The pandemic has finally been declared ‘over,’ though COVID-19 continues to linger. The phenomenon of burnout has been well documented pre-pandemic, in many cases due to understaffing. This was exacerbated by the severe strain of COVID-19 placed on the healthcare system, with nurses leaving in droves post-pandemic. While nursing professional organizations and unions have long advocated for formalized standards around nurse staffing in a variety of care settings, there has traditionally been stiff opposition, particularly from hospitals, nursing homes, and certain healthcare associations.

California has long led the way on nurse staffing, with specific staffing requirements across various care settings, viz., a 1:1 nurse-to-patient ratio in the operating room, 1:2 in intensive care units, labor and delivery care areas, and critical care patients holding in the emergency department, 1:3 in stepdown units, and 1:4 in emergency departments, telemetry, and ante/postpartum care areas. This has resulted in lower mortality and failure-to-rescue rates in California hospitals compared with other states (Lasater et al., 2021). However, it should be noted that there are circumstances in which a 1:1 ratio may be necessary. The Neurocritical Care Society recommends not only 1:2 staffing ratio, but also 1:1 staffing in particularly high acuity situations (Moheet et al., 2018).

This year, New York became the first state in the post-pandemic era to legislate on the issue of nurse staffing. However, as has traditionally been the case, key groups expressed strong opposition to the legislation, resulting in a watered-down version of the law that is restricted to staffing in the critical care environment. This version requires a 1:2 registered nurse-to-patient ratio in critical care areas. Outside of critical care, the law merely requires an internal committee to handle staffing in these areas, the composition of which must be 50% nurses and 50% hospital administrators.

It is a welcome change to finally codify the requirements that have long been known to be best practice regarding staffing in ICUs. The legislation will certainly introduce much needed accountability for hospitals to provide appropriate nursing care for critical care patients. Civil fines will ensue for hospitals failing to meet these requirements after submission of a corrective action plan. While this is a victory for critical care professionals, we cannot be insular in nature. A key tenet of critical care – neurocritical care being no exception – is to prevent critical illness and reduce admission and readmission rates as much as possible. For this reason, we must be equally concerned with nurse staffing in medical-surgical units and other patient care areas inside and outside the hospital. Therefore, the remaining aspects of this law likely fall short of its aim to police nursing staffing ratios and adhere to best practice. Even with a committee with half its composition including nurses, the law provides that the other half of the committee be composed of hospital administrators.

The law does not provide give the nursing members of the committee any real power or other tools to enforce recommendations, rendering this provision of the law a toothless tiger. Furthermore, the reality of the power differential between hospital administrators and nurses on the committee, particularly, in non-union environments, can easily give rise to situations where nurses are pressured or intimidated into not speaking freely regarding staffing issues or giving in to less-than-ideal staffing decisions emanating from this committee. This is yet another instance of politically active, well-funded, and powerful interest groups successfully opposing the implementation of safety-based measures in service to the almighty dollar.

It has been demonstrated that lower nurse-to-patient ratios results in decreased patient mortality, shorter lengths of stay, and decreased cost (Lasater et al., 2021; Musy et al., 2021; Rae et al., 2021). Yet even in this technologically advanced era, we are still having conversations about improving nurse staffing. Hospitals do not understand that lower ratios result in more individualized nursing care and long-term cost reductions, even after increased staffing is factored into the cost equation. For example, how many of us in the neuro ICU have avoided transferring a complex patient to the floor, for fear of the lack of attention the patient will receive on the medical ward? I, for one, have held onto several patients without critical care needs, but who did have a need for careful secretion management, including suction, chest physiotherapy, and other interventions that could be handled on the medical floor if it were not for staffing issues. Medical-surgical floors in several New York area hospitals, where I am based, have ratios in excess of 1:6, and in some cases up to 1:10, which even led to a recent New York City-wide nursing strike earlier this year.

This represents an increased ICU length of stay and increased costs associated with the hospitalization. It also represents fewer ICU beds available for other patients. This is intricately connected with the concept of “missed care,” which is nursing care left undone due to lack of time to implement all the necessary aspects of nursing care. Missed care is largely due to staffing issues, with nurses forced to triage which aspects of patient care are most critical while deferring the rest (Gehri et al., 2023). Few states across the nation have implemented any sort of legislation or regulation addressing the issue of nurse staffing. As the recent COVID pandemic showed us, the American healthcare system is in crisis. In truth, the pandemic was merely another data point telling us what has already been long known, namely that patient harm can and does occur due to inadequate staffing decisions made only to benefit hospitals’ bottom lines.

Nurses are becoming burned out. With an entire generation of nurses on the brink of retirement and a looming shortage, the lack of adequate staffing will only exacerbate the issue. Over the years it has become clearer that hospitals nationwide are unwilling to implement industry-recommended staffing ratios across all care areas. It is time for state and federal legislators and regulators to step in and mandate staffing ratios for all areas of the hospital. This should be done with nurses at the table. I would remind policymakers that a conversation about nursing without nurses at the table is not a conversation about nursing. Now is the time to take up this vital issue to prevent future harm. We can do better. We must do better.