Nurse-to-Patient Ratio Debate Heats Up – Again


There is a battle brewing in Massachusetts, and it will be decided at the ballot box this November. Question 1, also known as the Nurse-Patient Assignment Limits Initiative, was proposed by the Massachusetts Nurses Association, and is part of a larger fight nurses nationwide have been waging for years in an effort to secure safer staffing ratios.

A summary of the question that will go to a vote this November reads:

This proposed law would limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities. The maximum number of patients per registered nurse would vary by type of unit and level of care, as follows:

  • In units with step-down/intermediate care patients: 3 patients per nurse;
  • In units with post-anesthesia care or operating room patients: 1 patient under anesthesia per nurse; 2 patients post-anesthesia per nurse;
  • In the emergency services department: 1 critical or intensive care patient per nurse (or 2 if the nurse has assessed each patient’s condition as stable); 2 urgent non-stable patients per nurse; 3 urgent stable patients per nurse; or 5 non-urgent stable patients per nurse;
  • In units with maternity patients: (a) active labor patients: 1 patient per nurse; (b) during birth and for up to two hours immediately postpartum: 1 mother per nurse and 1 baby per nurse; (c) when the condition of the mother and baby are determined to be stable: 1 mother and her baby or babies per nurse; (d) postpartum: 6 patients per nurse; (e) intermediate care or continuing care babies: 2 babies per nurse; (f) well-babies: 6 babies per nurse;
  • In units with pediatric, medical, surgical, telemetry, or observational/outpatient treatment patients, or any other unit: 4 patients per nurse; and
  • In units with psychiatric or rehabilitation patients: 5 patients per nurse.

The proposed law would require a covered facility to comply with the patient assignment limits without reducing its level of nursing, service, maintenance, clerical, professional, and other staff.

The proposed law would also require every covered facility to develop a written patient acuity tool for each unit to evaluate the condition of each patient. This tool would be used by nurses in deciding whether patient limits should be lower than the limits of the proposed law at any given time.

The proposed law would not override any contract in effect on January 1, 2019 that set higher patient limits. The proposed law’s limits would take effect after any such contract expired.

The state Health Policy Commission would be required to promulgate regulations to implement the proposed law. The Commission could conduct inspections to ensure compliance with the law. Any facility receiving written notice from the Commission of a complaint or a violation would be required to submit a written compliance plan to the Commission. The Commission could report violations to the state Attorney General, who could file suit to obtain a civil penalty of up to $25,000 per violation as well as up to $25,000 for each day a violation continued after the Commission notified the covered facility of the violation. The Health Policy Commission would be required to establish a toll-free telephone number for complaints and a website where complaints, compliance plans, and violations would appear.

The proposed law would prohibit discipline or retaliation against any employee for complying with the patient assignment limits of the law. The proposed law would require every covered facility to post within each unit, patient room, and waiting area a notice explaining the patient limits and how to report violations. Each day of a facility’s non-compliance with the posting requirement would be punishable by a civil penalty between $250 and $2,500.

The proposed law’s requirements would be suspended during a state or nationally declared public health emergency.

The proposed law states that, if any of its parts were declared invalid, the other parts would stay in effect. The proposed law would take effect on January 1, 2019.

A YES VOTE would limit the number of patients that could be assigned to one registered nurse in hospitals and certain other health care facilities.

A NO VOTE would make no change in current laws relative to patient-to-nurse limits.

There are strong opinions on both sides of the issue.

Donna Kelly-Williams, president of the Massachusetts Nurses Association, said, “Setting maximum patient limits will put patients before profits — where they belong. Right now, decisions about patient assignments are made by hospital executives focused solely on reducing costs and increasing profits. We’re going all the way to the November ballot. And we’re confident that the voters understand how important this issue is to public health.” Kelly-Williams also said, “Hospital executives are the reason that we need safe patient limits in the first place. Hospital executives are the ones who have ignored nurses’ concerns, claiming a lack of resources for safe patient care, while pocketing seven-figure salaries.”

The opposition, which includes hospitals and nursing groups such as Organization of Nurse Leaders and the American Nurses Association Massachusetts, claim mandatory nurse ratios are not the answer, and that they do not improve patient outcomes and that some organizations would be negatively impacted by the cost of hiring more nurses.

Where do you stand on patient ratios? Tell us in the comments below.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

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  1. 1
    Kris thomason

    I work at a rural hospital with medical surgical and pediatrics all mixed together. We are responsible for watching our o2 sat monitor from the nurses station although we have no unit secretary or anyone assigned to keep a constant eye on it. We had a cost reduction and had a unit secretary at night and now we don’t. We are taking 6-7 patients including pediatrics. There is no acuity system in place for those patients who have a high acuity such as alcohol withdrawal patients or peds with respiratory problems. This impacts the safety of our patients on a daily basis. Our staff has mentioned to administration regarding the acuity system but they don’t seem to be concerned. It is an ongoing safety issue to the patients and the nurses license. There should be nurse to patient ratios especially on a medical surgical and pediatric floor. We need to count more than the amount of patients per nurse and also look at each diagnosis and the potential risks of giving a nurse more patients Than can be cared for at one time.

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