Transcript: Nurses Debate Ballot Question 1 On 'Radio Boston'

For those still wondering how to vote on Question 1, this might help.

WBUR's Deborah Becker and the Boston Globe's Priyanka Dayal McCluskey on Monday co-hosted a Radio Boston special debate over the ballot measure, which would establish nurse-to-patient ratios in Massachusetts. This transcript has been lightly edited.

Priyanka Dayal McCluskey: A "Yes" vote would establish nurse-to-patient ratios in Massachusetts, limiting how many patients could be assigned to each registered nurse at hospitals and certain other health care facilities. A "No" vote would mean no changes.

Deborah Becker: On both sides of this debate, there's a lot of money. Those in favor have raised almost $9 million; those opposed, about $12 million. Today on Radio Boston, we'll hear from both sides on Question 1. Our debate is brought to you by WBUR, The McCormack Graduate School at UMass Boston and the Boston Globe.

Before we jump in, a few ground rules: Each representative will have one minute to respond to each question, followed by a one-minute rebuttal. We, the moderators, will be able to ask follow-up questions at our discretion.

Let's introduce our guests now for today's debate. Supporting Question 1 is Donna Kelly-Williams. She's a registered nurse at the Cambridge Hospital Birth Center and president of the Massachusetts Nurses Association. And opposing Question 1 is Nancy Gaden. She's also a registered nurse, and the chief nursing officer at Boston Medical Center. Welcome, Nancy. We did have a coin toss before the start of the debate to choose the order for the opening and closing statements. So we'll hear first from Donna Kelly-Williams, representing the 'Yes' side.

Donna Kelly-Williams: Thank you, Deb. As a registered nurse who has spent her entire career of over 40 years at the bedside of patients, I am standing with nurses everywhere and asking everyone to vote 'Yes' on Question 1. Question 1 will put safe maximum limits in place for the number of patients that can be assigned to a nurse at one time. Currently, no limits exist outside of the intensive care unit. If you are in a hospital, you're pretty darned sick, and you are there because you required nursing care — that 24/7 monitoring that you won't receive from a doctor's visit or a minute clinic. Study after study shows that when nurses have too many patients at once, bad things happen, like higher rates of infection and medical errors. But think about it: do you want to be one of four patients or one of eight patients if you are in the hospital? Question 1 will establish a standard of care that does not exist right now. That's why voters should say 'Yes' on Question 1 for safe patient limits.

DB: OK, one minute now for Nancy Gaden, chief nursing officer at Boston Medical Center, who is representing the 'No' side.

Nancy Gaden: I've been a nurse in Massachusetts my whole career and have more than 20 years' experience in nursing administration, in both teaching and community hospitals. I am alarmed about what Question 1, if passed, will mean for delivery of care at my hospital and hospitals across the Commonwealth. This ballot question calls for very specific nurse patient ratios — ratios in every area — and we know that we will not be able to hire and train the required number of additional nurses we need. For example, if Question 1 passes, Boston Medical Center will have to reduce the capacity in our emergency department by more than 100 patients a day. Boston teaching hospitals like ours know that complying with rigid ratios will limit our ability to accept thousands of transfers of critically ill patients from community hospitals. Our state has some of the best hospitals and quality outcomes in the country. Passing this law will not improve care. It will cost more than a billion dollars, and it will have a devastating impact on access. This ballot question would destabilize Massachusetts health care, and it's irresponsible.

DB: OK. I'm going to jump off of opening statements here, because Massachusetts is known for its hospitals. They're touted all over the place, certainly locally, but we have a lot of studies that suggests that health care here is a very high quality. So Donna, why, then, do we really need this ballot question?

