A debate over Massachusetts Ballot Question 1, which would set limits on the number of patients that can be assigned to each nurse in Massachusetts hospitals, inflamed passions on Thursday, Oct. 18, at the League of Women Voters candidates debate. The debate, which occurred immediately after the Select Board candidates’ debate, was waged by two experienced nurses, before opening up to questions from the public. Approximately 60 people attended the meeting; mostly Harvard residents with some Emerson Hospital staff mixed in.
Question 1 would limit nurses to caring for a specific number of patients, with the exact ratio being dependent on the type of care being provided. The most severe cases would require a 1:1 nurse-patient ratio, while the simplest would require 1:5. Each violation of these limits would leave the hospital open to a $25,000 fine. Question 1 was proposed by, and is currently being championed by, the Massachusetts Nursing Association (MNA).
Mary Marengo of St. Vincent’s Hospital argued in favor of the measure, while Brenda McCurdy of Emerson Hospital argued against it. The key argument in favor of the measure, according to Marengo, is that the ratio of nurses to patients is correlated with better health outcomes for patients, according to independent studies by both the American Nursing Association and the American Hospital Association. While McCurdy did not challenge that underlying correlation, she argued that Question 1’s net effect would be an overall reduction in patient safety due to unintended consequences.
McCurdy contended that Massachusetts hospitals are already among the best in the nation and that their largest issues stem from the cost, rather than the quality, of the care they provide. Comparing Massachusetts to California, the only state where a proposal similar to Question 1 has been enacted, Leapfrog (an independent health care watchdog group) rates Massachusetts hospitals as the best in the country, while it rates California’s as middle-of-the-pack. Marengo countered with MNA data suggesting that California outperforms Massachusetts in areas where nursing is key—namely complications and patient readmissions.
McCurdy argued that implementing Question 1’s reforms would cost Massachusetts hospitals $1.3 billion, and that these costs, when not passed directly on to the patients, would reduce the quality of other aspects of hospital service. According to Marengo, MNA data shows that hospitals are overestimating this cost, and that the real number is closer to $47 million.
Marengo asserted that a provision in Question 1 forbidding hospitals to lay off other staff in response to the financial pressures it creates would protect patients from the consequences of hospitals dropping non-nursing staff to cut costs after its passage. McCurdy countered by explaining that hospitals have already indicated that, if the law passes, they will lay off these workers before the law takes effect Jan.1, dodging the legal restriction. Furthermore, these layoffs would be based on estimates about future impact, meaning that they may overshoot, causing greater injury to patient health than if the anti-layoff provision did not exist.
A question of flexibility
McCurdy criticized Question 1’s inflexibility, noting that it would end hospitals’ current practice of reducing nursing staff during low-activity hours (such as the middle of the night), reducing cost efficiency for little tangible benefit. She contended that it would also squeeze hospitals during unexpected surges of new patients, forcing hospitals to delay any treatment until enough nurses could be made available. She said that this phenomenon, where incoming emergency patients are sometimes forced to wait for indefinite periods on “The Wall” is a common issue in California hospitals. Marengo countered by noting a provision in Question 1 that allows hospitals to ignore patient limits during national or state health emergencies. However, according to McCurdy, this provision would be of limited help, as such emergencies are uncommon whereas random surges of emergency-care patients can happen at any time.
Tempers flare
According to Marengo, 86 percent of Massachusetts nurses support Question 1. McCurdy questioned the validity of this figure, stating that it was based on a biased survey conducted by the MNA itself.
Tempers flared at one point in the debate. Marengo pointedly accused nurses opposing Question 1 in TV ads of “renting their scrubs,” implying that any genuine nurse would support the proposal. On the other hand, McCurdy accused the MNA of using “bullying tactics” to suppress the voices of nurses who opposed the measure.
After the debate between the two presenters ended, the public was given the opportunity to ask questions. Most members of the public appeared to have a firm stance on the issue, with some asking questions emphasizing the strength of a particular argument. Others used the time to offer heartfelt narratives around a particular experience that informed their view of the situation. The lengthy questions meant that only a few people had time to ask theirs before the debate ended. The audience seemed split, with significant numbers supporting each side of the debate.
