BOSTON — Advocates on both sides of Massachusetts’ nurse staffing ballot measure are debating a law enacted thousands of miles away and almost 15 years ago — and its similarity to Question 1 could inform Bay Staters how to vote Nov. 6.
California became the first and only state to mandate nurse-to-patient ratios when it passed its law in 1999. Since it was put into effect in 2004, health professionals have been analyzing the results with mixed methods and reactions: some argue patient outcomes have improved, some say the law is restrictive, others claim the effects are inconclusive.
While California’s ratio experience offers independent research in a battle of information, how it’s gathered and interpreted has been just as polarizing.
“One of the things commissioners want to understand is the difference between what happened in California and what potentially might happen here,” said vice chair of the Massachusetts Health Policy Commission Wendy Everett, according to the State House News Service. The commission assembled a panel of health experts in mid-October to unpack the issue for the public.
“What was interesting about the panel was the focus on what implications the passage of the ballot question has,” Everett said. “My intent was to get past the rhetoric and down to the facts.”
When the discussion turned to California, panelists debated the effect ratios had on patient outcomes. Some said ratios resulted in lower patient mortality, citing a study by Linda Aiken, Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania.
Panelist Joanne Spetz, a published nursing expert and professor at the University of California-San Francisco, disagreed.
“There was only a correlation (not causal relationship) between patient outcomes and ratios,” Spetz said later. “When we looked at several years of nursing data, we found there was no systematic changes in patient outcomes, that it was a wash.”
When the California Nurses Association proposed Assembly Bill 394, the union claimed more nurses and patient limits would ensure greater safety for both. The California Hospital Association and other industry groups lobbied against the bill. It took decades to pass, but eventually assigned specific nurse-to-patient ratios to each type of hospital unit.
After 14 years, proponents and opponents still paint distinct pictures of the effects.
“When I worked in the ICU, I was the primary care coordinator for 24 patients at one point,” said registered nurse Cathy Kennedy, reflecting on what it was like to nurse in California before nurse-to-patient ratios. “Now patients are much more satisfied with their care, we’ve decreased the length of stay, and nurses feel much more satisfied because we can actually do a better job and educate families.”
Kennedy has been a registered nurse in California for 38 years and is secretary for the CNA. At her hospital, Kaiser Permanente in San Francisco, Kennedy said she hasn’t seen financial consequences from the law.
“From 1999 to now, Kaiser Permanente has grown exponentially,” she said. “If a hospital says that this law will debilitate them, just look at how much they are paying their CEO.”
Jan Emerson-Shea, who directs external affairs for the California Hospital Association, argues the rigidity of California’s ratios have made it harder to deliver quality care.
“It’s just not compatible with the dynamic environment of hospitals. Patients may have to wait before they are admitted to an inpatient bed,” Emerson-Shea said. “There’s no flexibility.”
To Massachusetts voters following the debate on ratios in the commonwealth, the arguments may sound familiar.
Aiken and Spetz are both respected, independent researchers, but their different methods and results have caused opposing advocacy groups to frequently cite their studies. The Massachusetts Nurses Association, which proposed the ballot question to impose patient limits, features one of Aiken’s studies on its website; Spetz is cited by the Coalition to Protect Patient Safety, opposing Question 1.
In her study published in Health Services Research, Aiken compared nurse surveys and discharge data between 2005 and 2006 from California and two states without ratios, Pennsylvania and New Jersey. Her study showed more California nurses believed they had a reasonable workload.
More notably, it also said patient outcomes improved with more nurses, measured by the number patient deaths and deaths after operable complications (failure to rescue).
“There were definitely some good results (from nursing ratios) and there was not very much bad to detract from it,” Aiken said. “People have made lots of predictions of dire consequences, but none of them ever happened in California.”
Spetz’s research produced different results, although not necessarily dire ones. Through years of surveys, discharge data, and interviews — both before and after the ratios were set — Spetz determined patient care did not change for the better or worse.
Under strict ratios, Spetz reported some indicators improved, others worsened, registered nurse hours increased, and emergency departments bottlenecked at times. Altogether, the quality of care remained similar, she said.
Spetz attributed the differences from Aiken’s study to methodology, claiming her own study considered a greater period of time (1999-2006) and more indicators of patient outcomes, like pneumonia mortality and bedsores.
“I see no reason why a very large data set on 444 hospitals and close to a million patients over a 2-year period would be skewed in any way affecting our results,” said Aiken, referring to the extent of primary data in her study.
She continued, explaining her choice to exclude bedsores and other outcome measurements. “Mortality is the gold standard for measuring patient outcomes,” she said.
Aiken and Spetz largely agreed on how ratios affected nurses; They claim that the ratios increased the number of staffed nurses and those nurses had higher job satisfaction.
The economic cost of ratios has not been calculated yet. It’s almost impossible to determine, said Spetz.
“At that time, California passed a lot of legislation that affected health care costs,” Spetz said. “There would be no telling how much was really attributable to the ratios.”
“I don’t think Massachusetts voters would be greatly enlightened by what happened in California,” said Health Policy Commission member Everett. She believes the issue is complicated enough in the context of Massachusetts.
Similarly, Spetz claimed, “There are limits to what we can learn from California. There are so many variables and differences at play.”
Among these differences are the laws themselves. While the Massachusetts ballot measure proposes strict limits and penalties for breaking them, California’s law allows hospitals to change other staffing levels and does not specify a penalty. Massachusetts’ law would also go into effect almost immediately; California took five years.
Due to these complexities, the Health Policy Commission and a Citizens’ Initiative Review Panel recently released reports to help voters understand what happened in California.
After hearing from an independent researcher, the citizens’ panel claimed patient outcomes improved. “The success of California’s legislation of nurse/patient ratios provides data strongly suggesting that this can improve patient care in Massachusetts,” its report read. The commission, which hired Spetz as a consultant, largely echoed her findings.
Patrick Lovett writes for the Gazette from the Boston University Statehouse Program.