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

Image Credits: AI Generated

DOI: Not provided

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

The scale of the investigation lends considerable weight to its conclusions. The research team examined the outcomes of more than 1.17 million patients treated at 143 for-profit and 798 nonprofit adult acute care hospitals across 10 states. By drawing on such a large patient population and a substantial share of hospitals in each ownership category, the researchers were able to compare mortality, readmission, and patient experience measures across ownership types while accounting for differences in nurse staffing, the factor that emerged as a central explanation for the quality divide. The findings suggest that the ownership structure of a hospital is not merely an administrative detail but a variable with tangible consequences for the people it treats.

The mortality differences were stark. Compared with nonprofit hospitals, for-profit hospitals recorded roughly 11 additional deaths per 1,000 medical admissions and 5 additional deaths per 1,000 surgical admissions. For medical patients, differences in nurse staffing were identified as a main explanation for the higher mortality observed in for-profit settings. In other words, a meaningful portion of the excess deaths was associated not with the complexity of the patients themselves but with the conditions under which nurses were working, particularly the number of patients each nurse was assigned to care for at one time. This distinction matters because staffing levels are, unlike many drivers of surgical outcomes, directly amenable to policy and management decisions.

Readmission rates told a parallel story. Thirty-day readmissions were 2.04 percentage points higher for medical patients and 1.76 percentage points higher for surgical patients at for-profit hospitals, which translates to roughly 20 additional readmissions per 1,000 medical discharges and 18 per 1,000 surgical discharges. Differences in nurse staffing accounted for 16 percent of the readmission gap among medical patients and 30 percent of the gap among surgical patients. Readmissions are widely used as a quality indicator because they often signal that a patient left the hospital without adequate recovery support, discharge planning, or in-hospital care that fully addressed their condition. The finding that staffing explains a substantial share of these differences points to a modifiable pathway through which hospital ownership may influence patient trajectories after discharge.

Patients themselves appeared to sense the difference. Individuals treated at for-profit hospitals rated their institutions lower overall than patients at nonprofit hospitals did, and worse nurse staffing accounted for the lower overall hospital ratings. Patient ratings are not simply measures of satisfaction with amenities or food; decades of research have linked patients’ assessments of their hospital care, particularly their confidence in nursing care, to objective outcomes including mortality and readmission. That patient perceptions aligned with the hard clinical endpoints in this study strengthens the argument that the staffing shortfalls documented by nurses were visible in the everyday experience of care.

The consequences for the nursing workforce were equally concerning. Nurses in for-profit hospitals reported markedly worse staffing conditions, with 71 percent saying their assigned patient workloads were not safe. Nurse burnout was significantly higher in for-profit hospitals, and nurses working in them were far less likely to recommend their hospital to family and friends, either as a place to receive care or as a place to work, because of concerns about poorer staffing. These findings matter beyond workforce statistics. Burnout and unsafe workloads are known drivers of turnover, and turnover compounds understaffing in a self-reinforcing cycle that can degrade care quality over time. A hospital that cannot retain experienced nurses faces rising costs and mounting risks to patients simultaneously.

Lead author Matthew D. McHugh, PhD, JD, MPH, RN, FAAN, the Independence Chair for Nursing Education, Professor of Nursing, and Director of the Center for Health Outcomes and Policy Research at Penn Nursing, as well as a Senior Fellow at the Leonard Davis Institute of Health Economics, framed the implications in pointed terms. Treating safe nurse staffing as a core component of quality rather than a discretionary operating expense is especially important where incentives to cut labor costs are strongest, he said. Minimum safe staffing requirements and ownership transparency are practical safeguards for patients and nurses, he added. The statement underscores the study’s central policy argument: because labor is one of the largest controllable expenses in a hospital budget, ownership models that prioritize profit margins have both the incentive and the opportunity to trim nursing resources, and the evidence suggests that some do.

The research was conducted with co-authors Karen B. Lasater, PhD, K. Jane Muir, PhD, Trissa Lyman, MPH, Angelo Petto, BSN, and Linda H. Aiken, PhD, several of whom are fellows of both the Center for Health Outcomes and Policy Research and the Leonard Davis Institute of Health Economics. The work was supported by the National Institute of Nursing Research of the National Institutes of Health under grant award numbers R01NR014855, T32NR007104, and R01NR021707. The study, titled Patient Outcomes and Nurse Understaffing in For-Profit Hospitals, carries the DOI 10.1097/MLR.0000000000002376 and is available open access, allowing clinicians, policymakers, and the public to examine the evidence directly.

