Adding just one more hospital patient to a nurse’s workload increases by 7 percent the likelihood of a patient dying within 30 days of being admitted.
That was the dire finding of a 2014 study in The Lancet, and it was used earlier this year by the Oregon Nurses Association to champion the passage of a bill to strengthen the state’s nurse staffing law.
“If they’re not staffing appropriately, then patients — your loved ones, your family members, your father, your mother, your brother, your sister, whoever — may not get the care that they need delivered in an appropriate manner at an appropriate time,” said Lynda Coats, an ONA member who has been a nurse at St. Charles Bend for nearly 30 years.
Such arguments convinced Oregon lawmakers of the need for updates to the state’s existing hospital nurse staffing law, passed in 2001. The Legislature approved the new law in late June. The final version garnered support from the state’s hospitals and nurses union, who don’t always see eye-to-eye, following a number of tweaks from its original incarnation.
Staffing laws are designed to ensure patients receive enough attention from caregivers who have the appropriate expertise and that those caregivers are not overworked or fatigued.
Several nurses from around the state urged lawmakers to support the bill, divulging in letters that their hospitals don’t staff enough nurses in an effort to cut costs, which ultimately puts patients at risk.
Vikki Hickmann, a nurse in St. Charles Bend’s emergency department, wrote to lawmakers that her supervisors place a lot of emphasis on how quickly the nurses can move patients through, but not on whether nurses receive their breaks or whether patients are forced to wait or are not seen due to insufficient staffing.
“The increased stress that RNs experience when they cannot provide care they know to be necessary, the lack of rest breaks, the forced use of substandard equipment and the inability to perform at a level required by hospital policy secondary to inadequate staffing, leads to negativity, injury, increased liability and diminished patient outcomes,” she wrote.
Coats said a group of emergency department nurses who work at St. Charles Bend recently filed a complaint to the Oregon Health Authority alleging the hospital isn’t staffing enough nurses in the department and isn’t providing adequate break time.
“There is a lot of nurse fatigue out there,” she said.
OHA spokeswoman Susan Wickstrom wrote in an email that the agency has received two separate but similar complaints from Bend’s emergency department nurses, but that it cannot make them public, nor can it reveal whether it will investigate them.
Details of the new law
The new rules require each hospital to establish its own nurse staffing committee comprised of half front-line caregivers and half administrators. That committee must then develop a written hospital-wide staffing plan and implement it by 2017.
Each of St. Charles’ four hospitals already have staffing committees, and the committee serving its Bend hospital has been spotlighted by the ONA as an example of a successful committee, said Pam Steinke, St. Charles’ chief nursing executive and vice president of quality.
The law also creates a 12-member Nurse Staffing Advisory Board comprised of nurses and nurse supervisors from across the state that will report to the OHA on nurse staffing trends and make recommendations based on complaints and staffing reviews.
Steinke said she knows of local providers who want to serve on the board.
“I think we’d be very blessed to have somebody from this side of the mountain at the table and not just have it be Willamette Valley folks,” she said.
Under the new law, the OHA must audit hospitals every three years. State officials must also initiate on-site investigations within 60 days of receiving complaints from hospital staff members. The law directs the agency to receive more than $500,000 to perform the additional duties.
Steinke said she’s happy OHA will be doing more oversight, which she said has lacked in the past. Only half of the state’s hospitals have been audited within the past decade, she said. In Central Oregon, the OHA has only performed a staffing audit on St. Charles Madras, Steinke said.
Audits are important because they tell hospitals what they’re doing well, which provides an opportunity to celebrate those things, Steinke said. They also identify areas where hospitals need to improve, she said.
“Sometimes it’s incremental improvements, sometimes it may be a big gap,” Steinke said, “but you don’t know what you don’t know until sometimes outside eyes look at that.”
The OHA also must now perform on-site inspections within 60 days of receiving complaints from hospital staff members.
The lag time between complaints and OHA follow-up has been problematic for St. Charles, which the OHA investigated in January in relation to a staffing complaint filed in December 2013 and a patient complaint filed in July 2013, Steinke said. The issues in those complaints had already been addressed, she said.
“Over a two-year period, there had been a lot of changes and we had addressed a lot of things,” Steinke said.
Staffing ratios struck down
The bill originally attempted to make hospitals subject to nurse-to-patient staffing ratios if caregivers and administrators disagreed on the issue and asked the OHA for help.
Legislators dropped the ratio requirement following opposition from the Oregon Association of Hospitals and Health Systems. Carol Bradley, an OAHHS board member, summed up the organization’s opposition to the ratios in written testimony to lawmakers.
Prior to joining Legacy Health five years ago, where Bradley currently serves as senior vice president and chief nursing officer, she wrote that she worked in California, which until last month had been the only state that mandated minimum nurse-to-patient ratios in hospitals since adopting its law in 1999. She said it forced hospitals to cut its numbers of other support personnel, forcing nurses to take on some of the duties previously assigned to those roles. She also said the increased patient handoffs resulted in decreased continuity of care.
St. Charles also opposed the staffing ratio. That’s because patients have different levels of need depending on the illness and its severity, and one-size-fits-all ratios don’t allow for individualized care, Steinke said.
“Nurses are an autonomous profession in which they depend upon their critical thinking and clinical judgment to make decisions about care,” she said. “When you play it as a numbers game, that takes that away.”
While California’s law helped increase nurse staffing levels in hospitals relative to those in other states, some California hospitals saw higher infection rates since the law’s passage, while others saw lower rates of patients who couldn’t be rescued relative to other states, according to a 2013 study in the journal Health Services Research.
Massachusetts approved regulations in June that limit each nurse to no more than two patients in intensive care units, making it the second state to impose minimum staffing ratios. More than 10 other states have laws that address nurse staffing in hospitals, but they don’t go so far as to require certain ratios.
— Reporter: 541-383-0304,