Nurse Workload Relief Offers a Powerful Fix for Emergency Department Crowding

Emergency departments across the United States have become the visible symptom of a deeper hospital-wide strain, and a new peer-reviewed study from researchers at the University of Pennsylvania School of Nursing points to a surprisingly direct lever for relief: the number of patients each nurse is expected to care for. The study, led by the Penn Nursing Center for Health Outcomes and Policy Research and published in the journal Medical Care, finds that when nurses report inadequate staffing, emergency departments become measurably more crowded, patients wait longer, and more people abandon the waiting room before ever receiving care. The research offers some of the most concrete quantitative evidence to date that nurse workloads are not merely a workforce morale issue but a central operational driver of one of American health care’s most persistent crises.

Emergency department crowding occurs when the number of patients arriving at a hospital exceeds the number of available inpatient beds to which they can be admitted. The result is a bottleneck: patients who need admission remain in the emergency department, often boarding in hallways, while new arrivals compete for limited treatment space. Crowding is associated with treatment delays, medication errors, and worse clinical outcomes, and it has worsened nationally as hospitals operate with razor-thin inpatient capacity. The Penn-led team approached the problem from a distinctive angle. Rather than measuring crowding solely through administrative data, they asked the people who experience hospital capacity firsthand, the nurses themselves, whether their units had enough staff to get the work done, and then linked those reports to objective emergency department performance measures across a large multi-state sample.

The scale of the analysis is notable. Drawing on survey and administrative data from 410 hospitals across ten states, the researchers examined how nurse-reported staffing inadequacy in both emergency departments and inpatient units correlated with three key indicators: overall patient length of stay in the emergency department, length of stay for patients presenting with behavioral health conditions, and the percentage of patients who left before being seen by a provider. These measures are widely used benchmarks of emergency care quality, and the Joint Commission recommends that hospitals keep the leave-without-being-seen rate below 2 percent and behavioral health length of stay under 4 hours. The average hospital in the study failed both benchmarks, with 2.8 percent of patients leaving without being seen and behavioral health patients waiting an average of 5.5 hours.

The statistical associations the team uncovered were striking in their consistency. A one standard deviation increase in emergency department nurse staffing inadequacy was associated with an 18-minute increase in emergency department length of stay for patients being observed for behavioral health conditions, a 9-minute increase in overall patient length of stay, and a 0.4 percentage point increase in the proportion of patients leaving before being seen by a provider. In a system handling millions of visits annually, shifts of this magnitude translate into enormous cumulative delays. A 9-minute increase in average length of stay may sound modest for any single patient, but multiplied across every patient in a busy department every day, it compounds into hours of added queue time that push waiting rooms past their physical and clinical limits.

Perhaps the most consequential finding concerns the inpatient side of the hospital. The study found that staffing inadequacy reported by nurses working on inpatient units was associated with an 18-minute increase in emergency department length of stay for patients presenting with behavioral health conditions. This detail matters because it underscores that emergency department crowding is not confined to the emergency department itself. When inpatient units lack enough nurses to safely staff their beds, admitted patients cannot be transferred out of the emergency department in a timely way, and the entire flow of the hospital backs up. Jane Muir, PhD, MSHP, RN, Assistant Professor in the Department of Family and Community Health and CHOPR core faculty, who served as first author, framed the mechanism plainly: crowding occurs when hospitals do not have enough resources to admit patients into a bed, whether in the emergency department or on inpatient units.

The prevalence of the problem is itself a headline. More than 60 percent of emergency department nurses and 58 percent of inpatient nurses in the study reported that there were not enough staff to get the work done in their hospital. These are not marginal shortfalls at a handful of struggling institutions; they describe the typical condition of American hospital nursing. Muir stated that nurses are caring for more patients than they can safely manage, and that the findings suggest high nurse workloads are contributing to excessive delays in emergency department care. Her formulation of the capacity problem has already resonated widely in health policy circles: a hospital bed without a nurse to staff it is not an available bed. In other words, counting licensed beds or physical infrastructure dramatically overstates the true admission capacity of a hospital whose nursing workforce is stretched thin.

What distinguishes this study from much of the prior literature on staffing is its forward-looking, quantitative projection of what improvement would achieve. The researchers modeled the effect of funding additional bedside nurse positions across the 410 study hospitals and estimated that improving nurse staffing adequacy would be associated with more than 5,000 additional patients treated, due to shorter emergency department lengths of stay, and more than 250 patients retained in care who would otherwise have left the waiting room before being seen. Those retained patients represent a particularly important population, because people who leave without being seen frequently include those with time-sensitive conditions, and their departure represents both a clinical risk and a lost opportunity for early intervention. The projection suggests that staffing investment functions, in effect, as added emergency care capacity without constructing a single new room.

The policy implications extend into ongoing national debates about minimum staffing standards. Muir emphasized that hospitals can create more funded positions for bedside nurses to alleviate chronic understaffing conditions and solve long wait times in emergency departments, adding that the study emphasizes that safe nurse staffing matters to move the needle on safer, timelier care for the public. The findings align with a growing body of work from the same research group, including studies linking better nurse staffing to shorter emergency department boarding times and evidence-based safe minimum nurse staffing requirements developed from Pennsylvania hospital data. Together, this research program builds a case that staffing adequacy is among the most modifiable determinants of hospital performance, one that administrators and legislators can act on directly rather than treating crowding as an inevitable consequence of patient demand.

The study was supported by the National Institute of Nursing Research of the National Institutes of Health under award numbers R01NR014855, T32NR007104, and R01NR021707, reflecting sustained federal investment in the science of nurse staffing and patient outcomes. Co-authors include Linda H. Aiken, Daniela Golinelli, Karen B. Lasater, and Matthew D. McHugh, all of Penn Nursing’s Center for Health Outcomes and Policy Research, a group whose decades of survey-linked outcomes research have repeatedly connected nurse work environments to patient survival, readmission rates, and now emergency care timeliness. For hospital leaders weighing budget priorities, the message of this study is unusually actionable: every unfilled nursing position is not simply a human resources gap but a quantifiable source of waiting room delay, and funding those positions may be one of the most cost-effective strategies available for restoring timely access to emergency care.

Subject of Research: The relationship between hospital nurse staffing adequacy and emergency department crowding, length of stay, and patients leaving without being seen

Article Title: Safer nurse workloads could alleviate emergency department crowding

Article References: Safer nurse workloads could alleviate emergency department crowding. (n.d.). Original publication

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Keywords: emergency department crowding, nurse staffing, nurse workload, patient length of stay, behavioral health, hospital capacity, boarding, Penn Nursing, Medical Care, health policy, patient outcomes, workforce shortage