Pennsylvania Nurses Are Overloaded, Putting Patients at Risk

In 2004, California became the first—and for two decades, only—state to require acute hospitals to maintain specific minimum nurse-to-patient staffing ratios that vary by hospital units.

In 2026, Oregon implemented the final phase of its mandatory minimum nurse-to-patient staffing law. Both states’ laws draw on research suggesting that when nurses tend to fewer patients, both groups fare better. Much of the important work on nurse staffing ratios has come from Penn Nursing’s Center for Health Outcomes and Policy Research (CHOPR), founded in 1989 by LDI Senior Fellow Linda Aiken, Professor of Nursing and Sociology at Penn.

Key Takeaways

The case for minimum staffing ratios has strengthened, but isn’t settled. Heavier nurse workloads are linked to more patient deaths, infections, burnout, and longer hospital stays, Penn LDI researchers say. Critics counter that much of the research on staffing is observational and cannot definitively prove that ratios cause better outcomes.

Pennsylvania’s “nursing shortage” may be a workplace retention problem. Hospitals cannot recruit enough nurses to meet mandated staffing ratios, especially in rural areas, executives say. But Penn LDI researchers say excessive workloads drive nurses to leave their jobs.

The dispute is ultimately about whether mandates raise costs or save money. Hospitals and business groups warn that hiring enough nurses may be unaffordable, especially as hospitals face pressure from looming Medicaid cuts. By contrast, LDI Fellows say moving the state’s medical-surgical units toward a 1:4 nurse-to-patient ratio could save over $305 million annually through lower turnover and shorter hospital stays.

In 2023, after a decade of attempts to pass similar legislation, it was Pennsylvania’s turn to vote on nurse overload. State Rep. Thomas Mehaffie, a Republican from south-central Pennsylvania, introduced House Bill 106, which would have mandated nurse staffing ratios statewide. The legislation passed the state House with bipartisan support but stalled in the Senate. The bill referenced Penn studies showing that “greater nurse workloads directly correlate with adverse patient outcomes,” Aiken said.

A recent study of medical-surgical units in Pennsylvania hospitals found an average staffing ratio of 5.9 patients per nurse, with some hospitals reporting as many as nine patients per nurse. “In our research, each additional patient per nurse increased the likelihood of surgical patient mortality, hospital-acquired infections, and nurse burnout,” Aiken reported.

Mehaffie “absolutely” intends to reintroduce House Bill 106 in the next legislative session, he told LDI through a spokesperson. “Nurses in my district are concerned about burnout, stress, and demands on their attention while at the bedside” due to high workloads, he said.

Opposition to this type of legislation is strong, particularly among hospital executives, partially because of the costs involved. Here are the main arguments being made about mandated nurse-to-patient ratios.

Is there still doubt that nursing mandates improve care and save money?

Yes: The link between minimum nurse-to-patient ratios and better patient outcomes does not establish causation. For instance, overall hospital quality, patient level of illness, and patient demographics are also believed to affect patient outcomes. Other potential factors include the mix of staff expertise, the nursing unit’s physical layout, teaching status, and the hospital’s technology level. The vast majority of studies on staffing ratios are cross-sectional, meaning that data is collected at just one point in time.

No: A longitudinal study centered in Queensland, Australia provides stronger evidence of cause and effect. The study, published in The Lancet and conducted by LDI Senior Fellow Matthew McHugh, Director of CHOPR, along with Aiken and colleagues, followed two sets of hospitals for two years: those subject to staffing requirements established in 2016 and those that were not. The state of Queensland mandated nurses in adult medical-surgical wards at 27 public hospitals to care for no more than four patients at a time during the day and no more than seven at night. The study found that nurses’ workloads declined significantly in the intervention hospitals but not in the comparison ones. After two years, hospitals with mandated minimum staffing levels showed much more improvement in patient outcomes. “There were fewer deaths—30-day mortality rates decreased 7%; fewer readmissions—fewer patients were readmitted after a week; and shorter lengths of stay— patients left hospitals 3% faster,” reported Aiken.

Will mandates hurt rural hospitals in particular?

Yes: Rural areas are especially low on nurses and are at risk of closing if mandates become law. Of particular concern to many legislators is the ability of rural hospitals to recruit more nursing staff. “In rural Pennsylvania, we already have a hospital desert and a desert for OB-GYNs,” said state State Rep. Kathy Rapp, a Republican from northwestern Pennsylvania who opposed the bill.

No: Rural hospitals in Pennsylvania are better staffed than others in the state. A July 2026 Medical Care article by LDI Senior Fellows K. Jane Muir, Karen Lasater, Aiken, McHugh, Heather Brom, and colleagues challenges the notion of a general rural nurse shortage. “We found that rural hospitals in Pennsylvania are actually just as well, if not better, positioned to be in compliance with the staffing law than other hospitals,” explained Lasater, Professor of Biobehavioral Health Sciences at Penn Nursing. “They tend to be better staffed, and have less turnover.”

Will nursing mandates make nursing jobs harder to fill?

Yes: The nursing shortage prevents hospitals from being able to fill mandated slots.

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“There simply are not enough nurses. Government-mandated ratios … will effectively force Pennsylvania hospitals to close beds or reduce services to comply with state law, and, in many communities, put hospitals at risk,” wrote the Hospital and Healthsystem Association of Pennsylvania (HAP), which represents 235 hospitals statewide, in opposition to House Bill 106. “The solution would be to educate more nurses,” said Rep. Rapp.

No: Nurse retention, rather than a nurse shortage, is the key issue. “We don’t have enough nurses at the bedside, but that’s not because there aren’t enough actively licensed nurses in the country,” Lasater said.

