction', Journal of the American Medical Association, 2002,
I have been in orientation for 2 weeks at small hospital (30 psych beds, 60 med surg beds) and am really scared about the ratio I've been covering. Census was 25 and there was one charge nurse, one other nurse, and me. Myself and my preceptor had 16 patients. Add into that, technology problems, and I was terrified I was giving the wrong meds to the wrong patient. I am thinking of quitting - I have no hospital experience (I worked with DD adults prior to this job) and like working with this population but am really scared something bad is going to happen. Any thoughts? Thanks!
I have been in orientation for 2 weeks at small hospital (30 psych beds, 60 med surg beds) and am really scared about the ratio I've been covering. Census was 25 and there was one charge nurse, one other nurse, and me. Myself and my preceptor had 16 patients. Add into that, technology problems, and I was terrified I was giving the wrong meds to the wrong patient. I am thinking of quitting - I have no hospital experience (I worked with DD adults prior to this job) and like working with this population but am really scared something bad is going to happen. Any thoughts? Thanks!
I need to ask...what type of patients were the 16 you had? Psych or med-surg? We're they counting on you to provide care or just shadow?
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.
I should have quoted this when I made the following comment: I've been in orientation for 2 weeks at small hospital (30 psych beds, 60 med surg beds) and am really scared about the ratio I've been covering. Census was 25 and there was one charge nurse, one other nurse, and me. Myself and my preceptor had 16 patients. Add into that, technology problems, and I was terrified I was giving the wrong meds to the wrong patient. I am thinking of quitting - I have no hospital experience (I worked with DD adults prior to this job) and like working with this population but am really scared something bad is going to happen. Any thoughts? Thanks!
I need to ask...what type of patients were the 16 you had? Psych or med-surg? We're they counting on you to provide care or just shadow?
Hi Been There, I meant to quote Umbdude's post when I posted this originally. To answer your question, I'm working in psych - the 16 patients were psych patients, with varying degrees of mental illness. I was supposed to be shadowing, but had to pass meds, using poor technology (bands that didn't scan, slow slow slow computers) and had to resort to scanning stickers with bar codes because some of the patient's bands weren't scanning. The RN who was precepting me had to do 2 admits, so I had to take on med passing after 2 days of following RNs who were passing meds. Again, I'm just super freaked out that staffing levels are usually this messed up, and in addition to learning bad habits, I'm concerned for patient safety.
I should point out too that because this orientation has been rush, rush, rush due to poor staffing levels, preceptors have just said 'click here, here, and here" when charting just to get through it. Conceptually I understand what I'm charting, but don't understand the method or what it all really means to the patient's outcomes and care. Maybe this is common in orientation, but I'm very worried about passing the wrong meds or missing something. Thanks again for any input.
Mrs.D., BSN
132 Posts
Professional Firefighters of MA president promoting Yes on 1. My husband's a FF and they're backing us, plus the teachers and many others. I find it embarrassing that other blue collar professions understand the problem, and see through the propaganda provided by the nurse leader and hospital organizations, yet some of our very own cannot figure this out. That's my burden to bear.
Anyway, if you'd like to see the video on Facebook and haven't already...
"Purely ridiculous" – How firefighter/paramedic Rich MacKinnon describes the claim Question 1 will mean long ambulance waits at the emergency department.
#SafePatientLimits = Safe, quality care in the ED and every hospital unit.
That is why Rich and the more than 12,