HAP Resource Center

Fact Sheet: Pennsylvania’s Nurses Are More than Just a Number


Only One State Has this Law—and the Results are Mixed


  • HAP opposes legislation mandating nurse staff requirementsCalifornia remains the ONLY state mandating nurse staffing ratios at all times
  • This mandate added $2.9 billion annually to the cost of care in California1
  • The law2
    • Increased costs to hospitals
    • Generated non-nurse staffing cutbacks
    • Caused reductions to other programs and services
    • Increased emergency department wait times
    • Had a negative impact on safety-net hospitals
  • A government-funded cost analysis of proposed staffing ratios in Massachusetts found that:
    • Mandated nursing ratios in Massachusetts would result in greater nurse shortages in high public-payor hospitals, disproportionately stressing institutions that provide care to the most vulnerable populations3
    • Total costs for imposing mandatory nurse staffing ratios would range from $676 million to $949 million, excluding costs for turnover and penalties for non-compliance4
  • When this measure was put on the ballot in Massachusetts, the voters defeated it, 70 percent to 30 percent

There is NO Evidence that Staffing Ratios Improve Patient Outcomes

  • In Pennsylvania, liability court cases have fallen in the last 20 years5
  • There is no conclusive evidence to support that nurse staffing ratio laws lead to better care, improve patient safety, or increase patient satisfaction6

Mandated Nurse Staffing Ratios are Impractical

  • Every hospital is unique, making a one-size-fits-all staffing ratio approach unrealistic
  • Hospitals need the flexibility to weigh a number of factors—such as the number of available care givers, the medical conditions of current patients, and anticipated additional influx of new patients—when setting staffing levels for a shift
  • Mandated nurse staffing ratios drive up the cost of services and would lead hospitals to make difficult choices, such as cuts to behavioral health programs or cuts to other positions to make room for additional nurses in a shift, regardless of need

Mandated Nurse Staffing Requirements Do Not Address Nursing Shortages

  • Staffing ratios do not create more nurses. Instead, this puts the burden on hospitals and nurse leaders, which are forced to manage rigid state-determined staffing ratios within dynamic teams in an ever-changing environment
  • Hospitals experience surges and declines in patient admission. During times of the year when there is a decrease in patients, hospitals will need to cover the costs of staffing, even if there are no patients to serve
  • Experts project that the current national and state nursing shortage will increase over time7

Mandated Staffing Ratios Would Jeopardize Community Well-Being

  • Because Pennsylvania does not have a public hospital system, every hospital serves as a safety net for the state’s poor and most vulnerable. Hospitals must have the flexibility to manage the demands of diverse patient populations
  • With more than one-third of Pennsylvania’s general acute care hospitals reporting negative operating margins8 mandates add to financial challenges
  • The risk of the impact of hospital loss to rural and other underserved communities cannot be understated and would have a devastating impact on community health

Hospitals Already Are Required By Federal9 And State10 Law To Provide Care Safely With Appropriately Trained Clinicians, Including Nurses

  • Nurses are integral to the patient’s care team, working closely with other health professionals. Dictating nursing ratios limits the hospitals’ ability to efficiently balance care teams with other types of clinicians
  • When hospitals work together with nurse leaders to set individual staffing levels, they are using the knowledge of their own facility to make the best determinations for them. This flexibility allows hospitals to provide the best care as efficiently as possible

HAP opposes House Bill 106 and Senate Bill 240, which impose a one-size-fits-all approach to patient care by setting staffing ratios for patients, as well as certain free speech protections, safe harbor protections when rejecting a work assignment, and fines and civil penalties.


House Bill 106 The Health Care Heroes and Public Health Preparedness Act
Senate Bill 240 Nursing licensure compact legislation
Any legislation that mandates specific nurse-to-patient staffing levels Efforts for the collection and analysis of nurse workforce data
Burdensome mandated nurse staffing report legislation Funding opportunities for hospitals faced with financial distress; behavioral health programs


1California Hospital Association. Recent Amendments Fail to Address Shortcomings of Duplicative Nurse Staffing Ratio Penalty System. July 9, 2019.
2Teresa Serratt, PhD, RN. California’s nurse-to-patient ratios, part 2: 8 years later, what do we know about hospital level outcomes? The Journal of Nursing Administration. October, 2013.
3Drs. David Auerback and Joanne Spetz. Mandated Nurse-to-Patient Staffing Ratios in Massachusetts: Research Presentation. Massachusetts Health Policy Commission. October 3, 2018 (last updated October 15, 2018). Last accessed: December 24, 2018.
5Medical Malpractice Case Filings: 2000-2020. The Unified Judicial System of Pennsylvania. December 2, 2019.
6Teresa Serratt, PhD, RN. California’s nurse-to-patient ratios, part 3: 8 years later, what do we know about hospital level outcomes? The Journal of Nursing Administration. October 2013.
7Nursing Education Programs in Pennsylvania: Data from 2014 Nursing Education Program Annual Reports. PA Dept of Health, Division of Plan Development, Bureau of Health Planning. Volume 13. 2017. Figure 5, p. 18. Last accessed: December 5, 2018.
8Pennsylvania Health Care Cost Containment Council. Financial Analysis 2020, PA General Acute Care Hospitals – News Release. June 3, 2021. Retrieved from: https://www.phc4.org/reports/fin/20/nr060321.htm. Last accessed: 09/29/2021
942 CFR § 482.23(b); SOM A-0392
1028 Pa. Code § 109.4



Topics: Access to Care, State Advocacy, Workforce

Revision Date: 10/4/2021

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