Nursing Ratios + Healthcare

Blog post by Colin Hung.

Last week I attended #SHSMD18 – the annual conference of the Society for Healthcare Strategy & Market Development. While at the event, I had an unexpected conversation with several marketing leaders from hospitals in the US Northeast. They were all concerned about the upcoming vote in Massachusetts on mandatory nursing ratios that would be on the November ballot.

According to the website of the Secretary of the Commonwealth of Massachusetts, William Francis Galvin, voters at November 6th State Election will be asked if they approve of the law that would “limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities.”

The proposed law sets specific limits on the patient-nurse ratio. For example:

  • 3 patients per nurse in units with step-down/intermediate care patients
  • 1 patient under anesthesia per nurse in units with post-anesthesia care or operation room patients
  • 5 patients per nurse in units with psychiatric or rehabilitation patients

Not surprisingly the powerful Massachusetts Nurses Association has thrown their support behind the proposed law. They have mounted a strong campaign that equates mandated staffing levels to patient safety. They cite many studies that show better patient outcomes when nurses are assigned fewer patients, like this one from 2017 – “Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study”. They claim that in the current healthcare environment, hospital administrators are more concerned about the bottom line than about patient safety – and this law is needed to balance the scales.

On the other side, the Massachusetts Health and Hospital Association strongly opposes the proposed law. They argue that the one-size-fits-all approach to nursing levels at every hospital in the state is far too rigid. They claim that should the law pass, it will cost nearly $900 Million every year to staff to the mandatory levels and that patients will end up footing most of that bill as costs are increasingly being downloaded to individuals through high-deductible plans. The association also claims that ER wait times will skyrocket as patients will be made to wait solely because there aren’t enough nurses in the ER and in order to comply with the law, they will have to queue up patients in need.

I must admit, that when I first learned of the proposed law, I thought it sounded pretty logical. More nurses = better care for patient AND less burnout for nurses. Who wouldn’t want that? But when I started to read more, I realized that the debate is much more nuanced.

The State of California has had mandatory nursing laws since 1999 (fully implemented in 2004). In a recent interview with WGBH News (Boston’s local public radio station), Joanne Spetz, a professor at the University of California, San Francisco, who has been studying the results of this law had this to say:

“Overall, there is evidence of what I would describe as better nurse outcomes — more satisfaction, better pay, less burnout, lower injury rates. When you look at patient outcomes, it’s a wash. Maybe hiring more RNs, but laying off your aides, meant that you had an improvement in one area and then you had something get worse in another area.”

Spetz also mentioned that the patient wait times in ERs never materialized in California – something that had been feared before the passing of their mandatory nurse ratio law.

The rest of the WGBH News article provides an excellent overview of the Massachusetts debate.

I honestly don’t know how I feel about the proposed law. On one hand I believe that some hospitals and healthcare organizations need more nurses – not just for better patient outcomes but for improved quality of life for nurses themselves. Fewer nurses leads to burnout and workplace injuries. On the other hand, who is going to pay for the nurses that need to be hired and where are they going to come from? It has been suggested that nurses from school districts and home care agencies will be drawn away to fill the mandatory spots.

As a believer in HealthIT I also feel that the law ignores advancement in technology. What if one day we have robotic nurses? Or more likely, what if we find better ways to keep people out of hospitals entirely and at home? Will home care agencies be able to compete for nurses with hospitals? No matter what advances happen, it is highly doubtful lawmakers will be able to keep up with the pace of change in healthcare.

I’m going to be very interested in this healthcare question on the MA ballot on November 6th.

Join me Tuesday October 16th at 8:30pm ET (for your local time click here) as we explore the nursing situation in healthcare.

  • T1 Where do you feel nurses are most urgently needed in healthcare right now? Hospitals? Home Care? Schools? Private Practice?
  • T2 Should nurse-to-patient staffing ratios be mandated? Why or why not?
  • T3 What could healthcare leaders do to help the nursing situation if not through mandatory ratios?
  • T4 What technology, process or workflow solution could help nurses give the best care possible to patients?


McCluskey, Priyanka Dayal. “Nurses union, hospitals battle over ballot question setting patient limits“, The Boston Globe, 20 March 2018,, accessed 14 October 2018

Pecci, Alexandra Wilson. “Nurse-Patient Ratio Law in MA Raises Cost, Quality Concerns”, HealthLeaders, 23 June 2015,, accessed 14 October 2018

Emanuel, Gabrielle. “Seven Questions About The 2018 Nurse Staffing Ballot Question In Massachusetts”, WGBH News, 2 July 2018,, accessed 14 October 2018

2018 Ballot Questions, William Francis Galvin, Secretary of the Commonwealth of Massachusetts,, accessed 14 October 2018

Heath, Sara. “How Nurse Staffing Ratios Impact Patient Safety, Access to Care”, Patient Engagement HIT, 14 August 2018,, accessed 14 October 2018

Aiken LH et al. “Implications of the California nurse staffing mandate for other states”, Health Services Research, 9 April 2010,, accessed 14 October 2018

Tevington, Pamela. “Mandatory Nurse-Patient Ratios”, MedSurg Nursing, October 2011,, accessed 14 October 2018

Abraham, Tony. “Fight for mandatory nurse-to-patient ratios heats up”, Healthcare Dive, 15 June 2018,, accessed 14 October 2018

Lee, Anna et al. “Are High Nurse Workload/staffing Ratios Associated with Decreased Survival in Critically Ill Patients? A Cohort Study.” Annals of Intensive Care, 2017,, accessed 14 October 2018

Image Credit

Nurse – Robert Bieber

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