When the first wave of COVID-19 hit Brooklyn Hospital Center, April Kehoe often found herself rushing between six different patients in a makeshift Intensive Care Unit—far more than the one- or two- patient caseload typically considered safe for nurses in this setting.

The second surge has brought fewer hospitalizations, but Kehoe says the staffing shortages remain. She is still routinely assigned three or four intensive care patients at a time, a situation she says increases the risk of making medication errors or missing changes in a patient’s status.

“It affects patient safety and outcomes, but it also affects the stress levels of the nurse,” Kehoe says.

This problem isn’t new, but one exacerbated by the pandemic. Significant research exists linking nurse staffing levels in hospitals to patient outcomes, including mortality rates. The same goes for nursing homes.

For years, Kehoe’s union, the New York State Nurses Association (NYSNA), has been pushing a bill to establish minimum nurse staffing levels in hospitals and nursing homes across the state. California is the only state that currently has such regulations for its hospitals. Faced with significant pushback from hospital and nursing home associations, the New York bill—called the Safe Staffing for Quality Care Act—has at times passed the state Assembly but never the full legislature.

NYSNA is reviving this fight given new attention to the dangers of stretching hospital staff too thin. The pandemic shed light on the deep disparities in staffing and other resources between city hospitals serving rich and poor patients. A recent report from the state Attorney General’s office also found that nursing homes with less staff had higher rates of COVID-19-related deaths.

At the same time, the pandemic has strained health care resources and budgets. A report released last August by the state Health Department raised questions about whether mandatory staffing requirements would be feasible, affordable, and the most effective way to improve patient outcomes. Data supporting the efficacy of state-mandated staffing ratios, particularly at the hospital level, is also limited, and there isn’t clear evidence in favor of improved patient outcomes.

The Health Department report cited the pandemic as a reason not to support the regulations: “While the Department supports measures to improve quality of care and patient outcomes, the COVID-19 pandemic has only highlighted the need to maintain workforce flexibility.”

The report essentially aligned Cuomo’s Health Department with hospital and nursing home lobbyists that have long opposed the Safe Staffing for Quality Care Act, stacking the odds against the bill. Gothamist contacted the governor’s office and state Health Department for comment. In reply, a spokesperson said the health department does not comment on pending legislation but that it remains committed to the highest level of patient care.

The proposed regulations would involve hiring some 25,000 new hospital staff and 45,000 new nursing home staff statewide, costing between $3.7 billion and $4.7 billion, the report found.

“Given the huge revenue losses and increased costs hospitals continue to suffer due to the pandemic, such a mandate now is unthinkable,” said Brian Conway, a spokesman for the Greater New York Hospital Association. Other evidence suggests the increased costs associated with the staffing requirements might have precipitated service cuts at some California hospitals. Some states have opted to require individual hospitals to establish and adhere to their own staffing plans.

Even before the pandemic, paying for the plan would have likely required state subsidies. Cuomo has agreed to do that for previous mandates, such as the $15 minimum wage, but it’s a tough sell at a time when he is seeking federal aid to make up for a projected $15 billion budget shortfall over the next two years.

Nursing homes say they face recruitment and retention issues that could make staffing up difficult. Research is still ongoing as to how the pandemic has affected the state’s nursing workforce overall, according to Jean Moore, director of the Center for Health Workforce Studies at SUNY Albany.

Judy Sheridan-Gonzalez, president of NYSNA, insists that universal standards are the only way to ensure equity and hold health care providers accountable. Even after getting some hospitals to include staffing ratios in union contracts, Sheridan-Gonzalez says they have been hard to enforce.

“Having a law is much better because it’s universal,” she said. “There’s better accountability and enforcement mechanisms. The hospital can’t just say, ‘File a grievance.’ No, we’re going to file a complaint with the Department of Health or Department of Labor. It’s more powerful.”

NYSNA recently accused the Montefiore Health System of keeping staff down by being slow to fill vacancies—a claim Montefiore says is “baseless.” “We are aggressively recruiting to fill vacant positions and maintaining sufficient staffing levels, even as we care for our community through a second COVID surge,” Montefiore said in a statement.

When more than 200 nurses at Montefiore New Rochelle went on strike in December, in part over staffing demands, Montefiore accused NYSNA of using COVID-19 as a “political football.” It also listed concessions made to the union in its contract, but increased staffing was not among them.

Editor's note: This story was updated with a comment from the New York State Department of Health.