The buzz on Question 1

Ballot initiative could determine staffing levels for nurses.

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Question 1 on the upcoming election ballot is about patient-to-nurse ratios. — Gabrielle Mannino

On Nov. 6, Massachusetts voters will decide whether they believe yes, patient-to-nurse ratios should be regulated by law, or no, patient-to-nurse ratios should remain in the hands of hospitals. The proposed law was written by the Massachusetts Nurses Association (MNA), a labor union that has pushed this law for decades. The question would apply to all hospitals across the state, as well as certain additional healthcare facilities. Here on-Island, the law would apply only to Martha’s Vineyard Hospital.

Before we get into the Vineyard buzz around Question 1, let’s take a look at logistics under the proposed law.

  • In step-down or intermediate-care units — transitional units between intensive care and general medical surgical wards — the maximum patient per nurse ratio is 3 to 1.
  • In post-anesthesia or operating room units, the ratio is one patient under anesthesia per nurse, or two patients post-anesthesia per nurse.
  • In emergency services, one to two critical-care patients per nurse, depending on patient assessment; two urgent, nonstable patients per nurse; three urgent, stable patients per nurse; or five nonurgent, stable patients per nurse.
  • In maternity wards, one patient in labor per nurse, during birth and for up to two hours postpartum, or until mother and baby or babies are stable. Postpartum, six patients per nurse. In continuing care for babies, two babies per nurse. Well babies, six per nurse.
  • In pediatric, medical, surgical, telemetry, four patients per nurse.
  • In psychiatric or rehab units, five patients per nurse.

The law would take effect on Jan. 1, 2019. Under the law, hospitals would have to comply with the patient assignment limits without reducing their level of staffing. Hospitals would also develop a written patient acuity tool to assess if limits should be lower than the proposed law. The law would not override any existing contracts, but would take effect after contact expiration.

The state Health Policy Commission would regulate and implement the proposed law. It could conduct inspections and report violations to the state attorney general. Fines could be up to $25,000 per violation, plus $25,000 for each day the violation continued after the commission notified the hospital. During a state or national public health emergency, the law would be suspended.

The argument for No
Hospital leadership across the state say they’re voting no, citing additional costs, staffing, and rigid regulations among top issues.

“I certainly am not for it,” Denise Schepici, CEO of Martha’s Vineyard Hospital, said in an interview with The Times. “It will hurt the way we deliver great quality care here at the hospital.”

According to Schepici, patient-care decisions are made moment by moment, day by day, by teams of professionals at the hospital. “They are not managed by a government mandate that says, Do this, do that,” Schepici said. “The mandate takes away the flexibility that nurses and doctors have.”

Schepici gave an example — if two nurses were on staff in the emergency room, and both were at their maximum patient capacity, if another patient came in to the ER, the hospital would have to turn that patient away until another nurse could come in.

“That patient would have to sit in the ambulance and drive around,” Schepici said. “And if we were to do the morally correct thing and take that patient in anyways, the hospital would be fined $25,000.”

According to Schepici, nurses manage their own environments, and are able to rearrange and reassign situations as needed, in ways that best serve their teams.  

“That’s going to change if this bill passes,” Schepici said.

She added that wait times during the Island’s seasonal peak periods would increase “astronomically.”

“We won’t be able to put patients in rooms,” she said. “We turned away no patients last summer. My nurses are dedicated to taking care of the community, and we give them the resources to do that.”

Mental health and Windemere add a couple of more layers to this debate, on the Island especially. At Martha’s Vineyard Hospital, there are aren’t any designated beds for mental health patients. That being said, the hospital still accommodates those patients by putting them in ER beds until they can be placed in mental health beds off-Island.

“That sometimes takes two to three days,” Schepici said. “If this passes, those ER beds are going to close to mental health patients. We won’t have anywhere to put them.”

She noted a prediction that about 1,000 mental health beds could close across the state, and hospital mental health units could close altogether.

Staffing Windemere, the hospital’s nursing and rehabilitation center, is tough enough as is,  according to Schepici. “We are struggling to find nurses to go into subacute-care nursing home arenas,” she said, nodding to a wider problem staffing nursing homes across the state. “Sixty percent of our [Windemere] staff are agency staff from off-Island. If the law passes, the demand for these nurses is going to go up. Agencies can pay double what we can to send these nurses off-Island, to provide their services elsewhere.”

Schepici cited another prediction that about 4,000 subacute-care nurses will be required to fulfill the mandate in nursing homes across the state: “Where are we going to get those nurses?”

The argument for Yes
Michael Savoy is an R.N. patient care manager at Island Health Care in Edgartown. While Island Health Care is a prominent healthcare facility on-Island, the proposed law does not affect it. According to Island Health Care CEO Cynthia Mitchell, the organization does not and will not take an official position on the question, but she invites her employees to do so.

Savoy worked for the MNA for 10 years. He was also a union negotiator at Brigham and Women’s Hospital for the same amount of time. “My position on this is kind of clear,” he said. “I’m going to vote yes.”

Savoy said his work in tertiary care at the teaching hospital showed him that there are still staffing issues related to acuity, even among hospitals with strong ties to the union like Brigham and Women’s. Working on the board of directors at the MNA got him plugged into the movement of holding hospitals accountable for staffing their facilities.

“Organizing locally in each individual hospital wasn’t enough,” Savoy said. “The second way to do this was to create a bill for hospitals to staff themselves appropriately to acuity. We’ve gotten the support of hundreds of legislators and local unions.”

