Executive Summary of 2019 State of Nursing in Massachusetts

This document reports the findings from a survey of 501 Massachusetts registered nurses conducted April 2-18, 2019. The survey, which has been conducted annually since 2014, included telephone interviews with RNs randomly selected from a statewide list of all licensed RNs. As has historically been the case, most responding nurses are not members of the Massachusetts Nurses Association.

Executive Summary

Six months after hospitals defeated a ballot initiative to establish safe limits on the number of patients that could be assigned to nurses at one time, Massachusetts RNs see a worsening staffing situation and worsening quality of care in the state’s hospitals.

Four-in-ten nurses – a record high – think the quality of hospital care is getting worse. RNs are also grappling with a sicker patient population than ever before, and six-in-ten think patients today are much sicker than those a decade ago.

Not having enough time with patients is nurses’ most significant challenge in delivering care, and two-thirds believe nurses are assigned too many patients at one time.

Nor is the staffing situation improving: a record-high 44% says staffing has gotten worse in the past four years, and a similar number say it has worsened since October. Just a third report that management typically adjusts patient assignments when they become unsafe.

Half of all nurses say caring for too many patients greatly decreases the quality of care they can provide. Two-thirds are aware of serious negative consequences of patient over-assignment, including readmission, medical errors, and other complications.

At the same time, nurses are also contending with workplace injuries and abuse. Six-in-ten have faced at least one instance of workplace violence in the past two years, and a quarter have been injured on the job. These issues are particularly acute for nurses at teaching hospitals.

Against this backdrop, nearly all nurses support creating an independent legislative commission to study the state of Massachusetts nursing. Nurses are broadly supportive of topics the commission could study, particularly nurses’ workplace injuries, the effects of patient limits on outcomes, and discrepancies between staffing plans and actual patient assignments.

Key Findings

Quality of Hospital Care

For the first time since 2014, nearly twice as many nurses say the overall quality of care in Massachusetts hospitals has gotten worse (39%) rather than better (21%). A record-high number of nurses now believe that the quality of care is getting worse.

Nurses are also grappling with sicker patients. Nearly nine-in-ten (88%) think patients today are sicker than patients a decade ago, up seven points from last year. Fully six-in-ten nurses (61%) think patients are much sicker now.

Nurses Lack Time For Patient Care

Nearly half of all nurses (45%) say they do not have enough time to provide their patients with the care and attention each one needs. Nurses also feel the problem is getting worse – 46% say they have less time to spend with patients than last year, while just 13% have more time for patient care.

Relatedly, nurses see patient assignment-related issues as the most significant challenges they face. Not having time to provide each patient with needed care and attention (47% major challenge) and having to care for too many patients at once (45%) far outstrip other concerns like inadequate pay (27%) or even on-the-job injuries (15%).

Patient Assignments and Hospital Responsiveness

Two-thirds of nurses (65%) believe nurses at acute care hospitals are assigned too many patients to care for at one time. Just 3% think nurses could safely care for more patients.

Nurses do not see the staffing situation improving. More than four-in-ten (44%) report that staffing at their facility has gotten worse over the past four years; just 12% think it has gotten better.

Nor has the situation improved recently: four times as many say staffing issues have worsened since last October (38%) as say they have improved (10%).

A record-high 44% of nurses find that hospital administrators are not responsive to feedback from RNs regarding patient loads and nurse staffing levels. Nearly six-in-ten (57%) report that management does not consistently adjust patient assignments when needed.

Impact of Patient Assignments on Care

Six-in-ten nurses feel patient over-assignment decreases the quality of care they can provide, including 50% who say unsafe patient assignments greatly decreases the quality of care.

There is widespread awareness of specific negative patient outcomes arising from unsafe patient assignments. Two-thirds of nurses have seen medical complications (65%), re-admission (65%), and medical errors (65%) stemming from unsafe patient loads.

Regulatory Solutions

Five years after it passed, nurses see the 2014 law establishing maximum patient limits in ICUs as a success – 64% believe the law is working as intended and just 16% say it’s not working.

Views were somewhat more evenly split on the 2018 ballot question that would have established safe staffing limits for other units. Nurses report backing the initiative by an 11-point margin, 51-40%.

During the 2018 campaign, hospitals gave materials opposing the initiative to patients, and also mailed opposition materials to patients’ homes. More than two-thirds of nurses (68%) feel these campaign activities were inappropriate.

Looking forward, nearly all nurses (93%) support the creation of an independent legislative commission to conduct studies on the state of nursing in Massachusetts.

The proposed commission could study a wide range of topics affecting nursing care – and nurses see each potential topic of study as an important one for the commission to take up.

Workplace Violence

Nearly half of all nurses (47%) report that workplace violence and abuse is a serious problem. Six-in-ten encountered at least one instance of workplace violence in the past two years, and one-quarter have been injured on the job.

The problem is particularly acute for those working in teaching hospitals – these nurses are more likely to report on-the-job injuries, workplace violence, and see violence and abuse as a serious problem.

Methodology

 “The State of Nursing in Massachusetts” was commissioned by the Massachusetts Nurses Association and conducted April 2-18, 2019.

The survey utilized gold-standard interviewing practices as outlined by the American Association of Public Opinion Research (AAPOR). Respondents were randomly selected from a complete file of the 100,000 nurses registered with the Massachusetts Board of Registration in Nursing, and geographic quotas were used to ensure accurate representation across all regions of the state. Interviews were conducted on landlines and cellphones by trained, professional interviewers; the average length of a completed interview was 20 minutes.

Screening questions were used to verify that respondents were registered nurses working in Massachusetts healthcare facilities. Slight age and care setting (teaching hospital, community hospital, non-hospital care) weights were applied to ensure the data accurately matched demographic information available on the statewide list of nurses and the actual breakdown of healthcare facilities across the state.

A majority (60%) of RNs interviewed were not MNA members.

A total of 501 interviews with Massachusetts nurses were completed as part of this survey. Many questions were split-sampled (asked of half the sample), with a sample size of approximately 250. Questions asked of the full sample have a margin of error of ±4; split-sampled questions have a margin of error of ±6 (both at the 95% confidence level).

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