All week we are reporting on the Massachusetts ballot questions. Perhaps the most confusing measure is Question 1, about nurse staffing limits. And things are getting pretty contentious. One minute, there's an ad promising the measure will improve patient safety. The next minute, there's a warning that if the ballot question passes, hospitals will have to close units and there will be a long wait-time in the emergency room. WGBH Radio's Gabrielle Emanuel has been reporting on the issue of nurse-patient ratios. She spoke with WGBH All Things Considered host Barbara Howard about her research, and answered questions posed by listeners about Question 1. The following transcript has been edited for clarity.
Barbara Howard: Before we delve in, can you tell us a bit about Question 1?
Gabrielle Emanuel: Sure. One way to think about this is a longstanding labor dispute. A nurses union that represents about 20 percent of the state's nurses really wants staffing limits, and hospital administrators have been resisting. Without success negotiating, the union has brought their desire for nurse-patient ratios to the voters. So this proposed law would set legal limits on how many patients can be assigned to a nurse in Massachusetts hospitals. These limits, the nurse-patient, ratios would vary based on the unit. So a labor and delivery unit would have a different requirement than, say, a rehab unit. They would also vary based on the patient's condition, which equates to how much attention that patient needs. But they don't take other things into account, like nurse experience. Now, the “Yes” campaign says this is needed to improve patient safety, and the “No” side says this would cost a fortune and would put patients at risk. Given that we are thinking about it as a labor dispute, it's worth noting that a Mass Inc. and WBUR poll recently found that nurses are divided on this issue, just about 50/50.
Howard: So here's our first question, it comes from Drew Hendrickson-Martinez of Somerville and it asks, “What's the real need? Are nurses overwhelmed?” So, do we have any data on that?
Emanuel: Yes, there are two numbers we can look to. Again, that Mass Inc./WBUR survey found that 41 percent of nurses say they are very frequently or somewhat frequently assigned more patients than they can handle. The other number comes from an interview I did with the Health Policy Commission. That's the independent state agency that's tasked with implementing this law, if it does pass. They said 66 percent of hospital shifts already have enough staff to meet the ratios laid out in this ballot measure. But they said that with a warning: they added there's a lot of variation across the state. So if you look at the big academic medical centers like Mass General or Beth Israel Deaconess Medical Center, they wouldn't have to hire as many RN’s — they already have quite a few nurses. But then you look at community hospitals across the state and they really would have to hire a lot more. So the “yes” campaign, their argument here is this measure would create a consistent standard of care, you wouldn't have this “have and have-not” issue. The “No” campaign says staffing is a very delicate science, and there isn't actually evidence that strict ratios would improve patient outcomes. So it does seem like there's an issue with nurses being overburdened, but it's not as clear how you want to fix it.
Howard: OK. Let's go to the next question from Libna Ramos of Allston, who asks, “Is it possible that it can be reformed, that law, or re-framed, that question?”
Emanuel: If you're asking from a voter perspective, no. It's a yes or no, up or down vote. You vote for all of it or nothing. But if this measure does pass in two weeks, can lawmakers change it retroactively? Say those ratios aren't exactly right — can they amend it? Say technology changes, what happens then? To help answer this, I reached out to WGBH’s State House reporter, Mike Deehan. He said what many Massachusetts voters may know: that our lawmakers have a long history of altering and sometimes straight-up ignoring past ballot measures. He said to look at the 2016 recreational marijuana ballot question. That's a good example of where it was heavily reworked. He also pointed to a measure in 2000, where voters said they want a lower income tax, about 5 percent. That still hasn't happened. So it's hard to know exactly how the government is going to deal with this law if it does pass.
Howard: Here’s a question from Jackie Kemp, who lives in Boston's West End. She asks what would happen in an emergency situation, “Would nurses not be allowed to help you because there was a regulation in place about how many people they were allowed to attend to? Or would it be all hands on deck?”
Emanuel: The first thing to know here is that in the most extreme situation, if there's a state or federal public health emergency, these ratios are temporarily lifted, so it is all hands on deck. Nurses are free to care for whoever they need to help, regardless of staffing limits. But let’s say there is a big car accident in the middle of the state and all the victims are taken to one hospital, all at once, and their nurses hit their maximum number of patients that they can see. What happens next? The “No” campaign says this is a real problem. They say you're putting hospitals in an impossible situation. If the nurses do take care of all the victims, they go over their limit of patients that they can care for and they risk big fines. The other alternative is that the patients have to wait to get care. That's what the “No” campaign says. The “Yes” campaign says hospitals are hiring more nurses and nurses flock to emergencies, so there won't be a crunch on available nurses. It's worth noting here that hospitals have a system for dealing with these situations called “float nurses.” And these are nurses that can go to anywhere where there is need. The only catch here is that they don't necessarily have expertise in the unit they're going to. Say the cardiac unit really needs help. A float nurse will go, but they may not know a lot about cardiac patients.
Howard: Well that sounds pretty complicated. Here’s our next question, from Rachel Guberman. She asked on Facebook when the ballot question would have to be implemented. On the ballot, it says it goes into effect January 1st. The “No” side says that that is too soon. The “Yes” side says January 1st is just the deadline for a plan to implement things.
Emanuel: Right, it's not entirely clear. There are just eight weeks between election day and January 1st, so that is really short. By reference, California, the only other state with ratios, had five years to roll out the new system. The “Yes” campaign has been arguing that the effective date and the implementation date are two entirely different things. So it really all depends on how regulators interpret this.
You can find our one-page guides to each of the questions on the Massachusetts ballot here.