DKW: Deb, for the past 20 years, nurses have been the canaries in the coal mine, and have been sounding the alarm that there has been an erosion of nursing care at the bedside — that nurses who are caring for patients are finding that they're not able to spend the time they need with their patients, to do adequate discharge teaching, to prepare them for the recovery at home, to adequately medicate them for pain, to watch out for signs and symptoms — either of them heading in the right direction or heading in the wrong direction. And over the past 20 years, while we have seen this erosion, we have been sounding the alarm and have done absolutely everything that we've been asked to do. We've gone to the Legislature, we've met with the Department of Public Health, we've met with hospital administrators, and we've said we need to be able to take care of our patients the way that we are licensed to do in the commonwealth of Massachusetts, and the way our patients deserve to be cared for. And what we found was hospital administrators telling us just to do the best that we can.

DB: So to clarify, you feel like you've exhausted every other every avenue. This couldn't be done through collective bargaining, couldn't be done through any kind of law on Beacon Hill, you've tried all of that — and this is it.

DKW: Absolutely.

DB: Nancy Gaden, what do you say to that?

NG: I say there's a reason that the Legislature hasn't picked up on this idea. We've had 14 years to watch California's outcomes. We've had 14 years to study what it means to have ratios, and in absolutely every single case, Massachusetts outperforms California. The reality is there are a lot of studies that look at the relationship between nurse staffing and patient outcomes. And every single case, the researchers warn against fixed ratios. They have unintended consequences.

PM: Let's get into the specifics of this law and what exactly it would mandate. For the typical medical or surgical patient, the law sets a limit up for patients to a nurse. In emergency rooms, the limit would be a max of five patients to a nurse. The limit for psychiatric units would also be five patients to a nurse. So Donna, how were these limits set into the question and why?

DKW: So, the limits were actually set using the professional standards of the organizations. One that you didn't mention was actually the A-1 standards, which govern the staffing guidelines for labor and delivery and maternity care. And that's exactly where we got those limits from. We looked at all of the research — including Dr. Linda Aiken's study who — when she studied the medical-surgical patients — the reason that it is one-to-four — with the flexibility, with the acuity tool for a medical-surgical nurse to take less patients — is because when you go above that limit, when a medical-surgical patient, a five is assigned to a registered nurse — that's when you get to see the beginning of the medical problems. Seven percent of an increase of medication errors, medical complications, happen with the fifth patient, and every subsequent patient after that compounds the increased risk to that patient. So we've done our homework on this and looking at California, what they did, we looked to the most recent research and actually modified ours to be more consistent with the fact that patients are sicker in the hospital now than they've ever been.

PM: Nancy, are any of these numbers written into the ballot question palatable to your side?

NG: I would say that the biggest issue with the ballot question is the rigidity of these numbers. The research that Donna was quoting is all based on averages. In every single case, people do not look at the ratio of nurse to patients, and the reason is because that ratio, when it is that fixed and when it is that rigid, has limitations for that nurse to be able to use her professional judgment, to be able to work with the physicians to decide to take another patient on her assignment. When we look across the board at the emergency department for example — your example of one-to-five — the emergency department requirements in the law are one-to-one first for the most critical patients; one to two if the patient needs care between 15 minutes and an hour; one to three...It's so rigid, and it would mean an emergency department that a nurse, even if she was ready to take another patient from the waiting area, she wouldn't be able to do it because this law would keep her from using her judgment.

PM: I'd like to follow up on something Nancy just said: you mentioned averages. Donna, this question is written for 'at all times.' So why was it written that way, why not use an average? Why do you need the same number of nurses at night as you do during the day?

DKW: I think that's a great question. But having been a night nurse for my entire career, I can tell you that nighttime is a critical time for patients, because even though we would like patients to be able to get adequate rest at nighttime, that's even a more critical time for nurses to be able to assess the patient's stability and their clinical status at that time. Because you have to do that while they're sleeping to make sure that you are covering all of the assessments that you need to do to make sure that your patient is the safest. And I don't think there's any secret that patients are in the hospital and out of the hospital as quickly as they possibly can be. So patients that would have had that extra day, perhaps, to be assessed in a different way, is already home. So we have a very short period of time to do all the work that's required to ensure a successful recovery.

DB: When we hear about, you know, almost a billion dollars a year, I'm just wondering, would that or would that not be passed on to consumers, patients here, or insurers? Nancy?

