What’s New in the Patient Safety World

October 2018

Nurse Staffing Legislative Efforts



In our March 6, 2018  Patient Safety Tip of the Week “Nurse Workload and Mortality” we noted California was the first state to mandate nurse:patient ratios and multiple other states have also already mandated or are considering mandating nurse:patient ratios. But the issue is more complex than simple nurse:patient ratios.


A seminal study by Aiken and colleagues found that each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue (Aiken 2002).


We fully support legislation that raises nurse:patient staffing ratios. But the issue is more complex than simple nurse:patient ratios. Those ratios do not take into account actual nurse workload nor do they take into account the fatigue factor that may accompany long work shifts or forced overtime. One factor that comes into play in those conditions is the concept of “missed nursing care” or “care left undone” (see our Patient Safety Tips of the Week for November 26, 2013 “Missed Care: New Opportunities?” and May 9, 2017 “Missed Nursing Care and Mortality Risk”).


We discussed the issue of nursing workload in detail in our Patient Safety Tips of the Week for March 6, 2018 “Nurse Workload and Mortality” and May 29, 2018                    More on Nursing Workload and Patient Safety”.


In the upcoming (November) election in Massachusetts one of the items to be voted upon is Question 1, which would mandate nurse staffing ratios at all hospitals. Nurse:patient ratios would take into account the type of unit and some measure of intensity.


The battle lines are drawn. The Massachusetts Nurses Association, which strongly supports the proposed legislation, has estimated the total cost of such a mandate would be $47 million. But other groups have estimated that the cost would be $74.8 million dollars per year just for the four state-run hospitals in Massachusetts (Coalition 2018). The Massachusetts Health Policy Commission, an independent state agency, says that “mandating of nurse-to-patient staffing ratios in Massachusetts could have a significant impact on health care costs, quality and access in the state” (Salsberg 2018). The opposition to Question 1, led by the Coalition to Protect Patient Safety, has received more than $11 million in campaign contributions while the support, led by the Committee to Ensure Safe Patient Care, has banked almost $6 million, according to the latest reports from the Massachusetts Office of Campaign and Political Finance (Cohan 2018).


Massachusetts had already passed a law, effective as of 2016, requiring a 1:1 or 2:1 patient-to-nurse staffing ratio in intensive care units (ICU) in the state, and guided by a tool that accounts for patient acuity and anticipated care intensity. Just published was an analysis of the impact of this legislation on patient outcomes (Law 2018). The researchers compared staffing levels and mortality and certain patient complications between Massachusetts ICU’s and out-of-state ICU’s. There actually were only modest increases in ICU nurse staffing ratios in Massachusetts (from 1.38 patients per nurse before implementation to 1.28 patients per nurse after) and those staffing increases were largely mirrored in other states that did not have the mandate. Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts or when compared with changes in hospital mortality in other states. Complications and DNR orders also remained unchanged relative to secular trends. The authors conclude that the law had little impact on either staffing levels or patient outcomes.


We’re not quite sure what to make of the results after passage of the previous Massachusetts legislation. We might have predicted that, because ICU’s are already staffed at high levels, we would not see much change. But the proposed new legislation is aimed at all hospital units, not just ICU’s, and that is where we are most likely to see a substantial impact on patient outcomes.


We believe the prior research that shows staffing levels do influence patient outcomes. But as we’ve discussed in so many prior columns, there needs to be a match between staffing levels and nursing workload. Patient acuity is only one potential component of workload. In our prior columns we noted several tools that have been used as better measures of nursing workload.


The proposed Massachusetts legislation is a political hot potato. It pits hospitals vs. nurses’ unions. Both should be interested in the most important outcome: what happens to our patients. We are concerned that the uncertain costs of implementing this legislation may lead to it being voted down and that a potentially useful strategy for improving patient care will be lost. We believe it would have been more politically expedient for Massachusetts to have funded a semi-controlled study in which the state would select a representative sample of different types of hospital (academic, community, rural, etc.) and foot the cost of any upgraded staffing there (CMS and other third party payers could also have contributed to such funding) and then compare patient outcomes against all the other hospitals.


Come November we’ll find out how the electorate of Massachusetts feels.



Some of our other columns on nursing workload and missed nursing care/care left undone:


November 26, 2013    Missed Care: New Opportunities?

May 9, 2017                Missed Nursing Care and Mortality Risk

March 6, 2018             Nurse Workload and Mortality

May 29, 2018              More on Nursing Workload and Patient Safety






Aiken LH, Clarke SP, Sloane DM, et al. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA 2002; 288(16): 1987-1993




Coalition to Protect Patient Safety (Press Release). Official Massachusetts Voter Guide Estimates Question 1 Will Cost State At Least $67.8 Million. September 28, 2018




Salsberg B. Backers of nurse staffing proposal object to agency's study. The Hour 2018; September 29, 2018




Cohan A. Fight over nurse workload. Hospitals battle unions in Nov. ballot question. Boston Herald 2018; September 30, 2018




Law AC, Stevens JP, Hohmann S, et al. Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations. Critical Care Medicine 2018; 46(10): 1563-1569





Print “PDF version














Tip of the Week Archive


What’s New in the Patient Safety World Archive