Hospitals across America face a persistent dilemma. Nurses report excessive workloads, burnout and unsafe staffing conditions. Hospital administrators respond that qualified nurses are difficult and expensive to recruit and retain.
Temporary staffing agencies can fill gaps, but often at substantial cost. Meanwhile, hospitals face mounting financial pressures, with some, particularly in rural communities, struggling to keep their doors open. But an important question is too often overlooked: How much of the pressure on nurses and financial burden on hospitals could be alleviated by moving beyond traditional hospital scheduling practices?
Eight years ago, during Massachusetts’ contentious debate over mandatory nurse-patient ratios, I suggested in a 2018 op-ed in the Boston Globe that neither side was adequately addressing a fundamental source of nursing workload pressures: avoidable fluctuations in patient admissions created by hospital scheduling decisions. Unless corrected, the staffing problem would return, and it has.
In New York City, nurses at Mount Sinai and Montefiore went on strike in 2023, winning agreements addressing staffing and compensation. In January 2026, nurses at those same hospital systems struck again, joined by colleagues at NewYork-Presbyterian. Nearly 15,000 nurses participated in a dispute that lasted weeks. At Kaiser Permanente, approximately 31,000 nurses and other healthcare professionals participated in a five-day strike in October 2025, followed by another strike beginning in January 2026 that lasted nearly a month.
Massachusetts hospitals have faced similar recurring disputes over staffing and working conditions. These disputes have legitimate and complex causes, including compensation, staffing, workplace safety and benefits. But negotiations often overlook an important opportunity that neither additional spending nor staffing ratios alone can provide: moving beyond traditional hospital scheduling practices can substantially reduce avoidable fluctuations in nursing workloads.
Consider what happens when hospitals concentrate elective surgeries and admissions early in the week. Patients admitted for scheduled procedures compete for beds and nursing attention with emergency patients whose arrivals cannot be scheduled. Nurses face excessive workloads, emergency patients remain boarded, and hospitals appear desperately short of capacity. Later in the week, those same hospitals may have substantial unused capacity. A 2024 peer-reviewed analysis, spearheaded by myself and colleagues at Stony Brook (N.Y.) University, of approximately 1.7 million New York hospital admissions demonstrated the magnitude of these fluctuations. For a hypothetical 500-bed hospital, the analysis found that accommodating Monday’s patient volume would require approximately 103 additional staffed beds, while Friday’s demand would require approximately 160 fewer staffed beds, relative to average capacity. These fluctuations have direct implications for nursing workloads. The consequences extend beyond nurses: When scheduled admissions compete with emergency patients for inpatient beds, the same operational practices contribute to emergency department boarding and overcrowding.
This broader problem has attracted bipartisan legislative attention. On Oct. 20, the American Hospital Association endorsed the ABC-ED Act, joining the Emergency Nurses Association and American College of Emergency Physicians in supporting efforts to address emergency department boarding. Smoothing elective admissions offers a practical operational approach to advancing these objectives while simultaneously alleviating nursing workloads. Hospitals face an expensive dilemma: staff for peak demand, and nursing resources may be underutilized on quieter days; staff for average demand, and nurses may become overwhelmed during admission peaks. Neither choice addresses the underlying cause. The solution is to distribute scheduled admissions more evenly across the week, coordinate operating room schedules with inpatient capacity and improve discharge processes. This can reduce unnecessary workload fluctuations while making more effective use of existing resources.
At Mayo Clinic Florida in Jacksonville, operating room scheduling redesign was associated with a 41% reduction in staff turnover and over $5 million in additional annual operating room net revenue. Overtime staffing also decreased substantially. At Cincinnati Children’s Hospital, patient flow improvements generated a reported $137 million in annual financial benefits and eliminated the need for a planned hospital expansion. Waiting times for urgent and emergency surgeries decreased, improving access to timely care. These examples illustrate how operational improvements can simultaneously benefit nurses, patients and hospital finances. The financial implications are particularly important for vulnerable hospitals, including those serving rural communities. As we wrote in an op-ed in May in Becker’s Hospital Review, persistent clinical labor shortages and rising staffing costs compound existing financial pressures. Better patient flow can help hospitals use scarce resources more effectively, reduce avoidable expenses, and strengthen their financial sustainability.
None of this replaces fair compensation, adequate staffing or appropriate staffing ratios. However, without addressing avoidable fluctuations in patient admissions, even substantial staffing investments leave an important source of excessive nursing workloads intact.
Smoothing elective admissions expands access to care, strengthens hospital finances simultaneously, and improves working conditions for nurses, without the need to spend more. Labor agreements can end strikes, but better hospital operations can help prevent their recurrence. Hospitals, nurses and patients deserve both.
Eugene Litvak, Ph.D., is President and CEO of the nonprofit organization Institute for Healthcare Optimization and an Adjunct Professor of Operations Management at the Harvard T.H. Chan School of Public Health.
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