Nurse ratios shouldn’t be set by law — or the ballot box

It was worrisome enough that the Massachusetts Nurses Association was trying to get legislators to write rigid hospital staffing policies into state law. Asking voters to impose similar rules at the ballot box is even more misguided. But having repeatedly been thwarted in its quest to push mandatory nurse-to-patient staffing ratios through Beacon Hill, the union now vows to take this problematic policy prescription to the voters. But ballot initiatives are rarely a good way to make complex policy decisions — especially in health care, a vital industry whose staffing needs are subject to change as technology and medical knowledge evolve.

The union’s plan would impose legal limits on the number of patients a nurse could care for in various hospital settings: no more than four on regular medical or surgical floors and a maximum of two in critical-care units. In emergency departments, the ratio would vary from one to three patients per nurse, depending on their conditions. Hospitals would be forbidden from meeting those staffing levels by reducing other members of the health care team.

In other words, the ballot question would lock hospitals into rigid requirements not just for nurses but for other medical staff as well. Hospitals would be subject to a $25,000 fine for each day they failed to comply with the law.


The nurses’ association has been pushing mandatory staffing ratios for more than a decade. It’s telling that, despite the Legislature’s heavily Democratic makeup, such a law has never made it to a governor’s desk. It’s a particularly bad idea now. As health care reform goes forward, there will be a need for flexibility and creativity in the way hospitals deliver care. Imposing strict nurse-to-patient ratios and big penalties for their violation is counterproductive. In that light, it’s noteworthy that the American Nurses Association does not support mandatory ratios.

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That’s not to underplay the importance of adequate staffing to proper patient care. But Medicaid and Medicare already penalize hospitals for preventable readmissions — one problem the nurses’ union cites as a justification for its plan. Quality of care, meanwhile, is an important aspect of the integrated-care approach that the health care sector is moving toward. And the state Department of Public Health already has the authority to investigate any complaints about improper hospital care.

Legislators should stand firm against this effort by the nurses’ association. And if the group does take the issue to the ballot, voters should be wary as well.