News & Events
New Approach to Safe Patient Limits on Beacon Hill by MNA Nurses and Healthcare Professionals Joins Legislation to Tackle Longstanding & Untenable Staffing Conditions Exacerbated by the COVID-19 Pandemic
MNA legislation filed for the 2023-2024 term focuses on patient care conditions, equal access to essential healthcare services, and workplace violence protection
BOSTON, Mass – The more than 25,000 nurses and healthcare professionals of the Massachusetts Nurses Association have joined with allies in the Massachusetts House and Senate to file new legislation that would enact safe patient limits for all hospital units through a process led by the Department of Public Health.
The measure responds to a longstanding and growing crisis in Commonwealth patients’ access to appropriate nursing care, a crisis that is endangering patients and has driven thousands of nurses away from hospital bedside nursing. The most glaring symptom of this crisis is the recent flurry of high profile strikes by nurses, including the groundbreaking 10-month strike by the St. Vincent Hospital nurses in 2021/2022, as well as more recent strikes or planned strikes in Minnesota, New York and California including several thousand nurses and allied health professionals – all of which called for safer staffing with safer patient limits as a primary issue.
The new patient safety legislation is entitled “An Act Promoting Patient Safety and Equitable Access to Care” and is sponsored by Sen. Lydia Edwards, D-Third Suffolk, and Rep. Natalie Higgins, D-4th Worcester. It features a different approach to developing nurse-patient limits in each unit of acute care hospitals than Question 1, the ballot question put forward by the MNA in 2018. The bill would empower DPH to hold public stakeholder hearings and promulgate regulations that establish specific limits on the number of patients a registered nurse shall be assigned to care for at one time.
“There is absolutely no question that limiting the number of patients a nurse cares for at one time is safer for patients and the only solution to the current nurse staffing crisis,” said Katie Murphy, a practicing ICU nurse, and President of the Massachusetts Nurses Association. “To be clear, there is no shortage of nurses in Massachusetts, there is a shortage of nurses willing to continue working under the current conditions and staffing practices implemented by profit-driven hospital administrators over the last 15 years. The benefits of safe patient limits were settled science before the pandemic, and today there is even more research and nurse experiences to support this legislation.”
"It's about safety,” said bill sponsor Senator Lydia Edwards, D-Third Suffolk. “Safety for patients and safety for nurses. I want to know that my nurse is working under the best conditions. To know what works best for nurses means we have to listen to them."
"I am proud to introduce legislation that will help address our nurse staffing and care quality crisis by directing the Department of Public Health to gather feedback and establish safe patient limits for all of our hospitals,” said bill sponsor Representative Natalie Higgins, D-4th Worcester. “Our nurses have fought to protect our loved ones during the pandemic, and we need to make sure they can continue to provide that care safely for all of our neighbors."
The approach featured in the new MNA safe patient limits legislation is like that taken by California when it enacted a safe patient limits law in 1999 and implemented it in 2004. Research has shown that California’s law reduced nurse workloads, improved recruitment, and retention of nurses, and had a favorable impact on quality of care.
NEW RESEARCH AND DECADES OF SCIENCE SUPPORT SAFE PATIENT LIMITS
A study recently published by a group of professors at the University of Pennsylvania School of Nursing – including Linda Aiken and Matthew D. McHugh, two of the world’s preeminent researchers of nurse-patient limits – demonstrates that nurse staffing problems predate the pandemic, were created by the hospital industry, and require permanent improvements to nurse working conditions. The highlights, as presented in the December 2022 edition of the journal Nursing Outlook, include:
• Better staffed hospitals before pandemic had better outcomes during it.
• Policies to prevent chronic hospital nurse understaffing are needed.
• Minimum hospital patient/nurse ratio policies recommended.
“Chronic nurse understaffing and poor work environments in hospitals that existed prior to the Covid-19 pandemic and worsened during it are the major explanations for why many hospitals cannot hire and keep enough nurses even though Covid-19 hospitalizations have dropped,” the study authors concluded.
