Nearly 10 years ago, California became the first – and so far only – state to pass a law mandating hospitals assign a certain number of patients to each nurse. As we reported in May, a growing number of legislatures in other states have or are currently considering nurse-to-patient ratio legislation. In addition, a handful of federal bills have been introduced in both the House and Senate that similarly seek to implement nurse-to-patient staffing plans and would provide whistleblower protections for nurses who refuse to accept an assignment if they believe that doing so would violate the requirements of the law or that they lack the qualifications or experience necessary to perform an assignment. Such proposals include the Registered Nurse Safe Staffing Act of 2013 (H.R. 1821); Nurse Staffing Standards for Patient Safety and Quality Care Act of 2013 (H.R. 1907); and the National Nursing Shortage Reform and Patient Advocacy Act (S. 739).  Another federal bill, the Nurse and Health Care Worker Protection Act of 2013 (H.R. 2480), would direct the Department of Labor to issue an occupational safety and health standard “to reduce injuries to patients, nurses, and all other health care workers by establishing a safe patient handling, mobility, and injury prevention standard.”

Now, the Massachusetts Nursing Association (MNA) has joined the chorus of nursing unions amplifying their call for nurse-to-patient ratio restrictions. Earlier this month, the MNA began a signature drive to place the issue on the November 2014 ballot.

For years, the MNA has unsuccessfully tried to get a nurse-to-patient ratio bill that would impose staffing requirements in acute-care settings passed by the state legislature. The union is now attempting to accomplish the same end by going straight to the voters. Massachusetts law requires that any ballot initiative be preceded by the introduction of a companion bill in the legislature and garner approximately 70,000 signatures (3% of the total votes cast in the state’s last gubernatorial election) by this November. Earlier this year, the Patient Safety Act was introduced in the state legislature and is still under consideration.

Both the bill and ballot initiative would require that each nurse in a medical/surgical unit be assigned no more than four patients, and that in critical care units, a nurse be assigned no more than two patients. Like its counterparts advocating for similar legislation in other states, the MNA is portraying the issue as one of patient safety.

The Massachusetts Hospital Association (MHA), however, opposes the legislation. Not surprisingly, the MNA and the MHA have come to starkly different estimates regarding the cost of implementing such mandatory staffing ratios statewide. According to a briefing on the issue by the Massachusetts Health Policy Forum (MHPF), the MNA estimates the cost to be $268 million, while the MHA says it could reach $450 million.

The MHPF’s briefing states that while researchers found that an increased number of registered nurses is associated with several positive results, including lower mortality rates, shorter length of hospital stay, lower rates of urinary tract infections, and fewer adverse outcomes for surgical patients, it also states that studies have been unable to identify the ideal nurse-to-patient ratio. The briefing explains that such a figure may be dependent upon a number of variables, including characteristics of the patients, nurses, and hospitals. This seems to be consistent with the position of the American Nurses Association, which opposes “one size fits all” ratios and instead supports cooperative staffing decisions that are made collaboratively by hospital administrators and nurses.

The MNA is ratcheting up its campaign to see the Patient Safety Act passed. Through the “Coalition to Protect Massachusetts Patients” website, it provides citizens with phone numbers to the Massachusetts Senate and House of Representatives switchboards and it offers to send a letter to legislators on behalf of citizens who fill out an online form. It remains to be seen whether its efforts will be enough to push the law to passage and make Massachusetts the second state to implement fixed nurse-to-patient ratio legislation