MNA Positions Statement on Sufficiency of Nursing Care

I. Introduction

In recent years, the health care industry has undergone a dramatic transformation in Massachusetts and across the nation, which has had an equally dramatic impact on nurses as they attempt to provide safe nursing care to patients in a variety of health care settings.

This transformation is characterized by a number of contributing factors, including an increased penetration of managed care, changes in health care financing (i.e. decreases in reimbursement for Medicare and Medicaid), deregulation of the industry resulting in unprecedented competition and consolidation among providers, and the entrance of for-profit health care providers into the Massachusetts’s health care arena. These trends have resulted in an increased focus by many providers on market competition and financial performance. often at the expense of their traditional mission of providing accessible, high quality health care.

For patients, these changes have resulted in shorter hospital stays, and more care and treatment being provided in settings outside of acute care environments. It also has resulted in a dramatic rise in the acuity level of patients in all health care settings. Patients entering a hospital today are more intensely ill. In many cases, patients will leave the hospital and enter home care and nursing home/subacute care environments in a more compromised condition than in years past.

In this environment health care providers have adopted a number of strategies to survive and compete that have had a direct impact on the nursing profession. These strategies are designed to cut the cost of nursing labor to support budgetary goals. They include efforts to downsize nursing staffs, resulting in fewer nurses caring for more patients; or to re-engineer nursing care delivery, resulting in the replacement of licensed nurses with lower paid unlicensed workers.

For nurses, the current health care environment has had a negative impact on their ability to provide adequate nursing care. At a time when patients are sicker and have a greater need for nursing care, nurses report having less time to provide the level of care their patients require. The ultimate reality of today's health care system is that many patients are receiving insufficient nursing care.

Patients cared for in understaffed environments are at risk for inadequate assessment of their condition, increased infection rates, skin breakdown, medication errors, inadequate pain management, falls, and inadequate preparation for discharge. Any or all of these factors can result in increased length of stay, readmissions, and increased cost to the patient, family, taxpayer and the health care system (i). Conversely, there is a positive correlation between an increase in nurse staffing levels and positive outcomes for patients in all of these areas.

This position statement recognizes one clear fact: the ability of nurses to deliver the care consistent with their professional standards is directly related to the number and/or complexity of the patients they are assigned. Current Massachusetts law/regulations, and health care provider policies do not provide appropriate guarantees, or the mechanisms to ensure patients a sufficient level of nursing care. While Massachusetts Department of Public Health regulations mandate that health care providers provide "sufficient" nursing care, "sufficient" is not defined in the regulations. It is hoped that this position statement can serve as the basis for future debate among policymakers, health care agencies and professionals; and in legislative/regulatory initiatives to bring about the changes necessary to guarantee all citizens access to sufficient levels of nursing care.

II. Philosophy

The Massachusetts Nurses Association believes that each patient in all health care settings is entitled to, and must be assured of uncompromised safe nursing care delivered by a licensed nurse. This care commences upon entry into the health care system and continues throughout the patient's clinical course. It requires ongoing assessment, planning, implementation and evaluation of a plan of care established by a Registered Nurse. Nurses have an ethical and legal responsibility to ensure that their nursing care is delivered at a level that meets recognized professional standards.

The Registered Nurse, educated in the art and science of nursing, plans care, maximizes the patient's ability to respond to the therapeutic plan of care, promotes and provides for adaptation to chronic illness and disability, and assures comfort and dignity to individuals and families in all stages of illness. An essential component of nursing care is a therapeutic nurse-patient relationship based on confidence and trust.

There must be sufficient professional nursing staff to enable the nurse to perform these functions as well as educate other members of the health care team to the optimal plan of care. The Nurse Practice Act states that the Registered Nurse “shall bear full and ultimate responsibility for the nursing care which s/he provides to individuals and groups”(2). Fulfillment of this responsibility is contingent upon the availability of a sufficient number of registered nurses who are able and qualified to carry out judgment activities at a level consistent with patient care needs.

III. Ensuring Sufficient Nursing Care

In order for the patient to achieve desired outcomes, nursing must assume responsibility for assuring that the patient's care is being provided by an educated and licensed nurse who has the documented competencies to meet the specific health care needs of the patient in the environment in which the care is being provided. Over the past two decades, studies have shown that care provided by Registered Nurses decreases length of stay, decreases patient complications, and increases patient satisfaction (3).

Characteristics of Sufficient Nursing Care

  • Sufficient nursing care must include patient assessment, plan of care, ongoing evaluation, patient education, discharge planning and follow-up care.
  • This care must be individualized to the patent’s specific needs. Lack of nursing presence may subject the patient to complications, which can increase length of stay and prolong the need for care.
  • The Registered Nurse must coordinate the patient's care, and when appropriate and necessary delegate care to other licensed and unlicensed providers.

