While waiting in line at the supermarket, the woman behind me noticed the logo on my jacket that identified me as a nurse.  She immediately asked how to vote on Question #1. She went on to say that while wanting to support nurses, she was unclear which ballot choice achieved this objective.  Others quickly turned to hear my answer. Knowing that professional nursing is highly regarded for its honesty by the American public, I answered carefully.

From the unique vantage points of being a nursing professor and a hospital-based nurse scientist, my conclusion is that whether the deciding vote on Question #1 is NO or YES, the result will not be a ‘win’ for nursing.  And by extension, for patients either.  The unintended consequences of this legislation are complex and far-reaching.

Judith A. Vessey

Judith A. Vessey

If the NO vote wins, the status quo persists. Nursing care will be provided, but at what quantity or quality?  Patients may be not be blocked at the door, but they may be found looking for care from their beds. Patient complexity continues to outpace increases in staff nursing positions. Today’s nurses are stressed, often worried about what they may have missed at shift’s end. Turnover rates are on the rise, now approaching 17%, and the highest among licensed healthcare personnel. Increased unionization is possible. It is useful to remember that failing to address long-standing staffing issues is what led to Question #1.

If the YES vote wins on Question #1, the immediate need for additional nurses will not be matched by an expansion of nursing’s educational pipeline, which is already struggling with a faculty shortage. Current nursing student education will also be jeopardized. Healthcare facilities are already informing nursing schools that student clinical placements cannot be ensured should Question #1 pass. Institutional budget reallocations and personnel shifts will result in more nurses at the bedside. However, a reduction in advanced nursing positions will diminish 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 problem with Question #1 is that regardless of the result, nursing’s authority in determining how best to meet patient care needs will still be constrained. Historically, the reasons underlying the allocation of nursing care are complex and tied to reimbursement, education, licensing, and gender issues. But in short, a ‘No’ vote today reinforces healthcare administrators' control of nurse staffing. A ‘Yes’ vote puts nurse staffing in the hands of legislators.  And none of these individuals are at the bedside delivering care.

If there is an upside to Question #1, it is that it serves as a clarion call for change. The public has the right to demand high quality nursing care from well-educated nurses. But the public’s voice needs to be heard beyond the ballot box.  Virtually all of us will be a patient at some point.  So today, we must recognize the role professional nursing plays in helping ensure good clinical outcomes. Demand that your hospital 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 your hospital’s or insurance company’s boards, as these board decisions will directly affect your care. Question why nurses are still restricted from working to the full scope of their license in many Massachusetts hospitals. And help create opportunities that support collegiate nursing education and professional advancement opportunities in clinical practice settings.

So, in response to the woman behind me in line—thank you so much for asking and listening, there are no easy answers. Go vote your conscience, but also think about what steps you might take to influence the future direction of patient care.  Our collective voice is needed.  

Judith A. Vessey, Ph.D., MBA, RN, FAAN
Lelia Holden Carroll Professor of Nursing