Mandatory Nurse to Patient Ratios


Where it began...

In 1999 California became the first state in the United States to implement mandatory nurse to patient staffing ratios.  Hospitals were required to maintain required staffing ratios starting January 1, 2004 or face hefty fines.  In 2006, a study demonstrated that by putting a limit on nurse patient assignments California has increased patient safety, decreased inpatient mortality, and increased nurse job satisfaction.¹  

What it would mean...

In November, Massachusetts will be voting on ballot question 1: mandated nurse to patient ratios.  With the exception of intensive care units, Massachusetts does not have laws or limits on the amount of patients a nurse can care for at any one time.  Currently, ICU RNs provide patient care with a ratio of 1:2 due to their high acuity and increased mortality risk.  

Question 1 on the Massachusetts ballot provides strict limits on patient assignments for units not limited to the ICU but encompassing all inpatient care throughout Massachusetts.  If passed, Massachusetts will be the second state in the United States to officially mandate nurse to patient ratios.   Hospitals will be held accountable for any violations of these limits.

Question 1 is widely supported by the Massachusetts Nurses Association and Nurses Unions

Arguments in FAVOR of Question 1:

  • Increase in volume and acuity of patients causes nurse burnout when staffing is not safe
  • Data claims that patient safety and decreased patient mortality is correlated with safe staffing ratios
  • Supports job retention by reduceing the amount of nurses voluntarily leaving the profession
  • Will not increase emergency room wait times as nurses will be better able to efficiently deliver care when not overwhelmed with unsafe patient assignments
  • Patient readmissions are reduced when nurses are able to spend adequate time on discharge planning and patient education

Watch this video to learn more about why the Massachusetts Nurse Association wants you to vote "Yes" on Question 1:

Click to read the article outlining the survey's findings


Opposition to Question 1 is supported by the Massachusetts Health & Hospital Association, Hospital industry, and the Massachusetts chapter of the American Nurse Association.

Arguments OPPOSING Question 1:

  • State mandating nurse to patient ratios may lead to longer wait times in emergency rooms as patients will have to wait to be seen by an available nurse 
  • Worsen the current nursing shortage
  • May pull skilled nurses from other areas limiting the amount of nurses available for home care, community health, and outreach programs.
  • Limit autonomy of RN's to decide what patient assignment is appropriate for their unit
  • Extreme cost to fund staffing requirement may cause units, hospitals, and special services to close and may increase healthcare costs for patients and insurers
  • The opposition denies there is any substantial data that supports the claim that mandated nurse staffing ratios increases patient safety. 

Watch this video to learn more about why the Massachusetts chapter of the American Nurses Association wants you to vote "No" on Question 1:

Which side should you choose...

Nurses all in all are split on the proposed mandates.  Nurses want to provide the safest care possible to their patients as well as the have the autonomy to decide what an appropriate assignment should be.   The value of the nursing profession to our healthcare system is immeasurable, however, the need of increased funding to staff stricter ratios may negatively affect other aspects of the healthcare system.  Clearly, there are challenges to both sides of the issue.


During a nursing shortage and a time where there is also a shortage of qualified, willing nursing educators, nursing schools are turning away prospective students.  Mandated nurse to patient ratios may be a step in the right direction to increase pressure for funding of nursing schools and the universities that are preparing RNs for the work force.

What you can expect...

If Question 1 passes in November, the Massachusetts healthcare system will have to take a multi-faceted approach to beefing up it's RN workforce. 

The new staff mandates must take effect by the January 1st, 2019 deadline.  Violations will be fined upwards of 25,000 for each occurrence.  Below is a table of what the proposed nurse staffing guidelines would look like:


If this ballot passes, Massachusetts may be just the beginning when it comes to ensuring safe patient limits for nurses and reducing nursing burnout overtime.

Thanks for reading!


1 Aiken, Linda H., Douglas M. Sloane, Jeannie P. Cimiotti, Sean P. Clarke, Linda Flynn, Jean Ann Seago, Joanne Spetz, and Herbert L. Smith. “Implications of the California Nurse Staffing Mandate for