NG: There's no question that that a billion dollars is a great deal of money to add to Massachusetts health care. We already have 25 percent of the hospitals that are in the red. It would cause another 25 percent, so a full half of the hospitals in Massachusetts would be running in the red. It's not sustainable. The community hospitals are very nervous about what this would mean for their ability to stay open, to do programs that they want to do. A billion dollars would definitely be passed on to consumers. And again, what are we trying to solve for? We have excellent hospitals in Massachusetts, some of the best in the country, excellent outcomes, and I think there's no question that billion dollars is money that is not well spent.

DKW: I'd love to respond to that. Nancy, as you know, hospitals are now corporations, and this is a $28 billion industry right now. Hospitals make choices about where they're going to put their resources. Our position is those resources need to first begin with the patient, to be sure that the patient has all of the necessary resources available to them, the safest nursing care possible when they are in the hospital. That is what this ballot question is all about, is to ensure that the health care dollars that are intended for patients are spent on patients, not spent on corporate buying of other facilities outside of the commonwealth of Massachusetts, outside of the country for that matter. We have corporations that are buying up facilities in Malta and China and opening up there. We're saying the health care dollars of Massachusetts should remain at the bedside of the hospital patients in Massachusetts.

DB: Ben is calling from Arlington. Ben, you're on the air.

Ben: Curious to know whether either side thinks this may risk setting a precedent for other medical professionals, physicians included, other paraprofessionals who have large censuses of patients when they care for them in the hospital.

NG: You know, to be honest, I've been focusing on what exactly it means to put a question like this in front of the voters. I think it is a big responsibility to write a ballot question and you have to consider all the different pieces of it. This ballot question, the way it's written, has so many unintended consequences, we are literally trying to imagine how we would hold onto the fragile gains we've made in substance use disorder, in mental health, the dollars that would be shifted to meet these ratios worry me on so many fronts. I don't know if it would lend itself to a broader implementation in other professions, but I think it would worry me just as much. There is no answer where rigid ratios are ever the right way for professionals to make decisions.

DKW: For the safety of the patient, if the research showed that other areas also needed to have limits put in place, absolutely there should be. And just as in Massachusetts, we're looking at safe patient limits for patients — we're not alone in Massachusetts. Surrounding states are also looking to do this. Other countries are doing this right now. And everyone in the nursing profession is looking at what is the safest way to care for patients.

PM: One of the concerns we've heard about this is that community hospitals will struggle the most to pay for the increased costs of hiring new nurses. And it could drive those hospitals to cut services or even close. Donna, what's your response to that concern?

DKW: I just want to reiterate, as I said earlier, that this is a $28 billion industry that can well afford to be taking care of their patients the safest way possible. And hospitals and services don't close because of the nurses. They close because they don't make enough money to the satisfaction of their executives. We've seen this over and over again, even when a service is deemed by the Department of Public Health to be an essential service. If it's not making enough money for the facility, the hospital — even with the Department of Public Health saying that it is an essential service — they go ahead and close it. So this is about choices that hospital executives are making every single day. And what we're saying is the patient needs to be the No. 1 priority and we need to be able to take care of patients in the hospital.

PM: We should point out that most of the hospitals in Massachusetts are structured as nonprofits. And Nancy, do you want to respond to what Donna said?

NG: I would just say there's no reason to vilify hospitals and hospital executives and leadership. I live in a community with a community hospital. I know there are wonderful community hospitals across the state of Massachusetts. I think it's absolutely naive to think that these hospitals will not struggle to meet these new expenses. And I am afraid of the programs and the services that would be at risk if they had to shift their resources to meet these mandated ratios.

DB: Andrew is calling from South Boston --

Andrew: Hi, my name is Andrew, I'm an EMT. I work in Cambridge primarily. My biggest issue, as far as my perspective is concerned, is that the fluidity of emergency rooms is very, very important. And when you look at the way that the actual law is written, it kind of sounds like there need to be maybe 10 times as many nurses as there actually are. And we could come in with multiple very acute patients in the span of five to 10 minutes — just the way that our company works — and it doesn't seem like that is something you can financially regulate.

