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PA OPINION

On the Massachusetts Ballot: The nurse to patient ratio and steps hospitals must take to attract and retain nurses

On 6 November 2018, Massachusetts voters rejected the Patient Safety Act (Question 1), which would have limited the maximum number of patients assigned to a single nurse. Supporters, led by the Massachusetts Nurses Association (MNA), argued that hiring additional nurses into overburdened teams would improve both patient safety and nursing workplace conditions. Opponents contended that hospitals, especially small and community hospitals, could not afford to recruit and hire additional nursing staff and that the extra expense would divert resources away from initiatives to support patient care. They also cautioned that an increase in demand for nurses could cause competitive wages to rise, further disadvantaging smaller hospitals.

So, while the people of Massachusetts have decided more nurses aren’t the answer, what are the problems that still need solving?

Nurses report concerns with patient safety and their workplace conditions

The addition of Question 1 on the ballot alerted provider organizations to rising levels of dissatisfaction among nursing teams. The increased staffing requirements proposed were intended to mitigate risks to both patient safety and nurses’ workplace conditions, which are widely reported by nurses in Massachusetts.

Proponents of Question 1 pointed to a number of studies to make their point. For example, they suggested each new patient assigned to a nurse had a seven percent increased risk of hospital-acquired pneumonia, a 53 percent increased risk of respiratory failure, and a 17 percent increased risk of medical complications. Nurses themselves report concerns, saying that compared to 2014, patients today experience longer hospital stays, more medication errors, and higher readmission rates. They attribute these increases to an overburdened nursing staff.

Nurses also report high levels of burnout, low job satisfaction, and work conditions that put patients at risk. Though patient-centered care is a key role of nurses, a study commissioned by the Massachusetts Nurses Association found that 86 percent of those surveyed report that they do not have the time to educate patients and provide adequate discharge planning, up from 68 percent in 2014. Similarly, many nurses indicate that excessive workloads are their top source of fatigue and 83 percent believe hospitals are losing skilled nurses due to poor workplace conditions.

The combination of these challenges can mean nurses are subjected to abusive and physically violent patient episodes, a situation that is exacerbated by the lack of available support staff to respond to difficult patients.

While voters have rejected the mandate to increase nurse staffing levels in Massachusetts hospitals, the patient safety and nursing workplace concerns still stand. Hospitals must take steps to improve conditions and patient safety.

What can hospitals do to build a satisfied and motivated nursing staff focused on patient safety and excellent clinical care?

To build highly motivated teams that deliver high-quality, patient-centered care, hospitals must respond to the concerns of nurses. They can provide more time for care by finding operational efficiencies, offering development and training opportunities for nurses, and focusing on continuous quality improvement to raise standards across their organizations.

Our new value-based care research shows why putting patients at the centre of healthcare is important and how to do it

Read more here

Putting patients at the center of care

The overarching objective of Question 1 was to increase the number of nursing hours committed to delivering direct patient care. Though detractors have focused on the requirement for additional recruitment, there are a range of non-clinical tasks that can be removed from nursing roles. Automation and digitization of certain operational and reporting functions, such as scheduling, lets nurses focus on care.

Engaging teams to understand their individual and collective objectives and agree the most appropriate ways to meet shared goals is an effective way to increase job satisfaction and patient outcomes.

Design roles and support staff to practice at the top of license

As many hospitals operate under value-based care contracts, training and developing all clinical employees to practice at the top of their licenses is crucial to containing costs, enhancing workplace satisfaction, and driving profits.

Developing enhanced roles and being clear about training and development opportunities to expand roles can be an effective way to deliver a wider range of skills within the same headcount and cost base. Similarly, cross-training and internal mentorship programs can serve as a catalyst for the transfer of knowledge from seasoned nurses to those who are newer to the job. Encouraging employee engagement to demonstrate the competencies of excellent clinical care can improve patient outcomes and enable more nurses to work at the top of their licenses.

By investing in training opportunities for clinical employees, hospitals can show they are committed to retaining their clinical staff, reducing turnover and the costly task of hiring new employees.

Invest in safety initiatives to protect patients

As a profession, nursing attracts dedicated and nurturing individuals who take pride in delivering a high standard of patient-centered care. Indeed, the survey data of nurses’ complaints shows the perceived deficiencies they see in the care they can deliver. Hospital leaders can implement new safety initiatives that demonstrate they are prioritizing safety among patients, nurses, physicians and administrators, alongside efficiency and value. By building an environment of continuous quality improvement, hospitals can foster a positive work culture that encourages nurses to more fully engage in their jobs, leading to increase job satisfaction and better outcomes for all stakeholders.

The inclusion of Question 1 on the Massachusetts ballot raised important concerns among the nursing workforce. Supporters and opponents of the measure voiced valid views. And while voters ultimately rejected the measure, its inclusion on the ballot reveals there’s a healthy conversation occurring about the importance of improving patient-centered care. That’s something we should celebrate.

Contact the authors

  • Charlie Paterson

    Charlie Paterson

    PA healthcare expert

    Charlie delivers successful time critical projects in acute healthcare environments with complex stakeholder relationships

    Insights by Charlie Paterson
  • Jenna Phillips

    Jenna Phillips

    PA healthcare expert

    Jenna collaborates with stakeholders throughout the healthcare system to design and implement complex strategy initiatives

    Insights by Jenna Phillips
  • Meghan Marx

    Meghan Marx

    PA healthcare expert

    Meghan is a revenue cycle transformation specialist with experience working on enterprise-wide IT and finance project deployments in the provider space

    Insights by Meghan Marx
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