We Asked a Public Health Expert about the Nurse Staffing Ratio Ballot Question

Nancy Kane, a professor of management from Harvard's Department of Health Policy and Management, discusses the nuances of the nurse staffing ratio ballot question.

ballot question 1

Photo via iStockphoto.com/PeopleImages

It’s safe to say that Question 1, the proposed law that would limit the number of patients assigned to nurses at any given time, is confusing voters, who remain deeply divided on the issue. The Citizen’s Initiative Review is a good place to start if you’re still (like most of us) trying to make sense of the ballot question. With nurses and hospitals on both sides making pretty strong claims, it can seem like one side has made a solid case, only for the other side to provide a strong rebuttal, and it continues on like that until you’re way down the rabbit hole. We chatted with Nancy Kane, a professor of management from Harvard’s Department of Health Policy and Management, to get her take on the matter, and to hopefully shed some light on how voters can come to a decision on November 6.

Are all hospitals facing the same staffing ratio issue?  

“This is so case-specific because every hospital is so different,” Kane says. Sure, you can look at a smaller hospital or hospitals where nurses are overworked and say that more nurses need to be hired to distribute the workload evenly and improve patient care, but then you face funding issues. Most hospitals, she points out, are already at the appropriate nurse-to-patient-ratio—this ballot initiative is pointing out the flaws in the few, not the many.

So is this a labor issue or patient-care issue?

Kane says it’s both. Patient safety is obviously something everyone is concerned about, and nurse burnout is something hospitals need to address, but she doesn’t seem to think this is the right vehicle to address either matter. “There’s no flexibility built into this law,” she explains. “It doesn’t take into consideration special circumstances when a nurse might call in sick, or if there’s a big nursing conference and 10 percent of the staff is gone. And the fines for not staffing up, or abiding by the law in those situations, create a huge problem for financially weak hospitals.” They run the risk of closing in an effort to meet the stringent requirements—which brings us back to patient care. It’s not very beneficial for patients for their local hospital to shut down, if the fines are drastic enough.

What could the fine mean for hospitals?  

As of right now, the penalty for breaking the mandated ratio is $25,000 for every infraction. “And that plays into how you staff a floor,” Kane explains. “If you have a 1-to-5 patient-to-nurse ratio and you have six patients come in, do you hire another nurse for that one patient or do you wait to treat that patient until another one leaves? When hospitals have this huge fine hanging over their head, I’m worried how decisions will be made regarding patients.” This could also affect training facilities and skilled nursing programs, like the ones at UMass, she says, because hospitals will draw nursing teachers out of those places, leaving their programs high and dry.

California successfully implemented nurse staffing ratio legislation in 2004. How did they do it differently? 

In the California legislation, they built in a plan for the flexibility to deal with unforeseen circumstances, because you never know how many people are going to be occupying a bed, Kane says. They don’t have strict penalties and they implemented it throughout a three year process. “This legislation in Massachusetts looks very similar to the marijuana legislation,” she says. “The people have spoken, but as a state we’ll have to figure out how to implement it, and it could take years.”

Yet another thing California allowed for was that 50 percent of their nurse workforce could come from licensed practical nurses—who are nurses that have about a year of nursing education, as opposed to a two or three year degree like registered nurses. When California hospitals had a nursing shortage, the legislation made it easier to hire more nurses. “All around, the law seemed more thoughtful,” she says.

So… how should we think about it heading to the polls on November 6?

Yeah, it still might be confusing, but isn’t the point of democracy having the opportunity to carefully consider all sides of an issue? That’s what has happened—nurses, on both sides of the argument, as well as hospitals, are being heard. Whether you ultimately vote yes or no is still going to come down to what you think on Election Day, but we’ll leave the final word here to Kane.

“By focusing all our attention on the input, as opposed to the results, I don’t think this is going to go to a happy place,” she says. “These are important goals and something we should address, but how do you live in this kind of rigid manpower, when that’s not how real life works?”

Still on the fence? Read our endorsement guide to see who’s voting which way.