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!
Specializes in Surgery,Critical Care,Transplant,Neuro.
Quote from Bridgid Joseph:
""THIS is the whole point. NO ONE opposes changing nursing ratios, but the bill, as it stands, is written poorly and in bad policy. That is the bottom line.""
I agree that there are flaws with the bill, that is the fault of whom ever wrote it. That doesn't mean that passing this bill still isn't a good first step. In my previous post I stated I have worked in Calif, and yes it is no by means perfect, but the ratios do help with the care of the patients by giving nurses more time with patients. I am not in Mass but I would vote yes to get the ball rolling in the right direction. The hospitals/admins will figure it out, I am sure they are already preparing.
Daisy- once it passes there is little room for change; what most people don't understand is the fact that there have been a multitude of options for improvement of the bill sent to the ANA who is pushing this bill, and they refuse to change some of the biggest issues: 37 days to become compliant is absurd. Since you live in CA, you know that they had up to 5 years to become compliant. There is no wiggle room in cases of emergencies: the ANA does not consider the Marathon bombing a state of emergency warranting that we may be off with staffing despite it being an unexpected (understatement) state of emergency for the city of Boston. The language needs to be cleaned up and some sticking points need to be clarified for it to be approved; just like anything else, once it is approved, you cannot un-approve. The issues are not the staffing ratios, it is the language and time frame surrounding it.
Your comment about california being #25 as readily accessible for healthcare than ma as number 1 is wrong again. In fact, here in southern california alone, majority of our patients are homeless, illegal immigrants, low income bracket and uninsured who are not capable of paying hundred of thousands dollars for staying even 3 days in the hospital. I know the bill because when i stayed one day in the hospital for arthoscopy in usc keck hospital here in los angeles, they charged me over 40,000 dollars that i almost fell from the chair upon seeing it but eventually my insurance covered it. It is so expensive wherever you go here in america. However, with those type of patients that does"t pay, the hospitals here are able to survive over the years with the implementation of nurse patient ratio for 13 years already.
Some of the things on that ballot measure might need some work
THIS is the whole point. NO ONE opposes changing nursing ratios, but the bill, as it stands, is written poorly and in bad policy. That is the bottom line.
Um, no. If NO ONE opposed changing ratios, they'd be changed. Management has had this power all along. You make it sound like hospitals have just been rarin' to make staffing more sane.
It's been the opposite, with assignments getting heavier and heavier. All this "interest" in improving ratios (minus this "bad" bill of course) will go the way of extra help during a Joint Commission visit.
It will disappear as soon as the immediate source of pressure is gone...
Don't be anxious, afraid or scared if you feel that your hospital is not going to survive because you're hospital is gonna float in the air no matter what because it has been proven and tested here in California for 13 years. Besides, with California leading the way for better quality healthcare for all with nurse patient ratio implementation, there should have been a domino effect in other states over the years. Just follow what California and now MA are doing so that you'll finally be successful in getting one for better quality healthcare for all.
Specializes in Surgery,Critical Care,Transplant,Neuro.
Your comment about california being #25 as readily accessible for healthcare than ma as number 1 is wrong again. In fact, here in southern california alone, majority of our patients are homeless, illegal immigrants, low income bracket and uninsured who are not capable of paying hundred of thousands dollars for staying even 3 days in the hospital. I know the bill because when i stayed one day in the hospital for arthoscopy in usc keck hospital here in los angeles, they charged me over 40,000 dollars that i almost fell from the chair upon seeing it but eventually my insurance covered it. It is so expensive wherever you go here in america. However, with those type of patients that does"t pay, the hospitals here are able to survive over the years with the implementation of nurse patient ratio for 13 years already.
Acessible means that people have access to care when they need it, without two day waits in the ED waiting room, to a hospital not hours from their home. I am not incorrect, I have posted the site that I obtained the statistics from numerous times. It has nothing to do with money; MA self insures more residents than most states, we always have been on the forefront of universal access to healthcare.
I am in no way worried that my hospital will close....
If hospitals are forced to implement this then they'll take away all the CNA's & other support staff. We can't win.
Yep! This is what happened in California.
And break relief...Hospitals are providing 1 nurse to provide break relief, and as I have posted before, it is impossible for 1 nurse to provide all breaks in a reasonable manner. For example, in order to get all breaks covered, 1 nurse has to take her meal break 45 mins after starting the shift, and another 45 minutes before ending the shift. You end up taking your breaks when the break relief nurses tells you to or you don't get one, and it is documented as refused.
The bottom line, is that even in California with staffing ratios, it is still extremely difficult to get all your work done and nurses still feel pressured and stressed juggling ALL the work involved. No CNAs etc...
I'm in a state where we use acuity tools to determine the staffing matrix. This too is fraught with issues - it can be skewed anyway you want it to be.
Best wishes to all the MA nurses...
This is the truth as well. One place I worked the managers would come around and question our choices on the acuityscoring and pressure us to change certain scores in order to reduce the number of nurses required for the next shift. The charge nurses would follow suit when the managers were not around.
I think that you are mistaken, OP. ANA is opposed to this ballot question, alongside both the nurse leader and MA hospital organizations (the bulk of their donations, as well as a couple well-off hospitals). In my opinion, the organizations whose members are doing well and making tons of money. For reference, the top donators who support this ballot question are blue collar organizations.
Hospitals don't want to pay for more nurses. THAT is why there are huge wait times in EDs, and that is what will cause it here. I know plenty a new grad that would love to get a chance to show their stuff by working in a hospital. We have "nursing shortages" in Mass because hospitals do not want to hire them. It may be a rocky 6-12 months, but if Cali worked out the kinks, so can we. The only way to make improvements is to try. We will NEVER have this perfect bill that you and the opposition are looking for. Never.
