Happy Nurses Week 2023: Advocating for Nursing Workforce Growth, Not Staffing Ratios

Updated on May 12, 2023
Group of nurses set on a white background

May 6-May 12, 2023

During this week in May, and the entire month of May 2023, we celebrate more than 4 million Registered Nurses (RNs) in the U.S. The American Nurses Association’s (ANA) theme for this year is “You Make a Difference”, to honor the many ways that nurses make a difference in our lives. (Nurses Month 2023) 

This is the 203rd year that nurses are recognized during Nurses Week, which ends on May 12, 2023, with the birthday of Florence Nightingale, the founder of modern nursing.

As we celebrate all nurses regardless of where they work in healthcare, we also recognize that healthcare is experiencing one of the worst shortages of direct care nurses who work at the patients’ besides in hospitals.

The nursing shortage escalated during the COVID pandemic, and states strict licensing restrictions were waived allowing temporary permission for registered nurses to work without going through the expensive and lengthy licensing process in each state. These waivers have now expired and created a void where many temporary nurses worked. 

This is evident across the US and in Pennsylvania, where we witness a nursing workforce shortage that is worse post-pandemic. At the end of 2022, Pennsylvania hospitals reported a 30.7% vacancy rate for registered nurses (RN) providing direct patient care (increased from 20.5 % in 2019), and this group of RNs had a turnover rate of 15.3%, increasing from 10.4% in 2019. (Report: Addressing Member Hospital Workforce Needs, HAP’s Workforce Shortage Survey Executive Summary. Jan. 2023. https://www.haponline.org/Resource-Center?resourceid=941

Hospitals have implemented multiple initiatives to fill the gap of direct care nurses. In addition to traditional measures of offering nurses overtime shifts, hospitals and healthcare systems are employing agency nurses (travel nurses), as well as creating their own internal nursing agency with premium pay and benefits that cost less than the exorbitant salaries demanded by external agencies. 

Another successful strategy of hiring International nurses to fill the direct care nurses gap has recently become threatened because of a Visa Retrogression. Hershey Medical Center hired 240 international nurses with E-3 visas that are now on hold. (Visa Bulletin, May 2023 https://travel.state.gov/content/travel/en/legal/visa-law0/visa-bulletin/2023/visa-bulletin-for-may-2023.html). This problem could be corrected if international nurses’ work visas would be reclassified as E-1, Priority Workers status. 

Other unique approaches to managing the nursing workforce shortage are being tried by hospitals across the Commonwealth and nationwide. 

However, hospitals and healthcare organizations’ ability to independently determine how best to fill the direct care RN gap caused by the nursing workforce shortage is being threatened by two bills at the Pennsylvania General Assembly called “Patient Safety Acts”. House Bill 106 Patient Safety Act was introduced and referred to the HEALTH Committee on April 28, 2023. The bill, sponsored by representatives, Mehaffie Tomlinson & Kosierowski, would mandate the number of nurses assigned to patients for each patient care unit in all Pennsylvania hospitals. The Senate Patient Safety Act has not yet been introduced in the SENATE by Senator Maria Collett 

The  Pa House Health Committee, chaired by Dan Frankel [D-Allegheny County] held a hearing on May 2, 2023 to discuss the benefits and risks of House Bill 106. If enacted, HB106 would mandate nurse staffing ratios for every unit in every hospital across the Commonwealth (Section 802-C). There will be no difference if the hospital is a Level 1 Trauma Hospital, or a rural hospital. Staff nurses and nurse leaders will not be able to modify staffing assignments if changes occur and logic dictates that a staffing adjustment can be made. 

If hospitals fail to meet these ratios, they will be subject to fines of up to $15,000 from the Department of Health for each violation/per shift, and there are no limits on how many fines would be issued.  The mandated nurse staffing ratios in House Bill 106, are strict, and the Department of Health cannot alter these ratios. 

Here is the breakdown:

  • Section 809 (d). “Penalties.–Following the receipt of a complaint and completion of an investigation described in section 808-C for a violation described in subsection (b), the department shall:
  • (1) Issue a warning for the first violation. 
  • (2) Impose a civil penalty of $7,500 for a second violation of the same provision. 
  • (3) Impose a civil penalty of $15,000 for each third and subsequent violation of the same provision.”

There are additional penalties with no cap on the number of fines. 

  • Section 809(b) Separate violations.–Each violation of a written hospital-wide staffing plan shall be considered a separate violation, and there is no cap on the times that a penalty may be imposed for a repeat of a violation.
  • The Department of Health can impose civil penalties or suspend or revoke a license of a hospital for a violation of any provision of this chapter. 

There is also laborious work related to Staffing Committee (Section 803-C) and Staffing Transparency (Section 805-C)

The civil penalty fines paid by hospitals will go to the state, and not in any way help the current nursing shortage. 

Managing all of the aspects of  House Bill 106 will be labor intensive, and it will take precious time away from the essential work of the hospital.  Hospitals and health systems will be reacting to and working under the threats and realities of fines, license suspension and revocation, instead of developing strategies to proactively manage nursing staffing shortages.

Appealing fines will result in lengthy appeals with the Department of Health. During the time of these appeals, fines can continue to be levied. 

Hospitals at max ratio will be forced to close beds on patient units, board patients in the Emergency Department for hours if not days, and divert ambulances to hospitals that aren’t at max ratio. With the current nursing shortage affecting all hospitals across Pennsylvania, ambulances may be diverted a long distance from Pennsylvania citizens’ communities. Rural hospitals will be especially impacted by this law and residents in these communities may need to travel hours to the nearest hospital that isn’t at max ratio. 

An even more serious consideration is that some hospitals will not be able to function under these strict nursing ratios and fines, and may close.  

The bottom line is that Pennsylvania is experiencing a major nursing workforce shortage and these Patient Safety Acts will only penalize hospitals that are currently struggling and using tried and true methods as well as new innovative approaches. 

Other options are available to legislators to help grow the nursing workforce.  There is no one size fits all for all hospitals and the nurse leaders and staff nurses need to be able to communicate continuously to manage staff nursing needs. 

Legislating mandatory nurse staffing ratios for hospitals is not the answer to today’s nursing shortage. 

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Mary O'Connor, PhD, MSN, RN
Professor Emeritus, PennWest University, California campus
Pennsylvania Organization of Nurse Leaders (PONL), Legislative Committee