1. Welton, John M. PhD, RN

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On June 30, 2014, Massachusetts Governor Deval Patrick signed Bill H.4228 requiring hospitals to staff ICUs at 1:1 or 1:2 nurse-to-patient ratios.1 This was a compromise reached between the Massachusetts Hospital Association and Massachusetts Nurses Association (MNA), a union representing some of the state's nurses, to avoid a more substantial mandatory staffing ratio law proposed by MNA in a ballot initiative scheduled for the November 2014 general election. Massachusetts is now the 2nd state to require some form of mandatory nurse staffing ratio albeit only for ICUs.

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There are 2 aspects of the new staffing law that merit further discussion: (1) the requirement to develop an acuity tool in consultation with staff nurses and other appropriate medical staff as a way to adjust staffing levels and (2) a stipulation to create 3 to 5 patient safety quality indicators to be used in public reporting by hospitals.2 These items represent a shift in the union's position away from strict mandatory ratios to a more flexible approach that recognizes a link between changes in patient acuity, nurse staffing requirements, and outcomes of nursing care.


Patient Classification and Nursing Acuity Instruments

There has been a longstanding issue and perhaps a sense of uneasiness in using the many instruments to classify patients and measure need or demand for nursing care. In a study over 20 years ago, O'Brien-Pallas and colleagues3 applied 4 different classification tools to 256 patients over 2 294 patient-days in both medical-surgical and ICUs. Overall, while the 4 instruments were correlated, there was a difference of 4.5 estimated nursing care hours for each patient.3 When the investigators examined only the critical care patients, predicted hours produced by the instruments varied from 12.1 to 20.8 hours for the coronary care unit and 19.7 to 28.6 hours for intensive care. A 2nd related problem is how to compare patient acuity across different hospitals as the new law requires measuring each hospital's compliance to the acuity-adjusted staffing standards. If hospitals use many different acuity instruments, the ability to make a fair and objective comparison of ICU staffing will be challenging and possibly untenable. Should only a single patient acuity instrument be used and if so which one?


What about nurse-patient assignments? A recent study conducted across 138 Veterans Administration Hospitals found units with more experienced nurses on the evening shift had significantly lower hospital lengths of stay.4 This raises an interesting question whether there are other factors beyond nurse staffing ratios, such as experience, academic preparation, or total hours worked in a shift or week that also influence patient outcomes? Should these also be considered as applicable measures under the new law? A staffing ratio only provides guidance on how many nurses are required for a particular shift based on the needs of the patients. It says nothing about the competencies or academic preparation of those nurses who provide patient care. Who should be assigned to the sickest patients?


Linking Nurse Staffing to Outcomes

There have been many studies examining the relationship between nurse staffing levels and clinically relevant outcomes such as unexpected mortality, infections, pressure ulcers, hospital length of stay, and patient injuries.5 Despite research findings, there is little consensus on what constitutes an adequate nurse staffing level and how staffing patterns are associated with outcomes of nursing care. A recent European study conducted across 12 countries surveying more than 10 000 nurses reported a range of nursing care missed during high workload shifts such as adequate patient surveillance (27.2%), skin care (24.5%), administering medications on time (19.4%), and pain management (10.0%).6 These missed care episodes have direct implications for care outcomes in the critical care units. For example, if antibiotics are not given on time, patients may receive a subtherapeutic or toxic dose of the drug leading to ineffective treatment of a life-threatening infection.


What are the appropriate critical care outcome indicators for Massachusetts that meet the intent of the new nurse staffing law? The Centers for Medicare & Medicaid Services (CMS) has initiated a value-based purchasing program (VBP) as a component of the Affordable Care Act.7 CMS will hold back a portion of a hospital's reimbursement, and then the hospital will submit metrics to CMS, resulting in adjusted payback amounts to hospitals based on overall performance. Because hospitals are already required to participate in the VBP, several of the National Quality Forum (NQF) indicators adopted by CMS may be potential choices for use by Massachusetts in linking nurse staffing levels to performance and outcomes of care8:


