Healthcare unions say contracts that specify how many clinicians should work each shift aren’t enough to hold hospitals accountable for ensuring sufficient staffing levels.
Staffing agreements have become increasingly common in union contracts over the past few years as bargaining committees seek to mitigate nurse shortages that are expected to reach 195,400 by 2031, according to the Bureau of Labor Statistics. However, union leaders say nurses have little power to hold health systems to staffing ratios, and the threat of penalties has not stopped hospitals from violating contractual agreements. This has led unions to call for strict state and federal legislation to enforce staffing ratios.
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Mount Sinai Health System paid more than $2 million last month to its nurses for violating agreed-upon nurse-to-patient ratios. The health system has been fined eight times for understaffing since negotiating a contract with the New York State Nurses Association in early 2023.
At Mount Sinai Morningside in New York City, frontline clinicians haven’t noticed any difference in staffing levels under the contract or through the arbitration process, said Maria Colon, a registered nurse in the hospital’s emergency department and a member of the New York State Nurses Association.
“[Morningside] claims that they have been making tireless efforts to hire, however, the rate that they're hiring at is barely enough to keep up with the rates that people quit at,” she said.
To reach registered nurse-to-patient ratios of 1:2 in the emergency department, 1:5 in acute care departments, and 1:8 in subacute care departments as laid out in the contract, Mount Sinai Morningside would have to hire around 94 full-time equivalent employees. In the last six months, the hospital has hired five, Colon said.
Mount Sinai did not respond to a request for comment.
Unions at health systems including HCA Healthcare and Kaiser Permanente also say they have run into issues with enforcing staffing agreements. However, the unions still think contract language that dictates staffing grids and ratios provides a valuable framework for nurses to tackle staffing issues with hospital leadership.
The Coalition of Kaiser Permanente Unions, which represents more than 85,000 workers, has had staffing language in its contracts with the health system for more than a decade. Its 2023 contract—which followed the largest strike in healthcare history last fall—added timelines for hitting staffing goals in every department by August 2025, bi-weekly meetings with union and health system leaders and an oversight committee, said Caroline Lucas, executive director of the coalition.
The contract includes staffing levels for clinical and nonclinical roles. But once those milestones are in place, union members will still have to make sure that system leaders are following through, Lucas said.
“It would be great to say we're confident that once we have an agreement, it's going to be followed to the letter of the law, but that's just not realistic,” she said. “We will have to work on holding Kaiser leaders accountable.”
Kaiser Permanente declined to respond to questions about its contract with the coalition.
Union leaders at HCA Healthcare facilities also say the burden is on rank-and-file members to step forward when contracts that include staffing levels aren't being met.
“There’s not a day that goes by that HCA doesn’t try to violate that staffing grid, and we are able to put a stop to that a lot of times,” said Hannah Drummond, a registered nurse at Mission Hospital in Asheville, North Carolina, and the facility's chief nurse representative with National Nurses Organizing Committee/National Nurses United. “We have so many stories of nurses speaking up about staffing and seeing the situation get rectified in real time. In a way, that would have never happened prior to having our union.”
The nurses at Mission Hospital voted to join National Nurses Organizing Committee/National Nurses United in 2020.
In a statement, HCA said staffing levels at all its hospitals—including those with unions—are determined by hospital leaders, and patient volume and acuity are their main considerations.
Staffing agreements are often the highest priority for union groups during contract negotiations even though they aren't always an effective way to fix chronic clinician shortages, said Rebecca Givan, associate professor in the School of Management and Labor Relations at Rutgers University.
At the very least, a contract with built-in fines for employers with short-staffed units means compensation for nurses who had to work there, Givan said.
“The reason that hospitals are operating short-staffed is because it saves money,” Givan said. “So making it less of a cost savings by putting [staffing] plans in place shifts how the hospital makes decisions.”
She said penalties also mean patients and community members are alerted when a hospital is not adhering to safe staffing ratios, which Drummond and other union members agree pressures facilities to reconsider their recruitment and retention efforts.
The American Hospital Association declined to comment on the use of staffing ratios in labor agreements.
Overall, nurses have limited options and little power to hold hospitals to staffing agreements outside of lengthy arbitration processes and notifying the state of unsafe staffing environments, said Peter Sidhu, executive vice president of United Nurses Associations of California/Union of Health Care Professionals.
“We’ve filed staffing grievances every year since 2015,” Sidhu said. “Typically what an employer will do is try to figure out the easiest way to get out of that. So they may say, ‘Hey, we're gonna hire a bunch of per diems,’ instead of providing full-time or part-time benefited positions.”
Union members are fighting for legislation to mandate hospital staffing levels nationwide, but Oregon, California, Massachusetts and New York are the only states with laws requiring specific nurse-to-patient ratios. The states' health departments oversee complaint-driven enforcement and issue financial penalties ranging from $5,000 to $30,000 per staffing offense.
Lawmakers introduced state and federal legislation proposing minimum staffing requirements, but these efforts have been opposed by health systems. Those attitudes might change as clinicians join unions, Givan said.
“Hospitals with staffing levels spelled out in their contracts may eventually start to see legislation as a good thing because it will level the playing field,” she said.
