Should states mandate nurse staffing ratios?

Greenbeard · Sep 26, 2018

Skeptic Bob said:
It seems reasonable if it only applies to public hospitals. I don’t think it should apply to private hospitals, if such a thing exists in Massachusetts.

There are only a few public hospitals in the state, the overwhelming majority are private (including the big name ones like Mass General). This ballot initiative would apply to all hospitals.

Kal'Stang said:
I voted yes. It really is equivalent to class sizes. The bigger the class the harder it is for even the best of teachers to properly teach the children. The more patients a nurse has the harder it is for them to give proper life saving care. And for me, both are just as equally important and money should be no object when it comes to either one.

Ideally money would be no object, but in reality wouldn't you say that it is?

Mycroft said:
If you are dying, you'd better hope the hospital has enough doctors...not nurses.

What do you think nurses do in hospitals?

The implication here that nurses don't save lives is just false.

Registered nurses (RNs) constitute the largest group of health care professionals in the United States and adequate nurse staffing has been linked to measures of both patient and nurse satisfaction, and quality of care provided to patients (Shi & Singh, 2008; Unruh, 2008). The relationship between nurse staffing and measures of patient outcomes (e.g. failure to rescue, mortality, and falls) and nurse outcomes (e.g. satisfaction and turnover) has received significant attention in the literature with often similar conclusions regarding patient and nursing related outcomes. Aiken and colleagues (2002) found that the risk adjusted 30-day mortality and failure-to-rescue rates of hospital surgical patients increased by 7% for every one patient increase in nurse workload. A higher proportion of nurses was associated with lower patient mortality rates (Needleman et al., 2011), lower rates of adverse hospital events, including pressure ulcers, urinary tract infections and falls (Unruh, 2003), as well as lower rates of other adverse patient outcomes (Mark Harless, McCue, & Xu, 2004; Lankshear, Sheldon, & Maynard, 2005; Unruh, 2008). A meta-analysis conducted by Kane and researchers (2007) concluded that higher RN staffing is associated with decreased risk of hospital-related mortality, hospital acquired pneumonia and other adverse patient outcomes. Overall, the majority of literature on nurse staffing and patient outcomes suggests that greater levels of nurses lead to overall better patient outcomes.

They're not just fluffing pillows.

MrWonka said:
Nope, we are fully aware of the consequences we just recognize the reality that you get what you pay for, and we shouldn't be trying to cut corners and save money at the expense of people's lives.

I don't disagree with the sentiment in principle, but I'm voting against this measure. This state in particular is focused like a laser on cost containment and increasing staffing is a step in the opposite direction. We can't say we want to lower health care costs/spending and then ask people to vote to deliberately raise them, particularly in the absence of evidence that we have some kind of clinical crisis on our hands (which, as far as I know, the unions pushing this measure have not shown to be the case).

There may be some benefit to patients here, though again it hasn't been well-quantified and it's not clear how nurse staffing levels here compare to other places--is it really inadequate today, and by what measure? But there's also a cost, which several groups have tried to quantify. I don't think the state should blindly commit to added health care costs without knowing if the juice is worth the squeeze. And trying to do it through a ballot initiative instead of the legislative process seems like the wrong way to go about it.

Kal'Stang · Sep 26, 2018

Greenbeard said:
Ideally money would be no object, but in reality wouldn't you say that it is?

It doesn't have to be. People can make it to where money is no object for those two things. All that has to happen is to not give into greed.

Let me ask you something, how many extra nurses do you think each hospital would need to make it to where a nurse could effectively do their job without over taxing them? Do you think that $300 million would cover such a cost once its figured out? Do you think an extra 5000 nurses nationwide would suffice?

Greenbeard · Sep 26, 2018

Kal'Stang said:
It doesn't have to be. People can make it to where money is no object for those two things. All that has to happen is to not give into greed.

Let me ask you something, how many extra nurses do you think each hospital would need to make it to where a nurse could effectively do their job without over taxing them?

I don't know, which is why I'm voting against setting the ratios in statute. At least via a method that relies on asking random people like me to make that determination, as this ballot initiative does.

Do you think that $300 million would cover such a cost once its figured out? Do you think an extra 5000 nurses nationwide would suffice?

The estimated cost to Massachusetts of what's on the table here is about $1 billion per year.