DB: An emergency room can get chaotic — you never know what's going to happen. Donna Kelly-Williams, what do you say about Andrew's concerns?

DKW: Absolutely. I think the most important thing to remember is that having more nurses in the emergency room is not going to be a delay in care. And certainly having a safe limit to the number of patients that a nurse will be caring for at one time will facilitate moving patients that need to either be inpatient, moved to an inpatient unit whether the nurse is readily available to assume the care of a patient that must be admitted, and at the same time be able to do all of that important discharge planning for that patient. So patients should be able to be moved in and out and over much quicker when the amount of staffing is consistent to the number of patients that are seen. And what we've also seen over the years is — we've seen this influx of patients coming into the emergency room, and for the most part, there's not a surprise there, especially when we're coming up to the World Series in Boston: the Boston hospitals will be staffing up knowing that they may be seeing more patients. With other hospitals, such as Cape Cod Hospital, they know after Memorial Day that there will be more traffic on the bridge and there'll be more patients, so accordingly, hospitals staff up.

DB: Nancy?

NG: I think Andrew knows exactly what he's talking about as an EMT. We have extreme variations every single day in the emergency department and by hour of the day. And I think it doesn't matter how much we planned or staffed up, in any given hour we could definitely have more patients than we had planned for. And the problem with the ratios and how rigid they are — and Andrew pointed it out — emergency departments are very fluid. When you have a rigid ratio, there will literally be a time where a nurse has the number of patients that the law calls for, and she will be not allowed to pull another patient in from the waiting area or take a patient from an ambulance.

DB: Donna?

DKW: Absolutely no nurse at any time would ever refuse to care for a patient, Nancy. Never ever, ever. If patients are at the door, the nurses will care for that patient. And if it does mean some moving around of those patients to get patients up to the floor quicker — every single hospital right now — and I'm sure Boston Medical Center as well, Nancy, has a plan when a lot of patients show up to the emergency room at the same time, and they move patients out and they do what they need to do to facilitate getting every patient in to be seen in the way that they're supposed to be seeing when they show up to a hospital.

DB: Nancy, are you saying that nurses would not be able to take care of patients here?

NG: I'm saying that the law is very specific, and it's very rigid, and if I am a nurse and I have my three patients, without breaking the law. And I think that's a lot to ask. I can't ask nurses to break the law. I think it puts them in a terrible moral distress. They will literally be faced with either break the law because they have their patients, or take another patient from the waiting area.

DB: Julie is calling from Holliston.

Julie: I read periodically about nursing shortage. Bottom line, if this were to pass, where would you find the nurses?

DB: Donna, do we have enough nurses?

DKW: Oh, absolutely, we sure do have enough nurses. There is no shortage of nurses in Massachusetts. We have more nurses per capita in Massachusetts than any other state in the United States with the exception of South Dakota. And I don't know how they beat us, but we have plenty of nurses here. We also have the highest number of nurses currently working part time and per diem. And I hear every single day from nurses that are telling us --- brand new nurses that are just graduating from school, and we graduate about 3,500 every single year in Massachusetts — and they cannot get jobs. They are not being hired by the hospitals. The nurses are there. The hospitals are not hiring the staffing.

DB: Nancy, same numbers?

NG: Same number of graduates 3,300 or 3,500. We have 4,500 nurses that retire every year. So already we are in a deficit position. Right now in Massachusetts, there are 1,200 nursing openings. We have a 5 percent vacancy rate. We absolutely do have people working part-time. I'm pretty sure they're all choosing to work part-time because we all offer them opportunities to go to full-time. This is a huge problem for us. We we would go from a 5 percent vacancy rate to way more than that. We don't have enough nurses.

DB: This makes it very confusing for people, when you've got two different splits here. We can't even decide if we have a nursing shortage. It makes it really hard for people to discern what to do about this question. So Donna, please respond to what Nancy said, but also clarify for people how you think they should make sense of two nurses disagreeing on this fundamental question.

