News & Events

To Protect Patients and Improve Care, Mass Nurses File Ballot Initiative for Safer Staffing Levels in Mass. Hospitals

CANTON, Mass. — In response to deteriorating patient care conditions in the state’s acute care hospitals, the Massachusetts Nurses Association/National Nurses United (MNA/NNU) announced today that it is filing a ballot initiative, the Patient Safety Act, that would dramatically improve patient safety in Massachusetts hospitals by setting a safe maximum limit on the number of patients assigned to a nurse at one time, while also requiring hospitals to adjust nurses’ patient assignments based on the specific needs of the patients.

The filing of the initiative follows the release of dozens of prominent research studies and reports that show beyond any doubt the need to set a maximum limit on the number of patients that can be assigned to each registered nurse if we are to avoid — mistakes, serious complications and preventable readmissions.


“The research is clear and unequivocal, the most important factor contributing to the health and safety of patients while they are in the hospital is the number of patients your nurse is assigned to care for during his or her shift,” explained Donna Kelly-Williams, president of the MNA/NNU and one of the 10 original signers of the petition to establish the ballot initiative. “The fact is patients in our hospitals are at greater risk because they are being forced to share their nurse with too many other patients at the same time.”


“In Massachusetts there is no law that states the maximum number of patients a nurse can safely care for at any one time, nor is there any requirement for hospitals to adjust their staffing levels based on the actual needs of the patients,” Kelly-Williams explained. “As a result, hospitals are forcing nurses to ration care, placing patients’ health in jeopardy. This ballot measure will ensure patients receive the care they need and deserve, when they need it, preventing thousands of patient complications, saving hundreds of lives, and yes, saving millions of dollars that are being wasted now because patients aren’t receiving adequate, timely care from their nurse.”


The nurses’ call for the law has intensified in recent years in reaction to dramatic changes within the hospital industry driven by state and national health care reform, including the merger, consolidation and conversion of non-profit hospitals into larger corporate networks. None of this has been beneficial for patients, according to the nurses, as the industry’s response has been to cut staff and to reduce services while many are adopting business practices employed by the retail and manufacturing sector, where patients are treated like widgets or products on an assembly line. It’s no surprise that as a result of these changes, Massachusetts hospitals were among the most heavily penalized by Medicare last year for preventable readmission of patients. In fact 54 of the state’s 67 hospitals were penalized by Medicare for poor care last year, and several received the highest penalty possible. 


“The focus now is on the almighty dollar, and not the patient,” said Karen Higgins, RN, a critical care nurse at Boston Medical Center and co-signer of the initiative petition. “The bottom line for nurses is our patients, and when we have too many patients to watch over and monitor at one time, bad things can happen, including delays in nursing assessment, delayed administration of medications and tests, nurses missing significant changes in patients’ health status, poor patient outcomes, patients falling due to lack of assistance in getting up and moving and patients being left in soiled beds for hours at a time.”


Below is a summary of key research findings that underscore the value of setting maximum patient limits:

·         Higher nurse workloads are associated with more patient deaths, complications, and medical errors — “State Mandated Nurse Staffing Levels Alleviate Workloads, Leading to Lower Patient Mortality and Higher Nurse Satisfaction,” Agency of Health Research and Quality, AHRQ Healthcare Innovations Exchange, Sept. 26, 2012.

·         JAMA reported that for every patient in addition to four assigned to a nurse, the risk of death and failure to rescue increases by 7 percent. The author of the study concluded that legislation to regulate RN-to-patient ratios was a credible approach to improving patient safety in hospitals.

·         Each additional patient assigned to an RN is associated with a 53 percent increase in respiratory failure, a 7 percent increase in the risk of hospital-acquired pneumonia, and a 17 percent risk in medical complications — AHRQ Publication No. 08-0043, 2008.

·         A recent study in the online journal BMJ Quality and Safety in Health Care established a direct link between nurses’ patient assignments and hospital readmissions for children with common medical and surgical conditions. It found an increase of just one patient in a hospital’s average staffing ratio raised the likelihood of a medical patient’s readmission by 11 percent – and the odds of readmission for surgical patients by 48 percent. Another study, published in JAMA Pediatrics, found that inadequate nursing staff and higher patient assignments in the neonatal intensive care unit led to higher levels of infections in low birth weight infants.