I have seen experienced nurses struggle with four patients during the day shift on my cardiac/tele unit during my day time clinicals, just to be handed a 5th at times. It's a pretty decent hospital, too, where I was glad to be offered a job for my first position on this very floor. I was told by my DON that I will be taking 6 patients on nights as a new grad on a floor full of new grads. It intimidates me because these are high acuity patients, but I have no choice if I want to work. This is one of the better hospitals that I should be lucky to work at. I've heard much worse from other new grads that I know. Again, we have no choice if we want to work. It's just the way things are. We fear for our license and those things we will miss with our patients since we are basically playing triage on med/surg floors.
Anyway, I have provided links to some materials that might help you (and others) learn about this ballot question (for and against), as well as a link to the actual document. Do what your heart tells you, but just try to think of those nurses that don't have it as well as you do where you can afford to vote no. Also, do not expect perfection because that will never happen. Things will only get worse while you are waiting. I don't want to offend you, of course, just help you think outside yourself before you make the vote.
Specializes in Critical care, tele, Medical-Surgical.
If hospitals are forced to implement this then they'll take away all the CNA's & other support staff. We can't win.
That did not happen in California. Our law stated that is not OK.
The text of the Massachusetts bill includes the following:
Section 23 ID: Each facility shall implement the patient assignment limits established by Section 231C. However, implementation of these limits shall not result in a reduction in the staffing levels of the health care workforce.
Section 23IE: The Massachusetts Health Policy Commission shall promulgate regulations governing and ensuring the implementation and operation of this act, including but not limited to regulations setting forth the contents and implementation of:
(a) certification plans each facility must prepare for implementing the patient assignment limits enumerated in Section 231C, including the facility obligation that implementation of limits shall not result in a reduction in the staffing level of the health care workforce assigned to such patients; and
(b) written compliance plans that shall be required for each facility out of compliance with the patient assignment limits.
Notwithstanding the terms of this or any other section of this act, the Massachusetts Health Policy Commission shall not promulgate any regulation that directly or indirectly permits any delay, temporary or permanent waiver, or modification of the requirements set forth in sections 231C and 23 ID above.
Section 23 IF: Patient Acuity Tool.
The patient acuity tool shall serve as an adjunct to the assessment of the registered nurse and shall be designed to promote and support the provision of safe nursing care for the patient(s); however, such tools are not to be utilized as a substitute for the assessment and clinical judgment of the registered nurse assigned to the patients.
Each facility shall develop a patient acuity tool for each unit designated in Section 231C. The patient assessment and use of the patient acuity tool shall be performed by the nurse who has accepted the assignment for that patient(s).
The patient acuity tool for each unit in a facility shall be developed by a committee, the majority of which is comprised of staff nurses assigned to the particular unit.
The patient acuity tool shall be developed to determine if the maximum number of patients that may be assigned to a registered nurse(s) should be lower than the patient assignment limits specified in Section 231C, in which case that lower number will govern for those patients.
The patient acuity tool shall be written so as to be readily used and understood by registered nurses, shall measure the acuity of patients not less frequently than each shift, upon admission of a patient, and upon significant change(s) in a patient's condition and shall consider criteria including but not limited to:
(1) the need for specialized equipment and technology;
(2) the intensity of nursing interventions required and the complexity of clinical nursing judgment needed to design, implement and evaluate each patient's nursing care plans consistent with professional standards of care;
(3) the skill mix of members of the health care workforce necessary for the delivery of quality care for each patient; and
(4) the proximity of patients to one another who are assigned to the same nurse, the proximity and availability of other healthcare resources, and facility design.
A facility's patient acuity tool shall, prior to implementation, be certified by the Massachusetts Health Policy Commission as meeting the above criteria, and the Commission may issue regulations governing such tools, including their content and implementation.
Such patient acuity tool and information contained and documented therein shall be part of the patient medical record.
Specializes in Critical care, tele, Medical-Surgical.
They actually can't. Even large teaching hospitals cant afford it.
Studies have shown that sufficient nurse staffing is cost effective and saves lives.
CMS decreases compensation for readmissions within 30 days, ventilator associated pneumonia, bloodstream and other nosocomial infections, and other complications
Examining the value of inpatient nurse staffing: an assessment of quality and patient care costs. From Med Care. 2014 Nov.
Increases in nurse staffing levels were associated with reductions in nursing-sensitive adverse events and length of stay, but did not lead to increases in patient care costs. Changing skill mix by increasing the number of registered nurses, as a proportion of licensed nursing staff, led to reductions in costs.
Hospitals with better nursing environments and above-average staffing levels were associated with better value (lower mortality with similar costs) compared with hospitals without nursing environment recognition and with below-average staffing
An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions
Adding just one child to a hospital's average staffing ratio increased the likelihood of a medical pediatric patient's readmission within 30 days by 11%, while the odds of readmission for surgical pediatric patients rose by nearly 50%.
There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights.
Bridgid Joseph, BSN, MSN, APRN, CNS
14 Articles; 67 Posts
Daisy- once it passes there is little room for change; what most people don't understand is the fact that there have been a multitude of options for improvement of the bill sent to the ANA who is pushing this bill, and they refuse to change some of the biggest issues: 37 days to become compliant is absurd. Since you live in CA, you know that they had up to 5 years to become compliant. There is no wiggle room in cases of emergencies: the ANA does not consider the Marathon bombing a state of emergency warranting that we may be off with staffing despite it being an unexpected (understatement) state of emergency for the city of Boston. The language needs to be cleaned up and some sticking points need to be clarified for it to be approved; just like anything else, once it is approved, you cannot un-approve. The issues are not the staffing ratios, it is the language and time frame surrounding it.