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!
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 the other ways to accomplish the same or similar goal? The general public having a say in our profession may be the only thing that improves the working conditions of nurses. It doesn't take a study to prove that better working conditions for nurses will improve safety for the general public. Unfortunately, nurses do not really control our on profession like physicians control their profession. We are a bullied group of powerful people who haven't yet realized our worth.
They actually can't. Even large teaching hospitals cant afford it.
Every hospital should be shut down in California if this was true.
Are there any med/surg nurses that are not laying in bed with management or being paid under the table that are also currently work full time willing to support your statement???
Reading a couple of journal articles this morning over coffee about the effects of California's law there is one big take home-- RNs say it has been a good thing, management says it's not been good.
Mandated ratios are clearly better for the patients.
One study found that there was no skill decrease in RNs and each patient received 1/2 hour more care per day from an RN.
Another article found a 30% decrease in RN injuries on the job.
My colleagues and I addressed a different research question: Could the law have improved safety for the nurses themselves? We found that it did; occupational injury and illness rates dropped over 30 percent. This is important, in part, because the nursing occupation generates more occupational injuries to women than any other occupation.
Every state should be doing this. If there is enough money for administration to get raises every year with "reward" bonuses, there is enough money to hire more nurses. A few of the comments mentioned the fact that the general public should not be voting on how nurses practice--every hospital in the country has been given ample opportunity to follow in California's footsteps, & they haven't. When people in charge do not do the right thing to ensure patient safety standards or the health & well being of the nurses already on staff, it's time to take the control away from them & put it in the hands of the public. Hospitals are concerned with one thing, and one thing only---moving as many patients in & out as quickly as possible to increase census for the sole purpose of getting more money. This has resulted in risky nursing practice & unsafe patient care. If a hospital would rather be fined $25k daily than comply with state law, they will lose tremendous amounts of money. It is is their best interest to hire more nurses. I've been a nurse for over 30 years, & the methods we used to utilize to cover sick calls or vacations was to have a per diem float pool that a supervisor could call to fill the spot. If schools can cover sick calls with substitute teachers, hospitals can do the same. An entire school class would not be split up & put into other classes because there was no teacher. Patient loads shouldn't be dumped onto other nurses over one sick call on a unit. I'm sure nobody but the managers would be boo-hooing over not getting their raises if mandatory nurses-patient ratios were made law.
And it's time to stop running hospitals like hotels, with nurses acting as chefs, concierge staff, housekeeping, etc. That is not their job. You don't go to a hospital for a vacation. If you're not happy with the nursing care, sign yourself out. Nurses are not there to make sure your coffee is the perfect temperature, or look on every unit & send somebody out to the deli to get Splenda for your tea. If you want Splenda, call up a family member & tell them to bring it to you. Hospitals have turned the hiring process into something that C-level employees at Fortune 500 companies go through---multiple interviews, 10 page applications, etc. How about hiring nurses that have licenses, providing adequate training & letting them actually work to obtain experience? How about doing things the way they used to be done? I was hired on the phone when I was a senior in college for a job in a major NYC hospital, sight unseen. I was told when to show up for my employee physical & what my start date was. I had a great orientation, great training & great experience. Nurses that have just graduated & passed their board exam are not C-level employees, and therefore do not have 15 years of experience. Give these nurses a chance. Making them go through a hiring process far more involved than it should be only to treat them like glorified wait staff is ridiculous.
I work for a for profit major hospital in MA and unionized. I'm voting YES. It might not do much for my hospital but for the local small hospitals whose CEOs like to use scare tactics saying they'll close. No they won't. Stop abusing your staff to fill your pockets.
Hi,
I must say that I was pleasantly surprised that despite working for what may be one of the prestigious hospitals, that you decided to vote YES. I work for a community hospital in MA, and they are doing everything possible to convince nurses to vote NO, and based on what I have been hearing, it appears their lies are working. I was appalled when one nurse said to me that if the law passes, that she would not get the yearly bonus which varies, last year she got $700. Everyone is entitled to their opinion, but she is willing to put patient's lives, safety, and her license at risk because of a mere $700. That to me sounded insane, not to mention depraved!!
Having 6 or 7 patients, not to mention having 2 self-care patients (those are pts that are not assigned PCAs) on top of that makes the practice incredulously unsafe. Also, having one PCA, to care for 40 pts, means the nurse will have to provide more selfcare even though they are already assigned. I work 12hr nights (sometimes 16hrs when mandated), and lunch time is almost non-existent, so for the life of me, I cannot see how voting NO will improve pt safety. I yearn for the day/night when I can be a nurse-meaning, I am there for my pts, instead of running around like a crazy person. I do not know why they continue to use the term, "bedside nurse" when nurses have no time to spend at the bedside.
I must also say that I try to understand why nurses would vote NO, and friends of mine that works in hospitals that are well staffed feel comfortable at their jobs. However, we cannot be selfish because our hospital is well staffed. Will you have that job forever? don't you care about the other nurses who are risking their licenses daily? Most importantly, what about pt safety? Those are questions that I continue to ask, and to date, have not heard a response that makes sense.
