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Nurse Staffing Ratios to Hit the Ballot in Massachusetts


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Will Massachusetts follow in California's footsteps and establish limits on the number of patients a nurse can care for at one time? Bay State voters will have the chance to make that decision in November, when the Patient Safety Act appears as a ballot measure.

On Monday, the Supreme Judicial Court rejected the challenge brought by the Coalition to Protect Patient Safety, a hospital-backed group that opposed the ballot measure.

The coalition argued that Attorney General Maura Healey should not have certified the measure because the ballot initiative's two main provisions — the patient limits and a prohibition on any "reduction in the staffing levels of the health care workforce" due to the implementation of the patient limits — are not linked closely enough to be part of one ballot question.

In response, the attorney general’s office said the proposed question was approved because “all of its parts are operationally related to its common purpose of implementing patient-to-nurse assignment limits in hospitals.”

Ultimately, the court agreed with the AG’s office. Justice Barbara Lenk wrote as part of the court’s ruling: "This staffing reduction restriction represents a permissible choice of the law's drafters as to how the patient assignment limits may be implemented. As long as all parts of the proposed law are related, as they are here, such policy choices are committed to the drafters' discretion and will not be disturbed."

Up for Vote
Now that it will be on the ballot, what does the proposal entail?

The Patient Safety Act is a proposed law drafted by the Committee to Ensure Safe Patient Care, a coalition is made up of advocates across Massachusetts, including registered nurses, patients and family members, health and safety organizations, community groups, unions, and elected officials. The Massachusetts Nurses Association also supports the initiative. For years, nurses have pushed staffing requirement legislation, but their proposals have failed to gain traction in the legislature.

The proposal outlines how it would limit the number of patients for each nurse based on unit type and level of care:

  • In units with step-down/intermediate care patients: three patients per nurse;
  • In units with post-anesthesia care or operating room patients: one patient under anesthesia per nurse; 2 patients post-anesthesia per nurse;
  • In the emergency services department: one critical or intensive care patient per nurse (or two if the nurse has assessed each patient’s condition as stable); two urgent non-stable patients per nurse; three urgent stable patients per nurse; or five non-urgent stable patients per nurse;
  • In units with maternity patients: (a) active labor patients: two patient per nurse; (b) during birth and for up to two hours immediately postpartum: one mother per nurse and one baby per nurse; (c) when the condition of the mother and baby are determined to be stable: one mother and her baby or babies per nurse; (d) postpartum: six patients per nurse; (e) intermediate care or continuing care babies: two babies per nurse; (f) well-babies: six babies per nurse;
  • In units with pediatric, medical, surgical, telemetry, or observational/outpatient treatment patients, or any other unit: four patients per nurse; and
  • In units with psychiatric or rehabilitation patients: five patients per nurse.


The main criticism of the proposal has to do with the prohibition on reducing the staffing levels of the healthcare workforce.

“The Workforce Reduction Ban is not limited to nurses, bedside caregivers, or any similarly tailored category," the coalition wrote in its argument to the court. "Instead, the ban dictates the retention of virtually everybody who works for or at a subject facility, including many workers (e.g., lawyers and marketers) whose job functions could not possibly have an impact on the quality of nursing care in particular, or on patient safety in general."

The issue will be put to Massachusetts voters on November 6, and if approved, would take effect January 1, 2019.