Tuesday, 13 November 2018


On November 6, voters in the state of Massachusetts were presented with a binding referendum question that would have had major ramifications for the profession of nursing in Massachusetts and possibly throughout the United States.
A Yes Vote on ballot Question #1 would have established mandatory nurse staffing ratios in hospitals throughout Massachusetts. A No vote would have maintained the status quo. While Massachusetts voters voted overwhelmingly against Question #1, the ballot question itself was a no-win for nursing and, by extension, the patients for whom nurses care.
The problem with Question #1 was that regardless of the result, nursing’s authority in determining how best to meet patient care needs was destined to remain limited. The No vote reinforced healthcare administrators' control of nurse staffing, while a Yes vote would have put nurse staffing in the hands of state legislators. The bottom line is that none of these parties is at the bedside delivering care to patients. Nurses are. And yet their voices often remain unheard in discussions of what constitutes appropriate staffing levels in hospitals throughout Massachusetts and the nation as whole.
As a professor of nursing and a hospital-based nurse scientist, I know that today’s nurses are stressed, often worried about what they may have missed at shift’s end. Turnover rates among nurses are on the rise, now approaching 17%, and the highest among licensed healthcare personnel. Patient complexity continues to outpace increases in staff nursing positions. The failure to address long-standing staffing issues is what led to Question #1 in the first place. It is an issue that presents itself in hospitals nationwide.
Another issue raised by the referendum: If Question #1 had passed, the immediate need for additional nurses would not have been matched by an expansion of nursing’s educational pipeline, which is already struggling with a faculty shortage. Current nursing student education also would have been jeopardized. Prior to the November 6 election in Massachusetts, healthcare facilities began informing nursing schools that student clinical placements could not be ensured should Question #1 pass. Institutional budget reallocations and personnel shifts would have resulted in more nurses at the bedside. However, a reduction in advanced nursing positions would have diminished nursing’s capacity for educating staff nurses about the newest technologies, addressing system-wide patient safety issues, improving care coordination between hospital and home, or advancing other strategic initiatives designed to improve the patient experience. Meeting mandated staffing needs by hiring travel nurses or recruiting internationally come with their own societal costs.
The upside to the debate about Question #1 is that it has served as a clarion call for change. Professional nurses play a vital role in helping to ensure good patient outcomes. The public has the right to demand high quality nursing care from well-educated nurses who have a say in best-practices.
Since virtually all of us will be a patient at some point, what can we do in an effort to achieve the best possible patient care? 
Unlike the Question # 1 referendum, solutions are less complicated:
  • Demand that hospitals be transparent about their nursing staffing policies, nursing staff mix, and turnover rates.
  • Inquire how hospitals determine new budgeted positions for professional nursing compared to those for non-clinical services.
  • Ascertain how many nurses sit on hospital or insurance company boards, as these board decisions will directly affect patient care.
  • Question why nurses are still restricted from working to the full scope of their license in many hospitals in and outside of Massachusetts.
  • Help create opportunities that support collegiate nursing education and professional advancement opportunities in clinical practice settings.
Our collective voice is needed to influence the future direction of patient care for the better. Too much is at stake to ignore the problem any longer. The question Massachusetts voters faced on November 6 is one that could easily find its way into other states that offer binding referenda questions, once again putting the decision making in the hands of either hospital executives or state government, as opposed to listening to the experts—hospital nurses themselves—who know what is best for the health and well-being of their patients.

Judith A. Vessey, Ph.D., MBA, RN, FAAN

Lelia Holden Carroll Professor of Nursing, Boston College

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