Sacrifices must be made for the greater good! We MUST remember where the profession of nursing is coming from; from being a "yes man" to everything doctors said to gaining autonomy. Those efforts included sacrifice, and we continue to fight to become independent as nurse practitioners. We are getting there, but this divide is not helping. We must remain UNITED to continue improving this great profession.
This site is typically used only by healthcare professionals, so those wanting to make real change should get out there, knock on doors, campaign, do everything possible to educate the public because they believe these commercials that they will be turned away due to lack of staffing. MA is not short of nurses!! In the days when there were nursing shortage, facilities would recruit student nurses and groom them for employment once graduated. They would also pay sign on bonuses. Those things are no longer happening because nurses are a dime dozen in this state. I know 7 new grads who pass the BOARDS since July and have yet to get a job despite applying to a minimum of 5 jobs each. My friend is a manager at a LTAC and they had 1-10 with pt's on vents and tele. Come on nurses, how can that be safe?! we cannot be SELFISH on this journey. Do not just think about your prestigious jobs, remember that there are other places out there that are abusing their staff and putting pt's lives at risk because they fail to hire nurses.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
Full disclosure, I am a Nurse Practitioner in the ICU and do not have bedside nursing responsibilities in my current role. I, however, have practiced bedside nursing in 2 states including California where I live now. The mandatory staffing ratios have had a positive effect on job satisfaction and nurse compensation in California. It's night and day compared to the understaffed and overworked nurses I used to work with outside of California. The law also allowed for creative ways to implement the rules. Many hospitals have float pools, on-call staff, Per Diem staff, break relief staff, etc all to make sure that the ratios are maintained. Charge Nurses have independent decision making to assign based on acuity while still adhering to the ratios.
Because of strong union representation and the need to staff more RN's, pay for California nurses have kept up with the high cost of living here. Nurses are not leaving the profession in droves because of being underpaid and overworked. They are not losing their homes because of low pay. The hospitals are not closing shop either. Hospitals are still posting profits. There are some hospitals that are struggling financially for sure but these were ones that have been poorly managed in the first place and ratio or not, the quality of care there has been substandard for years. The argument that patients will lose access to care in these kinds of hospitals is questionable to me - these are the kinds of hospitals I wouldn't entrust a family member's care to.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
OP, where did you get the data on state performance in terms of healthcare quality and access? California doesn't lead the US in healthcare quality and access but it surely isn't in the bottom. We also have our share of top institutions here albeit they are not concentrated in one metro area alone like Boston does.
The Commonwealth Fund does not rank California's healthcare on the low end:
This is not meant as a competition between the states but rather to illuminate that the world did not crash on California when the mandatory staffing ratio law was enacted.
Full disclosure, I am a Nurse Practitioner in the ICU and do not have bedside nursing responsibilities in my current role. I, however, have practiced bedside nursing in 2 states including California where I live now. The mandatory staffing ratios have had a positive effect on job satisfaction and nurse compensation in California. It's night and day compared to the understaffed and overworked nurses I used to work with outside of California. The law also allowed for creative ways to implement the rules. Many hospitals have float pools, on-call staff, Per Diem staff, break relief staff, etc all to make sure that the ratios are maintained. Charge Nurses have independent decision making to assign based on acuity while still adhering to the ratios.
Because of strong union representation and the need to staff more RN's, pay for California nurses have kept up with the high cost of living here. Nurses are not leaving the profession in droves because of being underpaid and overworked. They are not losing their homes because of low pay. The hospitals are not closing shop either. Hospitals are still posting profits. There are some hospitals that are struggling financially for sure but these were ones that have been poorly managed in the first place and ratio or not, the quality of care there has been substandard for years. The argument that patients will lose access to care in these kinds of hospitals is questionable to me - these are the kinds of hospitals I wouldn't entrust a family member's care to.
I really hope the original poster and others that are against MA 1 respond to you and the other California nurses that say it's been a really good thing.
It's just amazing that nurses would drink the management Kool Aid and vote against something that is clearly in their (and their patient's) interest.
Access in CA is related to population density- the hospital I work at keeps building and can't keep up with our region. That's irrelevant to nursing ratios. Some of the things on that ballot measure might need some work, but patient ratios make patient care much better. As for missed breaks- we have dedicated break nurses. Massachusetts may need more than the allotted timeframe to train or recruit more nurses to comply, reasonably. Otherwise, the issue of nursing ratios is very important.
We have 7-10 patients on average . At night in a MASs hospital, on a medsurg tele floor with very sick patients who need 24 hour care. No time for lunch or bathroom breaks. Most nights we have 1 or no CNAs. Its a very unsafe environment for patients, RNs and other staff. The hospital has done nothing to fix this and they want us to vote no. The RNs and CNAs are burnt out. We all love our job. We just want to be safe, for us and patients.
Hospitals are passing out news letters, and sending emails with statistics and why people should vote no. Even holding rallies. So are some nursing orginaztions.
gcupid
528 Posts
What are the other ways to accomplish the same or similar goal? The general public having a say in our profession may be the only thing that improves the working conditions of nurses. It doesn't take a study to prove that better working conditions for nurses will improve safety for the general public. Unfortunately, nurses do not really control our on profession like physicians control their profession. We are a bullied group of powerful people who haven't yet realized our worth.