Some days, Ashley Grieco feels behind the second she steps into the neonatal intensive care unit at UPMC Magee-Womens Hospital.

On those difficult occasions, three critically ill babies might need her attention — all at once.

Ideally, Grieco would spend more time with each infant, nurturing language skills by reading to them or strengthening their muscles with physical therapy. But her most pressing days don’t afford that luxury. They feel more like a checklist: “Change the baby, feed the baby, move on.”

Grieco can be left with a sense her patients are shortchanged — not because she lacks skill or passion but because she is stretched thin.

“I feel like many of us often leave (work) feeling like we could have done more or wishing that we could have done more,” Grieco, 35, of Whitehall said recently.

For the country’s 3.3 million working registered nurses, each day can be a test of whether their love of patient care outweighs the job’s daily toll.

Some already have made up their minds, with more than 200,000 telling the National Council of State Boards of Nursing in a survey last year they plan to leave the profession by 2029.

The pending mass departures could worsen an already acute staffing crisis in Pennsylvania, which has 147,000 working nurses. The average hospital in the state had a 19% vacancy rate for registered nurses providing bedside care last year, according to the Hospital and Health­system Association of Pennsylvania, an industry group.

Nurses and their employers recognize the staffing crisis. But what’s driving these gaps in the workplace — and how to fix them — is where consensus gives way to battle lines.

The real flash point: mandatory patient-­to-nurse ratios. Long discussed in Pennsylvania but never passed into law, such policies exist in only a handful of hospitals in the state.

Ratios usually are based on the needs of different units and the conditions of patients. Nurses generally are assigned fewer patients in intensive care units than emergency rooms, for instance.

Many nurses, like Grieco, say hospitals can help staff and patients alike by capping the number of patients they’re assigned.

They’re backed by more than 20 years of data from Linda Aiken, a University of Pennsylvania nursing professor whose research underpins arguments for mandatory ratios that limit the number of patients per nurse.

Perhaps Aiken’s most impactful paper appeared in the Journal of the American Medical Association in 2002. It showed the risk of patient death rises by 7% and nurse burnout by 23% for each additional patient under a nurse’s care. Burnout, in turn, can drive nurses to leave the profession, Aiken explained.

Wayne Reich Jr., CEO of the Pennsylvania State Nurses Association, said hospitals fail to understand this connection, trying everything but lower workloads to solve staffing issues.

“Once hospitals recognize why the nurses are leaving, then I think they can work on what they can do to keep nurses there,” Reich said. “And I think they’re unwilling to look at that now.”

Hospitals counter by claiming strict ratios will drive up wait times and reduce available beds while doing little to boost the number of nurses. In general, they see nursing vacancies as more of a recruitment than a retention issue and are investing heavily in producing more nursing school graduates.

Allegheny Health Network opposes government-mandated ratios. Hope Waltenbaugh, the health system’s interim chief nurse executive, said these policies don’t reflect the complex variables, such as unit layout and nurse experience, that go into staffing decisions.

UPMC declined to explain its stance on ratios, but the vice president of its health services division, Lauren Lloyd, said in her opinion, there’s little evidence they work well.

Traci Fick, chief nursing officer at Independence Health System’s Westmoreland and Frick hospitals, said her system faces registered nurse vacancy rates in line with regional averages. She rejected mandatory ratios, saying Independence believes “staffing decisions are best made at the local level, based on patient acuity, available resources and team dynamics.”

None of the hospitals framed strict ratios as a tool to attract and keep nurses.

“We would like to have more registered nurses,” said Robert Shipp, vice president of workforce and clinical affairs for the Hospital and Healthsystem Association of Pennsylvania. “The simple matter is they’re not there.”

What money can’t buy

Last year’s survey by the National Council of State Boards of Nursing, which identified the looming worker exodus, tracked job dissatisfaction in several ways.

Of more than 500,000 responding nurses, 59% said they feel “used up” at least once a week, 54% “emotionally drained” and 44% “burned out.”

Nearly all hospitals are offering raises, flexible scheduling, professional development opportunities and other amenities to recruit and retain nurses, according to the Hospital and Healthsystem Association of Pennsylvania. UPMC and AHN say they’re among them. Independence claimed similar tactics but did not mention higher pay.

The average registered nurse in the state makes $76,000 a year, according to NurseJournal.org.

But pay and perks go only so far, said Kathleen Anne, a registered nurse at West Penn Hospital. “All the money in the world cannot make up for losing a patient on your shift,” Anne said.

Staffing grievances were key to the union drive that gave West Penn nurses their first contract in 2021. The union successfully bargained for a minimum number of nurses per unit, which has a similar effect as patient-to-nurse ratios.

“I can’t remember the last time we went over ratios,” Anne said. “They have been remarkably compliant, and they make every effort to respect the guidelines that we set.”

Anne used to have up to eight patients in the post-surgery unit where she works. Now she has no more than five.

Heritage Valley nurses in Beaver first secured required ratios in their 2010 union contract. The system, which is being absorbed by AHN, extends these ratios to its other, nonunion hospital in Sewickley.

The limits allow nurses to feel more comfortable with their assignments, according to Linda Homyk, chief nursing officer at Heritage Valley. The trade-off: Patients in the emergency department sometimes must wait longer than before for an inpatient room so the hospital can maintain proper ratios.

