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Brenda Pignone, a staff nurse at Massachusetts General Hospital, arrives before 7 a.m. on a typical day. For 26 years, she’s taken the elevator to a floor known as White 7, where most of her patients are healing after abdominal surgery.
This 27-bed unit, like hundreds of others across the commonwealth, has become ground zero in a statewide debate. On Nov. 6, Massachusetts voters will decide whether the number of patients a nurse can care for should be regulated by law.
Pignone works in a unit that is already at or close to the proposed nurse-to-patient ratios, and she helps determine that. When Pignone arrives, she picks up her assignments for the day, finds a spare computer, and logs into a system called Quadramed. Pignone classifies each patient based on the number of times she’ll take their vital signs, the number of drains they have, whether they have catheters and whether they have emotional needs.
“Each time I click one of those buttons my patient gets classified according to a certain number,” says Pignone. “The higher the number, the more acute they are.”
And the more time they need with a nurse. Not all hospitals in Massachusetts use a patient acuity tool right now, but they would all be required to if Question 1 passes. At Mass General, Pignone will click another button during her shift if a patient needs to be watched constantly. She’ll unclick buttons as her patients improve. Pignone’s assignments will change along with the needs of her patients.
“We do that kind of exchange every single day, I mean it’s pretty much minute-to-minute many times,” says Theresa Capodilupo, the nursing director on White 7.
Capodilupo never assigns nurses on this unit more than three patients during the day. That wouldn’t have to change, since Question 1 requires one nurse for every four patients on what are known as med-surg units. But the Question 1 ratio applies 24 hours a day. Currently, night nurses on White 7 sometimes have five patients. To avoid hiring more nurses, Capodilupo says she’d have to shift nurses from day to night and some patient care as well, even though that might be disruptive.
“Nights, we try to promote sleep,” chuckles Capodilupo. “I don’t want to give bed baths in the middle of the night, and be trying to draw their blood at 5 a.m.”
Capodilupo says to have the government tell her how to run her unit would be infuriating. But she sympathizes with nurses who are regularly assigned too many patients to handle safely.
“There are some hospitals where a ‘yes’ answer to this question would help them, and we feel for our colleagues,” Capodilupo says, “but it’s not the answer for everybody.”
The problem, says Pignone, is the hospitals that don’t have adequate staffing.
“Why isn’t the focus more on what they can do to help change that situation versus making everyone follow the same cookie-cutter solution when we don’t need that?” she says.
There are no firm numbers that show how much staffing varies from one hospital to the next in Massachusetts. Judith Shindul-Rothschild, an associate professor of nursing at Boston College who supports Question 1, estimates that about a quarter of hospitals use the proposed or even better nurse-to-patient ratios, 50 percent comply with some or most, and a quarter routinely assign nurses an unsafe number of patients.
Shindul-Rothschild says her assessment is based on staffing plans hospitals post to a website run by the Massachusetts Health and Hospital Association (MHA). But the MHA says those staffing plans reflect a daily average and can’t be compared to the proposed ballot question because it would require fixed staffing numbers around the clock.
The MHA and the Massachusetts Nurses Association (MNA) have been at loggerheads when it comes to nurse staffing for at least two decades. In 2014, the two sides reached a compromise on ICU staffing levels, but nurses at many hospitals say that wasn’t enough. The MNA says members filed more than 2,000 complaints about unsafe staffing in the past year and that management refused to change the nurse’s assignment in nearly every case.
Question 1 “is an effort of desperation,” says Shindul-Rothschild. “We are trying to make sure that there is equitable care across our entire system in terms of the quality of nursing care and the numbers of nurses available to provide care to patients, because there are wide, wide disparities.”
Shindul-Rothschild says her research also shows wide disparities in the quality of care across Massachusetts hospitals. She suggests a connection between nurse-to-patient ratios and patient outcomes. Many studies show that adequate nursing improves patient care. But does having four post-surgery patients rather than five make a difference? California, the only state with fixed ratios, has been the test case but has not delivered definitive results.
One of the most widely cited studies of patient outcomes in California found ratios are associated with, but not the cause of, fewer deaths. This state’s Health Policy Commission (HPC) concluded that “taken together, the literature indicates that California’s regulations did not systematically improve the quality of patient care.”
But Joanne Spetz, an author on the HPC report and a UC San Francisco professor who studies the California ratios law, says the law has delivered other benefits. During a panel discussion, Spetz told the HPC that job satisfaction among nurses has improved, that occupational injuries are down, that nursing education programs have expanded to relieve California’s perennial shortage, and that poorly staffed hospitals were forced to hire more nurses.
Some hospital administrators in Massachusetts say they would have to close units such as behavioral health or close altogether if they are forced to hire all the nurses needed to comply with Question 1. Hospitals that already have more money to spend on nurses, such as Mass General, still anticipate needing an additional $34 million a year.
Some nurses who helped launch Question 1 say they are frustrated by the state of the debate.
“The whole purpose is to provide safe patient care,” says Lyn Flagg, a nurse in the emergency room at UMass Medical Center. “Everyone is getting all caught up in the ratios, but unless hospital managers are held accountable, then nothing will change.”
And supporters say the threats of closure are a play on voters’ fears. Linda Condon, an emergency room nurse at Morton Hospital in Taunton, says nurses at all hospitals deserve the guarantee of adequate, safe staffing.
Mass General “hospital executives could choose to change how they’re going to do things,” Condon says, “could choose to increase the number of patients to their nurses, and there’s nothing to stop them from doing that.”
Condon says she’s routinely asked to do the work of three nurses during her shift. Nurses for and against Question 1 agree that should not happen.
“It saddens me that this is on the ballot,” says Debbie Burke, the chief nurse at Mass General. “Is it on the ballot because there are some organizations that haven’t listened to nurses? It’s sad that it’s come to this and we’re going to ask the general public what they think about how we should staff.”
Burke says a ‘yes’ vote would feel to her like a step backwards in the move to make nursing more professional.
“I can’t imagine that this would ever happen with physicians,” she says.
Burke represents one side of what appears to be a deeply divided profession and electorate, with polls showing near even splits on Question 1.