·         New Jersey hospitals would have 14 percent fewer patient deaths and Pennsylvania 11 percent fewer deaths if they matched California’s 1:5 nurse-to-patient limits in surgical units (California is the only state in the nation with a law establishing RN-to-patient limits) — Health Services Research Journal, August 2010.


·         With improved nurse staffing levels, patient risk of hospital-acquired infections and hospital length of stay decrease, resulting in lives saved — Medical Care, Volume 47, Number 1, 2009.


While the MNA/NNU has filed a companion bill in the legislature on this issue, the organization is pursuing a dual track by keeping the option open to take the issue directly to public via a ballot initiative should the Legislature not act. 


“For the better part of 15 years we nurses, along with more than 100 allied health care and consumer groups, have attempted to improve patient care by asking our legislature to create a law that stipulates the maximum number of patients a nurse can safely care for at one time. While we continue to push for a legislative solution, should the legislature fail to act, we are taking this issue directly to those who are most impacted and placed at risk by this issue – the voters,” said Kelly-Williams.


Massachusetts is one of 10 states and the District of Columbia to have filed legislation in the last two years to create a maximum limit on the number of patients that can be assigned to nurse at one time. California passed its landmark bill in 1999, with full implementation in 2004. Since then, the law has proven to be a resounding success, with studies like those cited above, showing improved patient outcomes and safety. And contrary to industry claims, not a single hospital has closed as a result of the law, and in fact, hospital profits dramatically increased since the law’s passage. 

“The time has come to pass this law, and we know the public supports it,” said Higgins. “We have conducted numerous polls in the past and every time, voters’ voice strong support for this measure. More than 100 leading consumer and health care advocacy groups have signed on to support our efforts in the past, and as nurses we know the public values what we do and the role we play in their care.”

The MNA/NNU intends to move this measure with the sweat equity of its 23,000 members, who will be out in their communities gathering the signatures needed to place the initiative on the ballot.  As part of the campaign a web site – – and Facebook page for the initiative have been launched to educate the public about this issue with the theme “Just Ask About Patient Safety.” The theme is based on the fact that the most important variable impacting the safety of our patients is the number of patients assigned to a nurse at one time.  The site provides information on the research supporting the initiative and the ability to sign on to the campaign to gather signatures. 

Fact Sheet on The Patient Safety Act

Currently there is no law and there are no standards in existence for the number of patients that can be assigned to a nurse at one time in Massachusetts hospitals, and there are no requirements for hospitals to provide an adequate level of nursing care. It is not uncommon for nurses in Massachusetts to have six, seven or even eight patients at a time, when a safe ratio would be no more than four patients for a nurse on a typical medical/surgical floor. This initiative attempts to reverse these trends by setting safe patient assignment limits that are 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:


  • Maximum safe patient limits for nurses would be 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 nurses to care for between one and three patients depending on the severity of the patient conditions, and for nurses in critical care units to have between one and a maximum of two patients based on the needs of those patients.
  • To provide flexibility in staffing and to account for patients who require more care, the bill calls upon a state agency to establish an “acuity” system, which is a standardized formula for rating the illness level of patients (a tool to measure how sick the patients are on a particular unit). Based on the acuity of the patients assigned to a nurse, the maximum safe patient assignment would be reduced if those patients require more intensive care. Right now, there is no law or regulation that requires hospitals to adjust RN staffing based on patients needs, and as a result, most hospitals rarely make such improvements.
  • All acute care hospitals would be required to adhere to these safe patient assignment standards and the acuity scale.
  • Hospitals would not be allowed to meet the necessary RN staffing standards for the safe patient assignment limits by diminishing other members of the health care team.
  • Hospitals found by the state to have violated the law will be subject to a $25,000 fine for each day they fail to be in compliance. 

“In the months to come, the nurses of Massachusetts look forward to working with the public on this initiative to ensure that all patients in all hospitals receive the highest standard of care when it matters most,” Kelly-Williams concluded.