News & Events

America’s Staff Nurses Cite Better RN-to-Patient Ratios As Top Solution to Nursing Shortage

MNA Cites Report as Further Evidence for MNA Sponsored Legislation – An Act to Ensure Quality Patient Care – To Regulate Registered Nurse-to-Patient Ratios in Massachusetts Hospitals

CANTON, Mass. — A study reported in this month’s issue of the American Journal of Nursing shows that more than 85 percent of nurses surveyed believe limiting the number of patients each nurse must care for is the most important solution to a growing staffing crisis in America’s hospitals.

More than 80 percent of the nurses surveyed report being understaffed, nearly 70 percent report having less time to spend with patients and they identified increased workload and burnout from these conditions as the key reasons for nurses leaving the hospital bedside. In fact, similar to previous studies, this study again found that nearly one in three nurses is considering leaving their position in the next five years.

The study provides further strong evidence to support efforts by a growing coalition of nurses and patient advocates seeking to pass legislation to regulate RN-to-patient ratios in Massachusetts hospitals, according to the Massachusetts Nurses Association which filed the bill, HB 1282, An Act to Ensure Quality Patient Care and Safe RN Staffing.

"The scientific evidence is clear and overwhelming: when nurses have too many patients, patients’ lives are in jeopardy. The evidence also makes clear that poor staffing conditions in Massachusetts hospitals have caused and are exacerbating a growing shortage of nurses willing to work in hospitals," said MNA President Karen Higgins, RN. "Passage of this legislation is key to improving care to our patients and to creating conditions that will retain and recruit the nurses we need to provide safe patient care."

In addition to safe ratios, fully 82 percent of those surveyed responded that increased pay was a top solution to the nurse staffing shortage. Other highly rated solutions include greater autonomy and control for staff nurses (66 percent) and safer working conditions (65 percent).

The study’s conclusions mirror the results of similar surveys conducted in recent years that also identified low RN-to- patient ratios as key to protecting patients, preventing complications and stemming the flood of nurses away from the hospital bedside due to unsafe workloads mandated by the hospital industry over the last decade.

The study also found that only half the nurses surveyed felt the hospital industry was doing a good job addressing the shortage and nurses thought many of the strategies being employed – including offering sign-on bonuses, hiring temporary nurses and foreign nurses, and mandating overtime – were ineffective.

In addition, while hospital industry reports often cite the need to provide nurses with flexible scheduling as a key solution to the shortage, nurses in this survey did not identify this as a problem. Again, nurses reported that they were most concerned about their lack of control over nurse-to-patient ratios.

Currently, the American Hospital Association reports that 126,000 RN positions are going unfilled. According to the Health Resources and Services Administration, there could be a deficit of 808,000 nurses by 2020; Bureau of Labor Statistics data suggest that this estimate could go as high as one million nurses by 2010. Direct links have been made between adequate nursing care in hospitals and better patient outcomes.

The national poll of 600 hospital staff nurses providing direct nursing care was conducted via telephone by Lake Snell Perry & Associates. To view the results, visit

The most recent study in the Journal of the American Medical Association (JAMA) shows that for each additional patient assigned to an RN, there is a seven percent increase in the likelihood of death within 30 days from a complication not present upon admission to the hospital. The difference between 4 to 6 and 4 to 8 patients per nurse is accompanied by 14 percent and 31 percent increases in mortality respectively. It is common for nurses in Massachusetts to be assigned six, eight, and even up to 10 patients on a given shift, placing thousands of patients at risk for serious complications and death.

The researchers also found that each additional patient per nurse was associated with a 23 percent increase in the odds of burnout and a 15 percent increase in the odds of job dissatisfaction. In conclusion the authors of the JAMA study state that nurse staffing ratio legislation is a "credible approach to reducing mortality and increasing nurse retention in hospital practice" and ….."Improvements in nurse staffing resulting from the legislation could be accompanied by declines in nurse turnover".

"Nurses are very clear about what needs to be done to protect patients and to solve the shortage. They need safe ratios," Higgins said. "It’s time for the industry and for policy makers to hear what the front-line nurses are saying and to act on what the evidence makes clear – safe staffing saves lives, and in the context of this study, it will end the shortage."

