If a bill before the Legislature's Joint Committee on Public Health becomes law, Massachusetts would be the second state to place limits on the number of patients a nurse can care for at one time.

For some hospitals, very little would change. For others, such as HealthAlliance Hospital's Burbank Urgent Care Center in Fitchburg, a law mandating fixed staffing ratios would require cost increases and significant changes to strategic patient-care plans.

The bill, on which the Public Health Committee held a hearing last week, would mandate statewide the maximum number of patients any one nurse can care for at once. The limit would be different for different units, but in hospital units for which the bills do not specifically set a limit, the maximum patient assignment would be four patients per nurse.

The proposed ratio is much lower than the current state average ratio in emergency departments, and for emergency departments such as the one at Burbank, the proposed ratio is one-third their average ratio.

According to the most recent data from the self-reported hospital data website Patients First, in 2013, each nurse in the Urgent Care Center at the Burbank facility saw an average of 12 patients in an eight-hour shift.

David Schildmeier, communications director for the Massachusetts Nurses Association, said these numbers are concerning for union members.

"Burbank is a place where, in 2014, they made the decision to save money and cut staff," Schildmeier said, "so patients have to wait longer before they're seen, and nurses don't have time to give them as much attention.

The Leominster location of HealthAlliance Hospital was also facing staffing cuts earlier this year, but a contract -- negotiated after a vote by nurses to strike -- resulted in the hiring of additional staff.

Mary Fortunato-Habib, HealthAlliance's chief nursing officer, said hospital administration has "worked very hard" since the strike vote and the finalizing of the new contract to ensure MNA members feel comfortable with the patient care they are providing.

"We've made a lot of strides since last year, with our union, to make sure that we're doing the right thing for patients," she said. "We've continued to have open dialogue and are trying to get more input from the staff. It's a work in progress, but the ultimate goal is to work together with the union to make sure our patients are happy and cared for and our staff to feel like they're doing a good job."

The MNA sees it differently.

According to Schildmeier, HealthAlliance nurses should never have had to go to the lengths they did to maintain adequate staffing levels.

"HealthAlliance in Leominster is the perfect example of why the law is necessary," he said.

The concern about staffing levels is by no means limited to HealthAlliance. According to a study conducted by Registered Nurse and Boston College professor Judith Schindul-Rothschild, which she used as testimony at last week's hearing, "there is a strong, statistically significant relationship, between the numbers of patients cared for by an RN (registered nurse) in Massachusetts emergency departments and how quickly patients are evaluated by a qualified health-care professional (such as an RN)."

Of the 63 emergency departments Schindul-Rothschild studied from 2010-14, the average number of patients one nurse cared for during an eight-hour shift was seven. There was, however, a large variation between hospitals -- more than 20 had an average of six or fewer patients, and seven had an average of eight or more patients.

In 2013 and 2014, Schindul-Rothschild found, patients in Massachusetts emergency departments waited an average of 42 minutes before they were evaluated by a qualified health professional. But at Cambridge Health Alliance or Massachusetts General Hospital, where RNs take care of the fewest number of ED patients, a patient waits less than 15 minutes before being evaluated. At places such as Clinton Hospital and Boston Medical Center, where RNs care for twice as many ED patients, a patient waits an hour and a half.

Fortunato-Habib said this is only one study, though, and Massachusetts has both a lower patient mortality rate and a higher-rated patient experience than California, the only state that currently mandates fixed staffing ratios. 

"The MNA has made claims about a correlation between staffing and quality of patient care," Fortunato-Habib said, "but in California, we've recognized that there isn't a body of research that validates that in an absolute way, that's valid and reliable."

Members of the MNA also testified at the hearing last week.

The State House News Service reported Donna Kelly-Williams, president of the MNA, testified that having no limit on the number of patients a nurse can care for at one time is "dangerous" and is "putting patients at great risk."

During her testimony, Kelly-Williams asked the three dozen nurses with her if they thought patient care was suffering due to a nurse being asked to care for too many patients at once, and whether they know of any medical errors that resulted from a nurse having too many patients in her care at once. Almost every nurse said yes.

"Every day that goes by without a law in place means more preventable medical errors, more avoidable complications, increased lengths of stay and readmissions," Kelly-Williams said, as reported by the State House News Service. "In some cases, it is the difference between life and death."

But the HealthAlliance administration said patient care is not about the numbers.

"It's more about the composition of the team than fixed numbers," said Fortunato-Habib, who is an RN herself, with a background working in the ICU. "We've worked on things like the roles of the nurse, what duties they perform, how we perform them, so that we can respond to the changing needs. It's less about looking at the absolute, but really looking at the decision making, that we can collectively come up with strategies."

If the bill before the Public Health Committee were approved, Fortunato-Habib said, "it would of course increase the overall cost of care, and we're all trying to be responsible and keep the overall cost of health care down."

It's not just about money, though. Fortunato-Habib said there would be other negative impacts if the state mandated fixed staffing ratios.

"Fixed ratios mean you have to keep it no matter what, (but) maybe you need something less for one patient and more for another," she said. "All patients have differing needs, we need to make sure we can deploy people in the most appropriate place, and fixed ratios are not adaptable to changing needs."

"Nurses are trained to think and make assessments and problem-solve," she added. "A government mandate doesn't necessarily allow us to draw on the skills we're trained to use. It's based on numbers rather than our own decision-making."

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