Making Hospitals Safer
Nursing-Patient Ratios and Whistle Blower Protections Likely Headed to House Floor Within Days
MOUNT DESERT ISLAND AND AUGUSTA—Nurse Nancy Graham knows what it’s like to be at a hospital scrambling to take care of patients because of poor nurses-to-patients ratios, and it’s not something she wants to experience again or have her patients experience either.
If the Maine House joins the Maine Senate in passing LD 1639, the Quality Care Act, those ratios might be changed. The bill was co-sponsored by Labor and Housing Committee House Chair Amy Roeder (D-Bangor) and may go to the House floor tomorrow, April 11, but that situation is fluid, Roeder said.
In late March, the Maine Senate passed the bill (22-13). The bill’s goal is to fix unsafe hospital staffing levels and it puts minimum staffing requirements into place. Those requirements are meant to be focused on patient needs. It’s supported by the Maine State Nurses Association (MSNA), a nursing union.
The bill and its staffing ratios has been an effort that hits home for Roeder, who still talks to the nurse that took care of her father when he was at the hospital. Each year, Roeder or the nurse, reach out to each other on the anniversary of his death. When nurses have time to take care of their patients, particularly their palliative patients, a connection forms. They don’t, however, always get that time. That nurse no longer works for a hospital system. She quit.
“Unsafe staffing issues are one of the reasons she left the hospital to be a school nurse,” Roeder said.
“What the Quality Care Act does is it gives nurses the backing that they need. Right now, there is no law that limits the amount of patients that a nurse can take care of or attempt to take care of,” Graham said. “And the Quality Care Act will actually be able to hit a minimum to a maximum of the amount of patients that a nurse can take depending on what department they're in.”
Graham knows firsthand what it’s like to deal with understaffing in an ER from her time before she worked at MDI Hospital and can call on her experiences working in an ER at another Hancock County facility to know just how much difference staffing levels make to both patients and nurses.
“My previous experience with the amount of patients, the facility that I worked at before I came to MDI, it would not be unheard of for myself as an RN overnight to have 10 to 10-plus patients,” Graham said.
She and the other nurse on duty would divide the ER patients’ care in half.
“If any traumas came in, we'd have to come together to focus on the trauma, which would leave all those other patients unwatched,” she said. “So, it led to a lot of stress, a lot of moral distress, in the sense that you could never do what you wanted to, you couldn't accomplish everything that you needed to accomplish.”
Graham felt like she was letting her patients down sometimes. That’s not the way she wanted to feel or to work or to heal and comfort.
That changed when she went to MDI, she said. “Now the most patients I have is one to three. And if there's a trauma, we are one-to-one, and they make sure of that. They are a great example of how safe staffing ratios, how they save lives.”
The administration’s support for those ratios is even more than that, she said. “It allows you to be the nurse that you wanted to be. That's the career that you wanted. It was to nurse, not to task.”
Roeder said that one of the stories she heard during testimony about the bill particularly resonates for her. “Everyone has their own story that is pulling them toward this,” she said.
For her, it’s the story of a palliative care nurse who had a patient that was in pain. They were understaffed. She told the patient that she’d be back soon to give him his pain medication, but she had to finish her rounds first, as was the procedure.
But when she finished her rounds, he had died.
“He had died in pain because she had such an overwhelming case load,” Roader said.
The bill also includes whistle blower protections for nurses dealing with assignments that they believe are unsafe, and it is meant to support nurses’ abilities to advocate for patients.
The bill was introduced by Sen. Stacy Brenner (D-Scarborough). Brenner is a midwife and nurse.
On the floor, in March, Brenner said, “Colleagues, I tell you with humility, that being in the legislature feels like a relaxing hobby in comparison to working as a bedside nurse. The fear of near misses and possibly devastating errors from working over capacity builds a sense of moral injury, one shift at a time.”
The bill has nurse-to-patient ratios that correlate with patient acuity. Roeder said that hospitals admit that staffing ratios is a problem but are offering no solutions. “It sounds right now that it’s a race to the bottom.”
One nurse she met said that when a nurse is feeling overwhelmed, they can call for a code lavender. The nurse will receive something to color and an energy bar. Roeder equated that to putting lipstick on a pig.
“That was upsetting,” she said.
