Should The State Decide How Many Nurses a Hospital Must Hire?

Under ObamaCare, those who believe the government should decide how much medical care you deserve, and how it should be delivered, are eager to impose their preferences nationwide. Nurses’ unions lead the charge, armed with a recent study that could use more examination than it is getting from politicians and the media.

In 2004, the California Nurses Association (CNA) strong-armed a law through the state legislature that mandates a 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. As of September 2009, 14 states and DC had such legislation or similar regulation, and 17 more states were considering legislation. The CNA, which has national ambitions, has long agitated for Congress to make this a federal diktat, and U.S. Senator Barbara Boxer carries the union’s water on Capitol Hill.

Sensing that the clock is ticking for the Democratic majority to impose such a law, the media tout a study by Linda Aiken, of the University of Pennsylvania’s Center for Health Outcomes and Policy Research. This study compared a number of outcomes for hospitals in California, New Jersey, and Pennsylvania. The latter two states have no mandatory staffing ratios and fewer nurses per patient. Aiken and colleagues concluded that if New Jersey and Pennsylvania hospitals had achieved California’s staffing ratios, New Jersey’s hospitalized patients would have experienced 13.9 percent fewer deaths and Pennsylvania’s 10.6 percent.

There are a number of ways to critically assess this study, and its political implications. First, the responses came from mailing surveys to 80,000 nurses in California, New Jersey, and Pennsylvania, of which about 22,000 responded. Many of the questions address quality of work-life, which was (perhaps obviously) reportedly superior in California. Self-reports might be acceptable for such indicators, but to expect nurses accurately to recall and report data on patient mortality is way too much to expect from a mailed survey. Actual claims data would result in much more confident conclusions.

Second, beyond government mandates, a number of causes drive nurse-patient ratios. In the June 18 New York Times, nurse Theresa Brown, cheerleading the study’s conclusions, unwittingly trumps her argument by reporting that the Pittsburgh hospital where she is employed voluntarily exceeds the recommended thresholds.

Third, even if the California standards are appropriate for California, and perhaps Pennsylvania and New Jersey, it is irresponsible to use this one study to demand that Congress apply them throughout the United States. If advocates want to use the results to influence legislatures in Harrisburg and Trenton to replicate the California law, that is their business. Congress, however, has neither the constitutional authority nor the competence to determine whether these standards should apply to 47 other states.

Fourth, the blunt conclusion of the study, that government should simply command hospitals to hire more nurses, ignores more fundamental causes of the nursing shortage. In a 2007 article, John M. Welton, RN, reported that most nurses were independently employed by patients until the 1920s, and provided care in the home. Nurses and patients agreed on payment directly. As technology enabled hospitals to deliver more acute care, nurses increasingly became employed by hospitals. Welton argued that the problem with nurse staffing lies not in numbers, but that nurses’ incomes are no longer determined by patients directly.

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 them by intensity of service. Obviously, this approach requires very complex data and collaboration between hospitals and insurers, which pay the bills. Thinking that the U.S. government could take the lead in such a valuable reform is utterly delusional, as the current legislative proposal to impose top-down, federally dictated, nurse-staffing ratios demonstrates.

Like schools, health facilities should be amongst the most innovative operations in 21st-century America, not the least. For Congress to impose an outmoded, industrial-age straitjacket on hospitals will condemn patients to inferior care at the mercy of union bosses. Those union bosses will soon become all-powerful, unless Obamacare is repealed.

Nothing contained in this blog is to be construed as necessarily reflecting the views of the Pacific Research Institute or as an attempt to thwart or aid the passage of any legislation.

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