Are Washington hospitals ready for the state to enforce their staffing plans?

By Lauren Gallup and Susan Shain

During her shifts at PeaceHealth Southwest Medical Center in Vancouver, Washington, registered nurse Dawn Marick said she routinely encounters the same problem: not enough staff. 

Marick said that she and her colleagues are so slammed that they often miss breaks. She has suffered from urinary tract infections from not being able to hydrate or go to the bathroom. She developed mastitis, a painful inflammation of breast tissue, from not being able to pump breast milk at regular intervals.

The issue doesn’t just affect nurses. Marick’s concern is that if nurses are stretched thin, it could impact the care they provide to their patients. Research shows that staffing levels can have a significant impact on patient safety.

“ When we’re short-staffed, we’re given (patient) ratios higher than we should have, which gives us less time with our patients,” Marick said. “That’s really hard for nurses because a lot of what we do depends on getting to know our patients.”

Nurses across Washington are dealing with similar challenges, as the state faces what is projected to be the worst nursing shortage in the country, according to the National Center for Health Workforce Analysis. 

In a bid to alleviate understaffing, nurse burnout and improve patient care, Oregon recently passed a law that established minimum nurse-to-patient ratios across its hospitals. 

Washington does not mandate maximum ratios. 

Instead, in 2023, Washington passed a law that requires hospitals to have formal staffing committees to make plans that dictate how many nurses have to be working in a unit at any given time. These ratios vary depending on the number of patients and how severe their conditions are. Hospitals had to submit their plans by the start of the year.  

Now, another important deadline is looming: On July 1, hospitals must begin complying with their plans, or Washington’s Department of Health and Department of Labor & Industries can investigate, and penalize hospitals. 

NWPB reached out to three hospitals, each varying in patient load and location, to ask if they were ready: PeaceHealth Southwest Medical Center in Vancouver, St. Joseph Medical Center in Tacoma and Providence St. Mary Medical Center in Walla Walla. Spokespeople at all three said they were already implementing their plans and are prepared to comply with the law. 

But some nurses at those hospitals don’t think the law alone will solve staffing problems.

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Insufficient ratios

In the past, PeaceHealth employees that have raised complaints over working conditions have had their contracts terminated.

One nurse who works at PeaceHealth Southwest asked to speak anonymously, citing concerns about job security. 

The nurse said they believe that nurses and administrators have different motivations when it comes to staffing decisions.  

In recent years, hospital staffers have held a strike and a picket, both of which protested what they called inadequate staffing. 

The nurse, who participated in some staffing committee meetings, said PeaceHealth Southwest’s plan received pushback from nurses. The staffing committee couldn’t agree on new ratios for four units.

In some areas of the hospital, the nurse said the final plan doesn’t align with research on safe staffing. 

In some of PeaceHealth Southwest’s medical-surgical units, where patients are recovering from a variety of health conditions, one nurse might be caring for six patients overnight, Marick said.

Research from the University of Pennsylvania shows that patient mortality can be decreased in medical-surgical units when nurses are not caring for more than four patients. 

The law in Oregon limits nurses to that number. 

Washington nurses have consistently called on hospitals to set maximum nurse-to-patient ratios in their collective bargaining agreements. Among the hospitals represented by the Washington State Nurses Association, only Tacoma General Hospital has done so. 

“What California and Oregon have done, like I said before, is amazing,” said the anonymous nurse. “Washington needs to do that because the hospitals themselves are never going to make that choice unless they’re forced to.” 

NWPB reached out to PeaceHealth Southwest to ask what the hospital’s priorities were in creating its staffing plan and how it responded to the claim that the hospital was more concerned with profits than patients. 

In an email, a spokesperson declined to participate, simply saying: “We will continue to uphold the staffing law.”

Why hospitals are short-staffed and why it matters

The COVID-19 pandemic made hospital staffing more difficult, and in its wake, hospitals tried to earn back money lost by keeping labor costs low. That’s according to Charlotte Yeomans, president of Northwest Medicine United, a union that represents nearly 800 health care professionals in the Pacific Northwest. 

Following the pandemic, Yeomans said hospitals kept labor costs low by minimizing provider positions and nursing and nurse’s aide positions. At the same time, many hospitals assigned increased patient loads to nurses and nurse’s aides— a move that she said has compromised both patient safety and overall quality of patient care. 