A study in 2021 determined that for every additional patient a nurse takes care of during their shift, there is a 12 percent greater chance of in-hospital mortality, and 7 percent increase that the patient might die within 60 days, and a 7 percent greater chance that they will be readmitted in 60 days.
If the bill becomes law, health care facilities would have to comply with staffing requirements for direct-care registered nurses beginning July 1, 2025. There are different staffing requirements for hospitals that are critical access in July 2025, and those change a year later. Critical access hospitals could also ask for more flexibility with some requirements.
Barbara Baker, of Bradley, testified to the Maine Legislature that she and her husband had stayed at both Northern Light and Saint Joseph’s in the past year.
“It was quite noticeable when nurses were understaffed, which caused a lot of stress on the patient and family member who feels helpless and angry when that occurs. It is also just as obvious when competent, knowledgeable, and efficient nurses provide expert care,” she told legislators.
NURSES AND RATIOS AND TIME
Outside of Maine, nurse and author, Deanne Dietz’s book, Why the Hell Did I Join the Medical Field, focuses on burn-out for health-care workers and her own experiences in multiple hospitals in the private, public, and government sectors.
She wrote, “Depending on the unit, state, and hospital requirements, nurses may have four to seven patients in a post-intensive care unit, telemetry, or medical/surgical unit. Within a skilled nursing facility, a nurse may have more than twenty to thirty patients. The patients are sicker; the acuity is higher. Patient staffing ratios are detrimental and unsafe at this time. In order to complete all of our tasks, medication passes, and assessments, we don’t have enough time in a twelve-hour shift.“
The book delves into this need in depth. Supporters of the bill testified about how short staffing hurts medical providers and patients.
“Along with implementing the safe staffing ratios, which would be based on the unit, what it (the bill) would do is based on the acuity of the patients, the professional direction or judgment of that nurse,” Graham said.
The bill also prevents whistleblowers from being retaliated against, she said, a retaliation that often is implied after events.
“But honestly, the Quality Care Act, if you read through it, it's really a no-brainer. These things should be in place already,” Graham said. “MDI is proof positive that you have better outcomes and what patient or family wouldn't greatly appreciate to have the nurse that's able to come in and answer all their questions and let them know what's going on with your care.”
It might be a simple question like how long for a CT scan, a question that understaffed nurses don’t have time to answer. It could be a seemingly simple act, such as turning a patient over on time, an act that nurses often might not be able to do in a timely manner when they have many patients.
“You're literally running from room to room to room to room to room and I was almost in shock when I went to MDI and really saw how much support you have there,” Graham said.
Small rural hospitals can be quirky sometimes, she said. “But it's, you know, it's a real, true community hospital and they're so rare, and it's just proof-positive that this works and it's ultimately a good thing for nurses; it's a great thing for patients; it's a great thing for their families. There's nothing negative with it at all.”
A press release from the Maine State Nurses Association (MSNA), which is a union for direct-care nurses that represents 4,000 nurses and caregivers states of the bill:
“LD 1639 does the following to help secure safe staffing ratios in Maine:
“Establishes mandated minimum RN staffing ratios that require additional staffing based on individual patient care needs.
“Safeguards nurses’ right to advocate in exclusive interests of the patients under their care.
“Protects nurse whistleblowers who speak out about assignments that are unsafe for the patient or nurse.
“Requires hospitals to post notices on minimum ratios and maintain records on staffing.
“Authorizes the Maine Department of Health and Human Services to enforce RN-to-patient limits.”
All those elements are why Graham supports it, she said and also because she believes the law is about creating patient and nurse relationships that matter.
“It breaks my heart that there are patients that will get discharged from an ER and you don't even know what happened to them or what the results were or where they went, and that they're just lost and you're in a facility that really just doesn't care,” she said. “They just want to fill the bed. Next body, next body, next body.”
Roeder said that’s exactly the opposite of what people go into nursing for.
“It’s heartbreaking because these are people who grew up their whole lives dreaming of going into nursing,” Roeder said. “For so many of them, it’s not a job. It’s a calling. When we’re exploiting that. . .?”
It’s not good for the nurses, the hospitals, or the patients, she said. “There are times when cutting corners does the wrong thing for the hospital. This is one of them.”