“Without fundamental improvements in hospital nurse staffing and work environments, the shortage of nursing care in hospitals will not likely abate even after the Covid-19 pandemic has run its course. Increasing the supply of nurses through short-term emergency measures is unlikely to solve the problem. Hospitals need to hire more permanent registered nurses, provide more favorable work environments, and earn back the confidence of nurses that quality and safety of patient care are institutional priorities. Because most hospitals have not implemented substantial improvements in either staffing or work environments over the past decade (Aiken et al., 2018; Sloane et al., 2018), policymakers should mandate hospitals to meet minimum safe nurse staffing standards.” (emphasis added)
The study joins decades of scientific research showing the benefits of safely limiting the number of patients a nurse cares for at one time. Recent research on the topic includes:
- “Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study,” BMJ Open, December 2021.
- “If study hospitals staffed at a 4:1 ratio during the 1-year study period, more than 1595 deaths would have been avoided and hospitals would have collectively saved over $117 million.”
- “Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study,” BMJ Quality and Safety, September 2022.
- “Our study shows that both the level of RN staffing and the seniority mix of RNs were associated with patient mortality outcomes, but HCSW and agency nurse staffing were not.”
- “The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study,” International Journal of Nursing Studies, August 2021.
- “Exposure to shifts with high levels of registered nurses had lower odds of mortality by 8.7% [odds ratio 0.91 95% CI 0.89–0.93]. Conversely, low staffing was associated with higher odds of mortality by 10% [odds ratio 1.10 95% CI 1.07–1.13].”
- “Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals,” Lancet, May 2021.
- “Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.”
- “Is Hospital Nurse Staffing Legislation in the Public’s Interest? An Observational Study in New York State,” Medical Care, May 2021.
- “Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions.”
- “Staffing levels and nursing-sensitive patient outcomes: Umbrella review and qualitative study,” Health Services Research, March 2021.
- “…fewer nurses likely increase the probability that patients do not feel cared for with an adequate amount of time or attention. One explanation for the strong evidence for length of stay and readmission could be that nurses facing understaffing might be less likely to detect complications or new health problems at early stages. Such complications might increase length of stay or become apparent and worsen after discharge, ultimately necessitating readmission.”
- “Chronic hospital nurse understaffing meets COVID-19: an observational study,” BMJ Quality and Safety, August 2020.
- “Hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health. Such risks could be addressed by safe nurse staffing policies currently under consideration.”
In addition, there is significant research specific to the California safe patient limits law and research connecting patient limits to safety in Massachusetts hospitals:
- Research Linking Safe Patient Limits to Patient Safety in Massachusetts Hospitals (PDF)
- Research Showing How a Law Setting Safe Patient Limits Has Improved Patient Care for California Hospitals (PDF)
8,300+ UNSAFE STAFFING REPORTS FILED IN 2022
Faced with this industry-created crisis, nurses in 2022 filed at least 8,320 official unsafe staffing reports at hospitals across Massachusetts. These reports document to hospital administrators instances in which nurses were forced to take excessive patient assignments that “poses a serious threat to the safety and well-being of my patients.”
“Objection and Documentation of Unsafe Staffing” forms, as they are called, are used by nurses in all MNA-represented hospitals, which is 73% of the state’s acute care hospitals. They are a tool for nurses to document, in real time, any situation where they come on their shift and are given an assignment that is unsafe for their patients, which prevents them from delivering the quality care those patients require.
The MNA has established a webpage featuring examples of unsafe staffing reports at www.massnurses.org/unsafeexamples. A newborn baby, who was supposed to be cared for by a single nurse, lay screaming for 10 minutes in a pediatric unit on Cape Cod while nurses struggled to manage another patient admitted in severe pain. Patients needed continuous telemetry and oxygen monitoring but are in an unsafe situation in a hallway in the Brigham and Women’s Hospital ED. A Beth Israel Plymouth nurse struggled with a high patient assignment in the Senior Behavioral Health Unit, including patients at risk for falls, with impulsivity and severe aggression. “This is not safe!” wrote a desperate nurse in the Cooley Dickinson Hospital ED about a shift when they need 11 nurses and had only nine.
The examples include a vivid explanation of a harrowing patient assignment given to a St. Vincent Hospital nurse. “Even with help from my colleagues, it was a terrible day, which left me sitting in my car, weeping, a broken heap of a nurse. I really wanted to walk that day,” the nurse wrote.
