In 1999, Gray Davis signed a law mandating a statewide ratio of one nurse to five patients in surgical wards, one to six in psychiatric wards, one to four in pediatric wards, one to three in maternity wards, and one to two in intensive care. The law was strong-armed to enactment by the California Nurses Association, an activist union with national ambitions. Today, the union wants Congress to make this a federal diktat, and U.S. Sen. Barbara Boxer now carries the union’s water on Capitol Hill.
Such laws move responsibility for safe hospital staffing away from communities and local governments in favor of distant bureaucracies that cannot be held accountable for the harm they cause. The California law has resulted in cases of reduced patient care: If a nurse calls in sick, wards sometimes cannot admit new patients because they would violate the rules.
Advocates of federally dictated staffing ratios tout a recent study by Professor Linda Aiken of the University of Pennsylvania . Aiken’s team mailed a survey to 80,000 nurses (of whom about one-fifth responded) in California and to two states that do not have state-dictated staffing ratios. They concluded that California’s staffing ratios improved patient outcomes. However, expecting nurses accurately to recall and report data on patient mortality is way too much to expect from a mailed survey. Another study, by consulting economist Andrew Cook and three professors at Carnegie Mellon University, found no evidence that the California law improved patient safety.
It’s not surprising that academic researchers arrive at different conclusions: A number of local influences determine nurse-patient ratios. Indeed, before California passed its law, some hospitals already had voluntarily adopted the nurse-staffing ratios, and the same is true in other states. In the June 18 New York Times, nurse Theresa Brown reported that her Pittsburgh hospital voluntarily exceeds the recommended thresholds.
Allowing the state or federal government to establish a one-size-fits-all rule for nurse staffing ignores real causes of the nursing shortage. In a 2007 article, John M. Welton, a registered nurse, argued that the problem with nurse staffing lies not in numbers, but that hospitals bundle nursing costs with room and board charges, leading to crude decision-making about staffing. Welton recommends that hospitals should unbundle these costs and charge by intensity of service. Obviously, this would require very complex decisions. Rigid rules that are imposed by Big Government destroy the flexibility and responsiveness needed to empower nurses, doctors and communities themselves to adopt standards for patient care that address local needs.
Health facilities should be among the most innovative operations in 21st-century America, not the least. Imposing an outmoded, industrial-age straitjacket on hospitals would condemn patients to inferior care at the mercy of union bosses.
Graham is director of Health Care Studies at the Pacific Research Institute in San Francisco. Hertzka, a former president of the California Medical Association, is an anesthesiologist in private practice in San Diego.