Nurses are not alone in their desire for minimum RN-to-patient ratios. Support among the public for this legislation is strong in Massachusetts. A poll of Massachusetts residents found that more than 75 percent of the public supports legislation regulating nurse-to-patient ratios. And last May, more than 80,000 Bay State residents signed petitions calling upon the legislature to pass a measure requiring an improved RN-to-patient ratio. Since filing its legislation in December, more than 100 legislators have signed on as sponsors for the measure, and more than 47 health care advocacy organizations have endorsed the legislation and joined The Coalition to Protect Massachusetts Patients, a campaign to support passage of the bill.

Similar legislation was passed in California in 1999, where ratios are scheduled to be implemented later this year. While MNA has filed safe staffing legislation in the past, the new bill is based on the most recent scientific data, the experience in California and on recommendations made by a special legislative commission, chaired by State Rep. Christine Canavan (D-Brockton) in 2001, which released a report recommending the regulation of RN-to-patient ratios as a means of addressing the nursing crisis in Massachusetts. Rep. Canavan, who is a registered nurse, is the lead sponsor for the bill, which is entitled "An Act Ensuring Quality Patient Care and Safe Registered Nurse Staffing."

What the Bill Does
Currently, there are no legal or regulatory mandates to ensure that patients receive a level of nursing care that is based upon accepted standards of nursing practice or on their actual need for care. Instead, nurse staffing is left to individual facilities to determine and, too often, those staffing decisions are primarily driven by financial and budgetary factors. As the health care system has moved to a deregulated, free- market system, where competition and cost drive the industry, the industry has responded to these financial pressures by cutting nurse staffing. This has resulted in dramatic increases in the number of patients each nurse is expected to care for.

This legislation attempts to reverse these trends by mandating nurse staffing that is sufficient to care for the planned and unplanned needs of patients. It is based upon significant nursing research and experience. The major provisions of the legislation include:

  • All acute care hospitals would be required to adhere to mandated minimum RN-to-patient ratios as a condition of licensure by DPH;
  • Minimum ratios are established for different types of units/departments in a hospital. The proposed law calls for one nurse for every four patients in medical/surgical units, where most patient care takes place. In emergency departments, the proposed regulations require between a 1-to-1 and a 1-to-3 ratio depending on the severity of the patient’s conditions. Ratios are 1-to-1 in labor and 1-to-2 for intensive care units while other units range from 1-to-1 to 1-to-5 ratio.
  • To provide flexibility in staffing and to account for patients who require more care, the bill calls upon DPH to create an acuity-based patient classification system, which has both standardized criteria as well as standardized ratings for the illness level of patients (a tool to measure how sick the patients are on a particular unit). Based on the acuity/level of illness of the patients assigned to a nurse, the ratio would be improved if those patients require more intensive care (meaning the nurse would be assigned fewer patients). This provision meets one of the key objections of the hospital industry, which has argued that by establishing minimum ratios (without this acuity system), meant that patients who need more care wouldn’t receive it.
  • The bill prohibits any hospital practice of assigning nurses mandatory overtime as a means of staffing. Mandatory overtime has been used by hospitals as a means of staffing hospitals in lieu of recruiting or retaining enough nurses to provide safe care.
  • Clear language related to the role of the licensed nurse and the inability for institutions to delegate to unlicensed personnel those duties which demand nursing expertise. Throughout the 1990’s, the hospital industry attempted to cut costs by replacing nurses with unlicensed personnel, which led to a deterioration in patient care, and helped create the current shortage of nurses.
  • Strong consumer protections for safe RN staffing including a "prominent posting of the daily RN-to-patient ratios" on each unit; and
  • Each facility will provide each patient and/or family member with a toll-free hotline number for the Division of Health Care Quality at DPH, which may be used to report inadequate nurse staffing. Such a complaint shall cause investigation by DPH to determine whether any violation of law or regulation by the facility has occurred and, if so, to levy a fine for substantiated violations.