In response to the rigidness of the law argued from the other side, Savoy said the law has provisions that allow for flexibility.

“It specifically calls for hospitals to set their own acuity standards,” he said. “Hospitals would decide how sick their patients are, and how many nurses they need to take care of them. Why so opposed, if they’re the ones setting their own regulations?”

Savoy also said there are provisions within the law that allow for workarounds and delays in implementation, especially for hospitals like the Island’s with such huge seasonal fluctuations in population.

“There’s a lot of legal room here that I don’t think hospital associations are highlighting,” Savoy said.

He said he knows hundreds of nurses that feel overworked. “I’m not exaggerating when I say hundreds,” he said.

Rick Lambos is an R.N. retired from Martha’s Vineyard Hospital. He worked there for 37 years, and said staffing at the ER was suboptimal.

“When we went from the old hospital to new, ER beds doubled from eight to 16, but staffing stayed the same,” he said. “The hospital adapted this unofficial ‘pull till you’re full’ policy. We’d put patients in rooms, but wait times weren’t going down — they were just sitting in rooms longer.”

He said on any given day, the ER would have two R.N.s with as many as 16 patients. On night shifts, the nurse count would go down to one. While he’s been retired from the hospital for about seven years, he’s still in touch with old colleagues who can attest that not much has changed.

In a Letter to the Editor published last week, hospital R.N. Helen Green wrote, “We are not asking for anything but the ability to give better care to our patients. I always ask people when they ask me about this bill, which nurse do you want taking care of you? The one with four patients or nine?”

When asked how many patients she has on average, she said, “I will say this about our hospital in comparison to the rest of the state. Maybe we’re OK, but we definitely have weaknesses. On any given day, you can be really short-staffed. Our weakness is nights. While I have complete respect for the administration of the hospital and our nurse managers, I’m not in agreement with them. Not on this one.”

Savoy said hospital organizations have spent $20 million on “Vote No” campaigns, compared with the $1 million the MNA spent on its outreach.

“There’s a lot of money involved in shooting down this bill,” Savoy said. “It’s causing misinformation and confusion among voters.”

“It’s disheartening for me,” Green said. “Highly funded organizations are pouring millions into this anti campaign against us. It feels funny as a nurse, to have someone trying to make us look bad. I want people to understand this isn’t the government. It’s nurses, bedside nurses.”

Community health centers
Cynthia Mitchell described the stance of the Massachusetts Association of Community Health Centers: “The association has taken the stance against Question 1,” Mitchell said. “That’s for a set of reasons. I’ll highlight two. One being the competition for nurses; if this question passes, it will put community health centers at a huge disadvantage from hospitals. Hospitals can traditionally pay more, and they’ll be in a position where they’ll experience a severe shortage of R.N.s. The second reason is cost. The cost of implementing this is going to be millions and millions. Healthcare centers question whether that money isn’t better spent at the preventative end of healthcare problems — keeping people out of hospitals and acute care, rather than spending on acute care happening in the hospitals.”

 

  • I find it interesting that the folks that own and operate the hospitals at the executive level want to vote no on this Question, but those folks who are regular paid staff in hospitals want to vote yes. It seems the vote yes on question 1 folks have the better argument and more people behind them. I think I’ll vote yes on Question 1.

  • Except, those who support the bill have spent over $10 million dollars if you check campaign finance records.

  • this is a case of “helicopter government”.
    I understand that having more nurses could lead to better care–nurses are , after all, the best thing going in the health care industry, but there is an economic reality that has to be addressed. I am not confident that a bureaucrat who sits at a desk all day is the best person to decide how much my health care will cost.

    • From what I’ve read of your posts, you think all government is “helicopter government”.

      I think Question 1 tries to address overpaid executive leadership and top heavy corporate hierarchy at for profit hospitals.

      • But nearly all hospitals in Massachusetts are not for profit. So, again how does a bill that is aimed at all hospitals in the state penalize the few for-profit organizations?

        • You are right. The top overpaid and top heavy organizational hierarchy is a problem whether they be for profit or non-profit.

  • One reason I am voting ‘Yes’ on Question 1 is my memory of hours spent with my mother, my wife, my children, and other loved ones in hospitals hearing the incessant din of alarms, and even occasional cries and groans of distress.

    I’m not talking about war zone triage nor even about the ER, I’m talking about inpatient care in major Boston hospitals (MGH, B&W, etc.). Nurses can’t answer the alarms right away when they’re busy with other patients. Delay addressing medical needs is not good healthcare. The din itself is stressful, antithetical to healing.

    “First, do no harm” rules doctors and nurses. Not so, administrators. The economic ‘forces’ they bend to are not rules of nature, they result from human inventions that define what a market currently is. Question 1 subordinates the latter to the former. Sure, everybody wants to reduce healthcare costs. Reducing essential staff is not the way to do it. You get what you pay for.

    One recent mailing quotes Donna Glynn, President of the ANA: “Under Question 1’s strict nursing quotas, hospitals will have to close the beds we need to fight our opioid crisis.” Nurses don’t close hospital beds, hospital administrators do. Translated, this is a threat: “If you make us provide more nurses, we’ll stop providing beds for opiate victims.” (And “quota” is a familiar dog whistle. It’s only a change to the staffing guidelines or ‘quotas’ that are in place now.) Other glossy fliers claim that only a demonized “nurse’s union” wants Question 1. Ask a nurse if having more nurses on the floor would be a bad thing.

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