Hospital Implements 1:4 Nurse-to-Patient Ratios—Here’s What Happened Next

In November 2025, Goshen Hospital in Indiana announced a new one-to-four nurse-to-patient ratio across all inpatient units. 

The hospital announced the one-to-four ratio as part of the hospital's commitment to:

• Patient safety
• High-quality care
• Nursing team well-being

“Establishing a one-to-four ratio affirms our belief that exceptional care begins with strong support for our nurses who work directly with patients,” said Julie Crossley, MSN, RN, Chief Nursing Officer at Goshen Hospital. “This change allows our nurses the time and focus they need to care for patients while at the same time ensuring a sustainable and healthy work environment for our nursing teams.”

Source: Goshen Health

How They Did It

Scheduling one nurse to four patients is clearly a financial investment, but Crossley explained that the hospital made it work by using funds previously set aside for overtime and incentive pay. 

The hospital bet on prioritizing patient safety and satisfaction, as well as their nurses, in the hopes that it would pay off in the long run. And so far, it's looking like they were absolutely right.

This initiative made Goshen a regional leader in staffing and nursing quality. Goshen Hospital's proactive investment in nursing team staffing also demonstrated its dedication to patient outcomes, team support, and community trust.

"Attracting and retaining nursing talent is fundamental to achieve organizational priorities," Crossley explained. 

What Happened After Goshen Started a 1:4 Nurse-to-Patient Ratio

In January 2026, months after Goshen implemented the 1:4 ratio, Crossley provided updates about the impacts of the change. She told Becker's Review that the investment seems to be "paying off."

Some of the early changes the hospital has seen already include:

• Veteran nurses postponing retirement to continue working
• Improved patient care indicators
• Stronger staff engagement 
• Lower turnover costs
• Higher retention rates in nurses
• Cost effective

Crossley explained that the hospital's decision to implement the 1:4 ratio was based on research that showed the "strongest predictor of patient safety and highest quality of care" is nurse-to-patient ratios.

She also pointed to the high "record" levels of burnout nurses are experiencing, which she linked directly to the growing demands placed on nurses at work. Crossley noted that high levels of burnout is leading the seasoned nurses to leave the nursing profession at higher rates than new grads can replace them. 

The ratio, then, is a step the hospital believes is a change in the right direction.

"Addressing manageable workloads improves nurse well-being and strengthens our workforce, which will lead us to that highest quality of care," said Crossley. 

Crossley was also honest about some of the challenges that implementing the ratio has had: namely, having enough staff to make it happen. However, she said the hospital is recruiting successfully, so that's one challenge she expects to be fixed relatively soon.

The Change Saved the Hospital Money

One huge part of the ratio change is that Crossley says the shift was actually cost-effective for the hospital — and that's a change that could mean more facilities would be willing to adopt it. 

"Our analysis confirmed that this strategy was really one that was cost-effective," she said. "It’s redirecting funds that we have historically been spending on incentive pay, traveler costs, overtime — all associated with the workforce. By doing this and strengthening our staffing ratios, we’re going to be more cost effective in the long run. What healthcare organization right now is not looking to be cost effective?"

What Nurses Think About a 1:4 Ratio

Crossley shared that nurses are reacting very positively to the changes. The ratio is also linked to other positive outcomes, including:

• Improved bedside reporting 
• Fewer call lights being needed
• More patients ambulating the halls with nurse assistance
• Improved communication
• Safety huddle engagement
• Decreased overtime dependence
• Improved work-life balance

"At the end of the day, when nurses care for fewer patients, patients have better care," she summarized. 

Legislation to Support Patient-Nurse Ratios

In May 2025, two Democratic senators and a representative reintroduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act. Senator Alex Padilla (D-California), Senator Jeff Merkley (D-Oregon), and Representative Jan Shakowsky (D-Illinois) introduced the bill on International Nurses Day. 

“For years, I’ve talked to exhausted nurses who have said they go home at night, wondering if they forgot to turn a patient because they were stretched far too thin,” Ms. Schakowsky said. “Study after study shows that safe nurse-to-patient staffing ratios result in higher-quality care for patients, lower healthcare costs, and a better workplace for nurses. It is past time that we act on the evidence, give nurses the support they deserve, and put patients over profits.”

The bill has been endorsed by: 

• National Nurses United
• Alliance for Retired Americans
• American Federation of Teachers
• SEIU Healthcare
• American Federation of State, County, and Municipal Employees

As of January 2026, there has been no further action on the bill, but it has been introduced. However, Goshen Hospital has taken matters into its own hands by implementing the ratio even without legisltation. 

Goshen Fast Facts

Goshen Hospital is a 105-bed, nonprofit, community-owned acute-care hospital serving patients in northern Indiana. Founded in 1913, Goshen Hospital has endless accolades, including

• Five Magnet^® designations from the American Nurses Credentialing Center (ANCC)
• American Nurses Credentialing Center (ANCC) accreditation for nursing continuing professional development
• Five-time silver-level Beacon Award for Excellence from the American Association of Critical-Care Nurses (AACN)
• Accreditation from the American Academy of Sleep Medicine (AASM) 
• American Society of Gastrointestinal Endoscopy's (ASGE) Award of Excellence
• Diagnostic Imaging Center of Excellence™ (DICOE) from the American College of Radiology (ACR)
• Inspire Hospital of Distinction from the Indiana Hospital Association for excellence in maternal and infant care

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