NOTE: This month’s column is co-authored by President Paula Milone-Nuzzo and School of Nursing Dean Inez Tuck.
On November 6, the voting citizens of Massachusetts will be asked to cast their ballot, either in support of or against Question 1, which defines mandated nursing staff ratios in hospitals.
If passed, Question 1 will have a lasting impact on health care delivery in the Commonwealth for years to come. While there are studies that report a link between nurse staff ratios and quality and patient safety metrics, a one-size-fits-all model does not take into consideration other factors such as patient acuity levels, the educational preparation of the nursing staff, nor size and type of hospitals. While California is the only state with mandated staffing ratios for nurses, Massachusetts hospitals - despite not having mandates - have higher quality metrics than those in California.
If enacted, every hospital, regardless of patient population or acuity, would have to abide by a rigid set of proposed staffing ratios without consideration of time of day or clinical circumstances. For example, the proposed staffing ratio for a medical surgical unit is one nurse to four patients yet we know that the acuity of patients is far different in a community hospital in central Massachusetts than it is in a quaternary health care facility in Boston. Nurse directors have the responsibility for assessing their unit’s clinical situation to determine appropriate staffing ratios that will meet patient needs. Mandated staffing ratios remove using professional judgment to make the right decision for patients. It also fails to recognize that care is provided by interprofessional teams of health professionals. By mandating only nursing ratios, the role of the team in providing high quality care would be diminished.
Just as important are the real workforce issues that must be considered. It is estimated that Massachusetts would need 6,000 additional nurses to meet the law’s minimum staffing ratio when the law is enacted, with another 1,500 nurses needed shortly thereafter due to retirements. A quick look at the numbers show it would take years to meet the workforce demands that these ratios would require. Massachusetts currently has 8,000 students in 25 baccalaureate and higher-degree programs that produces 2,000 graduates each year. While enrollments in entry-level baccalaureate programs increase approximately 4.3% annually, that number falls far short of meeting the demands of this new law.
Over the last seven years, the nursing profession has been undergoing a transformation to meet the complex needs of patients. In 2011, the Future of Nursing report called to raise the number of bachelor’s-prepared nurses to 80% by 2020. This goal, using the research done by Aiken et.al (2003, 2016) and others (Blegan et al, 2013, Liao et al, 2016), demonstrated a clear link between higher levels of nursing education and improved patient outcomes. While the goal has not yet been reached, the needle is moving in that direction. But that could be reversed as health care facilities scramble to meet the new staffing requirements. If hospitals are forced to close units or limit admitting patients, it will severely impact the availability of the clinical placements nursing students require to complete their education.
There are many questions that need to be answered. What will hospitals and employers do to meet these new staffing ratios? Will there be unintended consequences? One possibility is that hospitals would be forced to hire more associate degree-prepared nurses, undercutting the Future of Nursing’s target and jeopardizing the goal of better patient care that the law’s supporters tout. Or, hospitals could meet these new staffing requirements by hiring away BSNs from nursing homes and assisted living facilities, thus reducing patient care at those facilities.
The decision to vote yes or no on Question 1 in November is not an insignificant one. Creating a health care delivery system bound by new regulations and mandated staffing ratios will add another layer of external regulation, strain the ability of nursing schools to produce bachelor-prepared nurses, and jeopardize patient care at non-acute facilities. We encourage you look at the issue comprehensively to make a thoughtful decision.