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Stressed and overworked, nurses want strict hospital staffing requirements

A union representing Oregon nurses says staff-to-patient ratios will halt nurses from fleeing the profession, while hospitals worry about fewer beds for patients.
Understaffing concerns have helped fuel nurse union rallies such as the one outside Providence Health's Oregon headquarters in Portland on January 20, 2023. | JAKE THOMAS/THE LUND REPORT
February 9, 2023

Gina Ottinger said she considers herself an optimist but still has many nights where she cries after finishing the night shift. She works as an emergency department nurse at a Portland hospital, and cries after seeing patients die unexpectedly or witnesses someone in the throes of a mental health crisis. Other times she cries over frustration at what she sees as a “health care system on its knees.”

“I want to do what’s right for people,” Ottinger told The Lund Report. “And it’s challenging when you feel like this structure of health care isn’t meant to really look out for the patient.”

Ottinger said her emergency department should have at least 10 to 12 nurses working on her shift. Some nights, she said, she’s down to six or less if they have to take care of patients waiting for a hospital room. Meanwhile, she said some of her coworkers take other jobs or more lucrative positions with staffing agencies, driving turnover in her unit over 50%. 

Nurses like Ottinger feel undervalued and are withdrawing from the profession at a time when hospitals and other health care settings are desperately understaffed. But Ottinger’s  union, the Oregon Nurses Association, is pushing legislation she said will make her job less stressful. 

House Bill 2697 would establish minimum nurse-to-patient staff ratios for hospitals and impose stiff fines for violating them. The bill’s backers say it will make working conditions bearable and halt the hemorrhaging of nurses after what they call years of bare-bones staffing by money-conscious hospitals. Hospital administrators, however, say the bill would destabilize the pandemic-battered health system, increase the financial losses many facilities are reporting, and mean less care for patients.

Negotiations between the two sides are reportedly under way as they await committee hearings on the bill.

“The hospital association and the nursing association are supposed to be checking in with each other about that bill, and seeing if there are things that they can kind of come to agreement on,” said state Rep. Rob Nosse, a Portland Democrat who is the sponsor of the bill and chair of a key legislative committee. 

The union-backed legislation comes as lawmakers are wrestling with the complexities of growing Oregon’s health care workforce — and while tensions between nurses and hospitals have crescendoed. The bill would mean a consequential reordering of hospital resources, and the debate over it reveals the depths of Oregon’s nursing workforce challenge. 

State would lose beds, hospitals say

The union and the hospital association agree Oregon needs to rapidly ramp up its nurse workforce. Doing so could take years, and the nurses union said the bill is needed to prevent a workforce collapse. But the hospital association argues the bill will create a new, deeper crisis. 

“If hospitals cannot hire enough staff to comply with the ratios in the bill, they may be forced with no other choice than to shut down hospital beds,” Becky Hultberg, president and CEO of the Oregon Association of Hospitals and Health Systems, said in response to a question from The Lund Report during a press conference last month. 

She said that “could mean challenges, and further delays in transferring patients from rural settings into urban ones for a higher level of care. It could mean more people are waiting for needed procedures in their community.”

There are no authoritative numbers on how many nurses have quit their jobs in Oregon, Jana Bitton, executive director of the Oregon Center for Nursing, told The Lund Report. But other sources of data point to challenges to keeping nurses in their jobs. 

Registered nurse positions had the seventh highest number of job vacancies in Oregon in 2021, according to an Oregon Employment Department survey. Over 2,000 registered nurse positions were open that year, the survey found. 

Nearly all of the more than 5,000 registered nurses who responded to a survey  from the Oregon Center for Nursing reported a work-related stressor. The survey results, partially released last year, found that 83% reported feeling stressed and 80% frustrated. Roughly two-thirds reported feeling anxiety, exhaustion and burnout.

 “Right now, it is really tough to find enough of them that are willing to work within the hospital environment,” Bitton said.

Hospital nurses were subject to threats or violence from families unable to see loved ones because of pandemic restrictions. Some hospital staff nurses saw morale plummet when they found out temporary nurses called in during surges were being paid two to four times as much, Bitton said. 

