Re “Four months after nurses’ strike at Tufts, the dispute grinds on’’ (Business, Nov. 7): Massachusetts hospitals have never disputed that registered nurses are a key component of the caregiving team, nor have they ever argued against having appropriate staffing, including registered nurses, at the bedside. The debate has always been about how many patients should be assigned to each nurse, and whether a fixed ratio should be written into state law. Hospitals and the many front-line nurses who do not agree with the Massachusetts Nurses Association argue for flexibility in patient-nurse assignments, because patients and nurses differ widely across all hospitals, all settings, and even all shifts – in fact, patient conditions can differ from moment to moment. There simply is not a set number.

The 2014 study mentioned in the article did not identify or advocate for a fixed ratio. It examined hospitals in nine European countries with markedly varied health care systems and levels of nurse staffing and nurse education standards, and compared outcomes for nurses caring for averages of six and eight patients each; both of these are significantly higher averages of patients than Massachusetts nurses currently care for.

After almost 15 years of mandated nurse staffing ratios in California, our state still performs substantially better on nearly all mortality measures. California may have seen a faster decline than some other states in mortality after implementing ratios, but no causal link has ever been identified between ratios and improved mortality measures. The union’s argument for ratios lacks conclusive scientific backing. What remains true is that mandated ratios would negatively affect patients and our entire health care system.

Pat Noga

Vice president, clinical affairs

Massachusetts Health and Hospital Association

Burlington