MMS Expresses Concerns Over Nurse Staffing Ballot Question

State Update

After a thorough review by the Committee on Legislation of presentations from the Massachusetts Nurses Association (MNA) and the Massachusetts Hospital Association (MHA), the MMS has taken a position relative to a pair of ballot initiatives relative to health care facilities in the Commonwealth.

These ballot initiatives are a new strategy to go directly to the voters to achieve through the ballot process state laws which the legislature has rejected in the past.

House Initiative Petition No. 3843, the Patient Safety Act, would designate specific maximum nurse staffing ratios of registered nurses to patients in hospitals and certain other health care facilities. For example, in intensive care, each registered nurse could have no more than one patient. Ratios are specified in 13 subsections of the proposed law, addressing virtually every hospital setting and patient type.

Thus, the ballot initiative, if passed, will mandate the maximum number of patients that may be assigned to a given registered nurse in a variety of specified health care facilities, with ratios depending upon the type of unit and care delivered. The teeth in the initiative comes from the state Health Policy Commission (HPC), which would certify a patient acuity system that each facility would have to develop, and require the HPC to report violations of patient assignment limits to the Massachusetts Attorney General, with possibility for civil penalties of $25,000 per day for such violations. HPC oversight would come in addition to the Department of Public Health’s oversight of patient safety and quality and existing hospital licensing requirements.

In considering our position on this ballot initiative it was noted that the MMS has always advocated for the safety of all patients in Massachusetts health care facilities. The MMS also recognizes that there are significant changes in the manner in which such facilities are staffed, and the tasks that staffs are required to do both in terms of direct, hands-on patient care and indirectly when complying with ever increasing documentation regulations. The Society appreciates that efforts to accurately quantify nurse/patient ratios attempt to do so in the face of marked variation not only between hospitals (by nature of their specialty and sub-specialty patient populations) but even among nursing units within one institution. It seems logical to consider all of the factors which impact patient safety for a given unit when arriving at staffing recommendations, and to be careful not to limit the ability of those managing the nursing unit to make changes in order to maximally utilize available resources when an unanticipated need arises.

Mandate Will Force Cuts, Threaten Patient Safety

It also is clear that in the current environment, no additional funds will be diverted to health care for increasing nurse/patient ratios; in fact the fiscal policy of the state and the country is to decrease the cost of health care wherever possible. Mandating increasing nurse/patient ratios in this setting will of necessity require cutting costs in other health care disciplines. Reductions in numbers of hospitalists, physical therapists, respiratory therapists, pharmacists, transport staff, housekeepers, and dietary staff, to name a few, will invariably decrease the quality of the care offered and possibly prolong hospital length of stay in addition to giving rise to new concerns about a decline in immediate patient safety.

The MMS is advocating that the utilization of our nursing colleagues be reviewed to determine how much of their current non-patient-contact responsibilities could be reduced by either absolute reduction or transfer to non-nursing personnel, giving the nurses more time to spend with their patients. We also recommend that the MNA and MHA work together to evaluate more completely the aspects of nursing/patient ratios which impact patient safety. An attempt to come to agreement on a way to achieve maximal patient safety without the negative impact of simply mandating fixed ratios serves everyone’s best interests. The MMS is more than happy to contribute to this working group in any way to support such worthy goals.

California Assembly Bill 394, implemented Jan. 1, 2004, is the only law in the nation that defines mandatory nurse staffing ratios in health care settings.

Laws such as California’s measure have not been shown to improve patient safety. However, as common sense and experience support, the literature tends to indicate that “those hospitals that are most effective in ensuring patient safety generally find it optimal to employ more nurses per patient.” This conclusion highlights an important distinction: improved nurse staffing, in combination with other elements of the hospital, may contribute to improved patient safety; however, laws mandating patient nursing ratios have not had a significant effect alone on improving patient safety, and the effects of such laws have been difficult to distinguish given the number of confounding factors that contribute to patient outcomes in health care settings.

Nursing Community Mixed on Staffing Levels

The nursing community does not unanimously favor mandated nurse staffing levels. Although the MNA supports mandated nurse staffing ratios, the American Nurses Association (ANA) advocates for a more flexible approach. The ANA’s position accounts for patient numbers and the variable intensity of care required; the level of education, training, and experience of the nurses providing care; and care provided by other health care personnel, among other factors. The Organization of Nurse Leaders of Massachusetts and Rhode Island opposes the approach as well.

A second ballot initiative, also opposed by the MMS, would require greater financial disclosure by Massachusetts hospitals and limit the pay of top hospital executives. The proposal would require hospitals to detail all funds in offshore accounts, often used by self-insured hospital systems for medical malpractice coverage, and cap hospital chief executive salaries at 100 times that of their lowest-paid workers. Both ballot initiatives are being aggressively supported by the MNA, and equally opposed by the MHA.

—Ronna Wallace 
MMS Legislative Consultant

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