New legislation would boost nurse-to-patient ratios in Mass.
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As hospitals continue to struggle with overcrowding and understaffing, Massachusetts nurses are making a new push to limit the number of patients that can be assigned to a registered nurse at one time — a measure that advocates say would increase patient safety and lure more nurses back to the workforce.
Legislation to be filed this week by Representative Natalie Higgins and Senator Lydia Edwards would require the Department of Public Health to develop minimum staffing levels for all areas of the hospital, with input from a series of public hearings.
“It’s about safety — safety for patients and safety for nurses,” Edwards said in an e-mailed statement. “I want to know that my nurse is working under the best conditions. To know what works best for nurses means we have to listen to them.”
Hospital lobbyists have fiercely contested similar staffing legislation in the past, arguing it would create inflexible standards for hospitals regardless of their size or number of patients, and would bring insurmountable cost pressures for some. This time, the response appears more muted.
“Workforce is our top focus heading into the new legislative session,” the Massachusetts Health & Hospital Association said in an e-mailed statement. “We have not yet seen this proposal, but we know that it will take a united approach and continued flexibility to solve the capacity crisis, keep care accessible to patients, and grow the ranks of talented health care professionals.”
The proposal comes as hospitals are confronting a staffing crisis, with many using expensive, temporary staff to fill vacancies. The New York state nurses union recently reached a deal with two hospital systems that featured staffing ratios, after nurses went out on strike.
Katie Murphy, president of the Massachusetts Nurses Association and an ICU nurse at Brigham and Women’s Hospital, said patient limits would make nursing jobs more appealing and may help lure people back to full-time jobs.
“The thing that I hear since the pandemic is this moral distress, and this moral injury of nurses not being able to deliver the care. That’s driving nurses away from the bedside,” Murphy said. “If you said to that nurse we will hire you full time with benefits . . . and you will only have to care for four patients [at a time], you will find nurses taking those jobs.”
Under the proposed Massachusetts legislation, staffing limits would apply to facilities with 24/7 nursing care, including acute care hospitals, rehabilitation facilities, and psychiatric hospitals, though limits would be suspended during a state or nationally declared public health emergency. The country is currently under a federal public health emergency due to the pandemic.
The attorney general’s office would be able to impose a $25,000 fine for each day a hospital wasn’t in compliance with the staffing ratios until the facility begins to work to rectify it.
As it stands now, union officials say there were 8,300 reports of unsafe staffing made with the Massachusetts Nurses Association in 2022 alone. Some of the reports, created by the union to protect nurse licenses in the event of a lawsuit or hospital disciplinary proceeding, detailed a newborn in withdrawal at Cape Cod Hospital in March who was left crying for 10 minutes while staff attended to a 19-year-old who couldn’t be left until medicated. At the emergency department of Brigham and Women’s in December, limited staffing meant patients requiring continuous oxygen monitoring were left in hallways, where they could not be monitored safely.
Lori Jewett, chief operating officer for Cape Cod Healthcare, said pediatrics is always staffed with a minimum of two nurses on the unit, and the hospital assesses the number of patients and how ill they are multiple times a day, with a process to bring in more resources as needed.
Jessica Pastore, a spokesperson for Brigham and Women’s, said that over the last year the hospital has hired more than 550 nurses and reduced its nurse vacancy rate by 50 percent, with recruitment efforts ongoing.
Nurses in Massachusetts have tried for years to create limits on how many patients they can take at one time, often pointing to ratios California lawmakers mandated in 2004.
In 2008, a version of the union’s staffing limits bill passed the House, but ultimately died in conference.
In 2014, a fight over staffing limits resulted in compromise legislation that said no more than two patients could be assigned to a nurse working in the intensive care unit.
In 2018, the nurses union and hospital lobbying group faced off again on a ballot measure that would have created specific patient limits for different hospital units. Hospitals said the proposal would threaten the stability of smaller operators and spent a then-record-setting sum to fight the measure. Voters ultimately rejected the proposal.
However, the pandemic has further strained the workforce. A survey of hospitals conducted last summer by the Massachusetts Health & Hospital Association found that nurse vacancy rates were between 8 percent and 56 percent.
Nurse burnout and staffing problems predate the pandemic but have grown more serious since 2020. Recent research published in Nursing Outlook, which surveyed nurses in New York and Illinois both before and during the pandemic, found that 48 percent reported high burnout, and 57 percent reported staffing shortages before the pandemic. During the pandemic, those numbers rose to 51 percent and 67 percent, respectively.
Union officials say better staffing levels are associated with lower mortality rates, but published data have been mixed.
A 2021 observational study of hospitals in Illinois found that the odds of dying within 30 days of a hospital admission increased 16 percent for each additional patient in an average nurse’s workload.
But another study published by physicians at Beth Israel Deaconess Medical Center in 2018 found that the Massachusetts ICU staffing law only modestly improved staffing at hospitals. Also, the risk of mortality and the risk of complications in ICUs remained stable and in line with hospitals out of state.
The union contested the findings, saying the results were from too narrow a group of hospitals and happened too soon after implementation.
While DPH might ultimately create staffing limits that are higher than what nurses have advocated for in the past, Murphy said some limits would be better than nothing. The Massachusetts Nurses Association recommends staffing ratios in line with what they proposed in 2018, including that a nurse could have no more than four pediatric patients, and psychiatric department nurses could have no more than five patients.
The state estimated that the 2018 ballot measure that would have instituted a variety of similar staffing limits would have cost hospitals between $676 million and $949 million annually.
But Murphy said safer staffing limits ultimately would save hospitals money, allowing for better patient care and possibly lowering the risk of hospital-acquired illnesses or infections. Though hospitals recorded record-breaking levels of operational financial distress last year, they also received enormous sums from the state and federal government, she said.
“They say it would cost [money], but right now it’s costing human lives,” Murphy said.