Nurses in Oregon are hopeful a state law will solidify staffing ratios, but nurses in states with similar laws say state health department enforcement is generally lacking.
Hospitals in Oregon were required to meet staffing minimums as of June 1, joining health systems in California, Massachusetts and New York that must also adhere to staffing ratio mandates. These laws were championed by healthcare unions and, in some cases, supported by state hospital associations, but nurses say they aren’t the quickest or most effective ways to tackle understaffing.
Related: Unions struggle to enforce labor contracts' staffing requirements
Nurses in Oregon hope the health department will hold hospitals accountable for violations, said Christy Simila, director of professional practice with the Oregon Nurses Association.
“We're looking forward to the Oregon Health Authority being able to fully implement and impose fines when necessary during investigations starting next year,” Simila said.
Oregon has been phasing in its safe staffing law since it passed last August. The final part of the law will go into effect in June 2025, when the state health department can fine hospitals not complying with nurse staffing requirements.
The Oregon Health Authority said in a statement it is already investigating staffing complaints and issuing warnings to hospitals. The department has given warnings to two facilities: Kaiser Sunnyside Medical Center in Clackamas, Oregon and Bay Area Hospital in Coos Bay, Oregon.
Kaiser Sunnyside Medical Center is “working to hire as aggressively as possible” to meet the law’s requirements, the facility said in a statement. The state warned the facility about short staffing of certified nurse assistants and registered nurses.
“Like every healthcare organization, we have faced challenges at times in the wake of the pandemic, given the nationwide shortage of healthcare workers and competition for talent,” the facility said.
Bay Area Hospital failed to notify its staffing committee when deviating from set staffing levels, and said in a statement it has adjusted the communication process and will notify the committee moving forward.
As a result of the law and oversight from the Oregon Health Authority, there has been a noticeable increase in hospitals' commitment to hiring new nurses and working with those on staffing committees, Simila said.
But in other states, enforcement actions — including corrective action plans and penalties — are minimal.
Since New York's safe staffing act took effect in January 2022, the state’s department of health has looked into more than 400 complaints related to nurse-to-patient ratio violations. Around 340 are unresolved, as the department says most were improperly submitted.
Of the complaints the New York State Department of Health resolved, 35 resulted in Statements of Deficiency sent to hospitals, which must then submit corrective action plans. The department issued its first $2,000 fine in March, penalizing a hospital for not providing information the state needed to conduct a clinical staffing investigation.
“The department of health staff have been tirelessly enforcing the safe staffing law as prescribed by the enabling statute, including enforcement of hospitals found to be in violation of the law,” the department said in a statement. “The responsibility is on hospitals to ensure that they have a functional clinical staffing committee and a process to consider complaints and resolve them.”
Members of the New York State Nurses Association have filed nearly 100 complaints with the health department, and see the state's enforcement as inadequate.
NYSNA said filing grievances for violations of union contracts and going through arbitration is often the quicker and easier way to get hospitals to hire more staff or increase pay, rather than going through the state. For example, Ellis Hospital and Bellevue Women’s Center and Mount Sinai Health System were recently ordered by third-party arbitrators to compensate nurses working in severely understaffed units that did not hit the state's minimum requirements.
The New York union said going through the state is less effective than arbitration since there is less guaranteed follow through.
Nurses in California also raised concerns about the length of that state's complaint process.
“If you file a complaint, it [could be] months before you hear back from anybody," said Melissa Beebe, a registered nurse at UC Davis Medical Center in Sacramento and chief nurse representative with the California Nurses Association. "And you don't hear about what the response was from management. It’s a letter that comes back saying whether or not they found any violation.”
Despite being the first state to establish registered nurse-to-patient ratios for hospitals in 2004 and requiring the California Department of Public Health to impose penalties of up to $30,000 for staffing violations starting in 2020, California has only cited or fined a handful of facilities.
During the first year of the COVID-19 pandemic, hospitals could apply for temporary waivers to be exempt from meeting staffing ratios. The state’s health department did not begin fining hospitals until October of 2023. It has administered nine penalties to four facilities amounting to $225,000, six of which were given to Kern Medical Hospital in Bakersfield, California.
Kern Medical Center completed a corrective action plan to comply with state law, the facility said in a statement.
"This plan includes ongoing recruitment as well as use of traveler registry staff and there have been no further penalties or violations for staffing deficiencies," the hospital said.
The California Department of Public Health did not respond to multiple requests for comment about the number of staffing complaints it received or its process for investigating.
Hospitals aren’t subject to an administrative penalty for violating nurse-to-patient staffing ratios if facilities can prove fluctuations were unpredictable and uncontrollable, or immediate efforts were made to comply with required staffing levels, according to the health department. However, the department in September said a new policy would limit hospitals’ ability to claim unpredictable circumstances as a reason for violating the mandate.
In recent months, the health department has seemingly made more of an effort to check on hospitals and their compliance, Beebe said.
“Even without fines, it's the presence that's important,” she said. “Knowing that somebody is watching often can do enough with course correction.”
However, Beebe said filing a notice with management objecting to working at unsafe staffing levels is still the most immediate way for nurses in California to bring about change.
The Massachusetts Department of Public Health did not provide data on the number of staffing complaints it received or the number of penalties it doled out to hospitals, but said it reviews incident reports to determine if an unannounced facility survey is necessary. Following an investigation, the department may order a correction plan be submitted and follow up with the facility to ensure it is implemented.
Though it can be difficult to hold hospitals accountable to staffing ratios using union contracts and state laws, nurses say both are necessary.
“If we didn't have the state law, I don't even know what staffing would look like. It would be crazy,” Beebe said.
State staffing laws set a staffing floor that facilities can use to determine their individual needs, Simila said.
“We believe that staffing law is a vital step in creating safer healthier workplaces, for nurses and other healthcare professionals, and also allowing them to work in conditions that will give every patient the care they deserve,” she said.
