Steady rates in hospital closures after private equity takeovers underscore the urgency of understanding how hospital ownership impacts patient care. Hospital ownership type—whether hospitals operate as for-profit or not-for-profit—has become increasingly relevant in discussions of health care access, quality, and safety in the United States.

A recent study led by Penn Nursing LDI Senior Fellows K. Jane Muir, Matthew McHugh, Karen Lasater, and colleagues examined how hospital ownership status relates to investments in nursing services, using nursing survey and hospital financial data from hospitals across Illinois. The study found significant disparities in how hospitals allocate resources for nursing services based on their ownership type.

For-profit hospitals consistently demonstrated lower investment levels in nursing than not-for-profit hospitals, resulting in higher patient-to-nurse ratios, less supportive work environments, and poorer ratings on patient safety and infection prevention measures. Nurses in for-profit hospitals also experienced significantly higher levels of burnout, job dissatisfaction, and intent to leave their positions.

In our Q&A with lead author Muir and senior author Lasater below, we delve deeper into the study’s methodology, implications for hospital management and state-level policies, and future directions for their research.

How does hospital ownership type influence nurse staffing and patient care quality?

Muir: While most hospitals in the U.S. are not-for-profit, for-profit and private equity ownership are becoming more prevalent. That shift has raised serious questions about how financial motives influence patient care and nursing services. These concerns are part of what motivated our research—we wanted to understand whether ownership status is related to how hospitals invest in nursing services, which are essential to ensuring the safety and good outcomes of hospitalized patients.

What are the key differences between for-profit and not-for-profit hospitals’ nurse staffing and patient outcomes?

Muir: We found that for-profit hospitals invest less in nursing services compared to not-for-profit hospitals. For-profit hospitals had higher patient-to-nurse staffing ratios, meaning that patients in those hospitals received less nursing care than in not-for-profit hospitals. Nurses in these hospitals also reported less supportive work environments and gave lower ratings on measures of patient safety and infection prevention.

Our second most significant takeaway is that nurses in for-profit hospitals experienced higher burnout, intent to leave their jobs, and overall job dissatisfaction at significantly higher rates than nurses working in not-for-profit hospitals.

These findings are important because states are considering minimum staffing requirements for hospitals, and our findings suggest that government requirements may be necessary to close the gap between for-profit and not-for-profit hospitals. Our analysis focused on Illinois, where legislation is under consideration that would require hospitals to staff a safe number of nurses at the bedside for better patient outcomes. California was the first state to implement such legislation in 2004. Pennsylvania’s similar policy, the Patient Safety Act, passed through the House in 2023 and is currently being reintroduced in the Senate. Washington and Massachusetts are also actively considering state legislation requiring hospitals (both for-profit and not-for-profit) to staff enough nurses to care for patients safely.

What methodology did you use to assess the impact of hospital ownership on nursing services, and what are the study’s limitations?

Muir: We used a cross-sectional design using survey data from hospital nurses developed at the Center for Health Outcomes and Policy Research linked with publicly available hospital data in Illinois. This approach allowed us to assess frontline nurses’ experiences alongside hospital-level characteristics, making it well-suited to explore how ownership status relates to nursing services and patient care quality and safety.

The study is limited to one state, which may affect generalizability, and as a cross-sectional analysis, we cannot establish causality—only associations. We also only examined hospital operating margins as an indicator of financial performance in for-profit and not-for-profit institutions.

Despite these limitations, our findings are highly relevant in the context of current policy debates in several states considering minimum nurse-staffing standards.

How can state legislation address disparities in nurse staffing between for-profit and not-for-profit hospitals?

Lasater: Our results underscore the need for stronger policy oversight to ensure all hospitals are adequately resourced for their nursing services. States considering safe nurse-staffing legislation should view our results as evidence that safe staffing and supportive work environments are both achievable and essential for patient safety.

A frequent argument against such legislation is that adequate nurse staffing would be financially unsustainable. However, our study found only weak associations between hospital financial performance and staffing levels, challenging the notion that better staffing is unfeasible. In fact, our results, along with other research, suggest that investing in nursing supports safer care and can lead to cost savings through improved patient outcomes such as shorter hospital stays.

The weak relationship we observed between hospital finances and staffing suggests that underinvestment in nursing is more a matter of hospital priorities than financial constraint. Minimum nurse staffing ratio legislation is an evidence-based strategy to improve the nursing care patients receive in hospitals for safer care.

What future research is planned to explore the effects of hospital ownership on nursing services and patient care?

Muir: We’re expanding this research to a larger, multi-state sample to see if the patterns we found in Illinois are reinforced nationally. We’re also investigating how private equity ownership influences nurse staffing, work environments, and patient outcomes, to inform policies that support a safer and more sustainable hospital workforce.

---

The study, “Hospital Ownership Type Correlated With Investments in Nursing Services: Evidence from Illinois,” was published on April 30, 2025, in Medical Care. Authors include K. Jane Muir, Kathy S. Sliwinski, Daniela Golinelli, Matthew D. McHugh, and Karen B. Lasater.

---

Drs. Muir, Golinelli, McHugh, and Lasater are Senior Fellows at the Center for Health Outcomes and Policy Research at Penn Nursing.

---

Author

---