“ The fastest way to recoup that is to make everybody who works for us as an employee do more for less reimbursement,” Yeomans said. 

The Washington State Hospital Association agrees that its members lost money — to the tune of $4.5 billion since the pandemic. But it underscored that there’s a nationwide shortage of nurses, and disagreed with the idea that hospitals are intentionally understaffing. 

“Hospitals, in particular in our state, have done a really good job of trying to recruit more nurses,” said  Ashlen Strong, WSHA’s vice president of government affairs. “We are consistently ranked as one of, if not the best, states in the country to work as a nurse. And we’re in the top five for nursing compensation.”

The WSHA also says hospitals are between a rock and a hard place: Inflation and salaries have risen quickly, while Medicare and Medicaid payments haven’t.

“Labor costs alone between 2021 and 2024 increased 35%,” Strong said. “So that’s obviously increasing faster than inflation and faster than any of our payment contracts.”  

Neil J. Sehgal, who studies health systems at the University of Washington, said “very sound and settled science” shows that adequate staffing can improve health care outcomes. In particular, staffing can impact conditions such as inpatient mortality, hospital-acquired infections, medication errors and patient satisfaction, Sehgal said. 

He also underscored that adequate staffing is critical to retaining health care workers and reducing burnout — which, in turn, can lead to better patient care.

“There’s an organizational and a systemic responsibility to ensure that health care workers have all of the tools that they need to produce the most favorable patient outcomes,” Sehgal said. “And one of those tools is enough colleagues to distribute the workload.” 

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Compliance

Some nurses at St. Joseph Medical Center in Tacoma don’t think the new staffing plan regulations will necessarily lead to lower nurse-to-patient ratios. They tried to get their hospital to codify nurse-to-patient ratios in their latest collective bargaining agreement, but could not.

They think the law will, however, make the hospital adhere to the plans it’s created. 

“We can’t guarantee better, but as long as we stand united, we can make sure we’re not going backwards at all,” said Jared Richardson, who represents St. Joseph’s nurses for WSNA. 

Richardson said at St. Joseph, the nurses and hospital settled on rolling over most of the 2024 staffing plan, because they couldn’t come to an agreement on new staffing numbers. That’s one reason Richardson said the law doesn’t have enough teeth. 

For staffing committees to finalize each unit’s plan, over 50% must vote in favor of it. Because half of the committee is made up of medical staff and the other half is administrators, Richardson said it’s tough for the two sides to come to a majority consensus. 

Andrew Baxter, an executive at St. Joseph Medical Center, said in an emailed statement that the hospital has already begun planning for the staffing year that begins July 1. 

Baxter said the hospital continues to hire new positions as needed to support the staffing plan, and that the hospital expects to be fully compliant with requirements outlined by the state.

Richardson doesn’t think the hospital is in compliance with its plan yet. But the bigger question, he said, is how compliance will be measured.

“That’s gonna be some interesting issues to tackle as we move forward,” he said.

Once the July 1 deadline arrives, there are two avenues for reporting non-compliance: self-reporting and complaints, both to the Washington State Department of Health.

Frank Ameduri, a public information officer for the department, said that if the number of patients assigned to nurses is higher than what’s in the plan — on a per unit and per shift basis — hospitals must document it. 

If hospitals are out of compliance for 20% of the month or more, then they must submit a non-compliance report, according to the department.

Anyone can also submit complaints if they feel the staffing plan is not being followed.

Bruce Curnuck is a nurse in the operating room at Providence St. Mary Medical Center in Walla Walla. In addition to what he sees as many kinks to iron out with reporting, he said compliance will be difficult given Washington’s nurse shortage.

Over the 20 years he’s worked there, Curnuck said Providence St. Mary has been in a constant state of hiring, in part because it’s hard to recruit nurses to such a rural area. 

When reached for comment, a spokesperson for the hospital said it is “not immune to the challenges of recruiting healthcare caregivers,” but noted that it “has nurse retention rates well above and nurse vacancy rates well below the national average.” 

Overall, Curnuck is supportive of the staffing law, saying: “ It does kind of force health care facilities’ hands.” But, he added, it won’t do anything about nurses calling out or positions remaining vacant. 

“The state could make a ratio of one-to-one, one nurse to one patient,” he said. “It doesn’t make nurses magically appear out of the woodwork.”