Graham said that at her last facility, she became used to nursing being about that rush from one patient to another, that need to focus on tasks instead of people. Now, she has time to connect and care. That’s because of the staffing levels at MDI.
“It took me a while to learn how to do it again, to be able to feel comfortable to sit down and talk because I was so used to like barely making eye contact and just, doing the tasks that were set ahead. But I've been there long enough now that there are some that, unfortunately, have to come a lot. And I know them and they love that I know them,” Graham said.
She loves that she knows them, too.
“And a lot of times that helps with their overall care because I've seen them at the beginning and I've been taking care of them right along,” she said. “And that makes me feel good that they know that they'll be taken care of when they come to MDI.”
Another aspect of this, she said, is that dealing with this sort of situation takes its toll on nurses’ health. When she left that other facility to work at MDI, she was very morally distressed and was diagnosed with post-traumatic stress disorder.
She’d come home, off shift and run through her patients in her head, running through their medications, feeling like she’d done a bad job even if she did a great one.
“I didn't even really know the outcomes because I didn't have time to see if anything was working,” she said. “It's devastating to know that there are still hospitals, so many hospitals in Maine, that are continuing to do that.”
OPPOSITION TO THE MAINE QUALITY CARE ACT, LD 1639
Some opponents, like Christine Anderson of LincolnHealth, worried that the bill removes autonomy for nurses for fluid health decisions. Sharon Baughman of MaineHealth wrote in May 2023, that she strongly opposed the bill. MaineHealth is a health care system that provides services to patients in Maine and New Hampshire and has more than 22,000 care team members. She too framed the debate as stripping nurses of autonomy.
“Staffing is not always perfect, and the nursing profession is hard. But mandated ratios are not the solution to this issue. Training more nurses and building cultures of inclusion and feedback are,” she wrote.
The Maine Hospital Association, which advocates for almost 40 Maine hospitals, is against the bill. On its website, it writes that the bill will “cost well over $100 million. When nearly half of Maine hospitals were operating on negative margins before the pandemic, hospitals simply cannot absorb the substantial, increased costs from mandated ratios; limit access to hospital care. Hospitals that can't meet the rigid ratios will have to close beds units or even whole facilities. This means ill and injured Mainers may have to travel farther for care causing unnecessary and potentially dangerous delays.”
Roeder said that no hospital administrators testified during the public hearings and sent nursing administrators instead.
Other LD1639 detractors said that they worried the measures would require hospitals to hire more nurses when there are current shortages of nurses. Reports suggest that the state will need approximately 1,450 more nurses by 2025.
Graham disagreed. She worries about young nurses entering the profession and working with those sorts of patient-nurse ratios and that’s all they know.
“You know, they'll end up being the same as so many others of just being unwilling to work in that kind of environment anymore,” Graham said. “There is not a shortage of nurses in Maine. You just have a large group of nurses who are unwilling to work in an unsafe environment. If we can pull in the Quality Care Act and nurses see that and see that, you know, is seeing that safe ratios, safe patient ratios, save lives, those nurses are coming back. They will come in droves.”
Those sentiments echo those of Kelli Brennan, an RN at Maine Medical Center, who said in late March, “All of us nurses know other nurses who have left bedside care because of the conditions we and our patients face in hospitals today. There is no ‘nursing shortage,’ only a shortage of nurses who are willing to work in these conditions. If we want to fix Maine hospitals and our statewide health care system, we must enact reasonable and enforceable nurse-to-patient ratios. RN-to-patient ratios will bring nurses back to the bedside, keep the nurses we have, and protect the patients we are all committed to serve.”
Graham said that if the law passes, nurses around the state will be able to serve patients better. Short-staffing prevents that, she said.
“Basically, when you have that many patients, you're just tasking,” Graham said.
“The Maine Quality Care Act is great for everyone, for patients, for nurses,” Graham said. “Ultimately, it's, it's what our patient base needs. And we have a large amount of geriatric people in Maine, largest in many states, and we need these nurses.”
LINKS TO LEARN MORE
https://legislature.maine.gov/house/house/MemberProfiles/ContactYourLegislator
https://qualitysafety.bmj.com/content/qhc/30/1/1.full.pdf
https://themha.org/policy-advocacy/Issues/Nurses-say-NO-to-ratios
MSNA fact sheet
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