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The golden ratios?

May 25, 2006 -- Today The Boston Globe ran an Associated Press piece by Steve LeBlanc reporting that the Massachusetts House of Representatives had voted to set up a system under which the state would regulate the number of patients hospitals could assign to each nurse. That would make Massachusetts the second U.S. state (after California) to regulate nurse-patient ratios. The AP piece is headlined "Limits are voted on nurse workload: House backs bill on staffing rules." It does a fairly good job of laying out basic issues surrounding the vote, which comes after "almost a decade of wrangling" between hospitals, who oppose ratios, and the Massachusetts Nurses Association (MNA), a union which has sought them.

The piece explains that the bill would not itself set ratios. Instead, it would order the state Department of Health to set limits on how many patients each registered nurse could be assigned, and how many the nurse could care for in a particular shift. The piece does not say so, but presumably these ratios would vary by the type of hospital unit in question; we assume ICUs would get stricter limits than the floor, for instance. The piece does note that the House "gave initial approval to the bill in a 129-to-29 vote yesterday, and planned to return for a final vote before sending the bill to the Senate."

The article briefly describes arguments for and against the bill. It reports that the MNA, which has been the main force behind staffing legislation, says the bill would "force hospitals to assign enough nurses to guarantee quality patient care." (MNA communications director David Schildmeier serves on the Center's advisory panel.) The piece quotes state representative Peter J. Koutoujian (D-Waltham) as saying that the bill is "about patient safety" and that it would "save lives from Boston to the Berkshires." Koutoujian argues that hospitals would retain some flexibility to adapt staffing levels based on the patient and nursing mix, but that (in the piece's words) "in the end there would be limits to the number of patients assigned to a nurse." We assume this means that hospitals would be free to assign nurses fewer patients than the state required, and that they would also face no direct legal limits on the experience levels of the nurses used to meet the requirements. The piece might also have noted that a growing body of research shows that increasing nurse staffing saves lives.

The piece also reports that hospitals find the bill "too restrictive," arguing that it would "create costly new mandates as the state embarks on an overhaul of its healthcare system." The piece does not explain what that overhaul entails. The Massachusetts Hospital Association's Paul Wingle is quoted as saying that the state should not have the authority to "tell hospitals what kind of nursing assignments to have across all hospitals, all shifts, and all units." Janet Madigan, president of the Massachusetts Organization of Nurse Executives, reportedly opposes the bill because it does not regulate other staff members, such as licensed practical nurses. It's not clear how the failure to regulate other staff would make the bill a problem for hospital managers. If anything, that would seem to give hospitals more flexibility, and might even provide ways for hospitals to try to evade the bill's intent, by giving registered nurses the tasks of the other staff. The MHA's comment implies that the state will set a unitary standard for all types of units, but the basis for that view is not clear. As for the cost argument, recent research suggests that improving nurse staffing may not cost more in the long run, due to the resulting improvements in care and nursing turnover. If these Massachusetts ratios did ultimately cost more money, then the matter would seem to call for a cost-benefit analysis by policymakers.

We thank Steve Leblanc and the AP for this helpful piece.

See the AP article "Limits are voted on nurse workload: House backs bill on staffing rules" posted on the Boston Globe website on May 25, 2006.

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