We are not taking accountability as nurses, if we do not keep our promise and fidelity to our patient if we vote yes to lessen our burden, but in turn worsen theirs. We must put our patients first, like we have always done. The answer is NO ON QUESTION ONE.


Many. many of my friends, patients and families have been asking me about my thoughts on question 1, and the answer to this question is just simply not simple.

For question 1 it is most definitely a complicated decision and I was conflicted for a long time too. On immediate reading of the question everyone is like HELL YA I LOVE NURSES and it seems like an obvious “yes”, because who would say “no” to what seems to be like improved patient care, improved safety and better work conditions for nurses. However, there are several unintended consequences of this bill that will in turn negatively impact patient outcomes.

Before discussing question one further, I think it is important to recognize that both sides are advocates for patient safety and quality nursing care. However, question 1 is NOT the way to achieve this goal.

This bill would lessen nursing “load” but it would have severely negative unintended consequences for patients, especially in the community setting and in the Emergency Department.

Many people are thinking voting “yes” will mean the hospitals will just hire more nurses, in turn staff units appropriately and viola, problem solved.

Okay, so lets say they do that- let’s say the hospitals (that do have the financial means) hire more nurses to fill the need, that sounds great! However, this bill only gives 30 something days for a new nurse to be trained in a new unit. There is 0 feasible way that a new nurse will be a safe independent practitioner in a new unit in that short amount of time. Period. Typical new nurse orientation lasts 3-6 months, and that often feels too short.

Hiring new nurses however- is only truly an option for the big hospitals, it will not be that easy at community hospitals and clinics. Community hospitals will lose many of their valuable nurses to the “big” hospitals if this bill goes through. It will be nearly impossible for these community facilities to compete with big hospitals when it comes to nursing recruiting and retention. Oh and PS. there already is a nursing shortage in Massachusetts.

Aside from that- many community hospitals also will not have the means to fund the cost of hiring new nurses to meet the mandate, even if the nurses were available. What will this mean?

Community hospitals will not have enough staff/funding to stay afloat —> community hospitals will have to shut down —> our community will have less access to health care —> our vulnerable populations will suffer and not get the medical care and help they deserve.

The same will be true for detox centers, nursing homes, home health agencies, psych facilities etc.

How as nurses can we possibly vote for this law that makes access to health care in the community worse? We know, as indicated by Healthy People 2020, that lack of accessibility in the community is one of the greatest determinants of health.

By voting yes, we are disproportionately negatively impacting our vulnerable populations, making access to community health more difficult and in turn causing our patients to have unmet health needs including “delays in receiving appropriate care, inability to get preventive services and hospitalizations that could have been prevented.” (“Determinants of Health”).

As our nation battles with opioid crisis, mental health crisis and an influx in elderly patients needing care, we need to VOTE NO ON QUESTION ONE to protect our detox center, psychiatric facilities, nursing homes and community clinics.

From my experience both as an ED nurse and a nurse on a mobile health HIV clinic in our high risk communities- we already struggle greatly with limited resources for our patients needing detox, mental health care, or both. Patients often have to be put on a waiting list for MONTHS before they are able to access care. These months are critical to patient’s outcomes and success in stabilization programs. We cannot afford to make this existent problem even worse.

Now lets talk about the Emergency Departments-

What’s challenging about this bill is it takes a lot of the decision making about patient care away from nurses, especially in the ED (where I work). The proposed solution is to rank the acuity of the patients and then determine how many patients the nurse should be assigned relative to the patient’s ranked acuity. In turn, this ranking system makes the nurses and the patients just a number.

At any moment in the ER a mother could walk in with her baby actively seizing in her arms who is cyanotic (blue) and needs immediate attention. If that happens, or an adult arrives into an ED having an heart attack, what are we going to say? Sorry our nurses are at capacity, you have to wait?

Being at capacity or having mandated ratios does not change the fact that an actively dying child could come in off the street at literally any second in an ER.

This law will force nurses to either potentially…

1) Break the law and take care of the child in front of you (because that is the RIGHT thing to do if you are able)


2) Make the child wait until an nurse is “able” to take the patient (because she discharged another one- which is not always a fast process).

Question one will result in longer wait times in the Emergency Department and result in patient’s getting sicker and sicker in the waiting rooms.

Question one will also result in patients having to wait longer for admissions to the floor, resulting in them staying in the Emergency Department for even longer (causing more of a back up in the waiting room) because it will be MUCH harder to find a place to discharge patients to. (It all circles back to community health).

Many patients who get discharged from the hospital don’t get discharged right back to their home. Many patients require long term care facilities, rehabs, or visiting nursing to keep them stable and help them transition back to home- to the community. Voting yes on question one will make all of these resources (long term care, rehabs, visiting nursing) harder to come by. So what will we do with our child who has a new trach? Where will our new transplant patients go? Where will our burn patients go? Voting yes on question one will make it HARDER for nursing to find safe discharge plans for patients. Community resources will be drained and patients will have to stay in the hospital for longer as there will not be enough sustainable community care to help transition patients back to their home.

To summarize

Yes on question one means…

We will drain the community resources —> NO safe discharge plans for patients —> NO open beds in the hospital —> patients waiting longer in the ED for admissions —> NO beds in the Emergency Department open—> longer wait time in the Emergency Department —> patients who need immediate help will have to wait in the waiting room —> patients will get sicker and sicker while waiting for a nurse to have an “available spot” in her ratio.

Government has NO idea of patient care and what our basic nursing code of ethics (justice, beneficence, non-maleficence, accountability, fidelity, autonomy, veracity) and obligations in our profession truly look and feel like. I agree we need to improve patient care, but this is NOT the way to do it.

Question one does not provide justice for our community and our vulnerable populations.We cannot be beneficent when we are forced to break the law to care for a critically in need patient. We cannot fulfill our obligation of non-maleficence if we consciously decide to worsen the determinants of health for our community, making access to health care and life saving measures even more challenging. We are not taking accountability as nurses, if we do not keep our promise and fidelity to our patient if we vote yes to lessen our burden, but in turn worsen theirs. We must put our patients first, like we have always done.

The answer is NO ON QUESTION ONE.

The Principles of Ethical Nursing Practice;

Justice; be fair

Beneficence; do good/do the right thing for the patient

Nonnmaleficence; do no harm, whether it be intentional or unintentional (as stated in the hippocratic oath)

Accountability; accept responsibility

Fidelity; be true and keep professional promises

Autonomy; accept patients unique beliefs and wishes, allow patients to make their own decisions.

Veracity; be truthful with patients

(Silva, Mary., Ludwick, Ruth)



“Determinants of Health.” Determinants of Health | Healthy People 2020, Office of Disease Prevention and Health Promotion,

Silva, Mary., Ludwick, Ruth. “Ethics: Interstate Nursing Practice and Regulation: Ethical Issues for the 21st Century.” The Online Journal of Issues in Nursing, Vol 4, Issue 2.

LifestyleMairead Day