Advocating for Autonomy Over Nursing Practice
ONL’s Efforts in the Massachusetts Staffing Ratio Ballot Campaign
Never underestimate the power and influence of intelligent, aligned and impassioned nurses on a mission to educate the public about nursing practice and excellence in health care. During the run-up to the Massachusetts November 2018 election, a contentious public debate over a nurse ratio ballot referendum occurred throughout the state. Massachusetts nurse leaders strategically guided critical conversations with stakeholders across the care continuum and in every community about the proposed legislation’s impact on care delivery.
Developing the nursing voice was a critical component in the campaign that ultimately defeated the nurse staffing ratio ballot question by a 40 percent margin with 70 percent voting no and 30 percent voting yes (Ballotpedia, 2018). This article describes the movement within the Massachusetts nursing community during the 2018 election where nurses stood up for their professional practice and autonomy and became politically active—many for the first time.
History
For the past 20 years a nursing union in Massachusetts has proposed legislation to require mandatory nurse staffing ratios in all acute and post-acute care hospitals. During this time, legislators came to appreciate the complexity of this proposed legislation and understood the significant implications to health care access and cost. Despite continuous advocacy from the union, the legislature has not passed a nurse staffing law in Massachusetts. In a continued effort to advance nurse staffing ratios, the union completed the required process to place the issue on the ballot for the 2018 election.
The complex, six-page nurse staff ratio proposal would come down to a yes or no vote by the general public. The ballot question placed a limit on the number of patients a single nurse could be assigned at a time and imposed a $25,000 fine on hospitals that violate those ratios. The exact ratios would vary depending on the hospital department and the type of patients for which the nurse was caring.
While legislators had years to hear stakeholders input and consider the implications of mandatory nurse staffing ratios, the voters would have mere months to learn about nursing practice, nurse staffing norms and hospital throughput. The ballot question ignited an intense debate on both sides of the issue, capturing the full attention of voters across the state.
Initial efforts focused on selecting a public affairs company with experience managing ballot questions campaigns. Together, five organizations were partners co-leading the Coalition to Protect Patient Safety (see Figure 1). We wanted to ensure the essence of nursing and patient care was not compromised over the course of the 18-month campaign.
It was understood from the outset that the nursing voice would be paramount in this campaign, and it was confusing to the public that nurses were on both sides of this issue. The Organization of Nurse Leaders – MA, RI, NH, CT, VT (ONL), along with the American Nurses Association–Massachusetts chapter joined forces to amplify the voice of professional nurses. Nurse leaders in Massachusetts and surrounding New England states leaned in. They were up for the challenge of publicly translating the complexity of health care delivery, implications for health care access and costs, as well as the importance of clinical judgment, collaborative decision-making and interdisciplinary teams in health care. As the most trusted profession, our commitment was to preserve the voice of professional nursing.
Eight additional professional nursing organizations, including AONE, endorsed and actively supported our efforts to defeat mandated nurse staffing ratios in Massachusetts.
Leading a statewide dialogue
We knew we had a steep hill to climb. Focus groups conducted throughout the campaign informed our understanding of the public’s perception. Data revealed voters were confused about this ballot question, had highly favorable opinions about nurses and hospitals, and wanted to support nurses. Voters did not understand why they were being asked to weigh in on such a complex topic and frequently shared that they would seeking out a nurse to help inform their vote. Nurse leaders knew there was much work to be done to help all nurses understand the implications this ballot question could have on nursing practice and patient care across Massachusetts.
To begin the dialogue, ONL brought nurses and nurse leaders together for two focused retreats, with participants discussing what was needed to defeat the ballot question. These nurses were passionate about igniting a dialogue addressing the professionalism of nursing and the importance of the nursing voice when caring for patients.
These retreats sparked robust dialogue about messaging, and how to inspire, educate and engage staff nurses, nurse leaders, and the general public. Our goal was to prepare nurses throughout the state to present important data, describe unintended consequences, and bring light to the far-reaching implications of this ballot question.
Our messages included the negative impact that a rigid, at-all-times nurse ratio legal requirement would have on access to health care services, the decision-making power of nurses and the cost of care—our analysis estimated the requirement would add more than $800 million in health care costs each year. We made the case that complying with the proposed law would require significant investment with no guarantee that patient care would improve. The Massachusetts Health Policy Commission, a public entity charged with overseeing health care costs, agreed with the aforementioned financial analysis in its 2018 report on nurse staffing ratios. Further, the likelihood of community hospital closures and a devastating impact to behavioral health also was widely shared.
The nurses who participated in these retreats became core contributors throughout the campaign. The group was expanded to include CNOs and other leaders, with video conference meetings scheduled almost weekly to ensure an open dialogue with updates from both hospital leaders and the campaign/coalition. The group focused on finding solutions to challenges, answering questions and supporting each other with knowledge, time and shared materials.
