Nurses, hospitals divided over ballot question 1

  • Nurse Miko Nakagawa, left, last month was granted permission from the Athol Selectbaord to place political signs stating “Nurses Say Yes On 1” on the Uptown Common in Athol. Left to right — Nakagawa, Attorney John B. Barrett, and Selectmen William Caldwell, Rebecca Bialecki, Chairman Stephen Raymond, Lee Chauvette, and Holly Young. ATHOL DAILY NEWS/Deborrah Porter

  • Motorists pass the Vote No billboard on Main Street in uptown Athol. —Athol Daily News/Deborrah Porter

  • Above, vote “yes” lawn signs are seen on the Uptown Common in Athol, placed there by the Massachusetts Nurses Association. Below, motorists pass the vote “no” billboard on Main Street in uptown Athol. Athol Daily News/Deborrah Porter

For the Athol Daily News
Published: 10/23/2018 12:48:57 AM
Modified: 10/23/2018 12:49:01 AM

ATHOL — Some union nurses disagree with Athol Hospital’s campaign urging voters not to pass Question 1, a ballot initiative that would implement uniform nurse to patient staffing ratios in all hospitals across the state.

“The bottom line for Question 1 is we need more nurses at the bedside,” said Raenette Kramer, an Athol resident, longtime nurse and member of the Massachusetts Nurses Association.

After years of pushing the legislature to adopt the nurse to patient ratios, the Massachusetts Nurses Association, a union representing about 20 percent of nurses in the state, took the issue to the ballot for the first time this year. The “Nurse-Patient Assignment Limits Initiative” seeks to improve patient safety by ensuring nursing departments are not understaffed, and provide a statewide standard of care.

“Because it is a very rigid mandate, it will increase hospital cost tremendously which will have a trickle down effect into other things in the community,” said Tina Griffin, VP of Patient Care Services and COO for Athol Hospital. “Someone has to pay for that.”

The ballot question imposes different staffing ratios for patients at various levels of need. In emergency rooms, for example, a nurse could be assigned to no more than five patients in stable non-urgent condition, or two patients in urgent non-stable condition. The initiative would also require hospitals to redevelop their own “acuity tools” to determine when patients are stable enough for the attending nurse to take on another patient.

To comply with the ballot question, both sides admit the law would increase hospital expenses by requiring them to hire more nurses. Athol Hospital currently employs 46 nurses working full-time, part-time and per diem, with a maximum inpatient capacity of 18 beds.

Opponents of the ballot question suggest that smaller institutions would struggle financially to meet the ratios, especially with a tight deadline for compliance of Jan. 1. Administrators estimate it would cost Athol Hospital $1.97 million annually to implement changes required by the law, and cost Heywood Hospital $5.66 million annually.

“We just don’t have that kind of money sitting in the bank,” Griffin said. “I don’t have nurses waiting in line to work for a smaller hospital.”

Vice president of Development for Heywood Healthcare Dawn Casavant said that to pay for the additional staff, cuts to the would likely have to come from the hospitals’ mental health and substance abuse services.

“We lose money on that service, and we do it because it’s the right thing to do,” Casavant said.

Per the ballot question, a hospital cannot layoff any staff from other departments to meet the required ratio. Failure to comply could result in fines up to $25,000 per incident.

Union Nurses' Support

At a Select Board meeting last month, Athol resident and nurse Miko Nakagawa was granted permission to place pro-Question 1 signs on the town common. She is a member of the Nurses Association, and works out of town.

“To me, healthcare is healthcare,” Nakagawa said. “They’re making this into a business.”

The state Health Policy Commission estimates that passing the ballot question could lead to an additional $676 million to $949 million a year in healthcare costs. However, a study by the Journal of the American Medical Association found that for each nurse assigned to more than four patients, each patient’s chance of death increases 7 percent for each additional case a nurse takes on.

Other studies have shown that hospitals with more favorable nurse to patient ratios have lower rates of infections acquired at the facility and fewer re-admissions within 30 days, two metrics where Massachusetts is already performing poorly.

The ballot question has sparked campaigns on either side, both in the name of patient safety. Hospitals have been reaching out to voters through senior centers, businesses, billboards and lawn signs, urging them to vote “No” on Question 1. They say the law would restrict nurses from providing care as needed, and drain resources from elsewhere in the hospital.

“If I thought this was going to close Athol Hospital, I would not be in favor of it,” Nakagawa said. “They’re a great hospital, they’re not going to close.”

Athol Hospital is one of the state’s three “critical access” hospitals, a federal designation for rural hospitals that comes with certain Medicare and Medicaid reimbursements. The hospital aims to assign each nurse no more than four patients at a time for medical-surgical care, and five patients in rehabilitation.

In meetings with their staff, Griffin and Casavant say nurses are divided over the issue, with some afraid to voice their opposition and others confused as to how the ballot question would impact their workplace.  

“They’re not comfortable speaking up because because it’s a very tenuous environment,” Casavant said.

Kramer’s support for Question 1 comes not only from her decades of experience as a nurse, but also her personal experience in the emergency room. When her mother had a stroke on a busy night for Athol Hospital’s emergency room, she was shocked to learn only two nurses were on staff.

“There was no wiggle room at all,” Kramer said.

Throughout her career in the intensive care unit, Kramer remembers attending to seriously ill patients that kept her from performing other duties, like comforting family members of a dying patient under hospice care. This improved after September 2014, she said, when Massachusetts implemented the ICU Safe Patient Limits Law, setting the maximum number of patients nurses can attend to in the ICU. She would like to see a similar law implemented across all hospital departments.

“If a patient’s acuity is requiring one-on-one attention, I am able to single that patient out,” Kramer said. “They plan staffing for that patient.”

Nakagawa has heard of nurses being responsible for up to 13 patients at a time, and says short staffing problems are widespread. Fortunately, she works in a hospital that mandates its own nurse-to-patient staffing ratios, which is why she supports the statewide ballot initiative.

“Our wait time since we started having ratios has gone down, and we have almost no patients left without care,” Nakagawa said.

Casavant and Griffin admit there are short staffing issues in many hospitals, but say those are best dealt with on a case-by-case basis between nurses’ unions and the administration rather than the ballot’s “one size fits all” approach.

“You really do take the decision making out of the hands of your nurse,” Casavant said. “They don’t want to be stuck in that position.”

Another Athol resident, longtime nurse, and member of the Nurses Association Deborah McDevitt, said she left the profession because of unsafe patient limits.

“The unsafe staffing problem has been going on for a long time and just getting worse and worse,” McDevitt said. “I care about the kind of nursing care I give, and I can’t do it anymore and that’s why I quit.”

When nurses are stretched thin, it increases the likelihood of making mistakes, and leaves no time for less pressing forms of care like educating patients about post-discharge care. The majority of nurses she knows are in support of Question 1, but many are afraid to speak up for fear of losing their jobs.

Heywood Hospital acquired Athol Hospital in 2013 and is currently building a new building that will increase emergency room capacity and other services. Heywood Hospital’s nurses are part of the Nurses Association union, while no organized union exists in Athol.

“We expect to work really hard, but we expect to work safe,” McDevitt said.

Sarah Robertson can be reached at

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