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 Critical care, tele, Medical-Surgical.
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.
We still have uninsured residents of California, and unauthorized immigrants disproportionately fill their ranks.
Specializes in Critical care, tele, Medical-Surgical.
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).
After I turned 65 and had Medicare & a supplement I no longer needed to work full time for benefits. For nearly three years I worked as a "rare Per diem" required to be available for one 12 hour weekend shift.
What I really did, with my manager's approval, was sign up for a weekend shift that had enough already scheduled and work as a "break relief nurse.
One to five times a week I would go to work at 11:00 am or pm The charge nurse would assign me to get report and take over an RN's assignment while he or she went on a break. Then I would repeat until all breaks were taken.
Sometimes I went home about three and other times I would admit one or more new patients or take over patients due to increased acuity of one or more patients and stay until 7:30.
So I actually worked four to eight hours. That was much easier on my feet and stamina level.
Before ratios we often did not leave the unit for a break. We drank water or ate nearby. Does anyone think a nurse assigned to an unstable patient requiring 1:1 staffing should get to eat, go to the bathroom, or sit down while a break relief nurse takes over?
I do.
AND I think all nurses deserve break relief to prevent fatigue, accidents, and errors.
Specializes in Nursing Education, Public Health, Medical Policy.
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.
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.
I'm not sure where you're getting the 37 day time limit to become compliant from. The timeline for initial compliance would be defined by regulatory rules which wouldn't exist until after the bill passes.
I'm not sure where you're getting the 37 day time limit to become compliant from. The timeline for initial compliance would be defined by regulatory rules which wouldn't exist until after the bill passes.
You know, when I read it, I was thinking that hospitals would only need to have a plan of implementation by Jan 2019. Have you heard anything else about this? It sounds similar to what you are saying.
Agency for Healthcare Research and Quality, September 26, 2012
The California safe staffing law has increased nurse staffing levels and created more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in other states without mandated staffing ratios. Despite initial concerns from opponents, the skill mix of nurses used by California hospitals has not declined since implementation of the mandated ratios.
"Studies involving RN staffing have shown that when the nursing workload is high, nurses' surveillance of patients is impaired, and the risk of adverse events increases." "... We found that the risk of death increased with increasing exposure to shifts in which RN hours were 8 hours or more below target staffing levels or there was high turnover. We estimate that the risk of death increased by 2% for each below-target shift and 4% for each high-turnover shift to which a patient was exposed."
The researchers surveyed 22,336 RNs in California and two comparable states, Pennsylvania and New Jersey, with striking results, including: if they matched California state-mandated ratios in medical and surgical units, New Jersey hospitals would have 13.9 percent fewer patient deaths and Pennsylvania 10.6 percent fewer deaths. "Because all hospitalized patients are likely to benefit from improved nurse staffing, not just general surgery patients, the potential number of lives that could be saved by improving nurse staffing in hospitals nationally is likely to be many thousands a year," according to Linda Aiken, the study's lead author. California RNs report having significantly more time to spend with patients, and their hospitals are far more likely to have enough RNs on staff to provide quality patient care. Fewer California RNs say their workload caused them to miss changes in patient conditions than New Jersey or Pennsylvania RNs
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....
There's no way here in Southern California that patient's will wait in ED for 2 days since the implementation of nurse patient ratio for 13 years already. Our staffing is better since it's manned successfully by RNs with nurse patient ratio so patient's will not wait that long and they will be taken cared of right away. Aside from ICU, Med Surg, TELE floors that I do, I worked in ED too but not in California that sick people will wait hours to be triaged and treated. If you have some statistics to show please don't buy them but go around yourself so you'll know first hand what are you talking about. There's a lot of fake news out there that they will report but it's no way real.
So don't be afraid, scared or anxious if hospital will close with the nurse patient ratio because for 13 years already no hospital here in California was closed down because of that. It has been proven and tested for so long. If MA has self insurer than any other state, California will give treatment regardless of your race, immigration or ability to pay status so the bill is not an issue here in California. And still, hospital is still surviving if people themselves cannot afford the healthcare and pay for their own treatment.
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.
Yeah some hiring practices are ridiculous! Personality, vocabulary tests, and other nonsense.
Specializes in Critical care, tele, Medical-Surgical.
There's no way here in Southern California that patient's will wait in ED for 2 days since the implementation of nurse patient ratio for 13 years already. Our staffing is better since it's manned successfully by RNs with nurse patient ratio so patient's will not wait that long and they will be taken cared of right away.
Aside from ICU, Med Surg, TELE floors that I do, I worked in ED too but not in California that sick people will wait hours to be triaged and treated. If you have some statistics to show please don't buy them but go around yourself so you'll know first hand what are you talking about. There's a lot of fake news out there that they will report but it's no way real.
So don't be afraid, scared or anxious if hospital will close with the nurse patient ratio because for 13 years already no hospital here in California was closed down because of that. It has been proven and tested for so long. If MA has self insurer than any other state, California will give treatment regardless of your race, immigration or ability to pay status so the bill is not an issue here in California. And still, hospital is still surviving if people themselves cannot afford the healthcare and pay for their own treatment.
My husband was once in the ER from about 6:00 am to 7:40 pm during flu season because there were no beds upstairs.
He received excellent care. A good registry nurse cared for my husband and another telemety patient so the certified emergency nurse (CEN) could admit new patients to the ED.
Emergency Room Visits, Wait Times On The Rise In California
California's emergency departments are becoming more crowded - a trend experts say indicates larger problems in the health system.
New data from the California Health Care Foundation shows that emergency department visits rose 44 percent from 2006 to 2016.
California patients who get admitted to the hospital spend about an hour longer in the emergency room than patients nationally.
Renee Hsia, a professor of emergency medicine at the University of California San Francisco and author of the report, says part of the problem is the state's aging population.
"As people age, their needs become greater," she said. "We also have people with complex conditions that are surviving that may not have survived a few decades ago."..
... emergency rooms are holding high numbers of mentally ill patients and people abusing drugs and alcohol, she said.
That's due to a shortage of beds in drug rehabs and psychiatric facilities.
A lack of inpatient hospital beds may also be part of the problem.
"There are patients waiting downstairs that can't get upstairs," Hsia said. "So the ED ends up being a bottleneck."
And people may be going to the emergency room for ailments they could be addressing in a doctor's office...
... Some hospitals are adding inpatient and emergency room beds to alleviate the problem.
herring_RN, ASN, BSN
3,651 Posts
We still have uninsured residents of California, and unauthorized immigrants disproportionately fill their ranks.
Access to care is a complicated issue.
http://www.ppic.org/content/pubs/report/R_1012HLR.pdf