Kal'Stang · Sep 26, 2018

Greenbeard said:
I don't know, which is why I'm voting against setting the ratios in statute. At least via a method that relies on asking random people like me to make that determination, as this ballot initiative does.

The estimated cost to Massachusetts of what's on the table here is about $1 billion per year.

1 billion a year is going to be able to hire far more than 5k nurses that's for sure. $300 million easily covers 5k nurses if you pay them $30/hr. Average wage for RN's nationwide is $29.20.

In any case, I really don't care about the cost. If 1 billion is what is needed then so be it. That's only an extra $155 per year per person that a person in Mass would have to pay per year in taxes. Or $13 per month.

HonestJoe · Sep 26, 2018

Greenbeard said:
Here's a real world case. In a few weeks, voters in Massachusetts will vote on whether to mandate staffing levels for nurses (i.e., set a maximum number of patients that can be assigned to nurses). A new poll today shows public opinion on the question is tied at 44%-44% with 12% undecided.
Politically it's largely a fight between nursing unions (who argue for the ratios on patient safety and quality grounds) and hospitals (who oppose the initiative largely for pragmatic and financial reasons).
So how would you vote?

I think the problem with this kind of thing is that it’s more complex than a simple yes or no.

Nurses do a massive (and ever increasing) range of tasks in all sorts of different areas of healthcare so simply talking about numbers in general is almost meaningless. There are definitely areas of medical care where there will be a minimum level of appropriately trained and experienced clinical staff (not just nurses) necessary to provide the level of safety and treatment that should be expected. There will also be definitive improvements in patient outcomes and experience with numbers above that minimum, with steadily diminishing returns.

The difficult element of this is how we’d formally define the measurements of staff numbers and what the mandated minimum would be in any given environment. I can definitely see an argument for mandated bare minimums but no hospital should be anywhere close to that level on basic moral grounds. Frankly, if that would lead to massive costs increases for any hospital, they shouldn’t be in business in the first place. Hiring more staff obviously brings costs, especially when there are short-term or long-term staff shortages requiring expensive temporary staff to cover those minimums, but I think the costs of massively overworking staff and leaving vulnerable parents with insufficient care is much higher.

The problem could be if the mandated minimum is higher than strictly necessary (maybe higher than necessary at all times or in all places). I don’t know if this proposal has any of that detail behind it of if it’s just a call of legal limits in principle, with the specifics to be hammered out at a later date.

MrWonka · Sep 26, 2018

Greenbeard said:
This state, in particular, is focused like a laser on cost containment and increasing staffing is a step in the opposite direction. We can't say we want to lower health care costs/spending and then ask people to vote to deliberately raise them

No sane person wants to lower costs at the expense of quality care.

Greenbeard said:
particularly in the absence of evidence that we have some kind of clinical crisis on our hands

Well actually, just the other day there was a thread on this forum by some right wing nut saying that medical malpractice is the third leading cause of death in the United States. It looked like there were some issues with the study that didn't really say what he was trying to argue at all, but there is definitely a significant number of mistakes being made by medical staff that can either cause death or at the very least prevent the saving of a life. It could definitely be argued that hospitals attempting to skimp on staff to save money is a big part of the reason for that.

Moderate Right · Sep 26, 2018

Gamewell45 said:
I'd vote to support it. I think it's important to try to eliminate mistakes from occurring from nurses who are exhausted due to inadequate staffing. You get what you pay for in life and to me when it comes to your health there should be no compromise. Look at it this way; as an example; if you were going to have open heart surgery, wouldn't it make sense that the surgeon was well rested as opposed to being tired or exhausted?

Easy to say if you have the money to pay for it. Most don't have the money to pay for these costs now.

Greenbeard · Sep 26, 2018

Kal'Stang said:
In any case, I really don't care about the cost.

That’s a recurring theme with our health care system. In any particular instance, no one cares about cost. It’s Seinfeld in first class: “More anything? More everything!”

But when asked whether they’re satisfied with the cost of our health system, no one seems to be.

MrWonka said:
No sane person wants to lower costs at the expense of quality care.

And if there’s some evidence that hospitals in Mass are experiencing dangerous lapses in quality attributable to staffing levels, that would be a strong argument for these new requirements. But no one has shown that and Mass already has more RNs per capita than almost any other state.