Nationally, nurses have been exiting the profession in response to added stress and workloads from the pandemic. More than half of nurses are considering leaving their jobs, according to the survey results released last year by the American Nurses Foundation and American Nurses Association. The top reason for considering leaving was insufficient staffing, and 89% of nurses reporting staff shortages at their workplace.

According to figures from the Oregon Nurses Association, 27% of active nurses left their jobs in 2022 and more than a third of those remaining say they will very likely quit this year. 

“The health care system is in a state of collapse, and we need to interrupt the profound dysfunction of this system,” Matt Calzia, the nurse’s union director of nursing practice and professional development, told The Lund Report. 

The governing body of the Oregon Nurses Association last year overwhelmingly passed a resolution calling for the state to enact new hospital staffing requirements, Calzia said. 

Oregon is in the top five states with the highest pay for registered nurses, with an annual mean wage of $98,630, according to federal numbers. Why is Oregon struggling to attract and retain nurses when it has one of the highest rates of pay? The answer is complicated, according to Rick Allgeyer, research director for the Oregon Center for Nursing.

Reports of nurse shortages date back to the 1940s and 1950s, Allgeyer told The Lund Report. In more recent times, research shows nurses will leave high-paying jobs if they don’t feel aligned with their employer’s values or feel connected with their co-workers and bosses, he said. They’ll also look for other jobs if they don’t feel they’re being valued or treated well, he said. 

“The pay increases will make you happy for a little while, and they’ll increase your tolerance for an unhealthy work environment,” said Allgeyer. “But it doesn’t last forever.”

Calzia said the staffing bill is about slowing turnover and even bringing nurses back by improving working conditions with increased staff. 

Extent of shortage unclear

There are nearly 60,000 registered nurses in Oregon with an estimated 45,000 practicing, said Allgeyer, citing 2020 state numbers, which he said are the most recent. He said there is no clear number for how many nurses Oregon needs and rural areas may face ongoing shortages. 

A recent report produced for Oregon lawmakers by the center and University of California San Francisco professors pointed to past research suggesting the nurse shortage is due to education and licensing requirements, as well as slow wage increases and large employers’ market power, especially in small markets. 

The report noted that applications to registered nurse education programs have declined in recent years and enrollment has slowed. Oregon’s nursing programs have some of the worst vacancy and graduation numbers in the country. 

Both the union and the hospital association are backing legislation aimed at putting more needed nurses in the training pipeline. 

“Our health care workforce is our lifeline, our infrastructure to our hospitals that keep providing to our communities from one generation to the next,” Andi Easton, vice president of government affairs for the hospital association told the Oregon Senate Health Care Committee in January. 

There is a potential bright spot in otherwise gloomy nurse workforce figures. An analysis of Oregon by the Oregon Center for Nursing shows that registered nurses were renewing their licenses in 2021 at rates higher than during the pandemic. Bitton said that means registered nurses who pulled back on hours or took other jobs could be lured back to hospitals.

State Rep. Travis Nelson, a Portland Democrat and former Oregon Nurses Association official, told The Lund Report that if the bill is passed and has teeth he expects nurses to quickly return to the bedside and improvement to be noticeable within six months to a year. 

Charlie Tveit, the CEO of Lake Health District, which operates a hospital in Lakeview, told The Lund Report that the union has a point that nurses would be less burnt out and would stick around if there were higher staffing levels. 

“I think that’s absolutely true,” he said. “If I could hire more nurses, I would hire more nurses. My problem is I can’t find anybody that wants to be a nurse.”

Tveit said Lakeview, a town of 2,400 in south central Oregon, is probably the most remote community in Oregon and is served by the 24-bed critical access hospital. In addition to its remote location, Tveit said attracting nurses is difficult because nurses are required to take on a range of tasks at the small hospital. 

“One minute they’re taking care of a car accident, and the next minute they may be taking care of an obstetrical patient or they may be working with a patient who has a long term care condition,” he said. 

Tveit said the district has increased wages and is working with Klamath Community College, located 90 miles away, to produce more registered nurses. But he said there’s just not enough nurses and some that work at Lakeview’s hospital end up getting burnt out by the difficult job. 