The authors conclude that policies establishing minimum safe nurse staffing requirements and enhancing hospital ownership transparency could meaningfully improve patient, nurse, and hospital outcomes. Such conclusions carry particular relevance as state legislatures across the country debate mandated nurse-to-patient ratios and as regulators scrutinize private equity investment and corporate consolidation in health care. The study suggests that investments in nursing and state policies establishing safe staffing requirements are important and actionable mechanisms to ensure patient safety, nurse retention, and quality of care for patients regardless of the ownership type of their hospital. In practical terms, this means that the quality gap documented between for-profit and nonprofit hospitals is not an inevitability of ownership structure but a consequence of resource allocation decisions that regulation could influence.

The findings also connect to a growing body of research on hospital ownership and nursing investment, including a 2025 study by Muir and colleagues published in Medical Care showing that hospital ownership type correlated with investments in nursing services using evidence from Illinois. Taken together, this line of inquiry points toward a consistent conclusion: where the profit motive is strongest, nursing resources tend to be thinnest, and patient outcomes suffer as a result. For a health system grappling with nurse shortages, rising burnout, and intensifying corporate ownership of care delivery, the study offers a clear and testable proposition. Protecting staffing levels, whether through legislation, accreditation standards, or transparency requirements that let patients see how hospitals are resourced, may be one of the most direct levers available for improving the safety of American hospital care.

Subject of Research: The relationship between hospital ownership type, nurse staffing levels, and patient outcomes in US acute care hospitals

Article Title: For-profit hospitals linked to worse patient outcomes and nurse staffing shortfalls, new Penn Nursing study finds

Article References: For-profit hospitals linked to worse patient outcomes and nurse staffing shortfalls, new Penn Nursing study finds. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: for-profit hospitals, nurse staffing, patient outcomes, mortality, readmissions, hospital ownership, nurse burnout, Penn Nursing, Medical Care, health policy, patient safety, staffing requirements

The editorial is authored by senior author Eileen T. Lake, the Edith Clemmer Steinbright Professor in Gerontology, Professor of Nursing and Sociology, and Associate Director of the Center for Health Outcomes and Policy Research, together with Domenique Villani, a predoctoral fellow at the center, and Ysabella Perez, a recent Penn graduate and research assistant at the center. Their central argument is straightforward but consequential: building genuine climate resilience into the health system requires ensuring that bedside nurses have the organizational capacity and the material resources needed to deliver timely care and continuous surveillance during heat events, when patient volumes can spike suddenly and patient conditions can deteriorate rapidly.

The physiological rationale behind this argument is well established in clinical medicine. Extreme heat places severe stress on the human body, particularly the cardiovascular system, which must work harder to dissipate heat through increased blood flow to the skin. In vulnerable populations, including older adults, people with chronic cardiovascular or respiratory disease, patients taking medications that impair thermoregulation, and those with limited access to cooling, prolonged heat exposure can progress from heat exhaustion to life-threatening heat stroke. Heat stroke is a medical emergency characterized by core body temperatures above roughly 40 degrees Celsius and central nervous system dysfunction, and it can trigger a cascade of complications including rhabdomyolysis, acute kidney injury, coagulopathy, and multi-organ failure. Surviving such a cascade depends heavily on early recognition and rapid, sustained intervention.

This is precisely where nursing care becomes decisive. The editorial emphasizes that the management of heat-related illness requires immediate and resource-intensive nursing surveillance to prevent complications and to catch the signs of rapid patient deterioration before they become irreversible. Continuous monitoring of vital signs, fluid balance, electrolyte status, and neurological function is the daily work of bedside nurses, and during a heat wave the volume of patients needing this level of attention can rise sharply at exactly the moment when a hospital’s workforce is under maximum strain. Nurses themselves are also exposed to the same environmental conditions, and heat events can affect staff wellbeing and performance, adding another layer of pressure on the workforce during surges.

