1. Sofer, Dalia


Nurses, too, were split on the vote.


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In a November 6, 2018, ballot referendum, Massachusetts voters rejected a proposal-known as "Question 1"-that would have imposed nurse-to-patient ratios in hospitals according to the type of unit and the level of care. Under the proposal, a nurse on a step-down unit would care for no more than three patients at one time while an ED nurse would be responsible for no more than three patients who require urgent care but are in stable condition.

Figure. Theresa Capo... - Click to enlarge in new window Theresa Capodilupo, a nurse director, and Brenda Pignone, a bedside nurse, review the daily patient assignment sheet for a postsurgery and trauma unit at Massachusetts General Hospital. Photo by Jesse Costa / WBUR.

The proposal, defeated 70% to 30%, had been vigorously debated, with supporters-chief among them the Massachusetts Nurses Association-asserting that it would enhance patient outcomes, and opponents-including the American Hospital Association and its subsidiary, the American Organization of Nurse Executives-asserting that it would "dramatically impact hospitals' and health systems' ability to provide safe, quality care."


The Massachusetts Health Policy Commission, an independent group that monitors health system spending, estimated that the measure would require the hiring of 1,809 to 2,624 additional nurses and lead to an increased annual cost of $676 million to $949 million. Opponents of the ballot measure contended that among potential consequences would be increased ED wait times, reductions in opioid treatment and mental health services, and possible closure of some community hospitals.


Nurses, too, were split on the proposal. Advocating for its defeat, Nancy Gaden, senior vice president and chief nursing officer at Boston Medical Center (BMC), said in a BMC podcast that the mandate would cause the hospital's ED to care for 100 fewer patients per day and the medical-surgical units to lose 62 beds. Pamela F. Cipriano, then president of the American Nurses Association (ANA)-she was succeeded in January by Ernest Grant-applauded the proposal's defeat, saying in a statement: "The rigid, one-size-fits-all approach proposed by the ballot initiative failed to acknowledge the complexities of staffing and undermined nurses' professional autonomy and decision making in determining staffing on their units."


Nurse proponents disagreed, among them Linda H. Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. "Messaging to the public-including from the ANA-suggesting that patients could be harmed by the Massachusetts ballot initiative was very unfortunate and simply wrong, resulting in the public voting against their own interests," Aiken told AJN. Aiken's research on nurse staffing influenced the debate leading to California's adoption in 2004 of mandated nurse-to-patient ratios. In a 2010 study in Health Services Research by Aiken and colleagues, California nurses reported less burnout and job dissatisfaction and better overall quality of care after the mandated staffing ratios were in effect than nurses surveyed in two comparison states without mandated staffing ratios (Pennsylvania and New Jersey).


As AJN has reported (see In the News, December 2018), a recent study in Critical Care Medicine evaluating the impact of changes in Massachusetts state regulations mandating nurse staffing levels in academic medical center ICUs found no evidence of improvements in hospital staffing or in patient outcomes over time.-Dalia Sofer