How many nurses for a hospital patient? State’s voters will decide in November

On election day in November, Massachusetts voters, including those without a degree or employment in medicine, nursing, or hospital management, will be asked to decide “yes” or “no” on a simple question that will be wrapped in about 650 words: Should there be a limit on patient assignments for registered nurses working in hospital settings?

If a majority answers “yes” to the “Nurse-Patient Assignment Limits Initiative,” the curbs on scheduling would be determined by the type of medical unit or patient with whom a nurse is working, and the maximum numbers of patients assigned per the limits would be operational at all times.

For voters’ information, the initiative text lays out in detail the limits for nurse assignments for one patient (for example, a baby during birth and for two hours after birth) up to 6 patients (e.g., caring for well-baby patients).

In addition, approval of Question 1 would require that the limits imposed by the new law be met without reducing hospital staff levels, such as service staff, maintenance staff, or clerical staff, and mandate that any violations be reported to the state’s attorney general.

Anyone who has been watching television, reading a newspaper, or listening to radio in recent weeks knows that here has been a ramp-up in pro and con advertising with respect to Question 1. Numbers recorded at the State Office of Campaign and Political Finance through last week show that advocates for approval of the question have, over the last two years, raised $4.72 million and spent $3.86 million for their cause, while those asking voters to say “no” have raised $7.2 million in that same period and spent $7.01 million.

The often-cited rationale for approval as given by supporters of the Massachusetts Nurses Association, a union representing about 23,000 nurses across the state and the most prominent advocate for a “yes” vote on the initiative, is that save for intensive care units, there are no laws, or even standards, for how many patients a given nurses can be assigned to care for. Citing numerous cases where nurses have been hurt due to staffing inadequacies, backers point out that hospitals are under no obligation to define what they call an “adequate” level of nursing attention in units other than ICUs.

In response, Diane Hanley, president of the board of directors for the American Nurses Association Massachusetts, which is promoting disapproval of the question, said in a statement that “the initiative undermines the flexibility and decision-making authority of nurses and puts rigid mandates above patient safety, clinical nurse input, nurse manager’s discretion, and every other consideration in a hospital. This is the wrong path for Massachusetts, for patients and for nurses.”

Over the last month, I have heard from two nurses of my acquaintance, daughters of close friends of mine. One is passionate in her opposition to a “yes” vote on Question 1: 

“I do not pretend to be an expert on this topic, but I have been a nurse in a hospital for 15 years, both on a medical-surgical floor and in an ICU.  While there are times when staffing levels are not optimal, those situations are the exception, not the norm. Forcing strict nurse-to-patient ratios will not solve the problem; instead, I feel, such ratios will create more issues.

• Insurance premiums are going to increase as hospitals charge insurance companies more for services;

• Patients are likely going to wait longer to be seen in hospital emergency rooms. In California (the only state with a nurse to patient ratio law), ambulances often line up outside ERs or are diverted to other hospitals when an ER cannot care for more patients. Currently in Massachusetts, ambulance diversion is banned by the Department of Public Health so less acute patients will have extended wait times.

• To pay for the increased nursing staff, hospitals will likely have to make cuts in nursing support staff (physical therapists, occupational therapists, phlebotomists, transporters, nurses aides, IV nurses, educators, etc.)  Although per the proposal, layoffs are not allowed, open positions will not be filled. 

Logistically, I feel that having a strict nurse to patient ratio would be a nightmare.  There will be float nurses going to different floors to cover nurse’s breaks and times when a nurse being off the floor will create too low of a nurse-to-patient ratio.  In my opinion, this would actually lead to suboptimal patient care as every floor in a hospital is different and best staffed by the nurses who know the population.   

“At my hospital, nurses have the autonomy to decide when their population is more acute and more nurses are needed to staff the unit.  Resources can be shuffled accordingly.  Every day and every shift is different. Having strict nurse to patient ratios actually takes authority and flexibility away from nurses. 

“I encourage everyone to vote your heart. As a nurse, I thought you might want to hear my perspective on why you should vote “no” on Question 1.”

In a less-passionate message, my second RN, who has issues with the level of detail about nursing situations outlined in the initiative text, wrote, “I’m glad I don’t have to vote on this until November, because I am undecided on which way to go. I have been reading everything I can about the proposed law and I still have questions.

“If the ballot asked simply, ‘Should nurse-patient ratios be mandated by law?’ my answer would be a resounding “yes,” and I believe that any nurse who has worked in a hospital or nursing home would agree. I haven’t worked in a hospital in years, but I can remember being on an evening shift and being the sole RN responsible for 15 patients. And that was when I was a relatively young, inexperienced nurse.  It was also one of the reasons I left the hospital and started working in home care. 

“When I read the proposed law, I read it through the eyes of a seasoned registered nurse. While some of the ratios make sense, such as one-on-one care for patients under anesthesia or in an intensive care unit, others seem inappropriate, such as one nurse to four psychiatric or rehab patients. For those patients, much of the care is provided by non-nurses, such as mental health patient care attendants, psychologists, social workers, and physical and occupational therapists.

“In those care settings a registered nurse may be overseeing the care of the patient, administering medications, etc., but may not be providing a great deal of “hands on” care.  So mandated staffing ratios in those settings could result in fewer beds available for behavioral health or rehab patients. And there are already shortages of available beds for some of these patients. 

“The argument of those in opposition to the proposed law does not feel right to me, either. Yes, in a perfect world health care executives would leave the decision-making about staffing to the health care professionals, including nurses. But they do not. And will not. Health care is big business, run primarily by executives, mostly male, who earn seven-figure salaries. An article in the Aug. 15 Boston Globe underscores those facts.  Staffing ratios will be expensive, and hospital executives are not going to decrease their compensation in order to pay for them. 

“So, as you can see, if the proposed law were worded differently in places, I would vote yes today. Without question. But I think that more time needs to be spent figuring out specific staffing limits, and that some hospital units would not require such stringent scheduling. But I’m really glad that this ballot question has people talking. I think that even if this does not pass in November, that we will soon see a law mandating patient limits for nurses. A lot of nurses feel the same way about this very complicated issue.”