Early voting has already begun in Massachusetts, and one of the questions Massachusetts voters will face on the ballot is Question 1, which creates mandatory statewide maximum nurse-to-patient ratios for hospitals and other health care facilities. There is only one other state that has a similar law, and that is California. It’s a confusing proposal with a lot of opinions being offered on all sides. There is a good nonpartisan summary of the issue here: https://www.boston.com/news/politics/2018/10/09/massachusetts-ballot-questions-2018-question-1-nurse-staffing

I work as a hospitalist at the Massachusetts General Hospital and I wanted to offer my personal opinion on the proposed law. When I first superficially glanced at Question 1, it sounded like a good idea and it seemed to make sense. However, I have spoken to many, many nursing friends and colleagues and have heard virtually universal opposition from them. Having heard their views, and having looked more into the proposed law myself, I am convinced that it’s a good idea done badly, which is why I am voting against it.

Caps are not inherently a bad idea!

First, I want to be clear: I’m in favor of having a maximum limit or a “cap” on the number of patients a single physician or a single nurse can take care of in a day. I have caps on how many patients I see as a hospitalist on a daily basis. At our hospital, our nurses also have limits on how many patients they take care of at a time. That seems to make sense. Given that, on the surface, Question 1 might seem like a no-brainer: why would any decent human be opposed to nursing caps?

Reducing nursing burnout is extremely important in and of itself. If the law didn’t change patient outcomes but solely reduced nursing burnout, I’d be in favor of it. However, I worry that the law as written, instead of reducing nursing burnout, might actually make it worse through unintended consequences. I think my nursing friends who are all opposed to it are worried about the same thing.

The problem is in how those nursing caps are trying to be implemented. I fear that the method we are using is actually going to fail to live up to the idea and will end up doing harm.

Caps work best when determined at the unit level at the individual hospital, not the statewide level

First, about the caps that I currently have on seeing patients and that my nurse friends have on how many patients they see: Those caps weren’t created by law. They were not even created by hospital policy. My cap is determined within our hospital medicine unit, and it is constantly re-evaluated for effectiveness and safety. We have service lines that have higher or lower caps depending on whether that service line includes any students or whether the attending physician is teamed up with nurse practitioners and physician assistants versus seeing patients alone.

Likewise, our nurses determine the maximum number of patients per nurse not at the statewide level or even the hospital level, but rather at the level of the individual nursing unit. We have many “floor”-level nursing units (that is, as opposed to intensive care units), but they are not all created equal. Some floor units are accustomed to carrying much sicker patients than others. Some units are favorites for newer nurses to begin their careers while others are places where more experienced nurses prefer to work. The nurses within these units adjust their nurse-to-patient ratios based on knowing themselves and knowing their patients. And, they can do so immediately, not wait for a law to slowly make its way through committee after committee and vote after vote on Beacon Hill. Question 1 sets a rigid mandatory maximum for different unit types simply based on the “type” of unit. But not all units are created equal even when they are of the same “type.”

Just as not all units within a hospital are created equal, not all hospitals are created equal. The needs of a rural community hospital vary considerably from the needs of an urban academic referral center. Question 1 would create a one-size-fits-all mandate for all hospitals across the state. It assumes the needs, resources, and acuity of all floor units at all hospitals across the state are equal. It assumes the needs, resources, and acuity of all emergency departments at all hospitals across the state are equal. This is simply not the case.

Rigid caps allow no room for flexibility in the event of an emergency

Question 1 has only one built-in provision for allowing hospitals to suspend their mandatory rigid state-issued nursing caps: in the event of a statewide declaration of a state of emergency. Short of that, hospitals must stick to those ratios at all times.

However, this takes away the power of nurses to exercise discretion in the event of emergencies. If a unit exists where all nurses are already at maximum cap, and one nurse’s patient becomes critically ill, the other nurses are not allowed to take over any of that nurse’s other patients, even if they are willing and able to do so. If they do so, the hospital will face a fine. There is no exception for this kind of circumstance built into Question 1.

Simply put, the law robs nurses of their decision-making autonomy. Loss of autonomy is a major factor in burnout.

Question 1 doesn’t allow enough time or resources for implementation

California did a staggered 5-year implementation of its patient cap mandate, allowing hospitals enough time to hire extra staff or restructure their staffing accordingly. Question 1 will be voted on on November 6, 2018, and then will go live on January 1, 2019. This gives hospitals less than 60 days, and less than 40 business days, to actually comply with the law.

That’s not nearly enough time to hire all of the extra nurses that would be needed to meet these rigid mandates. As such, units will be forced to close off beds due to staffing shortages. At a time when emergency departments across Massachusetts are already constantly over capacity, this will mean longer wait times, which can be detrimental to patient health and well-being.

In addition, in California, hospitals were allowed to reduce staffing to meet the mandate, which is how many hospitals were able to afford it. However, Question 1 prohibits reducing staffing to meet the mandate. As such, hospitals will be forced to take on extra costs without extra funding. Massachusetts’ independent state healthcare watchdog, the Health Policy Commission, estimates hiring the nurses needed to meet the mandate will cost about $1 billion statewide. This cost will hit smaller and more cash-strapped hospitals the hardest, possibly forcing some of them to close, which in turn will increase the burden on larger hospitals. It is those same smaller and more cash-strapped hospitals that already face the problems of lower nursing satisfaction and higher nursing burden. In other words, Question 1 might end up hurting the very hospitals it is supposed to help.

There is no evidence that Question 1 will improve patient safety

Question 1 is being touted as being “necessary” for patient safety, so I just wanted to quickly address this point. As far as patient outcomes and safety go, Massachusetts is already doing better than California on 5 out of 6 “nursing-sensitive quality measures,” according to the Health Policy Commission. Furthermore, according to studies, California ultimately didn’t do universally better or universally worse in terms of improving patient safety after implementing its nursing caps. So, the argument that Question 1 is needed to improve patient safety simply does not hold water.

Hardwiring nurse caps into law makes them hard to change

If Question 1 passes, and we soon find the law isn’t working or is having unintended consequences, how will we change it? If it was a unit-level decision, the unit leadership could quickly get input from the unit staff and implement a change the next day. If it was a hospital policy, it would take longer, but the hospital leadership could work on it, customizing it for the needs of the individual hospital.

What if we wanted a statewide rule? Even in California, the actual caps were not codified into the law. Rather, it was written in the law that the California Department of Health and Human Services would determine the appropriate caps. It is much easier to rewrite a regulation if a cap is too high or too low than it is to go through the entire legislative process to rewrite a law.

Imagine that we find that Question 1 has passed and within a few months we know it’s not working. Now, imagine the correction for Question 1 going through committee after committee and vote after vote on Beacon Hill, until one day years later a heavily watered-down partial fix finally passes.

Some people have said that it’s better to put in a bad law now and fix it later than to have no law at all. However, I think the same principle applies in law as in medicine: first, do no harm.

Therefore, I am voting NO on Question 1.