As emergency department physicians, we respect and admire our nurse colleagues. There is perhaps no other field in medicine where doctors and nurses work so closely together. We want nothing but the best for our nurses who are our friends, teammates and co-workers.
It is precisely because we value our strong working relationship with emergency nurses that we, as emergency physicians, are so concerned about the ballot initiative this fall to mandate government-set nurse-to-patient ratios. It may sound good on the surface, but in reality it is a disaster-in-waiting for Massachusetts, especially for emergency departments.
At Southcoast Health's emergency departments at St. Luke's, Charlton Memorial and Tobey hospitals, we care for about 200,000 patients every year. Some are healthy people with minor issues – a sore throat, a sprained ankle. Others are critically ill or injured people who for the first few hours of care may require the undivided time and attention of several highly trained medical professionals.
The physicians direct the medical care of the individual patients. But it is nursing leadership that actually runs the department itself – that coordinates with EMS about where to put arriving ambulance patients, that choreographs getting patients to and from radiology, or to the OR, to a floor bed or to the ICU. Nursing leadership does this by overseeing teams of nurses, ED and radiology techs, lab phlebotomists, patient transporters and so on. Nursing leadership has the bird's eye view of the entire department, and no one knows better how to allocate staffing resources for the safest and best patient care.
The system works. Massachusetts hospitals were rated 4th in the nation this year by the Leapfrog Group, a non-profit devoted to patient safety. California, the only state in the union to mandate patient-to-nurse ratios, was ranked a mediocre 25th.
Question One on the November ballot to mandate a government-set nursing-patient ratio invites us to discard what already works, and instead adopt the California model – in fact, a far more extreme version of that model, because of the aggressive proposed timeline. What would happen in the emergency departments?
First, it's highly likely the cost of hiring many additional nurses would force hospitals to start letting go of non-nursing support staff. The proposed law would supposedly forbid this, but the reality is that would be impossible to enforce. We value and rely on the nurses we work with, but we also value our techs, transporters and other emergency department colleagues.
If nurses will be seeing patients with fewer (or no) support staff that means nurses will no longer be working at the "top of their license" medically. They might have fewer patients -- but they would also have to take over every aspect of care associated with those patients, including tasks like lifting, transporting, cleaning and toileting, that are now shared with other staff.
Second, it's highly likely that patients will be rushed in and out of the hospital more aggressively. It sounds great to hear, "My mother's nurse only has three other patients by law," until you realize that your mother has already been discharged home, far earlier than expected, to make room for the next patient.
Third, emergency department waiting room times will soar. Our emergency nurses are experts at the management task of getting tens of thousands of patients a year efficiently and safely seen, treated and either discharged or admitted. That has included letting some nurses care for several low-acuity patients simultaneously, while others focus on just a few that are potentially more ill. Once the government states that every nurse can only see four patients, this well-oiled machine grinds to a halt.
That's one reason the largest nursing organization in the state, the American Nurses Association, opposes this ballot idea – which has been put forward by one nursing union and aggressively marketed.
What happens when more patients come to the emergency department than we have nurses for?
Are we supposed to leave patients in ambulances, parked in a line out the door, until we can free up a nurse? Does crushing chest pain just have to take a seat in the waiting room?
We believe hospitals can do more to improve working conditions and job satisfaction for nurses. No one knows better than we do how hard our nursing colleagues work, sometimes under emotionally stressful conditions, as they keep the emergency departments open on nights, weekends and holidays.
But Question One is not a solution. As emergency department physicians, we doubt this will improve working conditions or job satisfaction for nurses. Instead, we worry this will cost jobs of ancillary staff, burden nurses with more low-skilled work, block patients in waiting rooms, rush patients out of the hospitals early, and break systems across the state that are already known for high-quality patient safety and care. We will vote no on Question One.
Jennifer Pope, MD, is chair of the St. Luke's Emergency Department. Brian Tsang, MD, is chair of the Charlton and Tobey Emergency Department. Matt Bivens, MD, is EMS Medical Director for Southcoast Hospitals.