DKW: Absolutely. And first to what Nancy said about the vacancy rate. If Nancy wants to send me her vacancy rate, her vacant positions, I'm happy to get that out to the nurses that call me every single day. They're looking for positions. Nurses are going to these hospitals, they're applying for these positions, but they are not being hired. And I think to be really clear on the who's who in this ballot question: nurses wrote the ballot question. And who is the opposition to the ballot question? Hospital executives. It's not nurses. Although this has been billed as a nurse-against-nurse issue, it absolutely is not. This is a patient bill. This is about being able to take care of patients the way they should be cared for in the hospital setting. That is why nurses came together to write this bill.

DB: I do want to say that WBUR did a poll and found an almost even split among nurses, for and against. So it felt almost like nurses against nurses. What do you say to that?

DKW: I think that what we are seeing and what we're hearing every single day is hospitals are putting up banners and have 'No' signs everywhere. And the intimidation of nurses and patients that are in hospitals right now is beyond anything that I have ever seen in my whole career as a nurse. It's actually horrifying and shameful, the way patients are being frightened and scared with the antics that are going on, with the commercials and the hold-the-wall nonsense and everything else that we're seeing. I think that Nancy ought to be ashamed of herself being up here and being the voice of the opposition to safe patient care.

DB: Nancy, I'll let you respond to that.

NG: I think calling this as hospital administrators against nurses is just patently untrue. You pointed out that the WBUR poll showed that nurses are split. Nurses that I talk to every day, the more they understand the unintended consequences, the more they are voting 'No.' But I will also tell you that every professional nursing organization in Massachusetts, including the Emergency Nurses Association and the Med-Surg Nurses Association and the American Nurses Association for Massachusetts and the Infusion Nurses Society and there's several others, and every health care organization that is taking care of patients — including the Home Care Alliance of Massachusetts, hospice and palliative care, Massachusetts Ambulance Association, mental health and the medical society — they're all 'No' on 1. Everybody giving care to patients across the state is 'No' on 1.

DKW: First of all, the nurses that wrote the ballot question were members of the Massachusetts Nurses Association — they voted on this. When you refer to the Emergency Nurses Association, seven out of nine of the people that voted for the Emergency Nurses Association were hospital executives that voted on that, and they had to put a disclaimer out about the fact that their membership did not agree with the vote of the members of the executive board. So when we talk about who is supporting this question, Nancy, there are over a million people that are supporting this. All you have to do is look at the almost 300 endorsements that we have received from people that are concerned and that have heard us over and over and over again saying there is a problem in hospitals, with the erosion of nursing care that's being provided to patients, and we need to have a safe limit in place. That is why we need people to vote yes on Question 1.

DB: OK, Jane posed a question on Facebook: she wants to know how this question might affect the poorest patients in Massachusetts. Nancy?

NG: I really appreciate the question, and I think one of the reasons that Boston Medical Center has been so outspoken about our concern about Question 1 is because we take care of the most vulnerable patients in Massachusetts. And we know that those patients will be at the most risk. The fragile gains we've made in substance use disorder and mental health care in Massachusetts are at risk with this ballot question. Paul Hattis and John McDonough from Commonwealth Magazine said that the evidence, better policy choice, and more socially just result points to 'No' on 1. And that is absolutely how I feel. I feel the social justice vote is 'No.'

PM: Let's talk about California, which is the only state to have a similar nurse staffing law. But there are some major differences between California's law and the one proposed for Massachusetts. One that's often cited is the implementation timeline. California's law had a five year phase-in, whereas this ballot question is so much quicker: it would go into effect January 1. Donna, why is there such a quick implementation on this?

