Massachusetts Question 1: The Impact Of Mandated Nurse Staffing Ratios

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By Keren Avnery, BSN, RN

This November in Massachusetts, there is a proposed 2018 ballot question that would mandate nurse staffing ratios in hospitals (not Skilled Nursing Homes or Long Term Care facilities). This question has the power to completely transform the state’s healthcare system. To date, with the exception of Intensive Care Units, California is the only other state to mandate nurse staffing ratios.

As a company devoted to improving staffing for both facilities and nurses, we wanted to host a conversation about the topic. There are valid concerns on both sides of the argument, and we wanted to provide a professional space for those directly impacted by these ratios to express their thoughts. Let’s provide a discussion that will help the public to make an educated decision about this question.

What would the ballot measure do?

  • Assign a legal limit to the number of patients a single nurse can care for depending on the level of care required by the patient.
    • In all med/surg and telemetry units, the maximum ratio is 4:1
    • All units in step down or intermediate care would have a 3:1 ratio
    • In ORs and PACUs, nurses will have a ratio of 1:1 if the patient is under anesthesia or 2:1 for patients post-anesthesia
    • ER ratios would differ depending on the patient’s illness level between 1-5 patients per nurse.
    • In all psychiatric units, the nurse ratio is 5:1
    • In all pediatric care units, the maximum ratio is 4:1
    • In all units with maternal child care patients, ratios differ depending on stage of labor and illness level of the mothers and babies
  • Designate the necessity of a “patient acuity tool” which would need to be used by each nurse each time they accept a patient assignment to ensure they have the correct ratio. This tool must be created by a committee at the hospital, which is to be mainly comprised of staff nurses on the units who would use the tool.
  • Would prohibit hospitals from laying off other hospital staff in order to comply with nurse staffing ratios.
  • If hospitals violate these ratios, they could be fined up to $25,000 per incident.
  • The Massachusetts Health Policy Commission would be responsible for maintaining a phone line and public website where complaints could be filed, and certification and compliance plans and violations will appear and be updated at least quarterly for each facility.
  • The bill would take effect on January 1, 2019.
  • Read the bill here: http://www.mass.gov/ago/docs/government/2017-petitions/17-07.pdf

What would it cost?

  • One study by the Massachusetts Health and Hospital Association estimates that this measure could cost the healthcare system $1.3 billion dollars in the first year and $900 million each year after that.1
  • To give this number some context, back in 2012 the average profit per hospital was $12.9 million.

Arguments in favor of nurse staffing ratios

The Massachusetts Nurses Association, a union that represents about 20 percent of nurses in the state, is the main force behind this ballot initiative. They believe that mandating ratios is the key to patient safety. They believe that by reducing the number of patients each nurse has to care for, patients will have significantly better outcomes, and will thereby reduce costs to the hospital in fewer hospital acquired infections, lawsuits, readmissions, medication errors, etc. Those supporting the measure point out that Massachusetts has among the highest number of nurses per capita. Plus, they say with better working conditions, there will be less nurse burnout and some nurses who left the profession may return.1

Arguments against nurse staffing ratios

Those opposed to the measure say there are not enough nurses to meet the new staffing levels, which will cause hospitals to scramble to meet the new requirements. This will cause hospitals to pull nurses from places like nursing homes, and those nurses may not have the proper skills necessary to work in hospitals.1 This may also leave nursing homes short staffed which may exacerbate patient safety issues for residents in long term care. Additionally, the measures would be enforced as early as January, which does not give institutions very much time to prepare for proper execution of the new measures.

What can we learn from California?

Similar legislation on nurse staffing passed in California in 1999, and it was implemented in 2004.1 Since then, there have been a few studies examining nurse outcomes and patient outcomes in California, intended to help other states evaluate if nurse-patient ratios are effective or ineffective. The studies found that since the enactment of the new law in CA, nursing outcomes improved; nurses had higher job satisfaction, less burnout and turnover, better pay, and lower injury rates. However, patient outcomes results are inconclusive; while some studies showed patient outcomes improved, others showed no significant difference.

It is important to point out that there are a few key differences between the California initiative and this Massachusetts one. Firstly, in California, the initiative allowed for much more time before going into effect, so institutions were able to take years to scale up. Secondly, California’s initiative did not stipulate that hospitals could not lay off other healthcare workers to balance out their costs, so while many institutions increased the number of nurses working, they decreased numbers of nursing aids and other staff. Supporters of the bill say this could be a key reason why they did not see patient outcomes improve.

Works Cited

  1. https://www.wgbh.org/news/local-news/2018/07/02/voters-to-decide-whether-to-limit-how-many-patients-nurse-can-be-assigned

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