Goshen (Ind.) Hospital made a bold commitment in November: implementing a maximum 1-to-4 nurse-to-patient staffing ratio across all inpatient units.

The move reflects a strategic shift to reinvest funds traditionally spent on overtime and incentive pay into sustainable nurse staffing — a decision aimed at strengthening retention, improving care, and ultimately reducing costs, according to Julie Crossley, MSN, RN, the hospital’s chief nursing officer. The 1-to-4 ratio serves as an upper limit, not a blanket assignment, she said in an interview with Becker’s. Many units, such as critical care and step-down, frequently operate with fewer patients per nurse based on acuity.

Just a few months into the change, Goshen is already seeing signs that the investment is paying off. Some veteran nurses who had been weighing retirement say they now plan to stay longer, and early indicators point to improved patient care and stronger staff engagement.

Becker’s recently spoke with Ms. Crossley about what prompted the hospital to act now, how leaders determined the 1-to-4 threshold, and what early outcomes suggest about the sustainability of the model.

Question: What made now the right time for this decision, and what internal or external signals prompted action?

Julie Crossley: We identified an opportunity to redirect funds previously spent on overtime and incentive pay; to invest in staffing through improved nurse-to-patient ratios. This strategy will help us create a sustainable and supportive professional practice environment. The return on this investment is through improved patient outcomes and lower turnover costs. Attracting and retaining nursing talent is fundamental to achieve organizational priorities.

Q: How did you determine that a 1:4 ratio was the optimal threshold for both patient safety and nurse sustainability at Goshen? Were there specific clinical outcomes or workforce indicators that influenced this choice?

JC: Research demonstrates the strongest predictor of patient safety and highest quality of care, is safe nurse-to-patient ratios. And the reality is, that the work nurses are tasked with today is incredibly challenging. Over the last 27 years, I have watched the growing demands placed on nurses leading to record numbers of burnout in the profession.

Seasoned nurses are leaving at rates that are faster than the schools of nursing can prepare new grads. Addressing manageable workloads improves nurse well-being and strengthens our workforce, which will lead us to that highest quality of care. We have always had great staffing as a Magnet organization. This workforce strategy is a bold commitment to have the best staffing in our region. We expect this to not only attract but also retain nursing talent. Through data analysis and benchmarking, we determined one to four patient ratios was the commitment level necessary. And based on the inquiries and phone calls I have received from across the state, the reaction suggests one to four was the right decision.

Q: What was the most significant barrier you and your leadership team faced in putting this into practice? How did you work through it?

JC: Our analysis and planning determined that this was the appropriate strategy for Goshen Health. If you want different outcomes, different approaches are necessary. The barrier we face is filling the handful of open positions to have the necessary workforce to achieve one to four or less everyday. Through our successful recruiting, I expect the barrier to be addressed soon.

Q: Many hospitals voice concern that strict staffing ratios can be financially unsustainable or misaligned with flexible, team-based models of care. What is your response to those who say staffing ratios are too rigid for today’s care delivery landscape?

JC: Our analysis confirmed that this strategy was really one that was cost effective. 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?

We expect a healthier work environment, improvements in quality of patient care, patient experience and nurse well-being. A strong workforce positively impacts the outcomes a healthcare organization is trying to achieve. Investing differently will lead Goshen to achieving and sustaining those outcomes. I am excited to see some of the early signs, validating this was the right strategy for us.

I understand the comments about rigidity with staffing ratios. I believe healthcare organizations face challenges and must determine their individual approach with the resources they have. For Goshen, the analysis was very clear.

Q: What early signs or feedback have you received since the shift — from nurses, patients, or other care team members?

JC: At the end of the day, when nurses care for fewer patients, patients have better care. Staffing is about giving that individualized care that patients deserve, and creating this environment where nurses can thrive. I can tell you that we’ve already seen some pretty positive outcomes since we’ve made this move. Naturally, when you increase the number of nurses, you improve outcomes. To name a few, I’ve walked these halls, and some of the seasoned nurses were telling me leading up to this decision that they were not sure that they could continue with the workload as it is today. Following this announcement, those seasoned nurses shared with me that they were considering retirement, and now they plan to stay longer. That is significant, especially when you look at the experience complexity gap that exists within healthcare today. Retaining seasoned nurses is huge.

Initially, we have experienced some other positive changes. Adherence to bedside reporting has improved, leading to a better patient experience. We have noted fewer call lights in the hospital environment, and observe more patients being walked in the halls. When you think about nurse sensitive indicators like falls and HAPIs, changes in progressive mobility have positive effects on quality of care and length of stay. We have seen improved communication and engagement in safety huddles and colleagues are leaving their shifts on time, decreasing overtime and improving work-life balance. These changes are improving our outcomes on all levels, organizationally, for the patient and the nursing colleagues.

Q: Earning Magnet with Distinction reflects excellence across many domains. Of all the elements that had to be “done well” for Goshen Hospital to achieve that honor, what’s one area you’d point to as exceptionally strong or defining for Goshen’s nursing culture?

JC: I believe we were the fifth organization to have received that level of distinction. Our culture is built on the foundation of empowering our colleagues through a program which we call ‘The Uncommon Leader.’ The underpinnings of that recognize that colleagues who are closest to the work can identify opportunities for improvement — improvement in many of our pillars.

At Goshen, the uncommon leader culture provides the foundation for our strong professional governance structure in nursing. Colleagues are empowered to shape the decisions that truly influence their clinical practice. Nurses own their professional practice, and have the opportunity to drive improvements around quality, satisfaction and work environment.

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