DKW: First of all, the seriousness of what's going on in hospitals actually make this a very serious issue. But going back to the implementation date, as anyone knows when you do a ballot question you have to have an actual date that the law is in effect. However, it's really up to the Health Policy Commission how fast all of the implementation is done. And following that implementation and the standards that are approved by the Department of Public Health, including the acuity tool that was referenced at the beginning of the show, all of those things have to be in place. There's no automatic fines set up on January 1, and the sky is not going to fall on January 1. But what will happen is that plans will have to be brought forth to the Department of Public Health for approval. They'll have to go through the Health Policy Commission, and then there will have to be enforcement regulation which will be up to the attorney general. So there are a number of things that have to be in place. And having done the ICU law, I can tell you that it will take some time.

PM: Nancy, your response?

NG: I'm not a lawyer, but the ballot question is very specific around this: it says that the Massachusetts Health Policy Commission may not delay or modify the requirements set forth, and it does say that it starts January 1.

DB: So when do you think it might go into effect? How long would it take?

DKW: So it really is dependent on the Health Policy Commission. But they do have the experience of the intensive care unit law that we worked with, and hospitals like Mass General that you heard at the beginning of the show already have an acuity tool that's in place, and may be used as a resource. And again, I know that we are going to be talking about California and how that worked in California. But we've been talking about this for 20 years. This is not a surprise to hospitals that this has been identified as an issue. And it should not take any hospital that long to get to where they need to be.

PM: If California is the example that you cite, Donna, why are the limits proposed for Massachusetts so different? They're much stricter. For example, for a typical medical or surgical patient, the ratio in California is five patients to a nurse. But in Massachusetts, you're proposing four patients to a nurse, and also the penalties in Massachusetts would be more strict.

DKW: First of all, having been a nurse for as long as I have, I can tell you that a lot has changed at the bedside of patients over the last 20 years. Patients are sicker than they have ever been. And that was the need for changing, and really looking at real-time research about what is going on in the hospital facilities. So that is why we have that important update to the numbers in the ballot question. They are based on the latest research, the guidelines from the most important standardization of staffing in hospitals based on the specialty area that a patient may find themselves in, whether it's in the maternity unit or the medical surgical unit. All of that is based on the latest research. And as far as the fine goes, that's an enforcement. It is never meant to be punitive, but it was actually at the suggestion of the legislature when we went forth with the ICU law and brought problems back to them concerning the fact that not all hospitals felt that they had to follow the law. And we were instructed by them to make sure that we had enforcement language in it.

DB: Let's talk about California. Claire is calling from Martha's Vineyard.

Claire: I just returned from California, having witnessed this firsthand. My son transitioning from the ICU to the floor, and the nursing and medical staff able to adapt to the needs of the patient in real time. I feel very conflicted on how to vote on this question because I see this as being very static and certainly not what my experience was [sic] in California. I think that the California rule works well because it allows for nurses and doctors to adapt to the needs of the patients; where at times it's one-on-one when the patient needs less the nurse is there half the time, and then in urgent situations, there could be three nurses and five doctors in the room. They're able to make the decision.

DKW: Claire, I just want to add, please take take a moment to actually read the ballot question. The acuity tool is part of the ballot question. So this is about having a maximum limit, not a ratio where it says that every nurse has to have four patients at all times on the medical surgical unit. But the maximum number of patients a nurse would have on the medical surgical unit is four patients. But based on that acuity tool that identifies what are the nursing needs of that particular patient, that nurse could certainly have three, or even two, patients if the patient warranted more nursing care. That would be identified through the assessment of the nurse and the acuity tool.

NG: The professional organizations that Donna was talking about earlier, they absolutely have white papers about staffing, and they absolutely say that ratios are not the right answer. And I get letters every day at Boston Medical Center about the great care that we gave. I'm sure across Massachusetts everybody knows that the patients here get excellent care, and this fluidity that Donna was referring to — it happens in hospitals today with the professional judgment, critical thinking, of the really expert clinical teams we have here. I'm proud of our care.

DB: Some of our callers are asking: What do you do about overworked nurses, then? And what do you do to make sure that there is consistent care at all hospitals? I also want to add a question from Dennis, who is calling from Foxborough. Dennis you're on the air.