These reports are an effort by nurses to communicate their concerns to management so that steps can be taken to improve care. In fact, in the hospitals represented by the MNA, nurses often meet monthly with hospital administrators where they present these reports in the hope of creating meaningful solutions. But rarely, if ever, are steps taken to address these issues. In other instances, nurses, like the nurses at Good Samaritan Medical Center in Brockton had to file a federal complaint with the Center for Medicare and Medicaid Services over chronic and dangerous understaffing and patient safety concerns in the hospital’s emergency department, after failed attempts to convince to address the crisis.
NEW STAFFING BILL EVOLVES FROM PREVIOUS EFFORTS
In 2019, the MNA filed the Workforce Development and Patient Safety Act following the defeat of Question 1. The legislation was an effort to clear up the confusion and misinformation caused by the intense debate over the issue of safe patient limits for nurses and the hospital industry spending more than $30 million on TV and radio advertising, as well as on direct mail to voters and policymakers, much of it containing misleading information about the issue to scare the public into opposing the measure. That legislation would have funded independent research studies on nurse staffing, the supply of nurses, and measures of care quality.
Since the pandemic hit, those issues have become much clearer. As evidenced in the research described above, numerous studies have shown the efficacy of safe patient limits in several different places. As WBUR has documented, there is not a shortage of nurses in Massachusetts. Rather, there is a shortage of nurses willing to work under the current conditions at the bedside. In addition, countless media stories and the MNA’s State of Nursing in Massachusetts survey demonstrate a care quality problem that must be addressed with nurse retention and recruitment tools that are accountable to the public and not just hospital executives. According to the 2022 survey, more than 8 in 10 nurses have seen hospital care quality worsen significantly, with 69% saying their biggest obstacle was understaffing and having too many patients.
“Now is the time for safe patient limits to help fix our broken healthcare system, address our staffing crisis and give the public a way to hold hospitals accountable for the quality of nursing care,” Murphy said. “Everyone deserves a safe standard of hospital care, and this advocacy – this fight we continue to wage on behalf of our patients – won’t be over until we achieve that goal.”
HOSPITAL EXECUTIVES CALLED FOR POST-QUESTION 1 NURSE STAFFING SOLUTIONS
After Question 1 was defeated in 2018, the Massachusetts hospital industry explicitly said it would continue looking for solutions. MHA President & CEO Steve Walsh said in a statement, “This is not a victory, but an opportunity to continue to find solutions together as health care professionals -- working together, as one, for patients. Question 1 forced some difficult and necessary discussions about the future of healthcare and the future of our workforce going forward.”
The Cape Cod Times reported that Michael Lauf, president, and CEO of Cape Cod Healthcare,
sent a statement to staff after the Question 1 vote saying now is the “opportunity to begin a greater conversation” about reforming health care. However, when the pandemic hit our state, Lauf decided to furlough more than 600 hospital staff, and then closed the maternity unit at Falmouth Hospital. A report subsequently issued by the Massachusetts Health and Hospital Association did not include any enforceable staffing improvement measures.
“Unlike nurses, hospital executives cannot be trusted to fix our broken healthcare system and staffing crisis,” Murphy said. “When the pandemic hit, hospitals were already barely staffed to meet corporate financial priorities. Hospital executives then exclaimed in wonder that they did not have enough healthcare workers. Safe patient limits will help halt this damaging cycle and prepare us better for future health crises.”
In addition to the new safe patient limits law, the MNA is filing with its legislative sponsors nearly 20 other bills. Proposed legislation includes clarifying the existing ban on nurse mandatory overtime, workplace violence prevention, protection for essential services, and bills to address the mental healthcare crisis. New legislation filed this term by the MNA includes bills to prevent home health violence, address the danger of surgical smoke, and examine the state of essential services across the Commonwealth. Click here for the full MNA 2023-2024 legislative agenda.
Founded in 1903, the Massachusetts Nurses Association is the largest union of registered nurses in the Commonwealth of Massachusetts. Its 25,000 members advance the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Legislature and regulatory agencies on health care issues affecting nurses and the public.