* ventilator bundle (NQF 302) percentage of ICU patients on mechanical ventilation at time of survey for whom all 4 elements of the ventilator bundle are documented


* severe sepsis and septic shock management bundle (NQF 500)


* confirmation of endotracheal tube placement (NQF 501)


* intensive care length of stay (NQF 702)


* intensive care in-hospital mortality rate (NQF 703)


* patients admitted to ICU who have care preferences documented (NQF 1626)


* hospice and palliative care-treatment preferences (NQF 1641)



What other outcome measures of nursing care can be collected and compared publicly? Should there be a consistent framework for measuring nursing care outcomes applied to all hospitals, and if so, what is the burden to collect these data?


Other Considerations

The new Massachusetts nurse staffing law represents a national experiment regarding legislation directed toward inpatient nursing care. We do not know how the law will change both nurse staffing levels and patient care assignments and if these new regulations result in better outcomes for critically ill patients. If unions representing nurses are shifting their position toward acuity-adjusted staffing and linking staffing to outcomes, will this influence policy making in other states or in Congress? Nurse staffing ratios have been a contentious issue that has polarized our national dialog how to achieve high-quality outcomes of care yet manage costs. Because nurses make up one of the largest component of the professional healthcare labor workforce, there is ample reason to seek national consensus on best strategies for regulatory as well as healthcare finance reform.


While the new Massachusetts nurse staffing law does not address hospital payment for care, ultimately any impact of future laws to regulate nurse staffing levels could be costly. Can we find consensus how to balance the need to improve quality and safety of nursing care with its associated costs? This will require agreement on both a policy making and regulatory framework as well as aligning the quality and outcomes of nursing care with direct payment to hospitals.


There is also a question about fairness and equity. Should small community hospital ICUs be held to the same nurse staffing standards as academic medical centers? A 2006 study found Massachusetts hospital adult critical care units had a mean RN care hours per day of 15.2 for community hospitals and 18.1 for academic medical centers (2.9-hour difference). The cost for nursing labor was $610 versus $723 or $113 per patient-day.9 If the community hospitals are required to staff to the same level as the academic medical centers, this could add hundreds of thousands if not millions of dollars in additional nursing labor costs for community hospitals.



The Massachusetts new nurse staffing law will provide insight how to implement acuity-based staffing and public reporting of outcomes for critical care units. Does this particular approach represent a viable alternative for policy making in other states, and if so, can we coalesce on a national framework for an acuity-adjusted nurse staffing (and assignment) approach and public reporting of outcomes of nursing care?




1. Bertoncini MR, Bloom HM. New Massachusetts law limits intensive care unit nurses to two patients, regulations expected. Natl Law Rev. 2014. Accessed June 30, 2014. [Context Link]


2. Bill H4228. An Act relative to patient limits in all hospital intensive care units. 188th General Court. 2014. September 16, 2014. [Context Link]


3. O'Brien-Pallas LL, Cockerill R, Leatt P. Different systems, different costs? An examination of the comparability of workload measurement systems. J Nurs Adm. 1992; 22 (12): 17-22. [Context Link]


4. de Cordova PB, Phibbs CS, Schmitt SK, Stone PW. Night and day in the VA: associations between night shift staffing, nurse workforce characteristics, and length of stay. Res Nurs Health. 2014; 37 (2): 90-97. [Context Link]


5. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007; 45 (12): 1195-1204. [Context Link]


6. Ausserhofer D, Zander B, Busse R, et al. Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Qual Saf. 2014; 23: 126-135. Accessed June 30, 2014 [Context Link]


7. CMS. Hospital Value-Based Purchasing. The Official Website for the Medicare Hospital Value-based Purchasing Program.Centers for Medicare and Medicaid Services; 2013. Accessed June 30, 2014 [Context Link]


8. O'Brien JM Jr, Kumar A, Metersky ML. Does value-based purchasing enhance quality of care and patient outcomes in the ICU? Crit Care Clin. 2013; 29 (1): 91-112. [Context Link]


9. Welton JM, Unruh L, Halloran EJ. Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals. J Nurs Adm. 2006; 36 (9): 416-425. [Context Link]