Should there be mandatory state enforced nurse-to-patient ratios?


On November 6th voters in Massachusetts are facing a very important health care-related question. In addition to voting for political parties in the midterms, they also face three ballot questions. The first of these is whether there should be mandatory state enforced nurse-to-patient ratios. For a general medical or surgical floor, this will be no more than four patients for every registered nurse. For other types of adult floors and the emergency room, ratios will be set differently, anything from 1 to 5. Here is the full proposed law.

As someone who works at the frontlines of health care in Massachusetts, this issue is obviously close to my heart. Over the last few months, I’ve heard a variety of different opinions expressed from frontline nurses. There are a number of strong arguments both ways, and it really has divided many in the health care community. For both the readers in Massachusetts who will be voting, and those out of state who may be interested, I wanted to briefly and simply summarize the main reasoning behind the two camps. I will divide this up by practical reasons each way, and then an ultimate philosophical one too.


Proponents of a no vote say that the law is poorly written, inflexible to different nursing needs, only allows just over a month for implementation, and is a one-size-fits-all approach. They also argue that it will have a devastating effect on health care finances, with some cost estimates around the $1 billion mark. At a time when the financial squeeze is on in health care, this is something that’s simply not affordable. Smaller community hospitals, in particular, are worried about the impact on their finances of having to hire more nurses (and whether there are even enough available nurses to hire at such short notice). Some people also cite the nurses’ union as being overly aggressive with the way it’s gone about this. Almost all health care facilities already take the issue of high-quality care and a culture of safety very seriously — especially in a competitive health care market. Hospitals are receptive to patient and family concerns and never want to deliver suboptimal care.

Those strongly in favor of voting no overwhelmingly include health care facilities, physician organizations, and politicians. Many frontline nurses too, have expressed major concerns.

A major philosophical argument for a no vote is that the government should never be involved in mandating an issue like this, and that it’s always a bad idea to have such strict restrictions with harsh financial penalties.


Nurses’ main argument centers around the issue of patient care and safety. It seems like common sense that the more nurse time that patients have, the better it is for everyone. How could four patients ever be deemed too few for a busy nurse? They are frequently rushed off their feet for the entire day and overwhelmed with bureaucratic requirements (it’s not just doctors who have to perform mind-numbing data-entry tasks). Most professionals at the frontlines of health care can attest to seeing nurses overwhelmed with several patients at a time (I know I have seen this many times), and the problems it causes. Would anybody want a loved one to be cared for under such circumstances? Nurses will tell you that they frequently feel unsafe during everyday patient care. This issue with having stricter ratios has been something they have been pushing for some time, and they reason that health care organizations have not come forward with any realistic alternative to help them care for patients safely, or put any other alternative proposals on the table.

A major philosophical argument around the yes campaign, is that many health care organizations in Massachusetts, including CEOs, are making millions — and that they can well afford to implement these changes and hire additional nurses if necessary. Partners Healthcare for example, the largest organization (and employer) in the state, which includes Massachusetts General Hospital, is reporting record operating revenues ($3.4 billion in the first quarter of 2018)  Although this is not total profit, it’s still a reasonably healthy financial position. The yes campaign is also accusing the No campaign of using broad and historically well-known scare tactics to persuade people to vote No. Hospitals are not just suddenly going to “close” (politically that wouldn’t be allowed, especially in underserved areas), and whenever an issue like this arises, many people and organizations have a deep vested interest in maintaining the status quo. Rarely does the world come tumbling down, and things have a habit of working themselves out and adapting.

There are some valid points to both sides. California is the only other state in the union with mandatory patient ratios for nurses, and I’ll let you read yourself the point of view that it’s been a staggering success, and the point of view that it hasn’t, which are widely articulated online.

It’s up to the people of Massachusetts now to decide on November 6th.

Suneel Dhand is an internal medicine physician and author. He is the founder, DocSpeak Communications and co-founder, DocsDox. He blogs at his self-titled site, Suneel Dhand.

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