What would the new staffing bill do?

Both the nurses union and the hospital association agree on one thing: Oregon’s current staffing law isn’t working. Oregon has a nurse staffing law in place that requires hospitals to have plans in place with minimal staffing levels. 

The most recent report from the state Nurse Staffing Advisory Board found widespread compliance issues. Hultberg, the hospital association’s CEO, told The Lund Report during a press call that the existing staffing law isn’t working for hospitals or staff. She said her group wants to scrap the old law and replace it with something that would provide flexibility and accountability. The union’s proposal, she said, is a cause for concern. 

“We are concerned that it could cause hospitals to shut down beds if they can’t hire enough staff to meet the prescribed ratios in the bill,” Hultberg said.

Calzia said that the requirements of the union’s bill aren’t “profound change from industry standards.” He added that proposals to allow nurses from out of state to become more easily licensed in Oregon won’t solve the problem fast enough. 

“It is an oversimplification to say we will close more beds,” he said. “It’s just a fear tactic.” 

For now, the momentum appears to be behind the politically connected union’s bill to tighten staffing standards. 

Nosse, a former Oregon Nurses Association representative who chairs the House Behavioral Health and  Health Care Committee, agreed to sponsor the union’s bill. He said a hearing will likely be scheduled in late February.  

The bill would require hospitals to form committees, comprised equally of managers and staff, to create staffing plans. If a committee can’t come to an agreement after 90 days of mediation, the hospital is required to adopt a staffing plan with minimal patient-to-registered-nurse ratios that vary by unit. 

For instance, in an emergency department, a registered nurse couldn’t be assigned more than three nontrauma or noncritical care patients, or no more than one trauma or critical care patient. 

Hospitals that violate the law will be subject to $10,000 fines for each day they’re below the required staffing numbers and could be exposed to civil lawsuits. 

Ottinger, the Portland registered nurse, said the staffing plan in her emergency department isn’t followed currently and the changes proposed by her union would make a big difference. 

“My shift would definitely be a lot less stressful,” she said. “I would be able to provide better care, better quality care, and I think we’d retain a lot more nurses.”

Easton, the Oregon hospital association’s vice president, told the Oregon Senate Health Care Committee last month that any staffing law can’t be oversimplified and needs to account for the differing workforce skills at Oregon hospitals.

“There is no conclusive evidence that a uniform statewide staffing ratio supports patient outcomes or satisfaction of our nurses,” she said.

Lessons from California

If passed, Oregon would be following the lead of California that nearly two decades ago passed what is considered to be the most stringent staffing law in the country and mandates minimum numbers of nurses for patients. 

A 2009 review of the law by the California HealthCare Foundation found that registered nurses worked more hours. But hospital leaders reported reducing budgets and services because of the law. It also didn’t improve results around nurses rescuing patients after a post-surgical complication or pneumonia mortality.

A 2018 article in the European Journal of Cardiovascular Nursing reviewing previous literature on nurse staffing found that “higher staffing levels were associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use and a greater number of patients receiving percutaneous coronary intervention within 90 minutes.” The study noted that more research is needed on the association between nurse-to-patient ratios and outcomes.

Joanne Spetz, director of the Philip R. Lee  Institute for Health Policy Studies at the University of California San Francisco, told The Lund Report in an email that California’s staffing law led to higher wages and job satisfaction for nurses and resulted in fewer occupational injuries. She noted that nurse job satisfaction has dropped off in recent years. 

She added there is “no evidence that the ratios caused better patient outcomes,” nor is there anything “in the peer-reviewed literature about fewer beds being the result of the ratios.”

When asked what advice she’d have for Oregon lawmakers considering following California’s lead, she suggested they increase Medicaid’s low payment rates to help hospitals cover the costs. She also said Oregon should require hospitals to assess patients’ acuity on each unit and staff accordingly. 

“Don’t assume the ratios will solve all nursing problems,” she said. “Nurses still face challenges with hostile work environments, unsupportive leadership, increasing complexly ill patients, etc. Ratios might help but they are not a cure-all.”

You can reach Jake at [email protected] or via Twitter @jakethomas2009.