Minimum Standards for Ensuring Sufficiency of Nursing Care

  • The nurse must have a caseload which allows enough time to provide the needed care. S/he must be provided a safe work environment, staffing patterns which are supportive of the care required, the opportunity for continuity of care. In assignments, educational opportunities that facilitate the development and/or maintenance of competencies, and the ability to advocate for the patient and his/her needs.
  • Core staffing should be adequate to assure continuity of care and allow for meeting the usual and customary patient needs. Factors determining core staffing include the patient's activity level, their functional capacity for self care, professional standards, an appropriate professional/non-professional skill mix and past statistical patterns.
  • When unusual events occur, a plan must be in place to assure that quality-nursing care continues uninterrupted.

Indicators of Insufficient Staffing

Indications of insufficient staffing, include, but are not limited to:

  • Frequent use of mandatory overtime
  • Floating of nursing staff from one unit to another
  • Use of temporary personnel
  • Unfilled nursing staff vacancies

Any or all of these indicators can lead to fragmentation and decreased continuity of nursing care.

Health Care System Accountability for Providing Sufficient Nursing Care

The agencies within the health care system must be held accountable for the provision of the structure to support sufficient nursing care and achievement of expected outcomes. Each agency and institution must utilize systems that allocate the optimum level of nursing resources for the provision of sufficient nursing cart. These systems must ensure:

  • Individual patient safety needs take precedence over other institutional needs and priorities.
  • The administrative structure allows the nurse to practice according to nationally recognized professional standards of care.
  • There is a system in place to adjust for variations in workload and staffing requirements.
  • A nurse can fulfill his/her professional and ethical responsibility to achieve resolution of any issues that may jeopardize patient care. without fear of reprisal.

IV. A Statement of the Patient’s Right to Sufficient Care

Each patient in all health care settings must be assured of uncompromised nursing care, delivered by a licensed nurse that meets professional standards. Each patient is entitled to:

  1. Care by a licensed nurse who has a patient assignment that allows time for completion of nursing interventions and prevention of complications.
  2. Timely assessments by a professional nurse.
  3. Collaboration with a nurse in developing a plan of care designed to meet their health care needs regardless of the setting.
  4. Participation by family and/or significant other(s) in developing and implementing a plan of care
  5. An environment in which the plan of care is able to be carried out effectively.
  6. Education related to their specific health problem(s) and treatment plan.
  7. Continuous evaluation of the patient’s family’s response to the plan of care.
  8. Discharge planning that takes into account the nursing care needs of the patient and the family.

Definition of Terms

ASSESSMENT: A systematic dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient. Data may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and life style.

PATIENT: The recipient of nursing actions. This may be a single person, or a family or group. Nursing actions towards clients/patients may be directed to disease or injury prevention, health promotion, health restoration, or health maintenance.

CONTINUITY OF CARE: A process that includes patients and significant others in the development of a coordinated plan of care. This process facilitates the patient’s transition between settings based on changing needs and available resources.

EVALUATION: The process of determining both the patient’s progress towards the attainment of expected outcomes and the effectiveness of nursing care.

HEALTH CARE PROVIDERS: Individuals with special expertise who provide health care services or assistance to patients. They may include nurses, physicians, psychologists, social workers, nutritionists/dietitians, and various therapists.

PLAN OF CARE: Comprehensive outline of care to be delivered to attain expected outcomes.

SIGNIFICANT OTHERS: Family members and/or those people significant to the patient.

STANDARDS: Authoritative statements that describe a competent level of clinical nursing practice demonstrated through assessment, diagnosis, outcome identification, planning implementation and evaluation (4).

LICENSED NURSE: Registered Nurse or Licensed Practical Nurse as defined in 244 CMR.


REGISTERED NURSE: Registered Nurse is the designation given to an individual who is licensed to practice professional nursing, holds ultimate responsibility for direct and indirect nursing care, is a graduate of an approved school for professional nursing, and is currently licensed as a Registered Nurse pursuant to M.G.L. c. 112. Included in such responsibility is providing nursing care, health maintenance, teaching, counseling, planning, and restoration for optimal functioning and comfort of those they serve.

UNLICENSED PERSON: A trained, responsible individual other than the qualified licensed nurse who functions in a complementary or assistive role to the qualified licensed nurse in providing direct patient care or carrying out common nursing functions. The term includes, but is not limited to, nurses, aides, orderlies, assistant, attendants, technicians, home health aides, and other health aides. (244 CMR 3.051)


1. American Nurses Association 1997 Implementing Nursing’s Report Card. A Study of RN Staffing Length of Stay, and Patient Outcomes: Washington, D.C., Author.

2. The Commonwealth of Massachusetts, Secretary of State, Regulation Filing and Publication: Regulation 244 CMR 3.01, Board of Registration in Nursing, 1991.

3. Shindul-Rothschild, Judith, RN, CS, Ph.D., “Patient Care: How Good is it Where You Work?” American Journal of Nursing, 1996 (March), New York, New York, Lippencott Publishing Co.

4. American Nurses Association (1191) Standards of Clinical Nursing Practice: Washington, D.C., Author.

Approved by BOD 11/98