Context Matters: A Case for Safe Staffing as Massachusetts Goes to the Polls

In 1974, the feminist periodical Off Our Backs reported that in June of that year, “4,400 members of the California Nurses Association (CNA) closed down all but critical care units in 41 Bay Area hospitals.” Nurses on the picket line carried signs saying “Better staffing — one night nurse for 38 patients is unsafe,” and “Patients’ Rights — Nurses’ Rights.” Nurses didn’t get everything they were asking for out of that strike, but twenty five years and another major strike later,  California passed the nation’s first – and, to date, only – nurse-patient staffing ratios law.

Now, twenty years after the CNA secured safe staffing ratios for California patients, voters in Massachusetts are being asked to decide Question 1. This ballot measure, proposed by the Massachusetts Nurses Association (MNA), would set nurse-patient staffing ratios across hospitals, determined by type of unit and patient acuity. It is strongly opposed by hospital industry administrators and management, operating under the name “The Coalition to Protect Patient Safety,” who have spent nearly $19M thus far in their efforts to prevent its passage. The Coalition claims (among other things) that the nursing shortage will make adherence to the proposed ratios impossible. It strongly criticizes the use of the ballot measure as a legislative strategy, and cites polls showing a nearly 50/50 yes/no divide among Massachusetts nurses.

The nursing shortage claim is both disingenuous and ahistorical. The national shortage of nurses is not a recent or temporary problem, but rather has been a topic of concern among public health officials since at least the end of World War II. In 1963, the US Public Health Service’s Division of Nursing published a report describing an ongoing national shortage; it noted, however, that the situation was least dire in New England. Both the national shortage and the local exception have continued, and today Massachusetts has one of the highest numbers of nurses per capita, at 1,250 per 100,000 (compare to California’s 700 to 100,000), while other areas of the country fare far worse. Massachusetts is, in fact, predicted to have a surplus of nurses by 2030. This is not esoteric information, but has been published by the federal Health Resources and Services Administration and others; the “No” lobby is fully aware that the national nursing shortage does not preclude safe staffing in this state.

In lamenting the tactic of legislating by ballot measure, the hospital industry is again relying on the public’s short memory. The MNA has been trying to get staffing legislation passed since 1995, even before California had theirs in place. Those efforts continued, and were continually rebuffed by industry administrators and lawmakers, throughout legislative sessions from 1995 through 2005 and beyond. In 2014, the MNA filed two ballot initiatives: the first proposed staffing ratios, the second capped hospital CEO salaries at 100 times the salary of the lowest paid hospital employee. As a leverage tactic, this worked. Industry groups came to the table, and eventually the MNA withdrew both initiatives in return for mandated ICU staffing ratios and other quality measures. With that historical context in mind, the public may well wonder why, in this current round of ballot initiatives, the industry has chosen to stonewall rather than engage in negotiation.

The near split between nurses on this measure seems counterintuitive and has been unsettling for the public, but one must remember that the word “nurse” encompasses an enormous range of professional roles and practice settings. Nurses are RNs in outpatient settings, long term care facilities, and hospitals, but also nurse practitioners and midwives, health care administrators, and faculty members in universities. The 2013 National Workforce Survey of Registered Nurses found that just 60% of nurses worked in hospital settings.  Further complicating matters has been the historically difficult relationship between nursing and labor organizing. The oldest professional organization for nurses, the American Nurses Association (ANA), has always prioritized the goals of professionalism and education; related tensions bound up with gender and class have often put it at odds with unions. In fact, the ANA had a formal no-strike policy until 1968. But in the 1930s, nurses began to join unions despite the ANA’s objections, and various ANA affiliates eventually severed ties in order to more effectively pursue labor organizing, including the CNA in 1995, and the MNA in 2001. Patient safety and staffing issues were at the center of three Massachusetts nursing strikes in 2017 alone; for the 60% of nurses who do work in hospitals, safe staffing is of paramount importance. While there is unquestionably concern about the implementation plan, particularly among nurses in emergency departments, the perception that bedside nurses are evenly split on Question 1 is not supported by fact.

As soon as I began writing and speaking publicly about Question 1, I started receiving horror stories from nurses who had experienced understaffing, both near and far. One California nurse compared practicing before and after there were ratios in place, recalling a night when she had to manage a crisis with one patient and asked her charge nurse to watch her other patients in the interim. The charge nurse “was supposed to watch my other patients, but she was busy with her patients and didn’t notice that my other patient had died because his tele[metry] monitor was just saying he was 100% paced.” She told another story of a colleague caring for labor patients during her own miscarriage, because the unit was severely understaffed and she didn’t feel she could leave her patients. “I am so glad we have ratios now,” she concluded. “No one should have to miscarry their baby while they help others deliver their healthy babies.” The California Nurses Association fought long and hard to get those ratios in place, and the Massachusetts Nurses Association is doing the same here.


Cory Ellen Gatrall is a Massachusetts bedside nurse in labor & delivery/postpartum care as well as in abortion services. In addition, she holds an appointment as a Five College Associate, which supports her work researching, writing, and speaking about the history of nursing and medicine.



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Gale, S., Noga, P. Vitello-Cicciu, J. (2015). Partnership paramount in efforts to influence nurse staffing legislation. Nurse Leader, 13(5), 23–25.

McAlevey, Jane. (2017, July 19). This Massachusetts nurses’ union is reviving the strike. The Nation.

National Council of State Boards of Nursing (2018). Progress and precision: The NCSBN 2018 environmental scan. Journal of Nursing Regulation, 8(4). s3-6.

Nurses strike in California. Off Our Backs. August/September 1974, 13.

U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. (2017). National and Regional Supply and Demand Projections of the Nursing Workforce: 2014-2030. Rockville, Maryland.

U.S. Public Health Service. (1963). Toward quality in nursing; Needs and goals. Report of the Surgeon General’s Consultant Group on Nursing. (Publication No. 992) Washington, D.C., U.S. Government Printing Office.

One thought on “Context Matters: A Case for Safe Staffing as Massachusetts Goes to the Polls

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  1. Thank you for this information, Cory Ellen! this issue is always fraught with mis-information and confusion – in part because it is so complex. Your explanations of the factors presented here shed much-needed light on the situation!

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