With Massachusetts officials debating this month about whether to mandate nurse-to-patient staffing ratios in that state's hospitals, disagreement continues about whether such standards are the key to good health in medical centers.

Union officials at The Medical Center, Beaver contend that a contract overwhelmingly ratified by nurses this week shows that rather than being a source of fear and loathing among administrators, ratios can be good for both nurses and management.

Ratios that were established at the hospital in 2003 have helped to improve patient safety and boost the job satisfaction of nurses, while coinciding with financial success for the medical center, said Neal Bisno, secretary-treasurer of SEIU District 1199P, the union that represents the nurses.

But hospital officials say the ratios set in the contract -- which they describe as "ratio ranges" -- are different than those proposed by legislators in Massachusetts, as well as those enacted in California in 2004. The experience at The Medical Center, hospital officials contend, exemplifies the broader criticism that the industry makes about legislative efforts: One size doesn't fit all.

"No one will dispute that having more nurses will improve care," said Paula Bussard, senior vice president for policy and regulatory services at the Hospital & Healthsystem Association of Pennsylvania. "The question becomes: Is it something you should set in law or regulation?"

In May, the House of Representatives in Massachusetts voted to approve a bill that would establish minimum nurse staffing standards for all hospital units. While the bill didn't set ratios, it would ask the state's public health department to do so.

The bill awaits action by the Massachusetts Senate, which remains in session through the end of the month.

California passed a law in 1999 that created nurse staffing standards, and 14 other states including Pennsylvania have similar legislation pending, said David Schildmeier, spokesman for the Massachusetts Nurses Association, a union group. Mr. Schildmeier said the contract adopted at The Medical Center -- which calls for no more than five patients per nurse in medical-surgical units during two shifts -- is relatively uncommon in setting ratios.

But he praised it, saying, "A smart hospital with a strong union, they've got a marketing advantage by saying 'We've got the California ratio in our hospital.' "

But Rosemary Nolan, the chief nursing officer at The Medical Center said the hospital's ratios include flexibility that is lacking in state mandates. Nurses can be asked to handle more patients if some of their colleagues call off work for a day, Ms. Nolan said.

"That's what people fail to understand when they talk about legislative ratios -- at the end of the day, you'll always get to a time or a place where you just don't have the nurse that you might need," she said.

The hospital schedules nurses to work presuming that all of its beds will be full, Ms. Nolan said. That's different than some other hospitals that staff based on projections that can leave workers short-handed during unexpected peaks in business.

When the hospital doesn't meet the 100 percent occupancy level, some nurses agree to go home. But the hospital has done extensive data analysis to better understand occupancy trends, and has closed beds so that it is operating at close to 100 percent occupancy most of the time.

The hospital's vacancy rate -- the percentage of nursing jobs that haven't been filled -- is below 2 percent, and patient satisfaction scores have soared.

"I don't want to go so far as to say this exact model will work for every hospital," said Bruce Edwards, the vice president of human resources for The Medical Center. "But our relationship with the union has continued to grow, and we believe that we're moving in the right direction."

Nurses are happier, too.

Debbie Sawinski, a nurse on the hospital's medical-surgical unit, said that prior to the ratios, nurses commonly worked mandatory overtime hours, leading to long shifts that sometimes raised safety concerns. Now, mandatory overtime is a thing of the past, she said.

Mandatory orders from managers for workers to go home in times of low occupancy have been replaced by calls for volunteers, said nurse Brenda Alston. Usually, there are plenty of takers.

"For me, time off is important," Ms. Alston said.

Mr. Bisno, the union official, acknowledged that the ratios in the contract at The Medical Center are not fixed in the way they might be with legislation. But the ratios are shared goals, he said, and when combined with other operational measures at the hospital they go a long way to making sure that patients benefit from an adequate amount of nursing care.

Still, legislation might be the only way to prod all hospitals down the path, he said.

Whatever the means, getting hospitals to provide adequate staffing can save lives, said Linda Aiken, a nursing researcher at the University of Pennsylvania.

Legislation often brings with it unintended consequences, Ms. Aiken said, saying the verdict is out on how well mandates in California have worked. But the push by unions and legislators to force action on the issue is understandable given the stakes involved, she said.

"Our research documents that patient outcomes and nurse retention is significantly better in hospitals where nurses care for fewer patients each," Ms. Aiken said. "Mortality increases by 7 percent for each patient added to a nurse's workload."