2018 Information For Voters

QUESTION 1: Law Proposed by Initiative Petition

Patient-to-Nurse Limits

Do you approve of a law summarized below, on which no vote was taken by the Senate or the House of Representatives on or before May 2, 2018?


This proposed law would limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities.  The maximum number of patients per registered nurse would vary by type of unit and level of care, as follows:•  In units with step-down/intermediate care patients: 3 patients per nurse;

  • In units with post-anesthesia care or operating room patients: 1 patient under anesthesia per nurse; 2 patients post-anesthesia per nurse;
  • In the emergency services department: 1 critical or intensive care patient per nurse (or 2 if the nurse has assessed each patient’s condition as stable); 2 urgent non-stable patients per nurse; 3 urgent stable patients per nurse; or 5 non-urgent stable patients per nurse;
  • In units with maternity patients: (a) active labor patients: 1 patient per nurse; (b) during birth and for up to two hours immediately postpartum: 1 mother per nurse and 1 baby per nurse; (c) when the condition of the mother and baby are determined to be stable: 1 mother and her baby or babies per nurse; (d) postpartum: 6 patients per nurse; (e) intermediate care or continuing care babies: 2 babies per nurse; (f) well-babies: 6 babies per nurse;
  • In units with pediatric, medical, surgical, telemetry, or observational/outpatient treatment patients, or any other unit: 4 patients per nurse; and
  • In units with psychiatric or rehabilitation patients: 5 patients per nurse. 

The proposed law would require a covered facility to comply with the patient assignment limits without reducing its level of nursing, service, maintenance, clerical, professional, and other staff. 

The proposed law would also require every covered facility to develop a written patient acuity tool for each unit to evaluate the condition of each patient.  This tool would be used by nurses in deciding whether patient limits should be lower than the limits of the proposed law at any given time.

The proposed law would not override any contract in effect on January 1, 2019 that set higher patient limits.  The proposed law’s limits would take effect after any such contract expired.

The state Health Policy Commission would be required to promulgate regulations to implement the proposed law.  The Commission could conduct inspections to ensure compliance with the law.  Any facility receiving written notice from the Commission of a complaint or a violation would be required to submit a written compliance plan to the Commission.  The Commission could report violations to the state Attorney General, who could file suit to obtain a civil penalty of up to $25,000 per violation as well as up to $25,000 for each day a violation continued after the Commission notified the covered facility of the violation.  The Health Policy Commission would be required to establish a toll-free telephone number for complaints and a website where complaints, compliance plans, and violations would appear.

The proposed law would prohibit discipline or retaliation against any employee for complying with the patient assignment limits of the law.  The proposed law would require every covered facility to post within each unit, patient room, and waiting area a notice explaining the patient limits and how to report violations.  Each day of a facility’s non-compliance with the posting requirement would be punishable by a civil penalty between $250 and $2,500. 

The proposed law’s requirements would be suspended during a state or nationally declared public health emergency.   

The proposed law states that, if any of its parts were declared invalid, the other parts would stay in effect.  The proposed law would take effect on January 1, 2019. 


A YES VOTE would limit the number of patients that could be assigned to one registered nurse in hospitals and certain other health care facilities.

A NO VOTE would make no change in current laws relative to patient-to-nurse limits.

See full text of Question 1


As required by law, statements of fiscal consequences are written by the Executive Office of Administration and Finance.

This proposed law may affect both state and municipal revenues and expenditures, with state-owned hospitals required to expend between an estimated $67,800,000 and $74,800,000 annually to comply with the proposed law, and the Health Policy Commission required to expend an estimated $1,281,200 annually to monitor compliance. There will also be an impact on MassHealth, the state’s Medicaid program, and state-funded employee and retiree health care obligations to the extent that the initiative increases hospital costs or causes hospital closures. The overall fiscal consequences to state and municipal finances, however, are difficult to project due to the lack of reliable data.


As provided by law, the 150-word arguments are written by proponents and opponents of each question, and reflect their opinions. The Commonwealth of Massachusetts does not endorse these arguments, and does not certify the truth or accuracy of any statement made in these arguments. The names of the individuals and organizations who wrote each argument, and any written comments by others about each argument, are on file in the Office of the Secretary of the Commonwealth.

IN FAVOR: I have worked as a bedside nurse for 40 years. I joined nurses from across Massachusetts to write this law and place safe patient limits on the ballot to improve the quality of patient care in Massachusetts hospitals. Independent scientific studies have consistently found that quality of care decreases dramatically when nurses are forced to care for too many patients at once, putting patients at increased risk for complications like pneumonia, medication errors, and more. This initiative establishes a safe maximum limit for the number of patients assigned to nurses in all hospital areas to ensure our patients receive the care and attention they need. It provides maximum flexibility, requiring hospitals to adjust Registered Nurse staffing levels based on the needs of patients and does so without reducing other members of the health care workforce. A recent survey found that 86% of Registered Nurses in Massachusetts favor this question.

Donna Kelly-Williams, RN
Massachusetts Nurses Association
340 Turnpike Street
Canton, MA 02021
(781) 821-4625 x 777

AGAINST: Nurses are asking you to Vote No on Question 1.

Massachusetts hospitals rank among the best in the nation, but Question 1 will put that patient care quality and safety at risk. It forces rigid, government-imposed nurse staffing ratios at every hospital, overriding the professional judgment of nurses and doctors.

Question 1 would create a massive unfunded government mandate costing more than one billion dollars in higher healthcare costs annually, causing community hospitals to close and forcing others to reduce emergency, addiction and behavioral health services. Question 1 has been called “the most irresponsible approach to healthcare”.

There is no scientific evidence that these rigid ratios improve patient care.

Question 1: higher costs, rigid mandates, and one-size-fits-all healthcare.

Nurses and over one hundred healthcare organizations, including American Nurses Association Massachusetts, Massachusetts Medical Society, Massachusetts College of Emergency Physicians, and every Massachusetts hospital urge: Vote NO on Question 1.

Amanda S. Oberlies, RN
Coalition to Protect Patient Safety
P.O. Box 15
Boston, MA 02137