This month, Massachusetts enacts a new law mandating a one-to-one nurse-to-patient ratio in ICUs of every hospital, public and private, throughout the state. Media coverage of Governor Deval Patrick's signing of the legislation last June suggested this all happened overnight, but the Massachusetts Nurses Association (MNA), which is allied with National Nurses United, tells a different story.

Figure. Massachusetts governor Deval Patrick-flanked by state representative Denise Garlick, RN, and Massachusetts Nurses Association president Donna Kelly-Williams-signs a new law mandating a one-to-one nurse-to-patient ratio in Massachusetts ICUs. Photo courtesy of the Massachusetts Nurses Association / National Nurses United.

Many legislators and hospital groups had opposed such a bill, claiming that the costs would be prohibitive for hospitals and that staffing limits don't consider patient acuity. The MNA fought back with data demonstrating that such limits deliver better patient outcomes, as measured using key clinical indicators, and reduce financial penalties associated with 30-day readmission, hospital-acquired infection, and mortality rates.

But opposition remained, so the MNA obtained more than 100,000 signatures on a petition (only 60,000 were required) to get the measure on a ballot for voters to decide. Such overwhelming public support (plus the threat of a second ballot measure requiring hospitals to post executive compensation and profit information) swayed enough legislators to push the bill through.

As an answer to the acuity argument, the law mandates staff nurses to assess patients' stability with an "acuity tool"-to be chosen or developed by each hospital-and allow a one-to-two ratio when it's deemed safe. All hospitals, prohibited from factoring cost or any other criteria into staffing decisions, must adhere to this standard.

In an interview with AJN, MNA president Donna Kelly-Williams said, "It was the pressure on the legislature and the industry by the prospect of a ballot measure that forced them to come to us with a compromise measure that, for the first time in Massachusetts, establishes a safe limit on nurse-patient assignments as a matter of law."

So why only ICUs? According to Kelly-Williams, "it was a gut-wrenching decision" to accept the legislature's ICU-only offer, but it was the only way to eliminate the risk of failing this year and not being able to attempt another ballot measure until 2020.

"It's no longer a matter of whether nurses in Massachusetts [will] have limits in all areas," said Kelly-Williams, "it's a matter of when. If we are not successful next year with legislation extending limits to all areas, we will be prepared to go to the ballot again in 2016 to finish the job."-Sibyl Shalo Wilmont, BSN, RN