Here’s why more nurses don’t mean better care

Question 1’s rigid ratios may undercut technology improvements

IS A VOTE FOR QUESTION 1, which sets mandatory nurse-to-patient ratios, a vote for safer care in hospitals? At first blush, it might appear so. How can it be otherwise that prescribing specific numbers of nurses per patient be anything other than good for patients? But such a conclusion is not only simplistic, but likely to be wrong—both now and into the future.

Debate on this issue has centered on the law’s likely cost. The Massachusetts Health Policy Commission has projected an annual cost of hundreds of millions of dollars. The proponents suggest that the HPC has overestimated by more than a factor of ten. No one denies that there will be some cost increase, but if we focus solely on the dueling estimates, we miss the heart of the matter: How are high quality and safe care best assured for our citizens?

Until I became CEO of a hospital, I did not know the extent to which the team of people involved in caring for patients extended well beyond the attending doctor and the nurse. Once in the job, I learned that the close collaboration of many people was key to successful care. Beyond the attending physician and bedside nurse, there are other people in patients’ rooms: consulting doctors from other specialties, residents, patient care technicians, respiratory therapists, radiology technicians, physical therapists, occupational therapists, pharmacists, phlebotomists, and even transporters, housekeepers, and food service personnel. And beyond the bedside nurses, there are the nurse managers, resource nurses, and other specially trained nurses on call for special situations.

It is the allocation of all these expert professions on each floor and specialized unit that creates the clinical team that assures the care you expect and deserve.  Yet, Question 1 takes just one of these categories and sets in stone the “proper” number of nurses in each type of unit.

To the extent that the new law would cause a greater number of nurses to be hired in a hospital facing financial limits, the hospital’s only course of action would be to allocate fewer of these other categories to patient care over time, or—if the law is read to preclude that–to cut back on other essential operating and maintenance expenses in the hospital. Which hospitals face financial limits? Well, virtually all of them do, but especially community hospitals and safety-net hospitals (i.e, those serving lower income families). These would be especially affected, as the federal Medicare agency, for example, would make no adjustment in hospital reimbursements for the newer higher nursing costs in Massachusetts.

Beyond the question of whether the bill’s numbers are correct, in a general sense, we have to wonder how they can be correct in the specific time and place that corresponds to your personal stay in the hospital. There is a constant need in hospitals to modify personnel assignments depending on the number and acuity of patients in any given part of the hospital. And yet, under the proposed law, if a hospital moved, say, two nurses from a unit experiencing very low acuity patients to one with a temporary need for help in caring for higher acuity patients, that hospital would be subject to a fine of $25,000 per day. The bill says that the state cannot permit any waiver—temporary or permanent—in the nurse staffing requirements.

And we need to ask whether the numbers are likely to be correct over time, even if they might be correct in a general way today. The introduction of new technologies suggests that ratios that would be set in stone in 2018 are likely to be inappropriate in the next several years. For example, a number of hospitals have started to use remote sensing equipment that provides continuous monitoring of patients’ vital signs, delivering that information in real time to doctors and nurses at both the central nursing station on a floor and to the caregivers’ cell phones. Such technologies were previously only in use in intensive care units, but are now available for general hospital floors.

But after all that, would such a law make a difference? California provides the only experiment so far, enacting a similar law over a decade ago.  The Health Policy Commission recently heard from Dr. Joanne Spetz, a University of California San Francisco expert on health care workforce issues. As reported by WBUR’s Commonhealth site, study results on the effects on patient care have been mixed.

“Some outcomes got worse, some got better, some had no statistical significance in their change,” she said. “And so, taken together, I interpret the literature as a little bit of a wash. It’s very hard to conclude that the California regulations systematically improve the quality of patient care across all outcomes.”

Meet the Author

Paul F. Levy

Former hospital executive and chairman, Massachusetts Department of Public Utilities
Are voters in Massachusetts ready to roll the dice, adding permanently to the cost of health care in the state, potentially causing financial harm to those hospitals with the least resources, and negating the value of implementing safety improvements that could develop over time, with no clear value to patients and families? I hope not.

Paul F. Levy was CEO of Beth Israel Deaconess Medical Center from 2002-2011.