Dennis: Thank you. This is really a question for Nancy. I have watched this issue. I'm a senior citizen so I'm certainly concerned that I'll be hospitalized, and in the past, I've found that there was inadequate care. Nurses would apologize because they couldn't get to me. And I understand that this has been going on for quite a while from there. What is it that management has not done that have caused the nurses to be in a position where they feel as though they have to take this action? I'll be voting 'Yes' from my own enlightened self-interest, but it seems to me a lot of years have gone by, other avenues have been tried. How did we get to this point? And what's management going to do about it if this question doesn't pass?

NG: First of all, sir, I would love that you don't vote 'Yes' for your own enlightened self-interest, because I think that's a very, very risky thing to do. If you are in a community hospital somewhere on the Cape, and you need to be transferred in town, it may well be that the hospital in town is at their legal limit and can't accept you in a transfer. The issue here is that it is all not about the numbers. It makes a difference for the nurses how much support they have, the nursing assistants, the individual patients, the presence of the IV team or transporters or rapid response nurses or pharmacy techs — it is about all the members of the team. I am absolutely not going to say that staffing is perfect in every hospital in Massachusetts at every minute. That is absolutely not true. I've worked in hospitals my whole life and I care more about nurse staffing than you could ever imagine. But I think the issue here is that the rigidity of the ratios — it's not the right answer. And we have to respond to the way the bill is written, and we have to deal with this — this would be a law as written. And the unintended consequences for access, and cost frankly, but for sure for access, are just something we just cannot live with.

DKW: I just want to add to something that Nancy had said regarding the team. We actually heard that, and we made sure that as part of this ballot question, that no members of the team can be diminished in order to have the safe limit put into place. And as Nancy can tell you, they recently just closed their East Newton campus and that moved 400 nurses from one campus over to the other campus. They sold that site for $200 million, which then relieved them of the responsibility of utilities, maintenance, insurance and other things. And you're sitting on a $163 million profit as a result of all that. You have the resources to provide all of the important programs for all of your patients in your area.

NG: I just want to remind you, we are talking about this ballot question and this law. It is true that we sold the Newton pavilion which was one of the buildings we used. All of that money, absolutely all of it — and $200 million is not the right number — and reinvested it in the Menino pavilion so that our patients will have the very, very best facilities to be in, and so, that is completely off topic.

DB: Closing statements. The order was decided by a coin toss prior to this debate. Donna Kelley Williams, you're first.

DKW: Thanks for giving me this opportunity to speak directly with the voters today and tell them how important it is to vote yes on the ballot Question 1. Nurses are not numbers on a balance sheet. We are the ones providing the vast majority of your direct care when you're in the hospital. When we ask for help now, nurses are told just do the best that you can, and we do what you and your family deserve to receive the quality nursing care that we are trained to provide. And right now, we can't do that. The conditions are far too unsafe. So let me be totally clear. Hospitals can afford to do this. They make choices about what they do with their money. Tell the hospital executives that you deserve the same quality of nursing care regardless of your geography or income. Join me in voting 'Yes' on Question 1 for patient safety. Thank you.

NG: Passage of this ballot initiative would absolutely limit access to care in Massachusetts and increase costs by a billion dollars a year without improving quality. While adding more nurses may seem like a good idea, this ballot question would become the law and would have tragic unintended consequences that will hurt patients in every community in Massachusetts. It would take away the decision making of our expert clinical teams. It is outrageous that physicians and nurses would not be permitted to take care of patients that need their care if they have met the ratio. Patients will have to wait longer to receive care and there are no exceptions. There is a reason that thousands of nurses, every single hospital, every physician organization, every community hospital and health center, every professional nursing organization and every organization that gives direct care to patients in Massachusetts have taken a position, and they're 'No' on 1.

DB: Nancy Gaden, Donna Kelly-Williams — I want to thank you both. Also thanks so much to our co-moderator today, Priyanka Dayal McCluskey. And thanks also to the Radio Boston team for producing today's debate.