If we’re going to push up health spending, shouldn’t we first have a case for doing so and some sense that doing so is worth it?

distraff · Sep 26, 2018

Greenbeard said:
Here's a real world case. In a few weeks, voters in Massachusetts will vote on whether to mandate staffing levels for nurses (i.e., set a maximum number of patients that can be assigned to nurses). A new poll today shows public opinion on the question is tied at 44%-44% with 12% undecided.

Politically it's largely a fight between nursing unions (who argue for the ratios on patient safety and quality grounds) and hospitals (who oppose the initiative largely for pragmatic and financial reasons).

So how would you vote?

WBUR Poll: Ballot Question About Mass. Nurse Staffing Is A Dead Heat

Ballotpedia has more.

I think that we shouldn't over-regulate our healthcare industry and this over-regulation is one reason costs are so high.

MrWonka · Sep 26, 2018

Skeptic Bob said:
We already have public roads and private roads.

We do huh? Can't say I've ever driven on or seen a private road anywhere.

Skeptic Bob said:
Nothing new to build so there is no reason they can’t operate by different rules.

Yes, there is. You see the public hospital and the private hospital are in competition with each other and if you're both playing by different rules then you have an unfair competition. The private hospital can try and get by with a skeleton crew even though it's somewhat more dangerous. As a result, they can charge lower prices than the public hospital. This leads more insurance companies to push their patients toward the private hospitals to save money even though they may have higher death rates. But wait... it's worse because the private hospital won't have higher death rates. Why? Because the private hospital will intentionally avoid high-risk patients. If an elderly person is in need of a risky surgery the private hospital will say no we're not doing it. That patient will have to go to the public hospital because they're the only ones playing by the rules of voters who know it's immoral to reject a patient like that just because they're high risk.

The result is that the public hospital will both have higher prices and higher death rates than the private one, and conservatives and libertarians will use this as proof that private entities are way better than public ones even though they're clearly not. The flow of patients to these private hospitals will then make the public ones fiscally infeasible and require layoffs unless of course, they start doing the same shady crap the private hospitals are doing.

MrWonka · Sep 26, 2018

distraff said:
I think that we shouldn't over-regulate our healthcare industry and this over-regulation is one reason costs are so high.

So you trust the business people who run hospitals to decide how many staffers they need per patient instead of medical professionals?

Rosie1 · Sep 26, 2018

I'll assume there is a nursing shortage nearly everywhere. My mom was a Licensed Practical Nurse. Most medical facilities I know have a huge amount of nurses aides who do most of the care (bathing, assisting patients, etc.). Practical nurses might do changing dressings, etc. Registered Nurses mostly do oversight of the floors in hospitals and dispensing medications (also intensive care and surgical assist). For Nursing homes, you won't see many staff in most (only the minimum number of Registered Nurses) required by each state. And if you stop at a nursing home during off hours, you may have to hunt down an aide.

If a state has a nursing shortage, community colleges can offer Registered nursing degrees, so funding those colleges is important.

I

MrWonka · Sep 26, 2018

Greenbeard said:
And if there’s some evidence that hospitals in Mass are experiencing dangerous lapses in quality attributable to staffing levels, that would be a strong argument for these new requirements. But no one has shown that and Mass already has more RNs per capita than almost any other state.

If we’re going to push up health spending, shouldn’t we first have a case for doing so and some sense that doing so is worth it?

https://www.usnews.com/news/article...rs-are-third-leading-cause-of-death-in-the-us

You see the problem with your thinking here is that each hospital is desperately trying to cut corners to save money to reduce prices to attract customers. As a result, each hospital is pushing their luck by the same amount and as a result, there's almost no way to see with any certainty how much the extra staff might cut down on these errors.

Kal'Stang · Sep 26, 2018

Greenbeard said:
That’s a recurring theme with our health care system. In any particular instance, no one cares about cost. It’s Seinfeld in first class: “More anything? More everything!”

But when asked whether they’re satisfied with the cost of our health system, no one seems to be.

I support UHC. Which apparently has recently been determined that it would save us in, what was it...2 trillion dollars I think it was?

Xelor · Sep 26, 2018

Over 100 high quality studies have established the correspondence between lower registered nurse (RN) staffing levels and outcomes such as lower death rates, preventable medical error that occurs in hospitals, and other adverse outcomes. Among the 100+ studies are:

Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction
The Effects of Mandated Nurse-to-Patient Ratios on Reducing Preventable Medical Error and Hospital Costs
The Association of Registered Nurse Staffing Levels and Patient Outcomes
Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States

Careful analysis of the research methodologies used and findings obtained reveals a causal correspondence between nurse-to-patient ratios (NTPRs) and hospital outcomes people deem desirable. There is, then, no rational basis for denying that NTPRs are inversely proportional to the incidence of "preventable medical error that occurs in hospitals," mortality, and a host of other health/live outcomes.

