Timmer Explains Question 1 on MA Ballot

The controversy surrounding the first ballot question on the upcoming ballot has split Massachusetts nurses and residents alike. Before voting on the issue it is important to understand the arguments from each side.

I am not an expert on Question 1, and I am not yet a registered nurse. Many people, however, have approached me and my peers seeking advice on how to vote, hoping that we will have some insight as nursing students or nursing assistants. While I will not tell you how to vote, here is a summary of the research I have done, and the things I have observed in the hospital setting to help you make an informed decision on Tuesday.

Question 1 on the November 6th Massachusetts ballot is proposing a plan to implement safe staffing for nurses by limiting the number of patients in each nursing assignment. The ballot question was added in an effort to improve patient safety by reducing the prevalence of human error in nursing care. Aside from in Intensive Care Units (ICUs), there is currently no set patient limit for nurses in Massachusetts.

There is no question that unsafe staffing is an issue in many hospitals and that nurses are often overwhelmed by their patient assignments. Many argue, however, that a “one size fits all” approach is not the correct way to solve this issue, leading to a confusing and vast controversy.

Arguments in Favor of Question 1:

The argument supporting Question 1 is heavily union-backed, as it’s supported by the Massachusetts Nurses Association (MNA). The MNA argues that mandating a maximum patient quota will improve patient outcomes and decrease readmission rates.

In a survey conducted by the MNA in April, 77 percent of nurses reported being assigned too many patients with an average of 6-8 patients per assignment (with the exception of the ICU). 86 percent of the nurses who completed the survey said that they plan to vote “yes” on Question 1. An article in the Boston Globe, however, states that the survey “appears to have been weighted towards MNA members”.

There is no debate that nurses are overworked and are frequently asked to juggle heavy patient assignments, and many of the nurses questioned stated that they did not have enough time with each patient to provide the best standard of care. Understaffing not only puts patients at risk for error but also increases liability among nurses. While many nurses and the MNA are largely in support of Question 1, the nursing population as a whole seems to be split on the issue.

Arguments Opposing Question 1:

Most nurses would agree that measures need to be taken to improve unsafe staffing issues but many also agree that Question 1 is not the correct solution to the problem. The patient limits set by Question 1 would vary depending on the type of unit and the stability of the patient (an Emergency Room nurse could be assigned one urgent unstable patient OR two urgent stable patients).

The ballot question, however, does not take into account the experience or skill level of each nurse. Those opposed to Question 1 argue that experience and skill level is largely what determines what is a reasonable patient assignment, for example, a recent graduate or novice nurse should not have the same expected patient quota as a nurse with twenty years of experience.

The mandated patient assignments would cause a loss of autonomy among hospitals and individual units to create a staffing plan tailored to their employees.

There is also the issue of cost. According to the Boston Globe, Massachusetts Governor Charlie Baker was undecided on the ballot question until seeing a cost analysis stating that the passing of Question 1 could cost anywhere from $676 and $949 million per year.

The president of Massachusetts General Hospital, Peter L. Slavin, brings to light the additional financial strain that would be put on each hospital in a newsletter to hospital employees that can be found online. Hospitals could be fined up to $25,000 per day for not complying with the necessary ratios, however, the cost of hiring hundreds of new nurses would be an even greater expense.

These increased costs could cause a huge financial burden on small community hospitals, potentially causing closures of certain departments or even the hospital as a whole. This could create a significant barrier to patients who are dependent on these hospitals for long-term care without the financial burdens associated with commuting or relocating.

There is already a significant shortage of mental health facilities and nursing homes in Massachusetts and many argue that the financial impact of Question 1 would only worsen this issue. The financial impact of Question 1 would put these facilities in jeopardy and prevent our society’s most vulnerable populations from receiving care. Slavin also states that there is not a sufficient quantity of new nurses to satisfy these quotas among the many Boston hospitals and community health centers, meaning that the $25,000 per day fine is a likely reality among many organizations.

Those planning to vote “no” state that, while Question 1 could improve some individual errors in the clinical setting, it would create a vast barrier to patient care by limiting the number of available patient beds in all facilities.

Many nurses are still undecided about how they plan to vote on the ballot question tomorrow. Many nurses believe that patient safety risk and overworked nurses is an issue that must be addressed. Others are worried that Question 1 is not the correct way to solve the persistent un-safe staffing issue but they still feel that it is at least a step in the right direction to improve working conditions and patient care.

Many nurses, however, also believe that the potential consequences of the increased costs are too great to risk and that the changes will result in poor access to healthcare among patients who are reliant on community hospitals, mental health facilities, or nursing homes for care. The information above is compiled from a variety of news articles, union statements, hospital newsletters, and issues that I have observed throughout my clinical experience as both a student and a nursing assistant.

For more information on Question 1, there are links articles of varying opinions and the full ballot question below.

The Ballot Question

In Favor: https://safepatientlimits.org/

Opposed: https://www.boston.com/news/politics/2018/10/09/massachusetts-ballot-questions-2018-question-1-nurse-staffing

Cover image from Don Treeger of The Republican.