The Governor of Massachusetts on Monday, June 30, 2014, signed into law a bill (H 4228) that dictates nurse staffing levels in intensive care units in all the state’s hospitals. An Act for Patient Limits in All Hospital Intensive Care Units will require a one- or two-patient-per-nurse ratio in intensive care units depending on the stability of the patient “as assessed by the acuity tool and by the staff nurses in the unit, including the nurse manager or the nurse manager’s designee when needed to resolve a disagreement.”  

According to the text of the bill, this “acuity tool”: 

shall be developed or chosen by each hospital in consultation with the staff nurses and other appropriate medical staff and shall be certified by the department of public health. The health policy commission shall promulgate regulations governing the implementation and operation of this act including: the formulation of an acuity tool; the method of reporting to the public on staffing compliance in hospital intensive care units; and the identification of 3 to 5 related patient safety quality indicators, which shall be measured and reported by hospitals to the public. 

This compromise bill brings to a halt, at least temporarily, the lengthy battle between the Massachusetts Nurses Association (MNA) and hospital groups regarding the implementation of broad nurse staffing guidelines covering all nurses. For over 15 years, hospital organizations had fought against broad nurse staffing guidelines on the grounds that their hands would be unnecessarily tied with regard to staffing decisions and that the staffing guidelines would not add value to patient care. The MNA based its demand for nurse staffing guidelines on concerns for patient safety, quality of care and patient satisfaction. 

In a relatively novel approach, the MNA ramped up its efforts by attempting to go straight to the ballot to ask voters to support two MNA initiatives:  the Patient Safety Act and the Hospital Profit Transparency and Fairness Act.  These initiatives would have required hospitals to make available information related to hospital CEO compensation, annual operating margins and hospital financial asset disclosures. The MNA had gathered enough signatures to place both measures on the November ballot, which likely led the legislature to compromise on nurse staffing guidelines for ICU nurses. As a result of the MA Senate passing the legislation on June 26th –  less than 24 hours after the bill cleared the House –  the MNA agreed to drop the ballot initiatives. 

Health care employers may want to keep their eyes on the use of ballot initiatives by nurses’ unions to influence legislatures to act with regard to staffing issues.  A few years ago, in California, nurses unions teamed with public employee unions to fight the suspension of a hard-won law that lowered patient-to-nurse ratios in the state’s hospitals and emergency rooms.  Due to the success of these initiatives, healthcare organizations may see more unions use these tactics to influence nurse staffing guidelines in the future.