From the OP:

Here's a real world case. In a few weeks, voters in Massachusetts will vote on whether to mandate staffing levels for nurses ... A new poll today shows public opinion on the question is tied at 44%-44% with 12% undecided. Politically it's largely a fight between nursing unions (who argue for the ratios on patient safety and quality grounds) and hospitals (who oppose the initiative largely for pragmatic and financial reasons).

Red:
Why has the OP-er presented information pertaining to a vote and asked an exogenously (re: context) normative question about a matter for exists some dozen or more "cases" -- assuming "case," to the OP means states that have enacted NTPR mandates; the OP-er doesn't tell us what "case" means, and in study after study, "case" refers to patients' specific treatment/care events -- that have been rigorously evaluated and had their health/life outcome impacts classified and quantified in both relative and nominal terms?

I don't know why, but I know the possible explanations for why include but are not limited to things like:

Ineptitude with survey question design
Deliberate obfuscation by way of omitting context
To establish an equivocal rhetorical setting to abet later having to defend an indefensible position.

Nonetheless, asking an exogenously normative poll question (rather than a positive one or an endogenously normative one) without providing highly credible contextual references is rhetorically, intellectually and discursively disingenuous.

Blue:
So what.

The answer to the question as posed here (rather than on the MA ballot and to MA voters) of whether NTPRs should be mandated has nothing to do with whether there is an upcoming referendum in MA.
The de-/merits of mandating NTPRs have nothing to do with what the general public thinks about doing so.

Conclusion:
While the impacts of lower NTPRs are unequivocal, I yet voted "no" in the poll. I voted "no" for the following reasons:

Laissez-faire and free trade (economics context) --> In general and by principle, I don't cotton to legislation that directly or indirectly imposes a tariff, quota or subsidy on the operational activities and policies a firm/industry operating under monopolistic or perfect competition may implement.

Were the health care provided under natural monopoly, I'd be okay with mandating NTPRs for their health care related operations.

It doesn't matter to me what outcomes lower NTPRs produce. Knowing that lower NTPRs affect health care outcomes in a ways, health-care-providing facilities can use that as a competitive edge and charge more or less for their services, in part, due to their higher or lower NTPR ratio. The market's "invisible hand" is mandate enough.
The exogenously normative poll question and related OP provide insufficient context for answering otherwise:
- Mandate for what nursing settings? Hospitals (And in what hopital context? Operating theaters, patient wards, the ER, etc?)? Nursing homes? Rehab facilities? Assisted living communities? Home health care? Hospice facilities? All of those? Some of them? Others? Specific settings within one or more of them?

Waddy · Sep 26, 2018

Teaching and nursing have at least one thing in common. It's up to the individual how good a job they do. Some (nurses and teachers) just naturally do the best job they possibly can; some do the bare minimum. Setting class size or nurse/patient ratios is no guarantee of better outcomes. It all depends on the individuals, and there isn't much ever done about the people who do only the minimum; they generally get to keep their jobs, too, especially if they are union. I'm sure this is the case in other fields of employment as well.

My wife switched nursing homes for her mother because every time she walked in the place the few nurses on duty were just socializing instead of taking care of their patients with bed sores. Those "nurses" were not much more than warm bodies. The kicker was that there were a couple of nurses who tried very hard to take care of the patients. Unfortunately, there weren't enough of that type, and they did do 90% of the care-giving. BTW; they were usually the first to find better nursing jobs.

It's easy to legislate quantity....... How do you legislate quality?

Kreton · Sep 26, 2018

Mycroft said:
If you are dying, you'd better hope the hospital has enough doctors...not nurses.

What do you think nurses do in hospitals?

A very large amount of work that is incredibly important and allows doctors to do their jobs more efficiently. Nurses save lives too.

earthworm · Sep 26, 2018

An ''automatic'' YES.
It will have to be this way until "the better people arrive" . My wife and I are approaching the time when we will have to be more dependent ..and I like this NOT !