Classroom solution

Hospital administrators, recognizing ongoing staffing challenges, are looking to education for a solution.

Waltenbaugh, the AHN administrator, cited a record enrollment of 355 full-time students at the system’s nursing schools, with locations at West Penn and the Pittsburgh Mills mall. She also pointed to a new part-time nursing school program with evening and weekend courses.

A rising number of graduates helped AHN hire more than 1,000 nurses last year and reduce vacancies on its 6,000-member nursing team.

UPMC has found similar success, boasting an enrollment of 1,024 at its six nursing schools across Pennsylvania — a 56% increase since 2023.

“We’ve done a lot of work in the last several years to really increase our pipelines of nurses — growing our own schools of nursing, working with our academic partners to make sure we’re doing everything possible to promote nursing as a desirable career,” said Lloyd, the UPMC vice president.

UPMC said just under 6% of its registered nurse positions are unfilled.

Most of the hospital-run programs award nursing diplomas in two years or less, making them attractive ways to cover staffing shortfalls versus traditional four-year bachelor’s programs.

Duquesne University School of Nursing Dean Mary Ellen Glasgow acknowledged fast-track approaches are needed to get more nurses to patients’ bedsides.

“I think we all want safe staffing, but if we don’t have nurses, I don’t know how we’re going to have safe staffing,” Glasgow said. “You can’t penalize hospitals if the nurses aren’t there or the faculty aren’t there to teach them.”

Keeping nurses in the field will take a fundamental shift in working conditions, according to Reich, the Pennsylvania State Nurses Association leader.

He likens the staffing situation to a leaky bucket: No matter how many new nurses get dumped in, they’ll eventually fall out of the bottom without tolerable workloads.

“If a business is looking at that high a turnover rate, they would look at what they’re doing, not necessarily complain they don’t have enough applicants for that job,” Reich said.

Running out the clock

In 2023, Pennsylvania’s Patient Safety Act cleared the state House in resounding and bipartisan fashion. Mandatory patient-to-nurse ratios looked possible, to the shock of many.

It certainly stunned hospitals, Reich said.

He recalled how the industry sprang into action with lobbying efforts and a statewide texting campaign that warned of hospitals closing and patients going without care under a ratio system.

The bill never made it out of committee in the state Senate.

Under pressure from hospitals, senators “ran out the clock,” said the bill’s prime sponsor, state Rep. Thomas Mehaffie III, R-Dauphin County. The experience made it clear to him nothing would change until nursing and hospital associations agreed on staffing solutions.

Mehaffie believes elected officials will have to force them to hash it out.

For now, the momentum behind statewide ratios has stalled. It’s not an easy law to get passed — only California and Oregon have legally mandated ratios across all units and specialties.

‘A seat at the table’

Union contract talks have become the more likely forum for nurses to secure ratios.

Some of the newly unionized nurses at Magee are hoping for ratios in their first contracts, claiming unmanageable patient loads are repelling new hires and exhausting veteran nurses (UPMC says it has lower-than-average turnover and vacancy rates at Magee).

“I think a lot of us realized our priorities were never going to align with UPMC’s priorities unless we had a seat at the table,” said Grieco, the Magee nurse.

State Rep. Arvind Venkat, D-McCandless, sees collective bargaining as the best way to set ratios. His experience as an emergency physician, where the number of patients and the severity of their conditions can swing wildly, has led him to believe a state mandate would be too rigid.

He was one of two House Democrats to vote against the Patient Safety Act.

“What I do support is these types of negotiations happening at the hospital level,” Venkat said. “We need to do far more to support the ability of nurses to organize and unionize.”

This legislative session, Pennsylvania lawmakers have turned their attention toward solutions on the education side, more in line with hospitals’ theories of how to boost nursing ranks.

Gov. Josh Shapiro’s proposed budget includes a $5 million investment to create the Nurse Shortage Assistance Program. The initiative would cover tuition for students who agree to work at a Pennsylvania hospital for three years after graduation.

“We know this model of tuition assistance works,” Shapiro said when the program was pitched in March. “And for the first time ever, we are proposing to help nursing students with an investment of state dollars that not only gives them peace of mind but creates a pipeline of new, highly trained nurses for our communities.”

State legislators have yet to pass a budget, which is more than three months overdue.

The drive to care

Nurses may have their beliefs about how hospitals and lawmakers can best support them, but most will take any help they can get toward improving patient care.

Angie Noel, 40, of Penn Hills finds her job much more fulfilling at Allegheny General Hospital since the nurses union and management agreed to set ratios in 2023.

She also recognizes the challenges hospitals face in finding staff, including in her telemetry unit, where a large portion of patients are recovering from a heart attack or stroke.

Noel worked as a teacher, baker and cosmetologist before becoming a nurse four years ago. Standing by the hospital on Pittsburgh’s North Side before a recent shift, Noel said a common theme runs through each of those jobs: taking care of people.

“One of the things they teach us in school is, it’s not just the medicine. It’s about being able to listen to your patients when they’re crying and they’re upset, helping them process difficult emotions,” Noel said. “When we’re actually adequately staffed, it’s amazing the things we can get done.”

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