Postmortem: Was the Failed Massachusetts Law Requiring Patient Limits for Nurses a Good Idea?

Nurse Leader Insider, March 28, 2019

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By John Palmer

This article appeared on PSQH.

One of the biggest news items to captivate the healthcare scene during the 2018 election season was the shutdown of a controversial proposal by nurses in Massachusetts to limit nurse-to-patient ratios in hospitals.

The proposal was supported mostly by nurses and patient safety advocates, while criticized by hospital administrations that were concerned with the possibility of rising operating costs.

The proposed law, which became known as “Question 1” because of its position on the referendum ballot, was soundly defeated in the November 2018 election, with about 70% of Massachusetts poll-goers voting “no.” An industry-backed campaign from hospital executives spent around $27 million exhorting voters to turn down the measure.

If passed, the law would have established ratios limiting the number of patients that could be simultaneously assigned to individual nurses at Massachusetts hospitals and health clinics. For most hospital departments, the maximum ratio would have been set at four patients per nurse, but that limit would have varied depending on the unit, as well as the condition and type of patient within those units—obviously, an emergency department (ED) or behavioral health ward would be busier than, say, a maternity ward.

The proposed law, which would have applied to all licensed hospitals in the state, also would have prohibited facilities from reducing the number of nurses on staff in order to comply with the restrictions. Any hospital or facility found in violation of the ratios could have been fined up to $25,000, though the requirements would have been dropped during national or state public health emergencies.

According to information from the Massachusetts Nurses Association (MNA), Massachusetts hospital ED patients experience some of the longest wait times in the nation—48th out of 50 states—because, the MNA says, there aren’t enough nurses in EDs to assess, treat, and stabilize patients. Further, they claim there are too few nurses on the other floors of the hospital to allow patients who are waiting to leave the ED to be moved onto one of those floors. Also, according to the union, California has had a similar nurse-to-patient law on the books since 2004, leading to more nurses in EDs and on hospital units; as a result, the MNA claims, wait times in California are 47% shorter than Massachusetts, and patient outcomes are better.

“As an emergency department nurse for more than 30 years, it simply defies common sense to claim that having more nurses on hand to treat patients in the ED would increase wait times or harm patients in any way,” said Kathy Reardon of Steward Norwood Hospital, in a published letter from the Massachusetts advocacy group Committee to Ensure Safe Patient Care. “Studies show that more nurses means better care and shorter wait times. And my own experience as a nurse shows that with more support, we can provide you with much better care.”

Pros and cons

It’s still unclear whether limiting the number of patients assigned to a given nurse would have a measurable effect on patient safety. With only one state in the country (California) having enforceable patient limit laws in place, it’s difficult to find reliable data to illuminate the issue. However, there are valid arguments on both sides.

Proponents claim that hospital downsizing, budget cuts, and the nationwide nursing shortage have led to overworked nurses who are forced to work longer hours with greater patient loads. A survey by the American Nurses Association found that 54% of their nurse respondents didn’t have sufficient time to spend on each patient. Overcrowding and understaffing can lead to stressful shifts for nurses, as well as higher burnout rates and lower nurse retention.

According to some statistics, appropriate nurse staffing helps decrease nurse fatigue, thus promoting increased safety as well as job satisfaction. It can also help promote healthier lifestyles, which decreases nurse burnout and its associated health effects, including chronic fatigue, irritability, insomnia, depression, weight gain, and other risks that come from being overworked and stressed.

Another issue that leads to nurse burnout and dissatisfaction, and that has been tied to staffing shortages, is patient violence. According to the U.S. Bureau of Labor Statistics, healthcare workers experience the most non-fatal workplace violence compared to other professionals, accounting for 70% of all non-fatal workplace assaults. A survey conducted by the MNA found that 75% of nurses said violence was a problem in their workplace, and the Emergency Nurses Association reports that 80% of ED nurses have been victims of workplace violence.

In general, patient violence against nurses has historically been accepted, if not welcomed, and many nurses have been injured or even killed on the job. As a result, many nurse advocacy groups have developed a no-tolerance policy and have begun developing legislation to help protect nurses exposed to violent incidents in their hospitals.

Simply put, happier nurses are more likely to want to stay in their jobs. Retention and recruitment rates have been shown to improve drastically with minimum nurse-to-patient ratios. Some published reports indicate that the year California’s law went into effect, the California Board of Nursing reported that applications for nursing licenses increased by more than 60%, and by 2008, vacancies for registered nurses in the state’s hospitals had plummeted by 69%.

With happier nurses and more attention to patients, outcomes naturally follow suit. Patient mortality and the number of preventable mistakes—including patient falls, pressure ulcers, central line infections, and healthcare-associated infections—have been shown to decrease after minimum nurse-to-patient ratios are instigated, according to the California Nurses Association (CNA).

California hospitals saw procedural mistakes decline as well as outcomes improve, according to CNA statistics. Fewer patients got sick in hospitals, more recovered, and fewer suffered post-treatment complications that required them to return.

On the other hand, the biggest hurdle to widespread nurse staffing changes seems to be the expense involved. Enforcing a minimum nurse-to-patient ratio creates steep fiscal costs on hospitals and allows them little say in staffing decisions. Funding for nursing programs would need to be increased, and hospitals would be required to hire more nurses, and to increase their salaries and benefits, to fill the positions required.

“MHA and its member hospitals and health systems value the efforts of the Health Policy Commission (HPC) to independently identify and analyze the true costs to Massachusetts from Question 1’s excessively rigid, one-size-fits-all mandated nurse staffing ratios,” said Massachusetts Health and Hospital Association (MHA) President Steve Walsh in a written statement. “The HPC’s findings conclusively confirm the outrageous costs that would be imposed by Question 1 without any benefit to patient safety.”

The HPC’s estimate of up to $949 million in annual increased costs is largely consistent with the costs identified by the independent research of Mass Insight/BW Research Partnership. The HPC also says its cost impact estimates are conservative; the estimates leave out some key areas that would be impacted by Question 1, including ED costs.

The HPC report cites evidence stating that mandated staffing ratios in California did not improve that state’s patient care, a claim that contradicts the statistics cited above. It also finds that Massachusetts already has better nurse staffing than California and performs better on multiple quality measures, according to Walsh.

In addition, patient safety and access might not immediately improve with a ratio law in place. Patients might actually have to wait longer for treatment even on a ward with a light patient load because nurses wouldn’t be able to see them due to the ratio requirement. Additionally, larger emergency situations happening within the hospital or the city might require drastic action and changes in staff assignments; however, the proposed Massachusetts law did attempt to account for greater staffing needs in EDs.

The Emergency Medical Treatment and Active Labor Act, passed by Congress in 1986, prevents EDs from turning away patients. Furthermore, the Department of Health and Human Services has a “no diversion” policy, which only allows the diversion of patients under extreme circumstances and calls for hospitals to develop comprehensive plans to deal with overcrowding.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at

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