Northern Light · Sep 26, 2018

It's a mistake to let the public decide on medical staffing issues. This is internal policy.

akyron · Sep 26, 2018

distraff said:
I think that we shouldn't over-regulate our healthcare industry and this over-regulation is one reason costs are so high.

The federal hijacking of such smacks of totalitarian activity regardless of the cost.

Grand Mal · Sep 26, 2018

Waddy said:
Teaching and nursing have at least one thing in common. It's up to the individual how good a job they do. Some (nurses and teachers) just naturally do the best job they possibly can; some do the bare minimum. Setting class size or nurse/patient ratios is no guarantee of better outcomes. It all depends on the individuals, and there isn't much ever done about the people who do only the minimum; they generally get to keep their jobs, too, especially if they are union. I'm sure this is the case in other fields of employment as well.

My wife switched nursing homes for her mother because every time she walked in the place the few nurses on duty were just socializing instead of taking care of their patients with bed sores. Those "nurses" were not much more than warm bodies. The kicker was that there were a couple of nurses who tried very hard to take care of the patients. Unfortunately, there weren't enough of that type, and they did do 90% of the care-giving. BTW; they were usually the first to find better nursing jobs.

It's easy to legislate quantity....... How do you legislate quality?

One way to control quality is with pay scale. You get what you pay for. Jobs like teaching and nursing and policing, it's hard to decide the value and easy to say they get paid too much but if you want to attract good people you'd better pay them well.

Greenbeard · Sep 26, 2018

Kal'Stang said:
I support UHC. Which apparently has recently been determined that it would save us in, what was it...2 trillion dollars I think it was?

But that largely works on the opppsite approach from this particular question. Single-payer and unions work in opposite directions. Unions function as monopoly sellers of labor to drive up the price of labor; in this particular case, the unions are attempting to do so beyond the scope of their own labor negotiations by mandating a greater statewide demand for nurses via a ballot initiative. Single-payer, on the other hand, is supposed to use monopsony buying power to drive down the price of labor. It promises to cost less by spending less on labor, whereas this nurse staffing initiative would raise costs by spending more on labor.

earthworm · Sep 26, 2018

Waddy said:
Teaching and nursing have at least one thing in common. It's up to the individual how good a job they do. Some (nurses and teachers) just naturally do the best job they possibly can; some do the bare minimum. Setting class size or nurse/patient ratios is no guarantee of better outcomes. It all depends on the individuals, and there isn't much ever done about the people who do only the minimum; they generally get to keep their jobs, too, especially if they are union. I'm sure this is the case in other fields of employment as well.

My wife switched nursing homes for her mother because every time she walked in the place the few nurses on duty were just socializing instead of taking care of their patients with bed sores. Those "nurses" were not much more than warm bodies. The kicker was that there were a couple of nurses who tried very hard to take care of the patients. Unfortunately, there weren't enough of that type, and they did do 90% of the care-giving. BTW; they were usually the first to find better nursing jobs.

It's easy to legislate quantity....... How do you legislate quality?

Remover the darkness, the cover ups, the silent treatment, when asked a pointed question . In the past, we have been too busy hiding the sloth and laziness - for 'fear'' of hurting, offending.. Even then , this is most difficult..

Waddy · Sep 26, 2018

Grand Mal said:
One way to control quality is with pay scale. You get what you pay for. Jobs like teaching and nursing and policing, it's hard to decide the value and easy to say they get paid too much but if you want to attract good people you'd better pay them well.

Both jobs pay well. And higher pay doesn't necessarily translate into higher quality. Isn't that simple. The problem in health care and teaching is that huge numbers of highly trained, highly motivated people to fill those positions just don't exist, no matter how high the pay scale. And the ones who are the best, brightest and most motivated aren't always the ones motivated primarily by money. They are much more interested in being in a job they really like.

Gamewell45 · Sep 26, 2018

Moderate Right said:
Easy to say if you have the money to pay for it. Most don't have the money to pay for these costs now.

I don't have a lot of money, however I prioritize how I spend my money. One would think people would put their medical care at the top of their list.

Should states mandate nurse staffing ratios?

Should states mandate nurse staffing ratios?

Yes

No

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Greenbeard

Kal'Stang

Greenbeard

Kal'Stang

HonestJoe

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Greenbeard

distraff

MrWonka

MrWonka

Rosie1

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akyron

Grand Mal

Russian warship, go f*** yourself!

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earthworm

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