Another strategy that emerged quickly as a best practice was to have a nurse leader representative of our coalition visit each hospital to lead a conversation about the ballot question. Materials were developed to illustrate the impact the ballot would have on patients, families, the health care system, and the professional role and voice of nursing. The messages in these presentations mirrored those shared publicly, however the content was more detailed and tailored to the health care leaders in the room. During these presentations, time also was dedicated to exploring how to best encourage open and honest nurse-to-nurse dialogue about the ballot implications. Nurse managers and directors would frequently share the conversations they were having with front-line staff. These presentations at hospitals were extremely useful for helping all levels of nurse leaders gain comfort with these important conversations.
Commitment to communication
Throughout the campaign, there was a need to keep the dialogue focused on the patients, nurses and data. Nurse leaders worked relentlessly to review and revise campaign materials, refine messages and keep them data driven, and develop and edit polling and focus group questions. This was an opportunity to showcase the strengths, talents and passion within the nursing community.
Working with the media was a large aspect of this campaign. Media training was available in one-one-one and group forums. Nurse leaders participated in televised and radio debates, interacted with local media in public forums, and were frequently quoted in print media. Nurses and nurse leaders wrote letters to the editor and were very active in public venues such as town hall meetings. During this campaign nurses, not a union, occupied the public dialogue about patient care, nursing and to a large extent, access to health care services. It was important to our group that this not be seen as a dispute between nurses and hospitals, but rather as an ill-written policy that would have significant and far-reaching negative consequences across the health care continuum.
At every opportunity we would ask nurses to follow and engage with the campaign through social media. This format was successful for two reasons: In addition to bringing information to nurses across the state, visits to social media sites engaged both pro and con perspectives in important discussions that served as a catalyst to bring more nurses into the campaign. It was one of the strategies that helped us build an informed and engaged community of nurses and contributed to our success in messaging the general public.
The spirit of servant leadership and nursing activism shone throughout the campaign. We worked with chief nurses, ONL members and nurses across the state who dedicated days and weeks of their time to meet with leaders throughout their organizations and health care systems, as well as with chambers of commerce and local community groups. We had nurses volunteer to canvas neighborhoods, work phone banks and participate in conversations through social media. The engagement was energizing and inspiring. For the first time we had nurses who were employed at different hospitals, or members of different professional organizations working passionately toward a goal—to defeat the nurse staffing ballot question.
Achieving success on Election Day was an important step in preserving access to affordable health care and nursing autonomy; however, much work remains. Nurses in Massachusetts were divided on this issue throughout the campaign, and now work moves to rebuilding a united nursing community. In the coming months we will engage with nurses throughout the state to develop a strategic approach to address nursing staffing, nurse workload and the professional practice environment in our relentless quest to advance health and lead practice.
Future considerations
The Massachusetts nursing community became politically active and engaged in defending professional practice and access to health care during the 2018 election. Prioritizing policy participation should be a goal for leaders, and all members of our profession. It is important for nurses to support policies that preserve clinical assessment and professional judgment, and all nurses should work diligently to retain and advance control over our practice.
Our experience would suggest that a public vote is not the ideal place to consider a complex policy proposal like the Massachusetts nurse staffing ballot question. Much is lost when legislating by ballot—with only the choice of voting yes or voting no, opportunities for stakeholder input and negotiation are lost. The impact of this policy proposal was in the details, and throughout the campaign members of the general public needed more information to understand the work and professional scope of nurses and nurse leaders. More than once we corrected a wrong assumption, noting that neither physicians nor hospital administrators oversee nurse staffing. Leaders should actively seek opportunities to discuss and elevate professional nursing practice in the public domain. Helping the public understand the work of nurses and nurse leaders is something every nurse should commit to—with pride.
References
Ballotpedia. (2018). Massachusetts, question 1, nurse-patient assignment limits initiative. Retrieved from https://ballotpedia.org/Massachusetts_Question_1,_Nurse-Patient_Assignment_Limits_Initiative_(2018)
Massachusetts Health Policy Commission. (2018, October 15). Mandated nurse-to-patient staffing ratios in Massachusetts. Retrieved from https://www.mass.gov/files/documents/2018/10/16/NSR%20Cost%20Impact%20Analysis_final%202.pdf
About the Authors
Amanda Stefancyk Oberlies, PhD, MBA, RN, CENP
Chief executive officer at the Organization of Nurse Leaders – MA, RI, NH, CT, VT in Woburn, Mass.
Therese Hudson-Jinks, MSN, RN
Chief nursing officer and senior vice president of patient care services, Tufts Medical Center in Boston.
Ashley Waddell, PhD(c), RN
Director of government affairs and educational programs, Organization of Nurse Leaders – MA, RI, NH, CT, VT in Woburn, Mass.