The authors warn that insufficient staffing and inadequate organizational support can severely limit a health system’s ability to deliver standard-of-care treatments during the sudden volume surges that heat waves produce. A hospital may have the physical beds, the cooling capacity, and the IV fluids to handle an influx of heat-affected patients, but if there are not enough nurses to perform the frequent assessments, administer cooling protocols, titrate fluids, and escalate deteriorating patients to higher levels of care, the theoretical surge capacity fails in practice. In this sense, the editorial reframes nurse staffing not as a cost line to be minimized but as a functional limit on how much emergency care a hospital can actually deliver when environmental disasters strike.

The argument rests on a substantial body of research from the Center for Health Outcomes and Policy Research and collaborators, which has repeatedly demonstrated that the ratio of patients to nurses and the quality of the nurse work environment are associated with patient outcomes including mortality, failure to rescue, lengths of stay, and rates of complications. Studies in this tradition have shown that hospitals with better work environments, characterized by adequate staffing, strong nurse-physician relationships, nurse participation in decision-making, and supportive management, achieve better outcomes even at similar staffing levels. Extending this evidence base to climate-driven emergencies is a natural progression, and it suggests that the organizational features that protect patients in ordinary times become even more critical when the system is stressed by a heat crisis.

Looking forward, the editorial does not stop at diagnosis. It outlines actionable recommendations across four domains: research, education, practice, and policy. On the research side, the authors call for studies that specifically examine how staffing and work environment characteristics shape outcomes during heat events, filling a gap in the disaster preparedness literature that has traditionally focused on infectious disease outbreaks, mass casualty trauma, and hurricanes. On education, the implication is that nursing curricula and continuing professional development should prepare clinicians to recognize and manage heat-related illness and to understand the systems-level factors that determine whether such care can be delivered effectively during a surge.

In the domain of practice, the editorial urges health system leaders to incorporate nurse staffing and workplace environment investments directly into disaster preparedness planning, rather than treating workforce questions as separate from emergency management. Concretely, this could mean including staffing models in heat response plans, ensuring that nurses have the equipment and authority to implement cooling and monitoring protocols efficiently, and designing work environments that protect staff as well as patients during extreme temperatures. On the policy front, the authors’ message is directed at regulators, accreditors, and hospital administrators: if extreme heat is now a recurring, predictable public health emergency, then the workforce that delivers the front-line response deserves the same strategic investment and planning attention as any other piece of emergency infrastructure.

The broader context gives this argument urgency. Heat waves in the United States have grown more frequent, more intense, and longer-lasting in recent decades, consistent with the warming trend driven by climate change, and emergency departments in many regions have reported rising numbers of heat-related visits during recent summer seasons. Public health agencies have long emphasized individual-level precautions, such as hydration, air conditioning, and checking on vulnerable neighbors, but the hospital-level response has received comparatively less attention. The editorial’s contribution is to shift the focus from the community to the bedside, insisting that what happens inside the hospital, and specifically how many nurses are available and how well supported they are, is a measurable determinant of who survives a heat emergency.

The authors state their conclusion plainly: extreme heat is no longer just a public health issue, but an immediate hospital preparedness priority that requires treating nurse staffing and supportive work environments as essential emergency infrastructure. As climate projections indicate that dangerous heat events will become more common in the coming decades, hospitals that invest now in their nursing workforce, in both numbers and working conditions, may find themselves measurably better equipped to protect their patients when the next heat wave arrives. The editorial, titled How Nursing Can Strengthen Hospital Preparedness for Extreme Heat, was published in Public Health Nursing in September 2026 and represents a call to action for health system leaders, educators, researchers, and policymakers alike to place the nursing workforce at the center of climate resilience planning.

Subject of Research: The role of hospital nurse staffing and work environments in extreme heat emergency preparedness

Article Title: New editorial calls for investing in hospital nursing workforce to address health impacts of extreme heat

Article References: New editorial calls for investing in hospital nursing workforce to address health impacts of extreme heat. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: extreme heat, nurse staffing, hospital preparedness, Public Health Nursing, climate resilience, heat-related illness, emergency department, patient outcomes, nursing workforce, health policy, University of Pennsylvania, heat wave