Nationwide, there are more than 7 million licensed registered and practical nurses, far exceeding the 3.5 million jobs for registered nurses (RNs) and 666,900 for licensed practical and vocational nurses. Pennsylvania ranks seventh among states in nurses per capita. Yet hospitals say they can’t fill positions. At a Republican Senate forum in Pittsburgh in June 2025, Ken Mittra, Chief Human Resources Officer at Independence Health, said his institution was short 200 RNs.

According to the CHOPR team, the real problem is that many hospital nurses find working conditions untenable and quit. “There is a cyclical issue of chronic nurse understaffing in hospitals, which means that nurses have high workloads, contributing to burnout and job dissatisfaction, which in turn leads to a stream of nurses leaving hospital work,” said Muir, Assistant Professor at Penn Nursing and CHOPR faculty. In a May 2026 Medical Care article, researchers Lasater, McHugh, and Aiken reported on a survey of more than 50,000 nurses conducted in New York and Illinois between December 2023 to March 2024. The results: 32% of nurses reported job dissatisfaction, and 27% intended to resign. Nearly half (48%) experienced burnout, which is strongly correlated with both high workloads and plans to leave their employer.

Poor working conditions erode nurses’ ability to deliver the care their patients need, and that erosion carries an emotional cost, according to LDI Senior Fellow Kathryn Connell, Assistant Professor of Biobehavioral Health Sciences at Penn Nursing and a practicing intensive care unit (ICU) nurse at a local hospital. In her recent study of more than 4,200 ICU nurses, published in Intensive and Critical Care Nursing, less favorable work environments were associated with higher levels of burnout, in part through a cascade in which necessary nursing care gets missed, and nurses then experience moral distress over the care they could not give.

“When this happens shift after shift, you experience moral distress, and as a result, you feel like you don’t want to be doing this work because you can’t do it well.” The findings suggest that preventing ICU nurse burnout means fixing the organizational conditions that set this chain in motion, rather than relying on individual nurses to build resilience.

A Better Solution for Nurse Staffing

“Continuing to expand the nursing workforce without addressing why nurses leave hospital employment—and what would reattract them—is akin to fueling a leaking gas tank,” Lasater said. “Inadequate staffing is a top reason RNs leave, and research suggests that improving staffing ratios could bring them back.”

California’s experience, where minimum staffing ratios stayed the same regardless of challenges such as the COVID-19 pandemic, providers further evidence that reasonable workloads can improve nurse retention. “Our center has looked at evidence on nurses’ jobs outcomes since 2004, and we have consistently seen that California hospital nurses compared to nurses in other states have lower odds of burnout, lower job dissatisfaction, and greater intent to stay in their jobs,” Muir said. “We’ve also found that patients in California hospitals get more direct care nursing hours.”

Will hospitals be unable to hire enough nurses?

Yes: Pennsylvania hospitals cannot afford to hire more staff, especially when HAP estimates that upcoming federal Medicaid cuts will directly reduce payments to state hospitals by $4.5 billion in the next 10 years and cause a 39% to 66% increase in uncompensated care. “Nurse staffing ratios could increase health care costs for Pennsylvania patients and employees by as much as $2 billion,” said Alex Halper, Vice President of Government Affairs for the Pennsylvania Chamber of Business and Commerce during debate on House Bill 106 in June 2023.

No: Nurse staffing requirements reduce hospital costs in the long term.

“Increasingly, research is documenting the cost savings to hospitals when they invest in staffing sufficient numbers of nurses at the bedside,” Lasater said. “We find that when patients are cared for in better staffed hospitals, they have better outcomes, and some of those outcomes, such as shorter lengths of stay and avoided readmissions are directly tied to hospital cost savings.”

In a recent article led by Muir, researchers in an observational study of 132 Pennsylvania hospitals estimated how much money would be saved if they switched from their current nurse-to-patient ratio (1:6, on average) to the 1:4 nurse-to-patient ratio proposed by House Bill 106 for medical-surgical units. Factoring in avoided nurse turnover and reductions in patient lengths of stay leads to statewide savings of over $305 million per year.

Similarly, “an analysis of changes in Queensland, Australia hospitals before and after implementation of staffing policy determined that the cost savings were more than twice the cost of the additional nurses it took to meet the ratio,” said Lasater.

Are the penalties for non-compliance too draconian?

Yes: “The biggest reason for my no vote is the severe penalties in the bill if staffing levels do not meet what the legislation required,” Rep. Rapp said. House Bill 106 called for a minimum penalty of $1,000 and a maximum of $2,500 per incidence of violation, with charges to increase upon repeat violations.

No: Some kind of penalty is necessary for enforcement. “Hospitals can voluntarily improve their nurse staffing ratios, but it’s unlikely they will change without some kind of stick or carrot,” Lasater said. However, Aiken noted, “In actual practice in California, penalties have been minimal.” California calls for much higher penalties than the Pennsylvania legislation: $15,000 for the first violation and $30,000 for the second, though there are many loopholes.

Are union contracts a good way to establish staffing ratios?

Yes: “For unionized hospitals, staff ratios can be settled through negotiations between hospitals and staff unions,” Rep. Rapp said.

No: Only 20% of registered nurses are unionized, according to the Bureau of Labor Statistics.

“Increasingly, unions representing nurses are including minimum staffing ratios in their negotiations,” Aiken said. “But unions have trouble enforcing ratios without a government mandate. Disruptive strikes are a last resort, as happened with the New York City nurses strike in early 2026, which was partly over staffing standards. Also, union contracts in selected hospitals are not enough to maintain safe nursing staffing for the population that doesn’t use those specific institutions.”

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